Community-based transconjunctival marginal rotation for cicatricial trachoma in Indians from the Upper Rio Negro basin

The objective of the present study was to describe, for the first time in Brazil, the use by a non-ophthalmologist of a community-based marginal rotation procedure by a posterior approach in the indigenous population from the Upper Rio Negro basin. Seventy-three upper eyelids of 46 Indians (11 males and 35 females) with cicatricial upper eyelid entropion and trichiasis were operated in the Indian communities using a marginal rotational procedure by a posterior approach by a non-ophthalmologist physician who had general surgery experience but only an extremely short period (one week) of ophthalmic training. Subjects were reevaluated 6 months after surgery. Results were classified according to the presence and location of residual trichiasis and symptoms were assessed according to a three-level subjective scale (better, worse or no change). Fifty-six eyelids (76.7%) were free from trichiasis, whereas residual trichiasis was observed in 17 eyelids (23.3%) of 10 subjects. In these cases, trichiasis was either lateral or medial to the central portion of the lid. Of these 10 patients, only 4 reported that the surgery did not improve the irritative symptoms. We conclude that marginal rotation by a posterior approach is an effective and simple procedure with few complications, even when performed by non-specialists. Due to its simplicity the posterior approach is an excellent option for community-based upper eyelid entropion surgery.

A carbohydrate-based mechanism of species recognition in sea urchin fertilization

In the present review, we describe a systematic study of the sulfated polysaccharides from marine invertebrates, which led to the discovery of a carbohydrate-based mechanism of sperm-egg recognition during sea urchin fertilization. We have described unique polymers present in these organisms, especially sulfated fucose-rich compounds found in the egg jelly coat of sea urchins. The polysaccharides have simple, linear structures consisting of repeating units of oligosaccharides. They differ among the various species of sea urchins in specific patterns of sulfation and/or position of the glycosidic linkage within their repeating units. These polysaccharides show species specificity in inducing the acrosome reaction in sea urchin sperm, providing a clear-cut example of a signal transduction event regulated by sulfated polysaccharides. This distinct carbohydrate-mediated mechanism of sperm-egg recognition coexists with the bindin-protein system. Possibly, the genes involved in the biosynthesis of these sulfated fucans did not evolve in concordance with evolutionary distance but underwent a dramatic change near the tip of the Strongylocentrotid tree. Overall, we established a direct causal link between the molecular structure of a sulfated polysaccharide and a cellular physiological event - the induction of the sperm acrosome reaction in sea urchins. Small structural changes modulate an entire system of sperm-egg recognition and species-specific fertilization in sea urchins. We demonstrated that sulfated polysaccharides - in addition to their known function in cell proliferation, development, coagulation, and viral infection - mediate fertilization, and respond to evolutionary mechanisms that lead to species diversity.

The way to organizational longevity - Balancing stability and change in Shinise firms

THE WAY TO ORGANIZATIONAL LONGEVITY – Balancing stability and change in Shinise firms The overall purpose of this dissertation is to investigate the secret of longevity in Shinise firms. On the basic assumption that organizational longevity is about balancing stability and change, the theoretical perspectives incorporate routine practice, organizational culture, and organizational identity. These theories explain stability and change in an organization separately and in combination. Qualitative inductive theory building was used in the study. Overall, the empirical data comprised 75 in-depth and semi-structured interviews, 137 archival materials, and observations made over 17 weeks. According to the empirical findings, longevity in Shinise firms is attributable to the internal mechanisms (Shinise tenacity, stability in motion, and emergent change) to secure a balance between stability and change, the continuing stability of the socio-cultural environment in the local community, and active interaction between organizational and local cultures. The contribution of the study to the literature on organizational longevity and the alternative theoretical approaches is first, in theorizing the mechanisms of Shinise tenacity and cross-level cultural dynamism, and second, in pointing out the critical role of: the way firms set their ultimate goal, the dynamism in culture, and the effect of history of the firm to the current business in securing longevity. KEY WORDS Change; Culture; Organizational identity; Organizational longevity; Routines; Shinise firms; Stability; Qualitative research

Implementation of Quantitative Reaction-based Model Refinement

Building a computational model for complex biological systems is an iterative process. It starts from an abstraction of the process and then incorporates more details regarding the specific biochemical reactions which results in the change of the model fit. Meanwhile, the model’s numerical properties such as its numerical fit and validation should be preserved. However, refitting the model after each refinement iteration is computationally expensive resource-wise. There is an alternative approach which ensures the model fit preservation without the need to refit the model after each refinement iteration. And this approach is known as quantitative model refinement. The aim of this thesis is to develop and implement a tool called ModelRef which does the quantitative model refinement automatically. It is both implemented as a stand-alone Java application and as one of Anduril framework components. ModelRef performs data refinement of a model and generates the results in two different well known formats (SBML and CPS formats). The development of this tool successfully reduces the time and resource needed and the errors generated as well by traditional reiteration of the whole model to perform the fitting procedure.

Climate change and global responsibility - the role of energy consumption, GDP and CO2 emissions

Climate change is one of the biggest challenges faced by this generation. Despite being the single most important environmental challenge facing the planet and despite over two decades of international climate negotiations, global greenhouse gas (GHG) emissions continue to rise. By the middle of this century, GHGs must be reduced by as much as 40-70% if dangerous climate change is to be avoided. In the Kyoto Protocol no quantitative emission limitation and reduction commitments were placed on the developing countries. For the planning of the future commitments period and possible participation of developing countries, information of the functioning of the energy systems, CO2 emissions development in different sectors, energy use and technological development in developing countries is essential. In addition to the per capita emissions, the efficiency of the energy system in relation to GHG emissions is crucial for the decision of future long-term burden sharing between countries. Country’s future development of CO2 emissions can be defined by the estimated CO2 intensity of the future and the estimated GDP growth. The changes in CO2 intensity depend on several factors, but generally developed countries’ intensity has been increasing in the industrialization phase and decreasing when their economy shifts more towards the system dominated by the service sector. The level of the CO2 intensity depends by a large extent on the production structure and the energy sources that are used. Currently one of the most urgent issues regarding global climate change is to decide the future of the Kyoto Protocol. Negotiations on this topic have already been initiated, with the aim of being finalised by the 2015. This thesis provides insights into the various approaches that can be used to characterise the concept of comparable efforts for developing countries in a future international climate agreement. The thesis examines the post-Kyoto burden sharing questions for developing countries using the contraction and convergence model, which is one approach that has been proposed to allocate commitments regarding future GHG emissions mitigation. This new approach is a practical tool for the evaluation of the Kyoto climate policy process and global climate change negotiations from the perspective of the developing countries.

The role of product features on buyer-supplier collaboration in packaging industry

The thesis presents the study relative to the collaboration between suppliers and buyers in packaging industry with the impact of product features. The main purpose of this study is to examine the importance of product characteristics on collaboration to develop better packaging and to figure out how buyer-supplier collaboration in the supply chain perspectives is conducted and managed in packaging industry. The theoretical part reviewed some basic frameworks of collaboration including the scopes and levels of collaboration, risks as well as powers of collaboration, relationship and some key factors for successful collaboration. Followed by the overviews of packaging industry with the main issues related to product characteristics in packaging. By using the qualitative method, secondary data consisting of articles, reports, websites and primary data through interviewing some well-known packaging companies and case companies are collected in the thesis. The empirical result emphasized the importance of product features’ analysis in packaging industry since it plays a central role in the materials, design process, production and innovation with the role of collaboration. Collaboration in packaging is vital for packaging companies to survive and grow in the competitive environment. Finally, some key factors for effective collaboration were summarized based on the perspectives of packaging companies. It is highly recommend building a long-run collaboration with their customers due to undeniable benefits With increasingly importance of collaboration in packaging industry, further studies may be conducted.

PERFORMANCE ANALYSIS OF A TACTICAL ASSET ALLOCATION – Evidence from the Black–Litterman model based fixed income portfolio

Over time the demand for quantitative portfolio management has increased among financial institutions but there is still a lack of practical tools. In 2008 EDHEC Risk and Asset Management Research Centre conducted a survey of European investment practices. It revealed that the majority of asset or fund management companies, pension funds and institutional investors do not use more sophisticated models to compensate the flaws of the Markowitz mean-variance portfolio optimization. Furthermore, tactical asset allocation managers employ a variety of methods to estimate return and risk of assets, but also need sophisticated portfolio management models to outperform their benchmarks. Recent development in portfolio management suggests that new innovations are slowly gaining ground, but still need to be studied carefully. This thesis tries to provide a practical tactical asset allocation (TAA) application to the Black–Litterman (B–L) approach and unbiased evaluation of B–L models’ qualities. Mean-variance framework, issues related to asset allocation decisions and return forecasting are examined carefully to uncover issues effecting active portfolio management. European fixed income data is employed in an empirical study that tries to reveal whether a B–L model based TAA portfolio is able outperform its strategic benchmark. The tactical asset allocation utilizes Vector Autoregressive (VAR) model to create return forecasts from lagged values of asset classes as well as economic variables. Sample data (31.12.1999–31.12.2012) is divided into two. In-sample data is used for calibrating a strategic portfolio and the out-of-sample period is for testing the tactical portfolio against the strategic benchmark. Results show that B–L model based tactical asset allocation outperforms the benchmark portfolio in terms of risk-adjusted return and mean excess return. The VAR-model is able to pick up the change in investor sentiment and the B–L model adjusts portfolio weights in a controlled manner. TAA portfolio shows promise especially in moderately shifting allocation to more risky assets while market is turning bullish, but without overweighting investments with high beta. Based on findings in thesis, Black–Litterman model offers a good platform for active asset managers to quantify their views on investments and implement their strategies. B–L model shows potential and offers interesting research avenues. However, success of tactical asset allocation is still highly dependent on the quality of input estimates.

Building climate justice : an analysis of how the nexus between climate change and human rights shapes public policy agendas and alternatives

This thesis provides an analysis of how the nexus between climate change and human rights shapes public policy agendas and alternatives. It draws upon seminal work conducted by John Kingdon, whose landmark publication “Agendas, alternatives, and public policy” described how separate streams of problems, solutions, and politics converge to move an issue onto the public policy agenda toward potential government action. Building on Kingdon’s framework, this research explores how human rights contribute to surfacing the problem of climate change; developing alternative approaches to tackling climate change; and improving the political environment necessary for addressing climate change with sufficient ambition. The study reveals that climate change undermines the realization of human rights and that human rights can be effective tools in building climate resilience. This analysis was developed using a mixed methods approach and drawing upon substantial literature review, the researcher’s own participation in international climate policy design; elite interviews with thought leaders dealing with climate change and human rights; and regular inputs from focus groups comprised of practitioners drawn from the fields of climate change, development and human rights. This is a journal based thesis with a total of six articles submitted for evaluation, published in peer‐reviewed publications, over a five year period. Denna avhandling analyserar hur klimatfrågan och mänskliga rättigheter i samverkan formar den politiska agendan och det politiskt möjliga. Den bygger på banbrytande forskning av John Kingdon, vars publikation “Agendas, alternatives, and public policy” beskriver hur en fråga blir politiskt viktig och lyfts upp på den politiska agendan. Med utgångspunkt i Kingdons ramverk, utforskar avhandlingen hur mänskliga rättigheter bidrar till att blottlägga klimatfrågan som problem; utveckla alternativa metoder för att angripa och hantera klimatfrågan; samt skapa ett politiskt klimat nödvändigt för att på ett ambitiöst sätt kunna angripa klimatfrågan. Studien visar att klimatförändringar undergräver mänskliga rättigheterna men att arbete med mänskliga rättigheter kan vara ett effektivt verktyg för att stå emot och hantera effekterna av klimatförändringar. Analysen har genomförts med hjälp av en rad olika metoder vilka inkluderar litteraturstudier, författarens egna observationer under klimatförhandlingar; intervjuer med ledande tänkare inom klimatfrågan och mänskliga rättigheter; samt data insamlad genom fokusgrupper bestående av yrkesverksamma inom klimat, utveckling och mänskliga rättigheter. Avhandlingen är baserad på totalt sex artiklar som publicerats i fackgranskade tidskrifter under en femårsperiod.

Assessing the dynamics of terms of trade in a model of cumulative causation and structural change

ABSTRACT The motivation for this paper stems from the steady decline in the share of consumer expenditures on goods produced in the global south, coupled with the (empirically ambiguous) Singer/Prebisch hypothesis that this can be explained by a secular decline in the southern terms of trade. Drawing on these sources of inspiration, the paper sets out to study the dynamics of the terms of trade using a multi-sector growth model based on the principle of cumulative causation. The upshot is a North-South model of growth and trade in which the evolution of the terms of trade depends on differential rates of productivity growth in different sectors of the economy - and in which terms of trade dynamics may not be the best guide as to whether or not there is an uneven development problem.

Viologen based electroactive polymers and composites for durable electrochromic systems

Electrochromism, the phenomenon of reversible color change induced by a small electric charge, forms the basis for operation of several devices including mirrors, displays and smart windows. Although, the history of electrochromism dates back to the 19th century, only the last quarter of the 20th century has its considerable scientific and technological impact. The commercial applications of electrochromics (ECs) are rather limited, besides top selling EC anti-glare mirrors by Gentex Corporation and airplane windows by Boeing, which made a huge commercial success and exposed the potential of EC materials for future glass industry. It is evident from their patents that viologens (salts of 4,4ʹ-bipyridilium) were the major active EC component for most of these marketed devices, signifying the motivation of this thesis focusing on EC viologens. Among the family of electrochromes, viologens have been utilized in electrochromic devices (ECDs) for a while, due to its intensely colored radical cation formation induced by applying a small cathodic potential. Viologens can be synthesized as oligomer or in the polymeric form or as functionality to conjugated polymers. In this thesis, polyviologens (PVs) were synthesized starting from cyanopyridinium (CNP) based monomer precursors. Reductive coupling of cross-connected cyano groups yields viologen and polyviologen under successive electropolymerization using for example the cyclic voltammetry (CV) technique. For further development, a polyviologen-graphene composite system was fabricated, focusing at the stability of the PV electrochrome without sacrificing its excellent EC properties. High electrical conductivity, high surface area offered by graphene sheets together with its non-covalent interactions and synergism with PV significantly improved the electrochrome durability in the composite matrix. The work thereby continued in developing a CNP functionalized thiophene derivative and its copolymer for possible utilization of viologen in the copolymer blend. Furthermore, the viologen functionalized thiophene derivative was synthesized and electropolymerized in order to explore enhancement in the EC contrast and overall EC performance. The findings suggest that such electroactive viologen/polyviologen systems and their nanostructured composite films as well as viologen functionalized conjugated polymers, can be potentially applied as an active EC material in future ECDs aiming at durable device performances.

Promoting Healthy Lifestyles with Personalized, APOE Genotype Based Health Information: The Effects on Psychological-, Health Behavioral and Clinical Factors

There is an increasing demand for individualized, genotype-based health advice. The general population-based dietary recommendations do not always motivate people to change their life-style, and partly following this, cardiovascular diseases (CVD) are a major cause of death in worldwide. Using genotype-based nutrition and health information (e.g. nutrigenetics) in health education is a relatively new approach, although genetic variation is known to cause individual differences in response to dietary factors. Response to changes in dietary fat quality varies, for example, among different APOE genotypes. Research in this field is challenging, because several non-modifiable (genetic, age, sex) and modifiable (e.g. lifestyle, dietary, physical activity) factors together and with interaction affect the risk of life-style related diseases (e.g. CVD). The other challenge is the psychological factors (e.g. anxiety, threat, stress, motivation, attitude), which also have an effect on health behavior. The genotype-based information is always a very sensitive topic, because it can also cause some negative consequences and feelings (e.g. depression, increased anxiety). The aim of this series of studies was firstly to study how individual, genotype-based health information affects an individual’s health form three aspects, and secondly whether this could be one method in the future to prevent lifestyle-related diseases, such as CVD. The first study concentrated on the psychological effects; the focus of the second study was on health behavior effects, and the third study concentrated on clinical effects. In the fourth study of this series, the focus was on all these three aspects and their associations with each other. The genetic risk and health information was the APOE gene and its effects on CVD. To study the effect of APOE genotype-based health information in prevention of CVD, a total of 151 volunteers attended the baseline assessments (T0), of which 122 healthy adults (aged 20 – 67 y) passed the inclusion criteria and started the one-year intervention. The participants (n = 122) were randomized into a control group (n = 61) and an intervention group (n = 61). There were 21 participants in the intervention Ɛ4+ group (including APOE genotypes 3/4 and 4/4) and 40 participants in the intervention Ɛ4- group (including APOE genotypes 2/3 and 3/3). The control group included 61 participants (including APOE genotypes 3/4, 4/4, 2/3, 3/3 and 2/2). The baseline (T0) and follow-up assessments (T1, T2, T3) included detailed measurements of psychological (threat and anxiety experience, stage of change), and behavioral (dietary fat quality, consumption of vegetables, - high fat/sugar foods and –alcohol, physical activity and health and taste attitudes) and clinical factors (total-, LDL- HDL cholesterol, triglycerides, blood pressure, blood glucose (0h and 2h), body mass index, waist circumference and body fat percentage). During the intervention six different communication sessions (lectures on healthy lifestyle and nutrigenomics, health messages by mail, and personal discussion with the doctor) were arranged. The intervention groups (Ɛ4+ and Ɛ4-) received their APOE genotype information and health message at the beginning of the intervention. The control group received their APOE genotype information after the intervention. For the analyses in this dissertation, the results for 106/107 participants were analyzed. In the intervention, there were 16 participants in the high-risk (Ɛ4+) group and 35 in the low-risk (Ɛ4-) group. The control group had 55 participants in studies III-IV and 56 participants in studies I-II. The intervention had both short-term (≤ 6 months) and long-term (12 months) effects on health behavior and clinical factors. The short-term effects were found in dietary fat quality and waist circumference. Dietary fat quality improved more in the Ɛ4+ group than the Ɛ4- and the control groups as the personal, genotype-based health information and waist circumference lowered more in the Ɛ4+ group compared with the control group. Both these changes differed significantly between the Ɛ4+ and control groups (p<0.05). A long-term effect was found in triglyceride values (p<0.05), which lowered more in Ɛ4+ compared with the control group during the intervention. Short-term effects were also found in the threat experience, which increased mostly in the Ɛ4+ group after the genetic feedback (p<0.05), but it decreased after 12 months, although remaining at a higher level compared to the baseline (T0). In addition, Study IV found that changes in the psychological factors (anxiety and threat experience, motivation), health and taste attitudes, and health behaviors (dietary, alcohol consumption, and physical activity) did not directly explain the changes in triglyceride values and waist circumference. However, change caused by a threat experience may have affected the change in triglycerides through total- and HDL cholesterol. In conclusion, this dissertation study has given some indications that individual, genotypebased health information could be one potential option in the future to prevent lifestyle-related diseases in public health care. The results of this study imply that personal genetic information, based on APOE, may have positive effects on dietary fat quality and some cardiovascular risk markers (e.g., improvement in triglyceride values and waist circumference). This study also suggests that psychological factors (e.g. anxiety and threat experience) may not be an obstacle for healthy people to use genotype-based health information to promote healthy lifestyles. However, even in the case of very personal health information, in order to achieve a permanent health behavior change, it is important to include attitudes and other psychological factors (e.g. motivation), as well as intensive repetition and a longer intervention duration. This research will serve as a basis for future studies and its information can be used to develop targeted interventions, including health information based on genotyping that would aim at preventing lifestyle diseases. People’s interest in personalized health advices has increased, while also the costs of genetic screening have decreased. Therefore, generally speaking, it can be assumed that genetic screening as a part of the prevention of lifestyle-related diseases may become more common in the future. In consequence, more research is required about how to make genetic screening a practical tool in public health care, and how to efficiently achieve long-term changes.

Internal communication during an organizational change: An ethnographic case study

This study discusses the importance of internal communication during organizational change of a case study company X. The purpose of this study is to find out how to use internal communication effectively during organizational change. This study is an ethnographic cade study where a unique case of an organizational change was chosen as the research object. The theoretical background of this study consists of literature relating to the concepts of communication, organizational communication, organizational change, change management and communication of change. The empirical research conducted for this study is based on an ethnographic research method where data was collected through participant observation, informal interviews and field records in the form of a research diary. The research data was collected between September and December 2015. During this period the researcher was working within the case study organization while observing the internal communication during the organizational change process. Triangulation was used to analyze the research data in order to build a united and theoretical picture of the topic. The study finds that without clear internal communication strategy the effectiveness of communication is ought to be poor, which may lead to resistance of change, lack of trust and lower level of overall job satisfaction. Moreover the study findings highlight the importance of managerial presence during an organizational change process and consistency in using formal and informal communication and utilizing multiple communication channels. Based on the findings of this research the study suggests that during an organizational change process a clear internal communication strategy should be carefully planned and executed. The goals of internal communication should be clearly stated and communicated to the company’s employees. The findings of this study enhance importance of managers promoting sense of belonging, developing awareness of the overall change process and contributing to the manager employee relationships and trust. In addition this study points out the key factors that should be included in the internal change communication strategy which are how to ensure that the communications, both vertical and horizontal, are constant. Future research is however necessary in order to gain a more comprehensive view of the research and wider perspective of the case study. Nevertheless, this study deepens the understanding of how to use internal communication effectively during organizational change.

Pollen and grain size records in abyssal sediments of the northwest Pacific Ocean as proxies of Plio-Pleistocene climate change /

A distinctive period of global change occurred during the PUocene between the warm Miocene and subsequent Quaternary cooling. Samples from Ocean Drilling Project Site 11 79 (-5586 mbsl, 41°4'N, 159°57'E), Site 881 (-5765 mbsl, 47°6.133'N, 161°29.490'E) and Site 882 (-3255 mbsl, 50°22'N, 167°36'E) were studied to determine the magnitude and composition ofterrigenous flux to the western mid-latitude North Pacific and its relation to climate change in East Asia since the mid-Pliocene. Dust-sized particles (including pollen), sourced from the arid regions and loess plateaus in East Asia are entrained by prevailing westerly winds and transported to the midlatitude northwest North Pacific Ocean. This is recorded by peaks in the total concentration of pollen and spores, as well as the mean grain size of allochthonous and autochthonous silicate material in abyssal marine sediments. Aridification of the Asian interior due to the phased uplift of the Himalayan-Tibetan Plateau created the modem East Asian Monsoon system dominated by a strengthening of the winter monsoon. The winter monsoon is further enhanced during glacials due to the expansion of desert and steppe environments at the expense ofwoodlands and forests recorded by the composition of palynological assemblages. The late Pliocene-Pleistocene glacials at ODP Sites 1 179, 881, and 882 are characterized by increases in grain size, magnetic susceptibility, pollen and spore concentrations around 3.5-3.3, 2.6-2.4, 1.7-1.6, and 0.9-0.7 Ma (ages based on magnetostratigraphic and biostratigraphic datums). The peaks during these times are relatively rich in pollen taxa derived primarily from steppe and boreal vegetation zones, recording cool, dry climates. The overall size increase of sediment and abundance of terrestrial palynomorphs record enhanced wind strength. The increase in magnitude of pollen and spore concentrations as well as grain size record global cooling and Northern Hemisphere glaciation. The peaks in grain size as well as pollen and spore abundance in marine sediments correlate with the mean grain size of loess in East Asia, consistent with the deflation of unarmoured surfaces during glacials. The transport of limiting nutrients to marine environments enhanced sea surface productivity and increased the rate of sediment accumulation.

Assessing evaluative measures for Internet-based courseware

Although there is a consensus in th~ literature on the many uses of the Internet in education, as well as the unique features of the Internet for presenting facts and information, there is no consensus on a standardized method for evaluating Internetbased courseware. Educators rarely have the opportunity to participate in the development of Internet-based courseware, yet they are encouraged to use the technology in their learning environments. This creates a need for summative evaluation methods for Internet-based health courseware. The purpose ofthis study was to assess evaluative measures for Internet-based courseware. Specifically, two entities were evaluated within the study: a) the outcome of the Internet-based courseware, and b) the Internet-based courseware itself. To this end, the Web site www.bodymatters.com was evaluated using two different approaches by two different cohorts. The first approach was a performance appraisal by a group of endusers. A positive, statistically significant change in the students performance was observed due to the intervention ofthe Web site. The second approach was a productoriented evaluation ofthe Web site with the use of a criterion-based checklist and an open-ended comments section. The findings indicate that a summative, criterion-based evaluation is best completed by a multidisciplinary team. The findi~gs also indicated that the two different cohorts reported different product-oriented appraisals of the Web site. The current research confirmed previous research that found that experts returning a poor evaluation of a Web site did not have a relationship to whether or not the end-users performance improved due to the intervention of the Web site.

Exploring the effects of change on nursing practice in acute ambulatory care settings : a qualitative study

As a result of the current changes taking place in the delivery of acute care services, the emergence of acute ambulatory care (AAC) settings is expanding. According to a literature review, the volume, acuity, and complexity of patient care in these settings is increasing while the time the patients spend under the care of nurses is decreasing. Two forces, hospital downsizing and advancing technology, are identified as the major contributors to the shift in acute care delivery. The effects that these changes are having on the clinical nursing practice of registered nurses working in AAC settings are not known. Given that AAC settings are rapidly expanding, it can be anticipated that the delivery of nursing care will continue to be compressed into a shorter time frame. Therefore, the following qualitative research question was formulated: What are the problems and issues related to clinical nursing practice in acute ambulatory settings? The purpose of this study was to explore the problems and issues associated with change and clinical nursing practice including the educational needs of nurses working in MC settings. Specific objectives of the study included the following: (a) to explore the problems and issues related to nursing practice in select AAC settings; (b) to explore the similarities and differences in perspectives related to role expectation between nurse managers, nurse educators, and staff nurses; and (c) to develop a conceptual framework that will guide the construction of an instrument needed for further research. This study used semistructured individual interviews and focus group sessions to collect data from the three categories of registered nurses. More specifically, data were collected from one nurse manager, two charge nurses, two nurse educators and fifteen staff nurses, working in three different MC settings of a major teaching hospital. Collected data were separately analyzed by the researcher and an external rater following grounded theory methodology. By using open and axial coding, the problems and issues identified by nurses were grouped into several major and minor themes. In final analysis, by using selective coding, the four core themes (intensification, moderation, frustration, and adaptation) were extracted. Each core theme was presented and discussed in relation to hospital downsizing and advancing technology. The relationships among the four core themes were discussed and depicted in a model termed the "Impact and Consequence Model on Nursing Practice in MC Settings." Implications for further research are discussed and research hypotheses, based on the research findings, are presented.