Trinity Health

A worldwide compilation of atmospheric total phosphorus (TP) and phosphate (PO 4 ) concentration and deposition flux observations are combined with transport model simulations to derive the global distribution of concentrations and deposition fluxes of TP and PO 4 . Our results suggest that mineral aerosols are the dominant source of TP on a global scale (82%), with primary biogenic particles (12%) and combustion sources (5%) important in nondusty regions. Globally averaged anthropogenic inputs are estimated to be ∼5 and 15% for TP and PO 4 , respectively, and may contribute as much as 50% to the deposition over the oligotrophic ocean where productivity may be phosphorus‐limited. There is a net loss of TP from many (but not all) land ecosystems and a net gain of TP by the oceans (560 Gg P a −1 ). More measurements of atmospheric TP and PO 4 will assist in reducing uncertainties in our understanding of the role that atmospheric phosphorus may play in global biogeochemistry.

AIM: This paper is a report of the analysis of the concept of missed nursing care. BACKGROUND: According to patient safety literature, missed nursing care is an error of omission. This concept has been conspicuously absent in quality and patient safety literature, with individual aspects of nursing care left undone given only occasional mention. METHOD: An 8-step method of concept analysis - select concept, determine purpose, identify uses, define attributes, identify model case, describe related and contrary cases, identify antecedents and consequences and define empirical referents - was used to examine the concept of missed nursing care. The sources for the analysis were identified by systematic searches of the World Wide Web, MEDLINE, CINAHL and reference lists of related journal articles with a timeline of 1970 to April 2008. FINDINGS: Missed nursing care, conceptualized within the Missed Nursing Care Model, is defined as any aspect of required patient care that is omitted (either in part or in whole) or delayed. Various attribute categories reported by nurses in acute care settings contribute to missed nursing care: (1) antecedents that catalyse the need for a decision about priorities; (2) elements of the nursing process and (3) internal perceptions and values of the nurse. Multiple elements in the nursing environment and internal to nurses influence whether needed nursing care is provided. CONCLUSION: Missed care as conceptualized within the Missed Care Model is a universal phenomenon. The concept is expected to occur across all cultures and countries, thus being international in scope.

BACKGROUND: Standard first-line chemotherapy for endometrial cancer is paclitaxel plus carboplatin. The benefit of adding pembrolizumab to chemotherapy remains unclear. METHODS: In this double-blind, placebo-controlled, randomized, phase 3 trial, we assigned 816 patients with measurable disease (stage III or IVA) or stage IVB or recurrent endometrial cancer in a 1:1 ratio to receive pembrolizumab or placebo along with combination therapy with paclitaxel plus carboplatin. The administration of pembrolizumab or placebo was planned in 6 cycles every 3 weeks, followed by up to 14 maintenance cycles every 6 weeks. The patients were stratified into two cohorts according to whether they had mismatch repair-deficient (dMMR) or mismatch repair-proficient (pMMR) disease. Previous adjuvant chemotherapy was permitted if the treatment-free interval was at least 12 months. The primary outcome was progression-free survival in the two cohorts. Interim analyses were scheduled to be triggered after the occurrence of at least 84 events of death or progression in the dMMR cohort and at least 196 events in the pMMR cohort. RESULTS: In the 12-month analysis, Kaplan-Meier estimates of progression-free survival in the dMMR cohort were 74% in the pembrolizumab group and 38% in the placebo group (hazard ratio for progression or death, 0.30; 95% confidence interval [CI], 0.19 to 0.48; P<0.001), a 70% difference in relative risk. In the pMMR cohort, median progression-free survival was 13.1 months with pembrolizumab and 8.7 months with placebo (hazard ratio, 0.54; 95% CI, 0.41 to 0.71; P<0.001). Adverse events were as expected for pembrolizumab and combination chemotherapy. CONCLUSIONS: In patients with advanced or recurrent endometrial cancer, the addition of pembrolizumab to standard chemotherapy resulted in significantly longer progression-free survival than with chemotherapy alone. (Funded by the National Cancer Institute and others; NRG-GY018 ClinicalTrials.gov number, NCT03914612.).

BACKGROUND: Improved inferior vena cava (IVC) filters have led to liberalization of the indications for insertion. Increased use, however, has been followed with a potential for unwarranted insertion. There are only sparse data on trends in the use of IVC filters in patients with pulmonary embolism (PE), patients with deep venous thrombosis (DVT) alone, and patients at high risk. We analyzed the National Hospital Discharge Survey (NHDS) database for such trends. METHODS: We used data from the NHDS, which is based on a national probability sample of discharges from short-stay nonfederal hospitals in 50 states and the District of Columbia. The numbers of sampled patients with DVT, PE, and IVC filters were determined from the International Classification of Diseases, Ninth Revision, Clinical Modification codes at discharge. RESULTS: The number of patients who had IVC filters increased from 2000 in 1979 to 49 000 in 1999. In 1999, 45% of IVC filter insertions were in patients with DVT alone, 36% were in patients with PE, and 19% were in patients who presumably were at high risk but did not have DVT or PE listed as a discharge code. The use of IVC filters was more frequent in northeastern states than in western states (P =.01). CONCLUSIONS: The use of IVC filters increased markedly during the last 2 decades in patients with PE, patients with DVT alone, and patients at risk who had neither PE nor DVT. Randomized controlled trials may lead to improved risk stratification and limit the number of unnecessary filter insertions.

BACKGROUND: With the aging of the US population, there is concern that the rate of venous thromboembolism will increase, thereby increasing the health burden. In this study we sought to determine trends in the diagnosis of deep venous thrombosis (DVT) and pulmonary embolism (PE) in the elderly as well as the use of diagnostic tests. METHODS: Data from the National Hospital Discharge Survey were used. These data are abstracted each year from a sample of records of patients discharged from non-federal short-stay hospitals in the entire United States. Main outcome measures were trends in rates of diagnosis of DVT and PE as well as trends in the use of diagnostic tests between 1979 and 1999. RESULTS: The rates of diagnosis of DVT and PE and of the use of diagnostic tests over 21 years were markedly higher in elderly than in younger patients (P<.001). Although the rate of diagnosed DVT in elderly patients strikingly increased over the past decade (P< .001), that of PE has been relatively constant. There was a proportionately greater use of venous ultrasonography, ventilation-perfusion lung scanning, and pulmonary angiography in elderly than in younger patients. CONCLUSIONS: Extensive use of diagnostic tests in elderly patients in the past decade has resulted in an increased diagnostic rate for DVT but not PE. The reason for this disparity is uncertain but may reflect early diagnosis and treatment of DVT. With the aging of the population, DVT will increase the health burden.

Decision aids are evidence-based sources of health information that can help patients make informed treatment decisions. However, little is known about how decision aids affect health care use when they are implemented outside of randomized controlled clinical trials. We conducted an observational study to examine the associations between introducing decision aids for hip and knee osteoarthritis and rates of joint replacement surgery and costs in a large health system in Washington State. Consistent with prior randomized trials, our introduction of decision aids was associated with 26 percent fewer hip replacement surgeries, 38 percent fewer knee replacements, and 12-21 percent lower costs over six months. These findings support the concept that patient decision aids for some health conditions, for which treatment decisions are highly sensitive to both patients' and physicians' preferences, may reduce rates of elective surgery and lower costs.

OBJECTIVE: To conduct a systematic review and meta-analysis of randomised controlled trials (RCTs) of the effectiveness and safety of oral pre-exposure prophylaxis (PrEP) to prevent HIV. METHODS: Databases (PubMed, Embase and the Cochrane Register of Controlled Trials) were searched up to 5 July 2020. Search terms for 'HIV' were combined with terms for 'PrEP' or 'tenofovir/emtricitabine'. RCTs were included that compared oral tenofovir-containing PrEP to placebo, no treatment or alternative medication/dosing schedule. The primary outcome was the rate ratio (RR) of HIV infection using a modified intention-to-treat analysis. Secondary outcomes included safety, adherence and risk compensation. All analyses were stratified a priori by population: men who have sex with men (MSM), serodiscordant couples, heterosexuals and people who inject drugs (PWIDs). The quality of individual studies was assessed using the Cochrane risk-of-bias tool, and the certainty of evidence was assessed using GRADE. RESULTS: Of 2803 unique records, 15 RCTs met our inclusion criteria. Over 25 000 participants were included, encompassing 38 289 person-years of follow-up data. PrEP was found to be effective in MSM (RR 0.25, 95% CI 0.1 to 0.61; absolute rate difference (RD) -0.03, 95% CI -0.01 to -0.05), serodiscordant couples (RR 0.25, 95% CI 0.14 to 0.46; RD -0.01, 95% CI -0.01 to -0.02) and PWID (RR 0.51, 95% CI 0.29 to 0.92; RD -0.00, 95% CI -0.00 to -0.01), but not in heterosexuals (RR 0.77, 95% CI 0.46 to 1.29). Efficacy was strongly associated with adherence (p<0.01). PrEP was found to be safe, but unrecognised HIV at enrolment increased the risk of viral drug resistance mutations. Evidence for behaviour change or an increase in sexually transmitted infections was not found. CONCLUSIONS: PrEP is safe and effective in MSM, serodiscordant couples and PWIDs. Additional research is needed prior to recommending PrEP in heterosexuals. No RCTs reported effectiveness or safety data for other high-risk groups, such as transgender women and sex workers. PROSPERO REGISTRATION NUMBER: CRD42017065937.

Medication errors and adverse events caused by them are common during and after a hospitalization. The impact of these events on patient welfare and the financial burden, both to the patient and the healthcare system, are significant. In 2005, The Joint Commission put forth medication reconciliation as National Patient Safety Goal (NPSG) No. 8 in an effort to minimize adverse events caused during these types of care transitions. However, the meaningful and systematic implementation of medication reconciliation, as expressed through NPSG No. 8, proved to be extraordinarily difficult for healthcare institutions around the country. Given the importance of accurate and complete medication reconciliation for patient safety occurring across the continuum of care, the Society of Hospital Medicine convened a stakeholder conference in 2009 to begin to identify and address: (1) barriers to implementation; (2) opportunities to identify best practices surrounding medication reconciliation; (3) the role of partnerships among traditional healthcare sites and nonclinical and other community-based organizations; and (4) metrics for measuring the processes involved in medication reconciliation and their impact on preventing harm to patients. The focus of the conference was oriented toward medication reconciliation for a hospitalized patient population; however, many of the themes and concepts derived would also apply to other care settings. This paper highlights the key domains needing to be addressed and suggests first steps toward doing so. An overarching principle derived at the conference is that medication reconciliation should not be viewed as an accreditation function. It must, first and foremost, be recognized as an important element of patient safety. From this principle, the participants identified ten key areas requiring further attention in order to move medication reconciliation toward this focus. 1 There is need for a uniformly acceptable and accepted definition of what constitutes a medication and what processes are encompassed by reconciliation. Clarifying these terms is critical to ensuring more uniform impact of medication reconciliation. 2 The varying roles of the multidisciplinary participants in the reconciliation process must be clearly defined. These role definitions should include those of the patient and family/caregiver and must occur locally, taking into account the need for flexibility in design given the varying structures and resources at healthcare sites. 3 Measures of the reconciliation processes must be clinically meaningful (i.e., of defined benefit to the patient) and derived through consultation with stakeholder groups. Those measures to be reported for national benchmarking and accreditation should be limited in number and clinically meaningful. 4 While a comprehensive reconciliation system is needed across the continuum of care, a phased approach to implementation, allowing it to start slowly and be tailored to local organizational structures and work flows, will increase the chances of successful organizational uptake. 5 Developing mechanisms for prospectively and proactively identifying patients at risk for medication-related adverse events and failed reconciliation is needed. Such an alert system would help maintain vigilance toward these patient safety issues and help focus additional resources on high risk patients. 6 Given the diversity in medication reconciliation practices, research aimed at identifying effective processes is important and should be funded with national resources. Funding should include varying sites of care (e.g., urban and rural, academic and nonacademic, etc.). 7 Strategies for medication reconciliation-both successes and key lessons learned from unsuccessful efforts-should be widely disseminated. 8 A personal health record that is integrated and easily transferable between sites of care is needed to facilitate successful medication reconciliation. 9 Partnerships between healthcare organizations and community-based organizations create opportunities to reinforce medication safety principles outside the traditional clinician-patient relationship. Leveraging the influence of these organizations and other social networking platforms may augment population-based understanding of their importance and role in medication safety. 10 Aligning healthcare payment structures with medication safety goals is critical to ensure allocation of adequate resources to design and implement effective medication reconciliation processes. Medication reconciliation is complex and made more complicated by the disjointed nature of the American healthcare system. Addressing these ten points with an overarching goal of focusing on patient safety rather than accreditation should result in improvements in medication reconciliation and the health of patients.

BACKGROUND: Discharge from the hospital is a critical transition point in a patient's care. Incomplete handoffs at discharge can lead to adverse events for patients and result in avoidable rehospitalization. Care transitions are especially important for elderly patients and other high-risk patients who have multiple comorbidities. Standardizing the elements of the discharge process may help to address the gaps in quality and safety that occur when patients transition from the hospital to an outpatient setting. METHODS: The Society of Hospital Medicine's Hospital Quality and Patient Safety committee assembled a panel of care transition researchers, process improvement experts, and hospitalists to review the literature and develop a checklist of processes and elements required for ideal discharge of adult patients. The discharge checklist was presented at the Society of Hospital Medicine's Annual Meeting in April 2005, where it was reviewed and revised by more than 120 practicing hospitalists and hospital-based nurses, case managers, and pharmacists. The final checklist was endorsed by the Society of Hospital Medicine. RESULTS: The finalized checklist is a comprehensive list of the processes and elements considered necessary for optimal patient handoff at hospital discharge. This checklist focused on medication safety, patient education, and follow-up plans. CONCLUSIONS: The development of content and process standards for discharge is the first step in improving the handoff of care from the inpatient to the posthospital setting. Refining this checklist for patients with specific diagnoses, in specific age categories, and with specific discharge destinations may further improve information transfer and ultimately affect patient outcomes.

BACKGROUND: Health care is changing with a new emphasis on patient-centeredness. Fundamental to this transformation is the increasing recognition of patients' role in health care delivery and design. Medical appointment scheduling, as the starting point of most non-urgent health care services, is undergoing major developments to support active involvement of patients. By using the Internet as a medium, patients are given more freedom in decision making about their preferences for the appointments and have improved access. OBJECTIVE: The purpose of this study was to identify the benefits and barriers to implement Web-based medical scheduling discussed in the literature as well as the unmet needs under the current health care environment. METHODS: In February 2017, MEDLINE was searched through PubMed to identify articles relating to the impacts of Web-based appointment scheduling. RESULTS: A total of 36 articles discussing 21 Web-based appointment systems were selected for this review. Most of the practices have positive changes in some metrics after adopting Web-based scheduling, such as reduced no-show rate, decreased staff labor, decreased waiting time, and improved satisfaction, and so on. Cost, flexibility, safety, and integrity are major reasons discouraging providers from switching to Web-based scheduling. Patients' reluctance to adopt Web-based appointment scheduling is mainly influenced by their past experiences using computers and the Internet as well as their communication preferences. CONCLUSIONS: Overall, the literature suggests a growing trend for the adoption of Web-based appointment systems. The findings of this review suggest that there are benefits to a variety of patient outcomes from Web-based scheduling interventions with the need for further studies.

OBJECTIVES: Although most pancreatic neoplasms are adenocarcinoma, there are many other histological types, some of which may be increasing in frequency. To better define these trends, we reviewed 16 years of data from a statewide tumor registry. METHODS: Using the State of Michigan tumor registry, all patients with primary pancreatic cancers from 1986 to 2002 were identified, and patients were excluded if there were insufficient data or the histological subtype was not clearly defined in the literature. RESULTS: There were 17,610 pancreatic neoplasms identified, and 2425 were excluded, leaving a final population of 15,185. Twenty-five types of primary pancreatic neoplasms were identified. The most common were adenocarcinoma, mucinous cystadenocarcinoma, nonfunctional neuroendocrine, adenosquamous, anaplastic, intraductal papillary mucinous, and acinar cell (8.37, 0.43, 0.18, 0.05, 0.04, 0.04, and 0.02 per 100,000 per year, respectively). The mean age at presentation was similar for tumor types, 69.2 years old, with the exception of endocrine neoplasms occurring at a younger age, 58.5 years old (P < 0.0005). There was a significant change in the incidence of nonfunctional neuroendocrine neoplasms, greater than 2-fold increase (P = 0.0003). CONCLUSIONS: The incidence of most pancreatic neoplasms has changed a little; however, nonfunctional neuroendocrine neoplasms increased greater than 2-fold. The etiology of this change is unclear.

An overwhelming body of evidence points to an inextricable link between race and health disparities in the United States. Although race is best understood as a social construct, its role in health outcomes has historically been attributed to increasingly debunked theories of underlying biological and genetic differences across races. Recently, growing calls for health equity and social justice have raised awareness of the impact of implicit bias and structural racism on social determinants of health, healthcare quality, and ultimately, health outcomes. This more nuanced recognition of the role of race in health disparities has, in turn, facilitated introspective racial disparities research, root cause analyses, and changes in practice within the medical community. Examining the complex interplay between race, social determinants of health, and health outcomes allows systems of health to create mechanisms for checks and balances that mitigate unfair and avoidable health inequalities. As one of the specialties most intertwined with social medicine, emergency medicine (EM) is ideally positioned to address racism in medicine, develop health equity metrics, monitor disparities in clinical performance data, identify research gaps, implement processes and policies to eliminate racial health inequities, and promote anti-racist ideals as advocates for structural change. In this critical review our aim was to (a) provide a synopsis of racial disparities across a broad scope of clinical pathology interests addressed in emergency departments-communicable diseases, non-communicable conditions, and injuries-and (b) through a race-conscious analysis, develop EM practice recommendations for advancing a culture of equity with the potential for measurable impact on healthcare quality and health outcomes.

Abstract The purpose of this document is to highlight practical recommendations to assist acute-care hospitals in prioritization and implementation of strategies to prevent healthcare-associated infections through hand hygiene. This document updates the Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals through Hand Hygiene , published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the Association for Professionals in Infection Control and Epidemiology, the American Hospital Association, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Atmospheric processing of mineral aerosol by anthropogenic pollutants may be an important process by which insoluble iron can be transformed into soluble forms and become available to oceanic biota. Observations of the soluble iron fraction in atmospheric aerosol exhibit large variability, which is poorly represented in models. In this study, we implemented a dust iron dissolution scheme in a global chemistry transport model (GEOS‐Chem). The model is applied over the North Pacific Ocean during April 2001, a period when concentrations of dust and pollution within the east Asia outflow were high. Simulated fields of many key chemical constituents compare reasonably well with available observations, although some discrepancies are identified and discussed. In our simulations, the production of soluble iron varies temporally and regionally depending on pollution‐to‐dust ratio, primarily due to strong buffering by calcite. Overall, we show that the chemical processing mechanism produces significant amounts of dissolved iron reaching and being deposited in remote regions of the Pacific basin, with some seasonal variability. Simulated enhancements in particulate soluble iron fraction range from 0.5% to 6%, which is consistent with the observations. According to our simulations, ∼30% to 70% of particulate soluble iron over the North Pacific Ocean basin can be attributed to atmospheric processing. On the basis of April 2001 monthly simulations, sensitivity tests suggest that doubling SO 2 emissions can induce a significant increase (13% on average, up to 40% during specific events) in dissolved iron production and deposition to the remote Pacific. We roughly estimate that half of the primary productivity induced by iron deposition in a north Pacific high‐nutrient low‐chlorophyll region is due to soluble iron derived from anthropogenic chemical processing of Asian aerosol.

Hepatocellular carcinoma (HCC) is refractory to chemotherapies, necessitating novel effective agents. The lysosome inhibitor Bafilomycin A1 (BafA1) at high concentrations displays cytotoxicity in a variety of cancers. Here we show that BafA1 at nanomolar concentrations suppresses HCC cell growth in both 2 dimensional (2D) and 3D cultures. BafA1 induced cell cycle arrest in the G1 phase and triggered Cyclin D1 turnover in HCC cells in a dual-specificity tyrosine phosphorylation-regulated kinase 1B (DYRK1B) dependent manner. Notably, BafA1 induced caspase-independent cell death in HCC cells by impairing autophagy flux as demonstrated by elevated LC3 conversion and p62/SQSTM1 levels. Moreover, genetic ablation of LC3 significantly attenuated BafA1-induced cytotoxicity of HCC cells. We further demonstrate that pharmacological down-regulation or genetic depletion of p38 MAPK decreased BafA1-induced cell death via abolishment of BafA1-induced upregulation of Puma. Notably, knockdown of Puma impaired BafA1-induced HCC cell death, and overexpression of Puma enhanced BafA1-mediated HCC cell death, suggesting a role for Puma in BafA1-mediated cytotoxicity. Interestingly, pharmacological inhibition of JNK with SP600125 enhanced BafA1-mediated cytotoxicity both in vitro and in xenografts derived from HCC cells. Taken together, our data suggest that BafA1 may offer potential as an effective therapy for HCC.

Acute renal failure (ARF) is rarely an isolated process but is often a complication of underlying conditions such as sepsis, trauma, and multiple-organ failure in critically ill patients. As such, concomitant clinical conditions significantly affect patient outcome. Poor nutritional status is a major factor in increasing patients' morbidity and mortality. Malnutrition in ARF patients is caused by hypercatabolism and hypermetabolism that parallel the severity of illness. When dialytic intervention is indicated, continuous renal replacement therapy (CRRT) is a commonly used alternative to intermittent hemodialysis because it is well tolerated by hemodynamically unstable patients. This paper reviews the metabolic and nutritional alterations associated with ARF and provides recommendations regarding the nutritional, fluid, electrolyte, micronutrient, and acid-base management of these patients. The basic principles of CRRT are addressed, along with their nutritional implications in critically ill patients. A patient case is presented to illustrate the clinical application of topics covered within the paper.

Importance: Catheter-associated urinary tract infection (UTI) in nursing home residents is a common cause of sepsis, hospital admission, and antimicrobial use leading to colonization with multidrug-resistant organisms. Objective: To develop, implement, and evaluate an intervention to reduce catheter-associated UTI. Design, Setting, and Participants: A large-scale prospective implementation project was conducted in community-based nursing homes participating in the Agency for Healthcare Research and Quality Safety Program for Long-Term Care. Nursing homes across 48 states, Washington DC, and Puerto Rico participated. Implementation of the project was conducted between March 1, 2014, and August 31, 2016. Interventions: The project was implemented over 12-month cohorts and included a technical bundle: catheter removal, aseptic insertion, using regular assessments, training for catheter care, and incontinence care planning, as well as a socioadaptive bundle emphasizing leadership, resident and family engagement, and effective communication. Main Outcomes and Measures: Urinary catheter use and catheter-associated UTI rates using National Healthcare Safety Network definitions were collected. Facility-level urine culture order rates were also obtained. Random-effects negative binomial regression models were used to examine changes in catheter-associated UTI, catheter utilization, and urine cultures and adjusted for covariates including ownership, bed size, provision of subacute care, 5-star rating, presence of an infection control committee, and an infection preventionist. Results: In 4 cohorts over 30 months, 568 community-based nursing homes were recruited; 404 met inclusion criteria for analysis. The unadjusted catheter-associated UTI rates decreased from 6.78 to 2.63 infections per 1000 catheter-days. With use of the regression model and adjustment for facility characteristics, the rates decreased from 6.42 to 3.33 (incidence rate ratio [IRR], 0.46; 95% CI, 0.36-0.58; P < .001). Catheter utilization was 4.5% at baseline and 4.9% at the end of the project. Catheter utilization remained unchanged (4.50 at baseline, 4.45 at conclusion of project; IRR, 0.95; 95% CI, 0.88-1.03; P = .26) in adjusted analyses. The number of urine cultures ordered for all residents decreased from 3.49 per 1000 resident-days to 3.08 per 1000 resident-days. Similarly, after adjustment, the rates were shown to decrease from 3.52 to 3.09 (IRR, 0.85; 95% CI, 0.77-0.94; P = .001). Conclusions and Relevance: In a large-scale, national implementation project involving community-based nursing homes, combined technical and socioadaptive catheter-associated UTI prevention interventions successfully reduced the incidence of catheter-associated UTIs.

The present study evaluated a technique for teaching self-control and increasing desirable behaviors among adults with developmental disabilities. Results showed that when participants were initially given the choice between an immediate smaller reinforcer and a larger delayed reinforcer, all participants repeatedly chose the smaller reinforcer. Concurrent fixed-duration/progressive-duration reinforcement schedules then were introduced in which initially both the smaller and larger reinforcers were available immediately. Thereafter, progressively increasing delays were introduced for the schedule associated with the larger reinforcer only. When initial short-duration requirements for access to the larger reinforcer were gradually increased, participants repeatedly selected the larger reinforcer, thereby demonstrating increased self-control.

ABSTRACT This paper examines the impact of the money supply and inflation rate announcements on interest rates. Survey data on expectations of the money supply and consumer and producer price indexes are used to distinguish anticipated and unanticipated components of the announcements. This distinction is used to test for the efficiency of the financial market response to the announcements of new information. The results indicate that the unanticipated components of the announced changes in the Producers Price Index and in the money supply have an immediate positive effect on short‐term interest rates. The Consumer Price Index announcement has no apparent effect. There is no evidence of a delayed announcement effect. However, there is some indication of a liquidity effect of the money supply change on interest rates. This takes place when reserves are changing and several weeks prior to the information announcement.

AIM: This study aimed to understand the interaction between interpersonal respect, diversity climate, mission fulfilment and engagement to better predict turnover in health care. BACKGROUND: Registered nurse turnover has averaged 14% and current nursing shortages are expected to spread. Few studies have studied employee engagement as a mediator between organisational context and turnover. METHOD: Study participants were employees working within 185 departments across ten hospitals within a large healthcare organisation in the USA. Although a total of 5443 employees work in these departments, employee opinion survey responses were aggregated by department before being linked to turnover rates gathered from company records. RESULT: Engagement fully mediated the relationship between respect and turnover and the relationship between mission fulfilment and turnover. Diversity climate was not related to turnover. CONCLUSION: Turnover in health care poses a significant threat to the mission of creating a healing environment for patients and these results demonstrate that workplace respect and connection to the mission affect turnover by decreasing engagement. IMPLICATIONS FOR NURSING MANAGEMENT: The findings demonstrated that to increase engagement, and improve turnover rates in health care, it would be beneficial for organisations, and nurse management to focus on improving mission fulfilment and interpersonal relationships.