The expression of many gene products required during the early stages of Bacillus subtilis sporulation is regulated by sinIR operon proteins. Transcription of sinIR from the P1 promoter is induced at the end of exponential growth. In vivo transcription studies suggest that P1 induction is repressed by the transition-state regulatory protein Hpr and is induced by the phosphorylated form of Spo0A. In vitro DNase I footprinting studies confirmed that Hpr, AbrB, and Spo0A are trans-acting transcriptional factors that bind to the P1 promoter region of sinIR. We have also determined that the P1 promoter is transcribed in vitro by the major vegetative sigma factor, ςA, form of RNA polymerase.
Natural environments are oligotrophic (35). Organisms such as the common soil bacterium Bacillus subtilis frequently exist in slow- or nongrowing physiological states. The rich diversity of B. subtilis transition-state regulatory systems (50, 55, 56) confirms the biological importance of managing the transition from rapid- to slow- to nongrowing cell states. Depending on the environmental cues present, B. subtilis transition-state regulation can channel a cell toward motility, nutrient scavenging through the production of extracellular enzymes, competence, or sporulation cell fates (for a review, see references 12 and 53). The best-characterized B. subtilis transition-state regulators are the AbrB, Hpr, Spo0A, and SinR DNA-binding proteins.
Recent structural studies have shown that the AbrB protein is a tetramer of 10,500-Da subunits that interacts with a variety of specific nucleotide sequences, presumably by recognizing a particular three-dimensional DNA architecture (54, 59, 62). AbrB can function as a repressor of genes such as spo0E, spo0H, spoVG, and aprE (14, 34, 43, 64) and as an activator of genes such as hpr and the rbs operon (52, 53). Transcription of abrB is controlled by negative autoregulation and repression by Spo0A (53, 55). The hpr gene product is a 23,718-Da protein, which was originally identified as a locus (hpr, scoC, and catA) for mutations causing protease overproduction and catabolite-resistant sporulation (10, 21, 39). Hpr binds to a consensus DNA sequence RATAnTATY (25, 53). Hpr represses the expression of the protease genes aprE and nprE and oligopeptide permease operons (20, 26) and when present on a multicopy plasmid can inhibit sporulation in an as-yet-undetermined manner (39). The Spo0A 29,691-Da protein is the master controller of early developmental events (55, 56). Metabolic and environmental signals cause the autophosphorylation of sensor kinases such as KinA, KinB, and KinC (1, 24, 27, 41), which transfer phosphate groups through a phosphorelay (Spo0F and Spo0B) to generate Spo0A∼P (24, 55, 57). Spo0A∼P recognizes a 0A box DNA sequence, TGNCGAA (51). Spo0A∼P is a repressor of abrB transcription and an activator of spoIIA, spoIIG, and spoIIE operon expression (4, 45, 51, 57, 63). spo0A expression is controlled by ςA and ςH promoters (9, 44, 49). Vegetative spo0A expression originates from the ςA promoter, and catabolite-regulated postexponential expression is controlled from the ςH promoter.
The dicistronic sin operon was originally identified as a clone which could inhibit sporulation and protease production when present on a high-copy-number plasmid (16, 17). The first gene in the operon encodes a 57-amino-acid protein, SinI, that posttranslationally antagonizes the activity of SinR, the product of the second gene in the operon (3). SinR is a 111-amino-acid protein, which is a repressor of aprE, amyE, sacB, spo0A, spoIIA, spoIIG, and spoIIE (17, 18, 31, 32, 33, 38, 50) and binds to a DNA sequence whose consensus appears to be GNCNCGAAATACA. The crystal structure of SinR has revealed that the DNA-binding domain is similar to that of the bacteriophage 434 repressor proteins, CI and Cro (30). The SinR tetramer represses transcription of the spoIIG promoter by inducing DNA conformational changes, preventing activation of transcription by Spo0A∼P (7). SinR is an activator of competence, motility, and autolysin production (15, 46). The sin operon is expressed from three differentially regulated promoters (17); promoters P1 and P2 precede sinI and produce RNAs which span the operon and terminate at two rho-independent terminators; the P3 promoter abuts the sinR gene and produces a transcript which starts 15 nucleotides (nt) upstream of the first sinR codon and terminates at the rho-independent termination sites. P1 expression is downregulated in vegetative growth and increases dramatically at the onset of stationary phase (17). P3-derived RNAs are expressed in vegetative growth and during the first 2 h of stationary phase. Synthesis of sin operon mRNA originating from P2 commences 2 h after entry into stationary phase. sinR gene disruptions suppress the effects of sporulation defects caused by null mutations in kinA and missense mutations in ftsA and spo0K (31). These effects are consistent with findings (33) that sinR deletions relieve repression of spo0A and would be expected to increase the concentration of Spo0A∼P, thus bypassing the effects of kinA and spo0K mutations. sinR deletions also cause derepression of the sinIR operon (16, 32), suggesting that SinR may autogenously regulate sinIR expression.
In the studies described here, we have investigated the interplay of these genetic factors in controlling the activity of the sinIR operon. We describe in vitro transcription studies suggesting that the sinIR P1 and P3 promoters are transcribed by ςA RNA polymerase. To elucidate the genetic factors that regulate expression from these promoters, we have examined the role of transition-state and spo genes in governing the in vivo expression of sinIR. These data establish that sin operon expression is regulated by the phosphorelay and Hpr.
Bacterial strains and plasmids.The strains used, their genotypes, and their sources are listed in Table 1. Plasmids containing the sinIR operon have been described (16, 17).
β-Galactosidase synthesis with B. subtilis lacZ fusion strains.The following lacZ fusions were used in these studies: sinI::lacZ and sinR::lacZ (17) are translational fusions and were introduced into the amyE locus as described earlier (31). The β-galactosidase expression from lacZ fusions was determined as described previously (11). Specific activity is expressed as nanomoles of o-nitrophenyl hydrolyzed per milligram of cellular protein per minute.
Cell growth, induction of sporulation, and sporulation quantitation.Cell growth, induction of sporulation in Schaeffer's medium, and sporulation quantitation were performed as described elsewhere (48).
DNase I footprinting analysis of the sinIR 5′ regulatory region.DNase I footprinting experiments were performed utilizing a fragment containing the first 395 bp (XbaI-AhaIII) of the sinIR operon (16, 17). The transcribed strand was labeled at its 3′ end by using the Klenow fragment of DNA polymerase I (Bethesda Research Laboratories) and [α-32P]dATP (Amersham). Protein binding and footprinting reactions were performed as described elsewhere (25, 51, 54). The labeled fragment was also subjected to Maxam-Gilbert A+G and C+T sequencing reactions (36) to generate a reference ladder. AbrB was purified as described previously (54). Spo0A was a gift from Jim Hoch. Each protein was purified separately from different Escherichia coli strains harboring expression vectors as described previously (25). Each protein preparation was >95% homogeneous as determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Spo0A was not phosphorylated.
sinIR in vitro transcription analysis.To map the in vivo and in vitro transcriptional start sites of the sinIR operon P1 and P3 promoters, primer extension with 5′ 32P-end-labeled primers and reverse transcriptase was performed as described previously, as was the purification of RNA polymerase (44). For in vivo primer extension reactions, 60 μg of RNA was harvested from cells grown in nutrient sporulation medium (NSM) at the T0 stage of growth. The in vitro start sites were determined with RNA prepared from four-times-normal-size transcription reaction mixtures. The sequence of the primer used for the P1 promoter mapping, OSIN-1 (5′-CAG CCA GTC CGG CCA TGA C-3′), corresponds to nucleotides −37 to −56 with respect to the start of the sinI coding sequence. The equivalent primer for P3 mapping, P3-1 (5′-CAG CTA GTT CTG ATA GTG AGT-3′), corresponds to nucleotide positions +270 to +249, also with respect to the start of the sinI coding sequence. The plasmid used for the in vitro primer extensions and for the dideoxy DNA sequencing reactions was constructed by subcloning the XbaI-NruI fragment, containing P1 and P3 from pIS74 (16), into a lacZ shuttle plasmid. This insert contains the MscI-NruI fragment that was removed from pIS109.
Plasmids. (i) pIS109.Plasmid pIS109 was constructed from excision of the XbaI-HinDIII fragment from pIS90 (16, 17) and ligation into XbaI-HinDIII-restricted pUC19. In this construct, a 240-bp internal MscI (BalI)-NruI fragment was deleted. This plasmid contains the sinIR operon P1, P2, and P3 promoters and the T2 and T3 terminators 5′ to the HinDIII site. Predicted transcript sizes are as follows: P1, 455 nt when terminated at T2 and 497 nt when terminated at T3; and P3, 142 nt when terminated at T2 and 184 nt when terminated at T3.
(ii) pSS60.Plasmid pSS60 carries a 256-bp internal sequence, +108 to +364 with respect to the start codon, from the hpr (scoC) coding region. This plasmid was used to inactivate hpr by Campbell integration.
(iii) pSS950.Plasmid pSS950 carries a null mutation in spo0A. A 64-bp internal fragment from the spo0A-coding region, +535 to +599 with respect to the start codon, was replaced with the erythromycin-resistance (Emr) gene from pHP13 (19) and cloned into a Topo vector (Invitrogen). The plasmid was linearized with SmaI restriction enzyme and used to inactivate spo0A by gene replacement.
(iv) pSS1750.Plasmid pSS1750 carries a null mutation in spo0H. A 30-bp internal fragment from the spo0H-coding region, +532 to +562 with respect to the start codon, was replaced with the Emr gene from pHP13 (19) and cloned into a Topo vector (Invitrogen). The plasmid was linearized with SmaI restriction enzyme and used to inactivate spo0H by gene replacement.
Transcriptional analysis of the sinIR promoters.Previous in vivo studies (17) had identified three separate and individually regulated promoters involved in the transcription of the sinIR operon. Among these promoters, P1 is the most important in regulating sinIR expression at the onset of sporulation and in determining the ratio of SinI and SinR proteins (3). Although P1 has typical ςA promoter motifs, it had not been directly demonstrated that P1 could be transcribed in vitro by ςA RNA polymerase. To more accurately establish the transcriptional start sites, we performed RNA mapping studies, utilizing reverse transcriptase-based primer extension assays. Total RNA prepared from IS75 (16) cells harvested at T0 and RNA isolated from in vitro transcription reaction mixtures with B. subtilis RNA polymerase holoenzyme containing ςA were used for these experiments. The in vivo and the in vitro extension products obtained for each promoter were similar (Fig. 1, lanes 1 and 2 for P1 and lanes 3 and 4 for P2), indicating that the in vivo and the in vitro start sites for P1 and P3 are identical. A minor extension product was observed, however, in the P1 in vitro reaction (lane 1) that was not present in the in vivo RNA reaction (lane 2). Its significance (alternative start site, degradation product, or an artifact of in vitro transcription) is not known. The mapping of the P3 start is ambiguous, in that the start site could be either an A or the adjacent G (Fig. 1, lanes 3 and 4). The DNA sequences in the P1 and P3 promoter regions are presented below, with the initiating nucleotide(s) in boldface: P1, GATTATAATAAAGGTATATT; and P3, TGCTATAATATCACAAGGA. These results confirm a previous transcriptional mapping of the P1 promoter, which had been obtained by the S1 nuclease protection method, to the nucleotide, but the results with P3 presented here indicate that the actual initiating nucleotide is 3 nt downstream of the one previously described (17).
Mapping of in vivo and in vitro transcription start sites for sinIR promoters. Start sites were determined by reverse transcriptase extension of 32P-end-labeled primers by using in vivo RNA isolated from IS75 (16), grown in NSM, and harvested at T0 and in vitro RNA isolated from transcription reaction mixtures. B. subtilis RNA polymerase holoenzyme containing ςA was allowed to transcribe pSM109 (16), a plasmid containing sinIR P1 and P3, with nonradioactive ribonucleoside triphosphates, and RNA was isolated from the reaction mixtures. After radioactive primers were annealed to the RNAs and after extension with reverse transcriptase, the samples were separated by electrophoresis on 6% polyacrylamide gels, followed by autoradiography. Dideoxy sequencing gel lanes 1 and 2 show the primer extension products obtained from in vitro RNA (lane 1) and in vivo RNA (lane 2) using primer OSIN-1. The dideoxy sequencing ladder adjacent to lane 2 was obtained with the same primer and pSM179. The nucleotide sequence with the arrow pointing to the derived transcriptional start sites, also indicated by asterisks, is presented in the adjacent lanes. Lanes 3 (in vitro RNA) and 4 (in vivo RNA) show the equivalent primer extension products with primer P3-1, which corresponds to a region ca. 60 nt downstream from P3. Adjacent to lane 4 is the sequencing ladder obtained from pSM109 (16) with primer P3-1. The DNA sequence and derived transcription start sites are also presented.
Spo0A, Hpr, and AbrB in vitro binding to the sinIR P1 promoter region.Previous studies had shown that sinI expression was regulated by Spo0A (17) and had suggested a possible regulatory role for Hpr (25). The negative effects of spo0A mutations on sinI expression could be due to a direct activation of sinI transcription by Spo0A (4, 58, 63), to an indirect effect of spo0A through control of hpr (39) or abrB (4), or to both. We examined the direct binding of these proteins by a DNase I protection assay. We found that Spo0A and AbrB bound to discrete sites at or near the sinIR P1 promoter (Fig. 2 and 3). In agreement with a previous report (25), we also found two Hpr binding sites in the sinIR upstream regulatory region (Fig. 2 and 3). P1 promoter binding by each of these proteins was independent and noncompetitive. We did not detect binding of any of these proteins to the P3 promoter region (data not shown).
DNase I footprinting of the sinIR promoter region. The regions bound by the indicated proteins are indicated in brackets at the left (also see Fig. 3). Lanes 1, 2, 17, and 18, no binding protein; lanes 3, 11, and 13 to 16, 1.5 μM AbrB; lane 4, 3 μM AbrB; lanes 5, 10, 12, and 14 to 16, 0.4 μM Hpr; lane 6, 0.8 μM Hpr; lanes 7, 9, 12, 13, 15, and 16, 2.5 μM Spo0A; lane 8, 5 μM Spo0A. Maxam-Gilbert A+G (R) and C+T (Y) sequencing ladders are shown for reference. AbrB binds the sinIR region with a Kd in the range of 40 nM (52); Hpr binds with a Kd of less than 20 nM (Strauch, unpublished); the Kd for Spo0A binding has not been determined, in part because of the recalcitrance of Spo0A-DNA complexes to be resolved by gel mobility shift assays (Strauch, unpublished).
Localization of protein binding sites within the sinIR upstream region. Boxes represent the binding regions of the indicated proteins on the nontemplate strand that corresponds to the DNase I footprinting regions identified for the template strand (Fig. 2). Dashed lines beneath the Hpr binding regions are sequences with homology to the putative Hpr recognition element. The dashed line beneath the Spo0A binding region is a sequence similar to the 0A box (TGTCGAA on the strand shown). P1 indicates the transcriptional start site of the sinIR promoter, which is postexponentially activated (17).
The phosphorylated form of Spo0A regulates sinI expression.DNase I footprinting results (Fig. 2 and 3) established that Hpr, AbrB, and Spo0A can bind to the sinIR upstream regulatory region. The region protected by Spo0A contained a perfect match to the 0A box consensus sequence (51). The location (−43 to −49) of the 0A box relative to P1 is similar to cases in which binding of Spo0A∼P has been shown to activate transcription (4, 45, 57, 63). These data suggested a dual regulatory mechanism for P1 transcription: activation by Spo0A∼P and repression by Hpr. We examined sinI::lacZ expression in spo0A mutant strains and in a number of other spo gene mutations that are known to prevent phosphorylation of the Spo0A protein. Postexponential induction of sinI was not observed in spo0A12, spo0A::Em, spo0F221, spo0H::Em, or spo0K141 mutant backgrounds and was substantially reduced in a kinA mutant background (Fig. 4A and data not shown). The rvtA11 allele of spo0A bypasses the requirement for many of the normal phosphorelay gene products and can suppress sporulation defects such as spo0F mutations (48). The rvtA11 allele restored sinI expression in a spo0F mutant background and elevated sinI expression in a wild-type background (Fig. 4A). The spo0E11 gain-of-function mutation encodes an overactive phosphatase that inhibits sporulation by specifically dephosphorylating Spo0A∼P (37, 43). sinI expression was also substantially reduced in this mutant background (Fig. 4A). These results indicate that the phosphorylated form of Spo0A is required for sinI induction.
Differential regulation of sinI::lacZ expression. (A) Dependence of sinI::lacZ expression on the phosphorelay. The indicated strains were grown in Schaeffer's sporulation medium and analyzed as described previously (11). T0 denotes the end of exponential growth. (A) β-Galactosidase expression of sinI::lacZ in SS13 (wild type) (◊), SS15 (spo0A12) (•), SS17 (spo0E11) (▵), SS19 (spo0F221) (□), SS40 (spo0F221 rvtA11) (▪), and SS27 (rvtA11) (❍) strains. (B) The effect of a loss-of-function mutation in hpr on sinI::lacZ expression. β-Galactosidase expression of sinI::lacZ in SS13 (wild type) (◊) and in SS30 (hpr16) (⧫) strains. (C) The negative effect of a loss-of-function mutation in abrB on sinI::lacZ expression is suppressed by rvtA11 mutation. β-Galactosidase expression of sinI::lacZ in SS13 (wild type) (◊), SS33 (abrB::Tn917) (▵), and SS37 (abrB::Tn917 rvtA11) (▴) strains. (D) The epistatic relationship between Spo0A and Hpr in the regulation of sinI expression. β-Galactosidase expression of sinI::lacZ in SS13 (wild type) (◊), SS15 (spo0A12) (•), and SS63 (hprOHgr;pMTL20EC spo0A12) (□) strains.
Hpr is a negative regulator of sinI expression.P1 expression is downregulated in vegetative growth and increases dramatically at the onset of stationary phase (17). We have examined whether the binding of Hpr near P1 can account for repression of this promoter. Loss-of-function mutations in hpr (hpr16 and hprOHgr; pMTL20EC) caused substantial overexpression of sinI::lacZ (Fig. 4B and data not shown), indicating that Hpr binding near the P1 promoter (Fig. 2 and 3) is repressive in nature. We have characterized the nature of the hpr16 mutation by DNA sequencing. This mutation is caused by a missense mutation (T→A) at position +205, with respect to the start codon, resulting in a Phe69-Ile amino acid substitution. sinI::lacZ expression remained inhibited in a spo0A hpr double-mutant background (Fig. 4D), indicating that Spo0A is epistatic to Hpr in regulating sinI gene expression.
Role of AbrB in the regulation of sinI and sporulation.sinI::lacZ expression is unexpectedly decreased in the abrB::Tn917 or abrB::Tet null mutant backgrounds (Fig. 4C and data not shown). Expression was restored to wild-type levels when the rvtA11 mutation was introduced into these abrB mutant backgrounds (Fig. 4C and data not shown).
Inactivation of spo0A, spo0F, spo0H, spo0K, or kinA substantially reduced the postexponential expression of sinI::lacZ. These results suggest that sinI expression is controlled by the spo0A phosphorelay. Two other lines of genetic evidence support this interpretation. The spo0E11 mutation, a gain-of-function mutation which causes increased dephosphorylation of Spo0A∼P (37, 43), also diminished sinI::lacZ expression (Fig. 4A). On the other hand, the rvtA11 mutation in spo0A, which bypasses the requirement for other phosphorelay gene products (27), restored expression of sinI in a spo0F mutant background and elevated sinI expression in a wild-type background (Fig. 4A). Loss-of-function mutations in hpr (hpr16 and hprΩpMTL20EC) caused substantial overexpression of sinI::lacZ (Fig. 4B and data not shown). sinI expression remained low in the hpr mutant background during vegetative growth (although reproducibly two- to threefold higher than the corresponding time points in the wild-type background) but was substantially derepressed as the cells entered postexponential growth phase. These data suggest that the absence of high-level expression from the P1 promoter during vegetative growth time points might be due to the absence of the phosphorylated form of Spo0A. This interpretation is supported by the finding that postexponential derepression of sinI, observed in an hpr mutant background (Fig. 4B), is abolished in hpr spo0A double-mutant backgrounds (Fig. 4D), indicating that Spo0A∼P binding may be essential for expression from the P1 promoter. Moreover, the −35 region of the P1 promoter is significantly different from the ςA RNA polymerase consensus sequence, supporting the interpretation that the P1 promoter may be weakly transcribed in the absence of its activator, Spo0A∼P.
sinI::lacZ expression was diminished in both abrB::Tn917 and abrB::Tet loss-of-function mutations (Fig. 4C and data not shown). The downregulation of sinI::lacZ expression in abrB mutants could be due to AbrB functioning as an activator of sinIR or as a repressor of another gene(s), such as spo0E, whose product directly or indirectly inhibits sinI::lacZ expression. Spo0E phosphatase inhibits sporulation by removing the phosphate group from Spo0A∼P (37, 43). Moreover, spo0E expression is inhibited by AbrB during the vegetative phase and dramatically increases during transition into stationary phase (43). The expression of sinI was fully restored in an abrB rvtA11 double-mutant background (Fig. 4C), suggesting that the in vivo levels of Spo0A∼P may be reduced in abrB null mutant backgrounds. The exact role of AbrB in regulation of the sinIR operon, however, cannot be unambiguously determined from these results and is currently under investigation.
Expression of the sinR::lacZ fusion driven from the P3 promoter was not affected by any of the mutations (spo, abrB, hpr, and rvtA) shown here to regulate sinI::lacZ expression (data not shown).
In vitro DNase I footprinting experiments (Fig. 2 and 3) confirmed that the proteins implicated by in vivo genetic studies of sinIR regulation (Spo0A, AbrB, and Hpr) were able to bind to regions upstream of the P1 promoter. The binding motifs for Hpr and Spo0A are typical of sites where negative (Hpr) (25; M. A. Strauch, unpublished results) and positive (Spo0A) (4, 45, 57, 63) regulation is exerted. In vitro primer extension transcription studies with sinIR templates and ςA RNA polymerase established that the RNA transcripts seen in vivo originated from the P1 (sinI proximate) and P3 (sinR proximate) promoters (Fig. 1). The P2 promoter site, which resembles a ςE sequence (17, 50), was not used in vitro by ςA RNA polymerase (data not shown).
Analysis of sin operon transcription provides an opportunity to investigate the genetic strategies used to control complex postexponential regulons. A diagram summarizing these interlocking control circuits is shown in Fig. 5. The combinatorial alternative states provided by positive and negative regulator interactions are more than sufficient to account for the effects of the sin operon on postexponential cell state regulation.
A diagram depicting the sinIR transcriptional control circuit. The arrows indicate a positive interaction at either a transcriptional or later step; the T bars denote a negative interaction. For clarity, several proteins and regulatory pathways affecting the phosphorelay have been omitted.
The balance of Hpr and Spo0A∼P effects on sin operon transcription may determine the set point of the system in terms of selecting sporulation cell fate. Hpr would appear to be a checkpoint for the commitment to sporulation. If insufficient levels of Spo0A∼P are present, Hpr repression will downregulate sinI transcription, allowing SinR to repress spo0A, spoIIA, spoIIG, and spoIIE expression (18, 31, 32, 33, 50) and to upregulate genes involved in motility and competence (15, 46). The finding that a sinR deletion can suppress the sporulation phenotypes caused by mutations in spo0K and the cell cycle control gene ftsA (31) is consistent with this interpretation. The principal regulatory interplay dominating the expression of the sin operon is thus determined by Spo0A∼P and Hpr. As critical nutrients become limiting, a sequence of transition state interlocks guide the cells to a "postexponential soft landing." Exponential-phase cells can enter motility, nutrient-scavenging, or competence postexponential differentiation pathways (for a review, see references 12 and 53). Cells committed to sporulation traverse these interlock pathways by inactivation of the Hpr system and culminate in the activation of the SinI interlock, which in turn relieves SinR repressive effects on sporulation, allowing subsequent progression to stage II and irreversible commitment to sporulation.
We thank Gopalan Nair, Patrick Lau, Allan Tang, and Ben Wen for technical assistance. We also thank Ehab El-Helow for useful comments on the manuscript.
This research was supported by NIH grants GM32651 (I.S.) and GM46700 (M.A.S.), DOE grant DOE 4976-75 (T.L.), and U.S. Army Corps of Engineers contract DACA399520005 (T.L.).
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One of the Most Important Parks in the Country.
Zoli Honduras currently has 20 buildings on 52 acres of land that house important manufacturing firms.
Copyright © 2014 ZOLI Honduras Industrial Park | All rights reserved.


text:
Dbag (2018-2019)
University of Notre Dame Rejected 03/03/18 -- -- 04/14/18 1 year
University of Minnesota Twin Cities Rejected 02/27/18 -- -- 04/12/18 1 year
University of Minnesota Twin Cities
University of Pennsylvania Rejected 02/27/18 -- -- 04/09/18 1 year
Georgetown University Waitlisted 02/20/18 -- -- 04/06/18 1 year
Case Western Reserve University Waitlisted 03/01/18 -- -- 04/02/18 1 year
University of Michigan Ann Arbor Rejected 02/15/18 -- -- 04/02/18 1 year
Penn State University (Dickinson) Waitlisted 02/27/18 -- -- 03/28/18 1 year
Penn State University (Dickinson)
University of Virginia Rejected 02/27/18 -- -- 03/28/18 1 year
College of William and Mary Rejected 02/27/18 -- -- 03/27/18 1 year
George Washington University Rejected 02/27/18 -- -- 03/26/18 1 year
Washington University in St Louis Waitlisted 03/01/18 -- -- 03/23/18 1 year
Washington University in St Louis
University of Iowa Waitlisted 02/20/18 -- 02/20/18 03/16/18 1 year
Indiana University Bloomington Pending 03/13/18 -- -- -- 1 year
University of Nebraska Lincoln Accepted $1 02/20/18 -- -- 03/02/18 1 year
University of Nebraska Lincoln
George Mason University Pending 03/01/18 -- -- -- 1 year
University of Wisconsin Madison Pending 02/27/18 -- -- -- 1 year
University of Wisconsin Madison
University of Georgia Pending 02/23/18 -- -- -- 1 year
Vanderbilt University Pending 02/23/18 -- -- -- 1 year
Northwestern University Pending 02/15/18 -- -- -- 1 year
Midwestern Purgatory
I am old. I have a lot of miles on me.
Considering chalking this cycle up to an ass-whipping, entering into an LSAT class, and getting the jump on next cycle. Nobody explained to me that submission deadlines are actually in December, regardless of what the school's website might say.

redpajama_set_name: RedPajamaCommonCrawl


Comment on "What makes an online community?"
Comment on "WHAT CAN WE LEARN ABOUT COMMUNITY FROM OUR STUDENTS?"
Justin, looking forward to our chat tomorrow, just thinking about your research and student's perceptions of community and what Dr Ann Milne talks about in terms of community for Māori, do you see any overlaps at all?
WHAT CAN WE LEARN ABOUT COMMUNITY FROM OUR STUDENTS?
Here are our community guidelines. Familiarise yourself with the edSpace community expectations and if you have any expectations of your own to add, please feel free to contact us and we'll endeavour to reflect your contributions.


Functionally the roto-translational system ensures that in deambulatory support phase (Action that during life occurs again to an innumerable cycles of times), in which knee reaches a flexion of 20-25 degrees, there is only a rotary motion which mechanically protects the articular surfaces from usury by rubbing.
In rotation to each point of the femoral condyle corresponds one point on the tibial plateau and the mechanical forces, developed by the burdening of body weight ,are transmitted to compression, without provoking usury.
running so that it will not be performed under load.
translation provides a slip between the parties in contact with surface usury, usury that is more important as the weight of the part that moves.
In the whole sphere of movement outside of pure deambulatory support phase ( jogging, sprinting, jumping, pedaling, with squat thrusts, impact, bending-ex. In ski-ride, etc..) action of friction is always directly proportional to the degree of bending reached and usury is proportional to the weight of the subject.


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Humla lies in Karnali Zone in Province 6 of Nepal. Simikot is the district headquarter. The district, with an area of 5,655 sq. km is divided into 27 VDCs. Humla has 9,479 households with a total population of 50,858 (Male 25,833 & Female 25,025).[1]
The topography of the district consists of high mountains and as such road access is very limited. Simikot is not linked to the national road network and is connected to the neighbouring districts by foot trails and air transportation.
Economic and Financial Landscape
Agriculture (including livestock) and cottage industries are the main economic activities of the district. Agriculture is the major source of income for about 95.55% of the households.[2] However, malnutrition rate in Humla is exceptionally high. Among the small and cottage industries registered, majority work in the agriculture and wildlife and service sector.
The district is served by five different branches of 'A' Class Commercial Banks. The population served per branch is 11,234 against the national average of 8,960[3]. This indicates the need to further expand the outreach of financial services and facilities to the unbanked population of the area.
GESI Issues
Humla's total population comprises of about 38.7% Chhetri, 19.64% Thakuris, 13.45% Tamang, 9.71 % Kamis followed by others, in terms of caste and ethnicity.[4] Although discriminatory practices have been reduced in Humla after the decade-long insurgency, the change has not been significant. Women and Dalits are visible in school management and other district level committees, however, their representation is more symbolic than influential. Female literacy rate stands at just 4.8%[5], which clearly indicates that women lack the access to education facilities. As of 2013, 1,423 freed Haliya families have been registered in the district, of which 162 have been issued identity cards needed to receive rehabilitation support.[6]
A major focus of Sakchyam is to help the financial institutions mainstream GESI principles. The programme will also attempt to increase access to financial services and products to women and other disadvantaged groups via innovative value chain financing tools in a manner that could improve their livelihoods and self-dependence.
Ongoing Sakchyam Interventions
Outreach Expansion
To increase financial access for rural poor, one branch of NUBL and one branch of Citizens Bank have been established in the district.
NUBL has extended financial services through the use of four tablets in the district.
Janata Bank and Prabhu Bank will establish three and one branches, respectively, under the Local Units Project in the district.
Financial Literacy Initiatives
Through Sakchyam's technical support, NUBL has conducted school level financial literacy campaigns. NUBL has also used IVR messages to disseminate messages in the district.
[1] National Population Census 2011 [2] National Sample Census of Agriculture 2011-2012 [3] Nepal Rastra Bank (July 2018) [4] National Population Census 2001 [5] Central Bureau of Statistics (cbs.gov.np) [6] http://un.org.np/sites/default/files/humla_district_profile.pdf


Red Hook [2009 DvdRip Xvid] » Развлекательный портал Jolly Roger Project.
Ten years after witnessing her older sister's brutal murder, Jenny Traylor leaves her hometown in North Carolina to start her freshman year at the University of New York City. Still traumatized by her sister's death and struggling with crippling agoraphobia, Jenny tries to cope with the overwhelming city and figure out her new life.


text:
New understanding of primary health care nurse practitioner role optimisation: the dynamic relationship between the context and work meaning
Nancy Côté1,2,
Andrew Freeman ORCID: orcid.org/0000-0003-1018-94522,3,
Emmanuelle Jean4 &
Jean-Louis Denis5,6
Optimising health professionals' contribution is an essential step in effective and efficient health human resources utilisation. However, despite the considerable efforts made to implement advanced practice nursing roles, including those in primary care settings (PHCNP), the optimisation of these roles remains variable. In this investigation, we report on the subjective work experience of a group of PHCNPs in the province of Quebec (Canada).
We used Giddens' structuration theory to guide our study given its' facilitation of the understanding of the dynamic between structural constraints and actors' actions. Using a qualitative descriptive study design, and specifically both individual and focus group interviews, we conducted our investigation within three health care regions in Quebec during 2016–2017.
Forty-one PHCNPs participated. Their descriptions of their experience fell into two general categories. The first of these, their perception of others' inadequate understanding and valuing of their role, included the influence of certain work conditions, perceived restrictions on professional autonomy and the feeling of being caught between two professional paradigms. The second category, the PHCNPs' sense of engagement in their work, included perspectives associated with the specific conditions in which their work is situated, for example, the fragility of the role depending on the particular clinic/s in which they work or on the individuals with whom they work. This fragility was also linked with certain health care reforms that had been implemented in Quebec (e.g., legislation requiring greater physician productivity).
Several new insights emerged, for example, the sense of role fragility being experienced by PHCNPs. The findings suggest an overarching link between the work context, the meaning attributed by PHCNPs to their work and their engagement. The optimisation of their role at the patient care level appears to be influenced by elements at the organisational and health system context levels. It appears that role optimisation must include the establishment of work environments and congruent health context structures that favour the implementation and deployment of new professional roles, work engagement, effective collaboration in interprofessional teams, and opportunities to exercise agency. Further research is necessary to evaluate initiatives that endeavour to achieve these objectives.
The worldwide need for highly skilled healthcare workers is increasing [1] and the underutilisation of health human resources is a significant social problem [2]. Strategies aimed only at increasing the numbers of healthcare professionals may not address all deficiencies of healthcare services [3]. Integrating and optimising the contribution of healthcare professionals, including ensuring that they are able to work to their full scope of practice, is perhaps one of the most critical actions that healthcare services are undertaking internationally [4, 5].
In one of the responses to these challenges, advanced practice nursing (APN) roles continue to be developed and used internationally [6]. Although some variability exists in how this role is defined [7], the International Council of Nurses [8] defines a Nurse Practitioner/Advanced Practice Nurse as "a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice".
In Canada, two types of APN roles are recognized: Nurse practitioners (NP) and Clinical Nurse Specialists. Only NP titles are protected. All provinces and territories in Canada have legislation and regulations for NPs [9]. From 2006 to 2019, NPs in the province of Quebec were the only ones in Canada not permitted to diagnose, communicate a diagnosis, or initiate treatment for a chronic disease. Paradoxically, Quebec NPs receive the most hours of theoretical and clinical (internship) training. Work is currently underway to harmonize pan-Canadian regulatory frameworks. In Quebec, long-term collaboration between the Ordre des Infirmières et Infirmiers du Québec, the Ministry of Health and Social Services and the College des Médecins du Québec led to the tabling in 2019 of Bill 43 (Loi modifiant la Loi sur les infirmières et les infirmiers et d'autres dispositions afin de favoriser l'accès aux services de santé). If passed, this law will authorise Quebec NPs, according to their specialty class and area of care, to diagnose certain diseases.
In Quebec, NPs currently work in five specialties: adult care, paediatric care, mental health, neonatology, and primary health care. Our focus in this article concerns this latter group, the Primary Health Care Nurse Practitioners (PHCNP). In Quebec, the PHCNP role was introduced in 2007 with the intention of improving the accessibility of care and front-line services [10]. The creation of 500 PHCNP positions was announced in 2010 to favour its' implementation [11]. Subsequently, in 2014, the Quebec government announced that the health network could count on the availability of 2000 extra APNs by 2025 for primary care and other practice sectors [12]. In light of this significant commitment, it is essential to understand the conditions necessary for the optimal use of this role.
Several studies have documented barriers and facilitators that influence the implementation of PHCNPs; it can be difficult to distinguish these given the possibility that barriers can be facilitators in some contexts and vice versa. Some of the factors that have been identified include: reimbursement policies [7, 13,14,15]; scope of practice clarity [7, 14, 16]; role definition, comprehension and recognition [7, 13, 14, 17,18,19,20]; integration process into primary care settings [21, 22]; organisational/administrative support [7, 13, 14, 18, 20, 23, 24]; work climate [25]; team functioning in general [26] and collaboration between APNs and physicians [13, 17, 19, 27,28,29] and with registered nurses and other professionals [16, 17, 19]. Studies have demonstrated the positive impact associated with adopting an systematic process to implementing the PHCNP role [19, 21]. In a related vein, others have noted the importance of considering multiple levels (e.g., organisational, health care system) in better understanding the elements needed for an optimal implementation [3, 16, 30, 31].
Various theoretical approaches have been used in efforts to understand how to optimise the use of PHCNPs, These approaches have included, for example: contingency theory [26], organisational levels of support practices [31], organisational change management framework [32], comprehensive conceptual model [3], a combined logic and implementation analysis [21], and deliberative dialogue [33]. A boundary work framework also was proposed, albeit within an acute care setting [34]. However, despite the useful insights gained to date regarding the integration and deployment of PHCNP roles, including the positive links found with patient health results, satisfaction with care, health care costs and even system improvements [35,36,37,38], the PHCNP foothold in general practice remains variable [39]. This inconsistent success suggests that further understandings are required.
Although some attention has been paid to identifying and describing multiple factors (e.g., work organisation dimensions; physician remuneration), limited attention has been given to the dynamic interaction between the individual, the organisation and the broader health system context [16, 19, 30, 31]. The interdependence between these different levels can shape a particular context that evolves over time and is a source of both constraints and possibilities.
In this light, we have used Giddens' [40] structuration theory to guide our investigation because it facilitates understanding of the dynamic between structural constraints and actors' actions. This theory takes into account four dimensions: (1) The structural, that is, the rules and resources that define organisations or social systems (e.g., Quebec health system); (2) the actions taken by the actors within these organisations; (3) the intentionality of these same actors, either the rationale or the motivation at the source of their actions; and (4) the spatio-temporal context. According to this theory, the structural presents a duality: it can be both constraining (setting limits to the actions of actors) and enabling (gives actors the skills to take action). In the context of our study, using this theoretical framework means taking into consideration how structures, embodied in rules and resources within a given health system, might constrain the ability of PHCNPs to exercise their role in an optimal way. It also leads us to pay attention to the active role that the PHCNPs might play in appropriating these rules and resources in order to act on the constraints of their practice. As well, this framework leads us to analyze different dimensions of the organisation of work of the PHCNPs at the individual, the organisation and the broader health system context levels. Ultimately, this theoretical approach would provide a basis for better understanding the variability in the optimisation of the PHCNP role within health systems and organisations.
In this article, we report on the subjective work experiences of a group of PHCNPs in the province of Quebec (Canada). By subjective work experience, we are referring to how these professionals experience and enact their role relative to the contexts within which their practice is situated. This understanding is necessary to create work environments and other contexts (e.g., Ministry of Health) that promote the optimal use of the role. The findings that we report in this article are one component of our global investigation, the objective of which was to better understand the factors that impede or facilitate local, regional and provincial stakeholders in achieving an optimal use of the PHCNP role.
We used a qualitative descriptive study design [41], guided by Giddens' theory, to empirically probe the dynamics between the factors that influence PHCNP role optimisation..
Study sample and participants
We conducted our investigation during 2016–2017 within three health care regions in Quebec due to their distinguishing characteristics (population, geographic location, services, administrative structures) and diverse conditions in which the PHCNP role was being implemented. There were 20, 6 and 25 PHCNPs respectively working in each of these three regions. This variability is consistent with the respective populations of people in these regions.
We conducted our investigation across a range of demographic (e.g., urban, semi-urban, rural) and administrative [community health clinics; family medicine practices of various configurations (e.g., university affiliation, drop-in clinics)] structures. To participate in the study, the PHCNPs were required to have worked in this role for a minimum of 6 months. We used a maximum variation sampling approach [42] to recruit these professionals in order to capture the diverse clinical settings in which they practise. In the three regions in which our investigation was conducted, we informed the PHCNPs about our study via their provincial professional association (Association des infirmières praticiennes spécialisées du Québec), and specifically via the regional representatives, who invited those individuals who were potentially interested to contact us for more information.
We created two advisory committees to support the rigour of our study by means of their expertise about the PHCNP practice context and current issues being faced by different stakeholders in the implementation of the PHCNP role. These committees provided advice regarding recruitment and data analysis. See Table 1 for the composition of these committees.
Table 1 Composition of advisory committees
We used both in-depth semi-structured individual interviews and focus group interviews. The respective strengths of these two approaches [42] permitted the emergence of a richer and more trustworthy understanding of the PHCNPs' subjective work experience. Given the potentially sensitive nature of the questions, the individual interviews were appropriate for understanding the subjective work experience of the PHCNPs, their perceptions of their role and how it was being used within multidisciplinary teams. In turn, the focus group interviews, because of the exchanges among participants, were appropriate for deepening understanding and exploring potential avenues for optimising the PHCNP role.
The individual interview guide reflected Gidden's theoretical approach. For example, we sought to understand how the PHCNPs' work was being experienced (motivations and actions) as well as the resources (what was needed, available or lacking). However, the open-ended questions also permitted the participants to discuss other elements that they considered relevant. Specifically, the individual interview guide included the four following principal dimensions: (1) the reasons for choosing to become a PHCNP; (2) the nature of their experience as a PHCNP, including their integration into the team and the evolution of their experience; (3) the use of their role in teams and any actions taken to increase their ability to exercise their role to its fullest extent; and (4) the resources and support necessary for the exercise of an optimal practice. The individual interviews (average 1.5 h duration) were conducted either face-to-face or by Skype, as requested by the participants.
In turn, the focus group interviews (average 2.25 h duration) were conducted following the initial analysis of the individual interview data. In these interviews, we further explored the impact of the conditions in which the PHCNPs exercised their role on how they viewed the meaning of their work. Specifically, we focused upon three themes that emerged from the individual interviews and that appeared to be significant for PHCNPs' subjective experience: (1) the integration and deployment of their role, (2) the optimization of teamwork, and (3) work meaning. We also pursued questions about the resources that they believed they needed to carry out their work, and potential solutions that would help them to optimise their role.
Participants provided written consent to participate in our investigation. As well, with the participants' consent, both the individual and focus group interviews were audio-taped.
The audio-taped individual and focus group interviews were transcribed and anonymised. We used the data analysis process outlined by Miles and Huberman [43]. Although the data analysis was deductive in the sense that its' starting point was the interview structures that were guided by Gidden's theoretical approach, the subsequent analysis was inductive. For both the individual and focus group interviews, a comprehensive summary of each interview was prepared; these summaries were structured according to the interview guide elements and the themes that emerged. This coding was carried out by the first author and two research professionals, using the NVivo software, to permit greater interrater reliability. Subsequently, a matrix was constructed to organise the themes as they emerged; this information constituted the first level of analysis. Over the course of the investigation, the analysis of the individual and focus group interview data was regularly discussed with the other researchers. As well, the emerging findings were presented to the members of both advisory committees. These members' questions and reflections were used to clarify the analysis of the data.
Consistent with the inductive and iterative data analysis process that we used, the data collection and analysis steps occurred simultaneously. This approach was also consistent with our intention to achieve data saturation. That is, as our understanding of the findings gradually emerged, we used subsequent interviews to pursue these impressions in endeavouring to arrive at a strong understanding of the phenomenon.
In summary, consistent with qualitative inquiry, we adhered to several criteria to create authenticity in our investigation [44], including: inductive data analysis, analysis records (e.g., decision trail, decision rules), audio taping/verbatim transcription for content, data saturation, accuracy, peer audit to confirm coherence (using the range of disciplines of the research team: sociology, nursing, rehabilitation, policy analysis), ongoing discussion with the members of the Strategic committee and the Work committee, and participants' actual quotations to provide thick description of their experiences.
A total of 27 PHCNPs participated in the study. Sixteen PHCNPs participated in individual interviews and 25 participated in one of three focus group interviews; 14 PHCNPs participated in both individual and focus group interviews. See Table 2 for the participant details by region.
Table 2 Participants
Data analysis revealed that the subjective work experience of PHCNPs interviewed in this study fell into two general categories: (1) their perceptions regarding the understanding and valuing of their role and (2) their sense of engagement in their work. The themes that emerged from the individual interviews and focus group interviews are essentially the same. However, work meaning, work engagement and the feeling of fragility depending on the environment in which working are themes that were mainly discussed during the focus groups.
Understanding and valuing of the PHCNP role
The specific perspectives that are linked to this category include the influence of certain work conditions, PHCNPs' perceived restrictions on their professional autonomy and the feeling of being caught between two professional paradigms.
The PHCNPS reported two elements associated with the conditions in which they practised that they perceived as indicative of an inadequate understanding and valuing of their role. First, the majority of participants reported that their large workload frequently obliges them to work overtime hours, either by prolonging their work day or by taking work home to be completed in the evenings or on the weekends. They are generally accepting of doing these overtime hours, believing them to be unavoidable and inherent within their role. However, they feel dissatisfied that these extra hours are not remunerated and that the measures in place for them to compensate for this time are not adapted to the reality of their role. The refusal to pay them for the overtime hours, in combination with a salary that many PHCNPs believe to be insufficient, makes them feel that their role is under-recognised and undervalued. As noted by one participant (#01):
"I made a big discovery this year. I'm paid 35 hours per week; I estimate that my workload is around 500 patients for which I'm solely responsible, plus 300 shared patients, who are not simple cases. Last year, I worked around 60 hours a week … there are lab results that arrive, there are ultrasound results that arrive, I have to talk with my physician partners, there are emergencies that arrive. You have no life!"
The second element concerns many participants' perception that their inflexible work schedule is not appropriate for their role. This schedule is not congruent with their responsibilities, which are actually more similar to those of physicians than those of registered nurses, with respect to the completion of patients' records and requests for specialist tests or lab results, among other examples. As noted by a participant (#02), "We're stuck in the straitjacket of our collective agreement; seven hours a day, no overtime, and so on."
Both of these elements are associated to some degree with the collective agreement within which the PHCNPs' work conditions are situated. As one participant (#05) noted, "For sure we have a … unionised role; however, nothing is adapted for us in the collective agreement".
Professional autonomy
The participants identified two main sources of frustration regarding restrictions on the professional autonomy within their scope of practice. In the first instance, the dissatisfaction for some PHCNPs is associated with the limits experienced in the context of their collaboration with their physician partners. Specifically, the PHCNPs felt that some physicians were preventing them from being able to practise to their full scope; that is, their role was being restricted to primarily meeting physicians' requirements rather than fully exercising their role in a way that was helping meet the goal of improving patients' access to quality primary care services. As noted by one participant (#03), "So where is the added value [of my role]? I feel like I'm in a survival mode, of protection, to try and protect what I've built."
In the second instance, the dissatisfaction experienced by some PHCNPs is associated with their perception that their scope of practice is unnecessarily restrictive, specifically with respect to being permitted to diagnose and to initiate treatments for chronic diseases. The PHCNPs believed these two elements to be key components within their professional identity within the context of the evolution of their scope of practice that had taken place in Quebec. Within this context, these professionals also wondered about the specificity of their role relative to that of their registered nurse colleagues given these latter professionals' recently acquired right to prescribe. "It's like we're caught. We're stuck in a straitjacket that has been defined more for roles with less accountability, less unpredictability, less responsibility." (#03).
These sources of dissatisfaction seemed to become more clear following the accumulation of a degree of experience in this role that occurs during the initial, approximately 18-month, integration phase. This phase is a period of adaptation for these professionals and includes elements such as appropriating their role and becoming familiar with their new clinical setting in general, with the procedures in place, with the services offered, and with their colleagues.
Being caught between two professional paradigms
The third perspective identified by the PHCNPs with respect to the understanding and valuing of their role is that of their perception of feeling pulled between two professional paradigms, that is, the caring paradigm underlying nursing versus the biomedical approach underlying medicine. On the one hand, as nurses, they privilege a global health approach that takes into account physical, psychological and social dimensions. This role is synonymous with a prevention and health promotion approach within which a proactive educational role is intrinsic. On the other hand, some PHCNPs feel perceived by family physicians to be the equivalent of medical residents (mini-doctors). Among the consequences of this latter perspective is their experience of significant pressure regarding the number of patients that they should see. This pressure can translate into more of a caseload-centred (number of patients to be seen) versus patient-centered (customising the care to each patient's needs) approach. This increased pressure was seen to be associated to some degree with the enactment in the province of Quebec in 2015 of Law 20 (Loi favorisant l'accès aux services de médecine de famille et de médecine spécialisée), which includes strong productivity expectations on physician practice. Although the PHCNPs recognise that a certain juggling of nursing and biomedical paradigms is an innate part of their professional role, they experience significant tensions in their practice when the nursing orientation is minimally or not acknowledged. As explained by one participant (#01):
We're compared both by physicians and by registered nurses; neither group understands [what we do]. [I'm asked] « Why haven't you gone to lunch yet? » Well, I haven't got time. « What do you think I should do? I have to finish what I'm doing. If I don't do it now, I'll have to do it later. So I might as well get it done now. » I can't put it off until tomorrow, because tomorrow, there will be another pile. The [registered] nurses, they don't get it either. How many times have they said to me « Come on, what are you doing? ». But they don't have my obligations … nobody seems to understand.
In this first section, the findings have revealed that the limits experienced by the PHCNPs in their daily practice appear to be associated with factors at the organisational and health care context levels. As will be seen in the next section, the rules and resources in place at these two levels shape the actions taken by the PHCNPs (actors) with respect to their sense of engagement in their work.
PHCNPs' sense of engagement in their work
The participants described several elements that influence their sense of engagement in their work. Some of these perspectives are associated with specific conditions in which these professionals' work is situated. For example, several PHCNPS commented upon the impact of the fragility of their role that they experience depending on the particular clinic/s in which they work (milieu-dependent) or on the individuals with whom they work (individual-dependent). PHCNPs' experiences vary widely, contributing to difficulties for them to fully engage in their work. It is as if they can never be quite sure to what extent they will be able to fully exercise their role and that the situation can change quickly. As one participant (#04) noted:
[It's] the disappointment and the risk of what we are going to do with the profession, as a result of a change. It's not a question of anxiety and then of fear of the unknown, it is the difficulty of finding a team that wants you to be there for the right reasons. And we don't find these teams everywhere. Thus, from the time that our team falls apart, well, we know very well that the likelihood of finding another team like this is pretty slim, which makes us not feel very hopeful.
On a similar note, a number of PHCNPS commented upon the impact of the fragility of their role associated with health care reforms. As summed up by one participant (#05), "We are in the whirlwind of change, and we have no control over what is happening." Among other elements, the participants are referring here to the increased productivity pressures on family physicians ensuing from the enactment in Quebec of Loi 20, which led to a restructuring of how some clinics functioned. As noted by a participant (#03):
The physician is at the center, he wants to see as many patients as possible, and he wants to surround himself with all the people who will help him achieve his goal … [This change has had] a negative impact on my partnerships, in the sense that there is a lot of energy being put into reorganise things for which my opinion is not sought. It is as if, in order to achieve the objectives, the new model is a physician with an auxiliary who sees all the patients before, then sees many, many, many [patients], then who does all that the physician asks him at the technical level, in order to go faster.
Subsequent to these and other similar types of situations, several PHCNPs spoke about their questioning of their future in the profession. As one participant (#01) specified:
It's not enjoyable; there isn't the same atmosphere. I've been here for 5 years but this is the first year that I'm not hopeful that things will improve. I'm asking myself "What am I doing?" I see other positions advertised but I ask myself if it's even worth it to change. Is the grass greener on the other side? What should I do? I'm not going to put up with 20 years like this.
A number of participants spoke about being in a survival mode, for example: "Actually, I survive by taking it day by day. That's how I see it. Each day, I'll go to work." (#01). As noted by another participant (#03), "I find myself in a survival mode, of protecting myself, in order to protect what I have built … I need to tell myself that's it's temporary and that things will improve. If they don't, I won't be able to hang on."
Similarly, several PHCNPs indicated that they were finding it difficult to see a future in this profession. As noted by a participant (#06), "What I find frustrating is that at the start, I really had the fire; I still have it but sometimes, it's true that after these three years, I envisage other perspectives. I'm willing to fight in order to eventually have better conditions, but not to the detriment of my health."
Maternity leave was identified by some PHCNPs as an opportunity (loophole) to take time out from the difficult conditions to reflect upon their professional future. As noted by a participant (#07): "I'm on maternity leave but I doubt that I'll return to the same job."
Some aspects of the subjective experience of work described by PHCNPs in our study regarding barriers to the optimisation of their role reinforce the findings of some other investigations. For example, the challenges associated with an inadequate understanding and valuing of their role have previously been noted [21]. In a related vein, perspectives regarding these professionals' scope of practice have previously been identified, whether related to the interpretation of this scope by physicians [17, 27] or registered nurses [17, 19] or to PHCNPs' beliefs that their scope of practice is unduly limited [14, 16, 45]. The tension between the biomedical and nursing paradigms has been noted in some other investigations [13, 14, 19, 46]. Some other studies also have identified a lack of congruence between the reality of PHCNPs' roles and the structures in which their practice is situated. Some examples, include the level of remuneration for these professionals' services [14, 47] and the nature of their work schedule [18].
However, beyond this reinforcement or convergence with some previous studies, our study has highlighted some other elements that have emerged less clearly to date. A more precise image has emerged of the sense of fragility experienced by PHCNPs regarding their role. Among other elements, this fragility appears to be associated with the milieu- (in which clinic/s they work) and individual-dependent (with whom they specifically work) nature of the implementation of their role. This fragility also seems to be related to health system-level changes as various reforms have continued to be enacted (e.g., legislation requiring greater physician productivity).
As noted, the various specific elements that characterise the PHCNPs' subjective experience of work appear to be grouped into two overriding themes: an inadequate understanding and valuing of their role, and concerns about their engagement in the work. However, beyond the clarity provided by these themes, our analysis suggests an overarching link between the meaning attributed by these professionals to their work and their sense of engagement in this work. The work context in which PHCNPs are required to practice can undermine this meaning of work and, in turn, can lead them to question their engagement in the work, or even within their profession.
By work meaning, we are referring to the sense of congruence experienced by individuals with the various elements upon which their work is constituted. Work is considered meaningful by individuals when the tasks and the context in which they are carried out are consistent with their identity [48]. The way in which PHCNPs describe their subjective work experience appears to reveal a significant gap between their expectations and their work reality, which in turn affects the meaning that they attribute to their work. This gap appears related to these professionals' perception that their role is not recognised nor used to its' full potential in the work teams. On the one hand, the dynamics of collaboration with the partner physicians and other professionals do not always permit the PHCNPs to fully utilise their skills. On the other hand, some of the structures in place appear to be poorly adapted to these professionals' level of responsibility for which they could legitimately be held accountable. In addition, these professionals' subjective work experiences appear to be influenced by their vulnerability in the face of changes that occur that are beyond their control both at the clinic (organisational) level or at the health care system level.
With respect to work engagement, we draw upon the concept of agency [40, 49] to conceptualise this notion as a practice situated in organisational and health system contexts with regards to the interrelationship between individuals (their expectations and aspirations for work; their life course), their profession (role, values, evolution of professional work), organisational characteristics (health organisations, professional and complex) and broader structural dimensions (evolution of the health system, gender inequality, professional hierarchies). In this conceptualisation, PHCNPs' work engagement is closely tied to their hopes regarding their work and their profession, but equally to the practice context and to the broader evolution of the health care system. The frustrations and uncertainty being experienced by many PHCNPs seem to have led them to various forms of disengagement at work including a questioning of their future within their profession.
Consistent with this analysis, it seems clear that the optimisation of PHCNPs' role at the patient care level is influenced by elements at the organisational and health system context levels. For example, these professionals' frustrations regarding their remuneration and schedule are related to structures that have been put in place at other levels (e.g., collective agreement). Similarly, although the obstacles experienced in their collaboration with some physicians may be linked to some of these latter professionals' reluctance to recognise the PHCNPs' distinct role, they also seem to be at least partly explained by new productivity pressures that were imposed on physicians within the context of a specific health care reform.
The theoretical approach that we have used has helped to highlight that the PHCNPs have to deal individually with these structural constraints in their working environment. The context, that is, the structural, plays a role in constraining action, limiting the optimal use of the PHCNP role. These professionals feel isolated and sometimes poorly supported both by their professional licensing body and their union, which do not always appear to have taken into account their specific requirements. This situation may be exacerbated for those PHCNPs who are the sole member of this profession in their clinic. Depending on the specific milieu within which they work or the physicians with whom they work, the PHCNPs, whether alone or with colleagues, have few levers to increase their capacity for action individually or collectively in order that the work more closely resembles their representation of their profession and the nature of their contribution in the health system. These professionals must fall back on the relationship with their partner physician(s) as the key lever to optimise their capacity for action.
To achieve an optimal use of the PHCNP role, it appears necessary to work at various levels to enable these professionals to increase their agency. Focusing solely on individual competencies and personal attributes, which tends to be the emphasis, appears insufficient. A more profitable approach is likely to also include the establishment of appropriate work environments and congruent structures across organisational and health system context levels that favour the implementation and deployment of new professional roles and new modes of collaboration in interprofessional teams.
Several specific avenues have emerged from our investigation. Our findings have reinforced the importance, also noted by some other authors, of ensuring a uniform understanding of the PHCNP scope of practice [16, 50] and the accompanying role description [20, 21, 23]. It also seems clear that endeavours to optimise PHCNPs' role must include better articulation between the individual, organisational and health system context levels. Our results also reveal the importance of fostering work environments that limit the individual- and milieu-dependent nature of PHCNPs' role so that they can increase their agency in the workplace, positively influencing their sense of engagement. Thus, optimizing the role of PHCNPs refers to the possibility for these professionals to take on leadership roles within multidisciplinary teams, to be involved in executive team meetings within clinics and to potentially participate in regional and provincial forums. Finally, since we completed our data collection, new guidelines for physicians have been published in Quebec with respect to the PHCNP role [51]. It is clear that further research will be needed to evaluate the impact of this type of initiative in addressing the challenges that we have identified.
Regarding the limits of our investigation, the generalisability of the conclusions may be limited by our focus upon PHCNPs' experiences in one jurisdiction (Quebec). Nevertheless, the broad trends to which these experiences appear to be linked (e.g., increased productivity pressures) suggest that our findings may have broader applicability [52]. The comprehensive nature of the individual and focus group interviews that were conducted as well as the ongoing validation of the findings carried out with the two committees over the course of the research lead us to feel confident that we have accurately understood some important trends despite the limited number of interviews in a single jurisdiction.
The findings of this investigation have revealed the sense of fragility experienced by PHCNPs regarding their role. There appears to be an overarching link between meaning attributed by these professionals to their sense of engagement in this work. The optimisation of PHCNPs' role requires coherent efforts across individual, organisational and health system context levels.
The individual and focus group data that support the findings of this study are unavailable due to being potentially identifiable.
APN:
Advanced Practice Nursing
CIUSSS-CN:
DNS:
Director of Nursing Services
PHCNP:
Primary Health Care Nurse Practitioner
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This research was financed by the Ministère de la Santé et des Services sociaux du Québec and the Ordre des infirmières et infirmiers du Québec. These funding bodies played no role in the design of the study, collection, analysis, interpretation of data, nor in writing the manuscript.
Faculty of Social Sciences, Université Laval, Quebec City, Canada
Nancy Côté
Centre de recherche sur les soins et les services de première ligne de l'Université Laval (CERSSPL-UL), Quebec City, Canada
Nancy Côté & Andrew Freeman
Department of Rehabilitation, Faculty of Medicine, Université Laval, Quebec City, Canada
Andrew Freeman
Department of Nursing Sciences, Université du Québec à Rimouski, Rimouski, Canada
Emmanuelle Jean
Département de gestion, d'évaluation et de politique de santé, École de santé publique, Université de Montréal, Montréal, Canada
Jean-Louis Denis
Chaire de recherche du Canada sur la transformation, le design et l'amélioration des systèmes de santé, Montréal, Canada
The content of this manuscript has not been published or submitted for publication elsewhere. All authors have read and approved the final version of this manuscript. NC, AF and EJ made substantial contributions to all stages of the research project, including design of the work, participant recruitment, data acquisition, analysis and interpretation, and preparation and revision of this manuscript. J-LD made a substantial contribution in the design of the work, and in the preparation and revision of this manuscript.
Correspondence to Andrew Freeman.
We specified the standard ethical protections to the potential research participants related to their participation in the individual or group interviews (e.g., participants' rights to withdraw from the investigation at any time and to refuse to answer certain questions; researchers' confidentiality obligations; focus group participants' confidentiality obligations). Participants provided written consent to participate in the investigation. This research project received ethical approval from the regional health organisation [Le comité d'éthique de la recherche sectoriel en santé des populations et première ligne (Population Health and Primary Care Sectoral Research Ethics Committee)] with which the first three authors are affiliated.
Côté, N., Freeman, A., Jean, E. et al. New understanding of primary health care nurse practitioner role optimisation: the dynamic relationship between the context and work meaning. BMC Health Serv Res 19, 882 (2019). https://doi.org/10.1186/s12913-019-4731-8
Primary health care nurse practitioners
Optimisation of health professional role
Work meaning
Organization, structure and delivery of healthcare


text:
All Things Music
Question - Answer with Songs
By Farin
March 25, 2009 in Fun & Games
andy7
I Miss You - Björk
Do You Wanna Dance? - The Beach Boys
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"Dance the Night Away" - Van Halen
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I Can Hear Music - The Beach Boys
Is She Really Going Out With Him? - Joe Jackson
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"In The Ghetto" - Elvis Presley
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Let's Dance - David Bowie
Who Me? - Buckethead
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How Am I Supposed To Live Without You? - Laura Branigan & Michael Bolton
Edited September 17, 2014 by Guest
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