Academic medical center clinical research professional workforce: Part 2 - Issues in staff onboarding and professional development

Background

Defining key barriers to the development of a well-trained clinical research professional (CRP) workforce is an essential first step in identifying solutions for successful CRP onboarding, training, and competency development, which will enhance quality across the clinical and translational research enterprise. This study aimed to summarize barriers and best practices at academic medical centers related to effective CRP onboarding, training, professional development, identify challenges with the assessment of and mentoring for CRP competency growth, and describe opportunities to improve training and professionalization for the CRP career pathway.

Materials/Methods

Qualitative data from a series of Un-Meeting breakout sessions and open-text survey questions were analyzed to explore the complex issues involved when developing high-quality onboarding and continuing education opportunities for CRPs at academic medical centers.

Results

Results suggest there are several barriers to training the CRP workforce, including balancing foundational onboarding with role-based training, managing logistical challenges and institutional contexts, identifying/enlisting institutional champions, assessing competency, and providing high-quality mentorship. Several of these themes are interrelated. Two universal threads present throughout all themes are the need for effective communication and the need to improve professionalization of the CRP career pathway.

Conclusion

Few institutions have solved all the issues related to training a competent and adaptable CRP workforce, although some have addressed one or more. We applied a socio-technical lens to illustrate our findings and the need for NCATS-funded academic medical centers to work collaboratively within and across institutions to overcome training barriers and support a vital, well-qualified workforce and present several exemplars from the field to help attain this goal.

Issues for recruitment and retention of clinical research professionals at academic medical centers: Part 1 - collaborative conversations Un-Meeting findings

Background

Identification of evidence-based factors related to status of the clinical research professional (CRP) workforce at academic medical centers (AMCs) will provide context for National Center for Advancing Translational Science (NCATS) policy considerations and guidance. The objective of this study is to explore barriers and opportunities related to the recruitment and retention of the CRP workforce.

Materials and Methods

Qualitative data from a series of Un-Meeting breakout sessions and open-text survey questions were analyzed to explore barriers and recommendations for improving AMC CRP recruitment, retention and diversity.

Results

While certain institutions have established competency-based frameworks for job descriptions, standardization remains generally lacking across CTSAs. AMCs report substantial increases in unfilled CRP positions leading to operational instability. Data confirmed an urgent need for closing gaps in CRP workforce at AMCs, especially for attracting, training, retaining, and diversifying qualified personnel. Improved collaboration with human resource departments, engagement with principal investigators, and overcoming both organizational and resource challenges were suggested strategies, as well as development of outreach to universities, community colleges, and high schools raising awareness of CRP career pathways.

Discussion

Based on input from 130 CRP leaders at 35 CTSAs, four National Institute of General Medical Sciences' Institutional Development Award (IDeA) program sites, along with industry and government representatives, we identified several barriers to successful recruitment and retention of a highly trained and diverse CRP workforce. Results, including securing institutional support, champions, standardizing and adopting proven national models, improving local institutional policies to facilitate CRP hiring and job progression point to potential solutions.

Tungstate sharpening: a versatile method for extending the profile of ultra sharp tungsten probes

The benefits of a new electrochemical etching method for the controlled sharpening of sub-micron tungsten probes are demonstrated. The proposed technique only utilizes the insulating effect of the WO₄(2-) by-product which offers more practical ways of controlling the process parameters. The electrosharpening method was fully automated through the analysis of the process current, bulk coulometry, shadowgraphs, and time lapse microscopy. Tip radii smaller than 15 nm were maintained over a wide range of controlled lengths up to 4.5 mm with conic angles of less than 1°.

Significant reduction in vancomycin-resistant enterococcus colonization and bacteraemia after introduction of a bleach-based cleaning-disinfection programme

BACKGROUND

Vancomycin-resistant enterococcus (VRE) colonization and infection have increased at our hospital, despite adherence to standard VRE control guidelines.

AIM

We implemented a multi-modal, hospital-wide improvement programme including a bleach-based cleaning-disinfection programme ('Bleach-Clean'). VRE colonization, infection and environmental contamination were compared pre and post implementation.

METHODS

The programme included a new product (sodium hypochlorite 1000 ppm + detergent), standardized cleaning-disinfection practices, employment of cleaning supervisors, and modified protocols to rely on alcohol-based hand hygiene and sleeveless aprons instead of long-sleeved gowns and gloves. VRE was isolated using chromogenic agar and/or routine laboratory methods. Outcomes were assessed during the 6 months pre and 12 months post implementation, including proportions (per 100 patients screened) of VRE colonization in high-risk wards (HRWs: intensive care, liver transplant, renal, haematology/oncology); proportions of environmental contamination; and episodes of VRE bacteraemia throughout the entire hospital.

FINDINGS

Significant reductions in newly recognized VRE colonizations (208/1948 patients screened vs 324/4035, a 24.8% reduction, P = 0.001) and environmental contamination (66.4% reduction, P = 0.012) were observed, but the proportion of patients colonized on admission was stable. The total burden of inpatients with VRE in the HRWs also declined (median percentage of colonized inpatients per week, 19.4% vs 17.3%, P = 0.016). Hospital-wide VRE bacteraemia declined from 14/2935 patients investigated to 5/6194 (83.1% reduction; P < 0.001), but there was no change in vancomycin-susceptible enterococcal bacteraemia (P = 0.54).

CONCLUSION

The Bleach-Clean programme was associated with marked reductions in new VRE colonizations in high-risk patients, and VRE bacteraemia across the entire hospital. These findings have important implications for VRE control in endemic healthcare settings.

Surface-relief diffraction gratings recorded by multiple-beam coherent phase exposure

Surface-relief hexagonal-array diffraction gratings have been produced by three-beam coherent exposure. Collimated light was used in an attempt to produce a uniform relief profile over the total area of a 7.6-cm plate coated with a positive photoresist. The resulting gratings were reproduced in nickel by an electroforming process and analyzed by atomic force microscopy. The topography of the gratings was found to be that predicted by theory. The results obtained show that the gratings were of uniform profile over their total area.

Hypothalamic blood flow autoregulation remains unaltered following surgical and pharmacological blockade of central vasopressin

Experiments were carried out in urethane anaesthetized, ventilated rats to determine if brain arginine-vasopressin (AVP) plays a physiological role in cerebral blood flow autoregulation. Autoregulation was tested by determining local hypothalamic blood flow in the mediobasal hypothalamic area (HBF; H2-gas clearance technique) during consecutive stepwise lowering of systemic mean arterial pressure to 80, 60 and 40 mm Hg, by hemorrhage. Endogenous AVP was blocked by transecting the rostral, lateral and dorsal neuronal connections of the hypothalamus (including the median eminence) from all major brain areas, by bilateral transection of the vasopressin-containing fibres in the hypothalamo-hypophyseal tract to the median eminence at the level of the lateral retrochiasmatic area (RCAL), and finally by intracerebroventricular (i.c.v.) administration of an AVP antagonist, d(CH2)5Tyr(Me)AVP (AAVP). Significant increases of daily water intake indicated impaired vasopressin release following both types of surgical transection. Resting HBF was significantly elevated both after surgical isolation of the hypothalamus and after 10 ng AAVP administration compared to controls. Blood flow autoregulation in the hypothalamic region was seriously impaired following surgical isolation of the hypothalamus. However, HBF autoregulation remained just as effective as that of the control rats following either selective bilateral transection of the vasopressin pathways or following AAVP treatment. The present data indicate that AVP may play a role in the control of resting hypothalamic blood flow, but does not support a role of AVP in HBF autoregulatory mechanisms.

Clinical validation of a second-generation fructosamine assay

The serum fructosamine assay, used to monitor short-term clinical glycemic control, reportedly has several technical drawbacks. However, technical improvements have resulted in a new second-generation assay of fructosamine. We evaluated this second-generation assay (from Roche Diagnostics) in 529 nondiabetic and diabetic patients and found a highly significant correlation with results of the first-generation assay (r = 0.91, P less than 0.001). Use of the second-generation assay with samples from patients classified on the basis of glycemic control according to their glycohemoglobin (GHb) values, enabled us to discriminate between the nondiabetics, diabetics with "good/moderate" control (i.e., GHb less than 10%), and diabetics with "poor" control (GHb greater than or equal to 10%). We evaluated the validity of the second-generation assay to assess short-term glycemic control in 23 non-insulin-dependent diabetic patients who participated for 10 weeks in an intensive intervention program designed to rapidly normalize the clinical glycemic profile. Results correlated significantly with the one-week average capillary blood glucose concentration (CBG) and with the three-week average CBG in all 23 patients. In addition, the second-generation fructosamine assay results demonstrated a significant decrease at each week of study, as did the average CBG. Results of the first- and second-generation assays correlated significantly at each week of study. GHb correlated significantly with both the second- (r = 0.78, P less than 0.001) and first-generation fructosamine assay results (r = 0.77, P less than 0.001) for the baseline blood samples of the intervention study, but this correlation decreased (to r = 0.35, P = 0.09 and r = 0.34, P = 0.09, respectively) by the conclusion of the study.

Terminally ill patients' expectations of nurses

This exploratory study was undertaken to discover what nursing behaviours terminally ill patients desire. To rank patients' attitudes and judgements a Q-sort consisting of 70 cards was used. The statements covered three categories: physical and psycho-emotional care of patients and psycho-emotional care of significant other/s. "I would like the nurse to help me remain at home for as long as possible" was the most favoured statement and the least favoured was: "I would like the nurse to talk to me about death and dying." The overall theme was that responsive rather than directive nursing behaviours were desired. Analysis identified five Factors from which a model of responsive nursing care was developed. Interpretation of the Factors indicated patients desired responsive nursing care that enabled them and their families to bring their own resources to the dying process, rather than having imposed upon them care which nurses deemed appropriate.

Differential effects of central angiotensin II and substance P on sympathetic nerve activity in conscious rats. Implications for cardiovascular adaptation to behavioral responses

The centrally induced effects of angiotensin II and substance P on the cardiovascular system and on neuronal efferent activity of the splanchnic, renal, and adrenal nerves were investigated in chronically instrumented conscious rats. The pressor responses to substance P injected into the lateral brain ventricle were accompanied by marked and short latency increases in heart rate, cardiac output, splanchnic, renal, and adrenal nerve activity, and a rise in plasma noradrenaline and adrenaline. Behaviorally, an arousal-type reaction was observed. In contrast, the pressor responses to intracerebroventricular angiotensin II were associated with initial decreases in heart rate, cardiac output, splanchnic, renal, and adrenal nerve activity, and a fall in plasma noradrenaline at the time of the maximal blood pressure increase. In some but not all animals, a second blood pressure peak associated with increases in heart rate and splanchnic nerve activity was observed after several minutes. Incomplete chronic sinoaortic baroreceptor deafferentiation prevented the angiotensin II-induced fall in heart rate but not the initial fall in splanchnic nerve activity. The decreases in splanchnic nerve activity also occurred in diabetes insipidus rats and persisted in Long Evans rats after vascular vasopressin receptor blockade with d(CH2)5AVP, despite marked reductions of the pressor responses in both groups. Peripheral alpha-adrenoceptor blockade with prazosin or ganglion blockade with hexamethonium inhibited the central angiotensin II pressor responses only in combination with vasopressin receptor blockade. On the other hand, either sympatholytic drug, alone, abolished the pressor responses in the diabetes insipidus rats. This indicates that in intact conscious rats the central pressor effects of angiotensin II are initiated by vasopressin release but become dependent on the sympathetic nervous system when vasopressin is absent or not effective. When rats were allowed to drink in response to angiotensin II, a further sharp rise in blood pressure occurred, together with increases in heart rate and splanchnic nerve activity. The results demonstrate fundamental differences in the mechanisms by which central pressor peptides can influence cardiovascular and autonomic function. It is conceivable that the distinct sympathetic response patterns to central angiotensin II and substance P receptor stimulation form part of a specific cardiovascular adjustment to the individual behavioral reactions, such as drinking, as in the case of angiotensin II, or arousal within the central processing of pain, as in the case of substance P.

Sympathetic activation following central vasopressin receptor stimulation in conscious rats

Vasopressin (AVP)-containing pathways from hypothalamic neurons have been shown to project to blood pressure controlling brain centres. This suggests that AVP neurons may be involved in central blood pressure regulation. The effects of central AVP receptor stimulation on blood pressure, heart rate and directly recorded efferent sympathetic nerve activity in the splanchnic nerve (SNA) were investigated in conscious chronically instrumented rats. Intracerebroventricular (i.c.v.) injections of AVP (1-100 ng) caused dose-dependent blood pressure increases (maximum 26.9 +/- 3.5 mmHg) together with marked rises in heart rate and SNA. More pre-treatment with the AVP receptor antagonist d(CH2)5AVP (3/micrograms i.c.v.) completely prevented the central responses to AVP. Intracarotid injection of the same AVP doses produced rises in blood pressure accompanied by drastic falls in heart rate and SNA, similar to those seen after i.v. AVP injection. Thus, stimulation of specific neuronal AVP receptors produces a characteristic haemodynamic and sympathetic response pattern with marked sympathetic nerve activation, which is clearly distinct from the responses to vascular AVP receptor stimulation. It is concluded that AVP pathways in the brain can contribute to central blood pressure control via regulation of sympathetic outflow to the periphery.

The cardiovascular effects of centrally administered substance P in the anaesthetised rabbit

The cardiovascular effects of Substance P (SP) administered into the cisterna magna (i.c.) of the pentobarbitone anaesthetised rabbit have been investigated. SP given i.c. in low doses (0.2-10 ng/kg) caused a dose related rise in blood pressure and bradycardia. Both responses were attenuated by pretreatment with intravenous (i.v.) pentolinium. SP given i.v. (1 ng/kg-1 microgram/kg) caused a dose related fall in pressure and tachycardia. The pressor response observed after i.c. administration was reduced by pretreatment with morphine and enhanced by naloxone. Bilateral sinoaortic denervation also enhanced the pressor effect of SP, but after deafferentation naloxone had no further effect. Pretreatment with clonidine abolished this rise in pressure. It is concluded that the central administration of SP has a direct pressor effect whereas the bradycardia appears to result from both direct and indirect effects, leading to a decrease in cardiac sympathetic activity. Both actions are mediated by the autonomic nervous system. SP may be involved in the central regulation of blood pressure and modulation of baroreceptor reflex activity.

Chemical stimulation of the nucleus of the solitary tract and the resulting blood pressure response

The cardiovascular effects of catecholamines and related substances after local application into the nucleus tractus solitarii (NTS) of the medulla oblongata of urethane anesthetized rats are summarized. The catecholamines in the nanomolar dose range appear to activate stereospecifically receptor sites in the NTS, resulting in a decrease in blood pressure. Bradycardia occurs after bilateral administration of higher doses. The type of catecholaminergic receptors involved is discussed on the basis of the effects of different catecholamine receptor stimulating agents and pharmacological blockade. Both alpha-methylnoradrenaline and alpha-methyladrenaline are active and it is concluded that they both may contribute to the antihypertensive action of alpha-methyldopa. It is probable that an alpha-type of receptor mediates these hypotensive effects in the NTS. The nature of this receptor needs further characterization.

Mechanism of cardiovascular effects of clonidine in conscious and anesthetized rabbits

The actions of intravenous clonidine [2-(2,6 dichlorophenylamino)-2-imidazoline hydrochloride] on blood pressure and heart rate were examined in conscious rabbits. Complete transection of thecervical spinal cord increased the intensity and duration of the hypertensive effect of 30 microgram/kg of clonidine and completely abolished the fall in blood pressure. Heart rate slowing by clonidine was reduced. Result were similar 1 hour, 24 hours and 7 days after cord transection. Bilateral aortic sinus nerve section (baroreceptor deafferentation) increased both the hypertensive and hypotensive action of clonidine but reduced the bradycardia. When cervical cord transection was combined with batensive action, were abolished. We conclude that whereas the hypertensive action results from a direct effect on peripheral adrenoceptors, the fall in blood pressure is related to a reduction in sympathetic tone mediated at the level of the brain stem or more rostrally. The heart rate slowing results from both a reduction in sympathetic tone and also an enhanced vagal outflow. The increase in vagal tone seems to be dependent on the intergrity of baroreceptor afferent pathways.