The glycoimmune checkpoint receptor Siglec-7 interacts with T-cell ligands and regulates T-cell activation

Siglec-7 (sialic acid-binding immunoglobulin-like lectin 7) is a glycan-binding immune receptor that is emerging as a significant target of interest for cancer immunotherapy. The physiological ligands that bind Siglec-7, however, remain incompletely defined. In this study, we characterized the expression of Siglec-7 ligands on peripheral immune cell subsets and assessed whether Siglec-7 functionally regulates interactions between immune cells. We found that disialyl core 1 O-glycans are the major immune ligands for Siglec-7 and that these ligands are particularly highly expressed on naïve T-cells. Densely glycosylated sialomucins are the primary carriers of these glycans, in particular a glycoform of the cell-surface marker CD43. Biosynthesis of Siglec-7-binding glycans is dynamically controlled on different immune cell subsets through a genetic circuit involving the glycosyltransferase GCNT1. Siglec-7 blockade was found to increase activation of both primary T-cells and antigen-presenting dendritic cells in vitro, indicating that Siglec-7 binds T-cell glycans to regulate intraimmune signaling. Finally, we present evidence that Siglec-7 directly activates signaling pathways in T-cells, suggesting a new biological function for this receptor. These studies conclusively demonstrate the existence of a novel Siglec-7-mediated signaling axis that physiologically regulates T-cell activity. Going forward, our findings have significant implications for the design and implementation of therapies targeting immunoregulatory Siglec receptors.

Failure Mode and Effects Analysis Prior to the Introduction of AI Generated GTVs for Brain Metastases in the Clinical Workflow

PURPOSE/OBJECTIVE(S)

AI autosegmentation of organs-at-risk (OARs) is common practice at many radiotherapy clinics. Despite the abundance of gross tumor volume (GTV) autosegmentation algorithms, adoption in clinical care has been slow due to the high risk associated with errors in GTV delineation. Here we present a failure mode and effects analysis (FMEA) to evaluate the risk associated with introducing AI derived GTVs in patients treated with stereotactic radiosurgery (SRS).

MATERIALS/METHODS

An AI GTV autosegmentation algorithm for brain metastases was developed in-house based on a V-Net 3D CNN. Registered CT and MR images and a contour of the brain are input into the software and all identified lesions are returned in a DICOM-RT structure set. Following algorithm evaluation, a workflow was developed to enable AI GTV autosegmentation to be introduced clinically for every SRS patient. The following steps were added to existing procedures: 1) workflow to send CT/MR and brain structure to external server, 2) autosegmentation run on the server, 3) AI GTV structures with a standard nomenclature added to existing OAR structure set, and 4) MD review, editing, and approval of AI GTVs. After successfully completing the physics evaluation testing of the new process, we formed a team of 10 faculty and staff including physicists, residents, physicians, and planners to perform the FMEA prior to clinical implementation. The team met to map the process, identify potential failure modes, and score their frequency of occurrence, severity, and detectability. A 3-point scale (1, 3, or 5) was used to simplify the scoring process. Occurrence was defined as rare, sometimes, or often; severity as low, medium, or high; and detectability as obvious, possible, or challenging. The risk probability numbers (RPNs) were calculated and the steps in the process with the highest RPNs were flagged for further discussion.

RESULTS

The FMEA team completed their process map and analysis primarily in 4 meetings. The process map began with acquisition of the patients CT simulation scan and ended with physician approval of final volumes for treatment planning. We identified 17 process steps and 72 possible failure modes, of which 26 were associated with the new workflow. Eighteen failure modes had an RPN greater than 30 (highest risk score in at least one category) and were flagged to assess mitigation strategies. Five were unique to the new AI GTV workflow and mitigation strategies will be designed prior to clinical use. Those involved risks related to inaccurate AI GTV contours, false positives, and an incomplete review stemming from over-reliance by team members on AI.

CONCLUSION

AI is increasingly being employed at every step of radiotherapy to automate and streamline processes. The FMEA analysis resulted in the identification of the riskiest parts of using AI GTV autosegmentation. This can be an effective tool in the development of checks to ensure that GTV autosegmentation methods can be safely introduced in support of patient care.

Comparative analysis of the myoglobin gene in whales and humans reveals evolutionary changes in regulatory elements and expression levels

Cetacea and other diving mammals have undergone numerous adaptations to their aquatic environment, among them high levels of the oxygen-carrying intracellular hemoprotein myoglobin in skeletal muscles. Hypotheses regarding the mechanisms leading to these high myoglobin levels often invoke the induction of gene expression by exercise, hypoxia, and other physiological gene regulatory pathways. Here we explore an alternative hypothesis: that cetacean myoglobin genes have evolved high levels of transcription driven by the intrinsic developmental mechanisms that drive muscle cell differentiation. We have used luciferase assays in differentiated C2C12 cells to test this hypothesis. Contrary to our hypothesis, we find that the myoglobin gene from the minke whale, Balaenoptera acutorostrata, shows a low level of expression, only about 8% that of humans. This low expression level is broadly shared among cetaceans and artiodactylans. Previous work on regulation of the human gene has identified a core muscle-specific enhancer comprised of two regions, the "AT element" and a C-rich sequence 5' of the AT element termed the "CCAC-box". Analysis of the minke whale gene supports the importance of the AT element, but the minke whale CCAC-box ortholog has little effect. Instead, critical positive input has been identified in a G-rich region 3' of the AT element. Also, a conserved E-box in exon 1 positively affects expression, despite having been assigned a repressive role in the human gene. Last, a novel region 5' of the core enhancer has been identified, which we hypothesize may function as a boundary element. These results illustrate regulatory flexibility during evolution. We discuss the possibility that low transcription levels are actually beneficial, and that evolution of the myoglobin protein toward enhanced stability is a critical factor in the accumulation of high myoglobin levels in adult cetacean muscle tissue.

Identifying Genetic Regulators of Protein-Glycan Interactions with Genome-Wide CRISPR Screening

Glycans are carbohydrate molecules appended to proteins and lipids on the surface of all living cells. Glycans play key roles in a wide array of biological processes, and structural changes in cell-surface glycosylation patterns have been connected to pathogenesis of several diseases. In particular, cancer cells frequently upregulate expression of glycans that bind to inhibitory receptors (lectins) on immune cells. These glycosylated antigens systematically inhibit immune activity and protect cancer cells from immune surveillance. Understanding how cancer cells generate these glycan ligands can thus lead to identification of novel druggable targets for therapeutic intervention. However, glycan ligand biosynthesis is subject to extremely complex genetic regulation, making it difficult to identify the key genes involved in production of immune-regulatory glycan antigens. In a recent publication, we described a CRISPR/Cas9 screening approach to identify genes that drive synthesis of ligands for glycan-binding immune receptors. Here, we outline a detailed, step-by-step protocol for completing this type of genome-wide screen. Our protocol produces a genome-wide atlas of all genes whose expression is required for cell-surface binding of a recombinant immune lectin. This dataset can be used both to identify novel ligands for immune lectins and annotate regulatory genes that drive changes in cancer-associated glycosylation. Our protocol serves as a general resource for researchers interested in the detailed study of cancer glyco-immunology. © 2023 Wiley Periodicals LLC. Basic Protocol 1: Generation of a genome-wide CRISPR library using lentiviral transduction Support Protocol: Generation of dCas9KRAB-expressing K-562 cells Basic Protocol 2: Staining of genome-wide CRISPR libraries with Siglec-Fc reagents and fluorescence-activated cell sorting Basic Protocol 3: Library amplification and sequencing Basic Protocol 4: Data analysis and hit identification.

45 INTERPROFESSIONAL EDUCATION AND COLLABORATIVE PRACTICE IN FRAIL OLDER PERSONS’ CARE

Background

Frail older adults present with complex care needs. Inter-Professional Education (IPE) is a means of creating a practice-ready workforce to improve patient safety and healthcare outcomes. A Steering Group was established comprised of acute and community clinicians, members of the Health Service Executive, service user, students and members of all Schools in the College of Medicine and Health in an Irish University (Medicine, Nursing and Midwifery, Pharmacy, Public Health, Clinical Therapies and Dentistry) to evaluate the effectiveness of IPE. A workshop dedicated to the management of frail older adults occurred for multidisciplinary healthcare students as part of a suite of three IPE workshops.

Methods

The validated ‘Interprofessional Collaborative Competencies Attainment Survey’ (ICCAS) evaluated student views of IPE pre- & post-workshop. This workshop involved a case-based study and facilitated discussion with involvement of frail older adult service users. One service user was in a rehabilitation unit post hospital admission, the other was living well at home. Their participation occurred using an online platform, supported by a consultant geriatrician in the rehabilitation unit and a relative for the home-based service user.

Results

Student scores on the six subscales of the ICCAS (communication, collaboration, roles and responsibilities, collaborative patient-centred approach, conflict management and team functioning) were compared. Scores in all categories achieved statistically significant increases after completion of the IPE workshop. The greatest positive change was observed in collaborative patient-centred approach with pre-workshop scores increasing from a mean of 2.61 to 4.25 (p<0.05).

Conclusion

This initiative explored the inclusion of a frail older adult workshop in the higher education setting. Older adults had an opportunity to share their lived experiences. Evaluation of this IPE initiative will inform future IPE activities to be incorporated into undergraduate education programmes. Similar IPE models can be replicated nationally to enable and enhance team-based working and integrated care.

Development of PARcific Approach: Participatory Action Research Methodology for Collectivist Health Research

This article explores the evolution of a novel approach designed to advance qualitative methods in cross-cultural health research. This methodology was developed by synthesising several research methods and involved in-depth stakeholder consultation with participants of a Pacific-based nursing and midwifery health leadership program. Many of these participants played a crucial role in creating, exploring and evaluating several research methods and implementing and evaluating this co-designed research methodology. Starting with a Participatory Action Research framework, the research methodology evolved as it was informed by the local Pacific methodologies (in particular Talanoa and Kakala frameworks), where researchers, co-researchers and participants alike, working from within their own collectivist/individualist paradigms, negotiated cultural differences. Finally, a methodological framework of 'best practice' for future health research methods was developed for use with capacity building research. The new methodology could provide a foundation for future co-designed cross-cultural research in collectivist cultures.

The impact of COVID-19 on population oral health

Over the last year, coronavirus disease 2019 (COVID-19) has accumulated over 37 million cases and over one million deaths worldwide (WHO, 2020). With no population immunity or vaccine at hand, all but fifteen countries issued 'stay at home' orders in a bid to contain the spread of the virus and limit the healthcare burden. 'Lockdown' included closure of dental practices. Both the virus itself and the various Government responses have had a profound impact on the work, home and social lives of the entire population and are likely to impact the oral health of many people. These oral health effects can be attributed to those caused directly by the virus and those caused indirectly through the subsequent societal response. Direct effects of COVID-19 on oral health include ageusia (an official symptom of COVID-19) and case reports of vesiculobullous lesions and necrotising periodontal disease (Patel and Woolley 2020). The ageusia associated with COVID-19 is transient and reports of other oral manifestations are based on low-grade and disputed evidence. The direct effects of COVID-19 are likely to be of modest consequence for population oral health.

Perforating the GORE® CARDIOFORM septal occluder and atrial septal defect occluder to gain access to the left atrium

OBJECTIVE

Perforate the expanded polytetrafluoroethylene membrane of the GORE® CARDIOFORM Septal Occluder (GSO) and GORE® CARDIOFORM ASD Occluder (GCA) after implantation.

BACKGROUND

Percutaneous transseptal access to the left atrium is necessary for many structural and electrophysiological procedures. The potential need to access the left atrium may influence decision-making for patent foramen ovale or atrial septal defect closure.

METHODS

Sixteen canines underwent implantation of equal number GSO or GCA devices. A transseptal crossing procedure was performed through the device 85 (±1) days postoccluder implantation. The crossing procedure was performed utilizing commercially available equipment: radiofrequency/SureFlex sheath and standard needle/Mullin's sheath. Progressive dilation of the perforation was performed to allow passage of a 12 French Mullin's sheath into the left atrium.

RESULTS

Left atrial access was achieved in all cases. Postmortem analysis demonstrated passage through both occluder discs in all radiofrequency/SureFlex sheath cases (4 GSO, 4 GCA) and half of the standard needle/Mullin's sheath cases (3 GSO, 1 GCA). The remaining standard needle/Mullin's sheath cases demonstrated perforation through the right atrial disc but passage around the septal aspect of the left atrial disc, thus not perforating the left atrial disc. No acute embolic complications from the procedure were observed.

CONCLUSIONS

Left atrial access may be achieved through the GSO or GCA devices after implantation and endothelialization. The combination of a radiofrequency needle and steerable sheath provides benefit over a standard needle and Mullin's sheath in accomplishing passage through both occluder discs.

Sugar Free: Novel Immunotherapeutic Approaches Targeting Siglecs and Sialic Acids to Enhance Natural Killer Cell Cytotoxicity Against Cancer

Natural Killer (NK) cells are cytotoxic lymphocytes that play a key role in the immune system, targeting and destroying invading pathogens and malignantly transformed cells. Evading NK cell-mediated immunosurveillance is therefore critical to facilitating cancer cell survival and metastasis. Signals from a range of inhibitory and activating receptors located on the NK cell surface regulate NK cell cytotoxicity. Recently, attention has turned to the role of hypersialylated tumor cell surfaces in mediating immune-evasion of NK cells. Two inhibitory sialic acid-binding immunoglobulin-like lectin (Siglec) receptors are expressed by NK cells: Siglec-7 and Siglec-9. The abundance of sialic acids on tumor cell surface is hypothesized to regulate NK cell-mediated cytotoxicity by interacting with Siglec-7 and Siglec-9, causing a dampening of NK cell activation pathways. Targeting Siglec-7 and Siglec-9, or the sialic acid coated tumor cell surface is therefore being investigated as a novel therapeutic approach to enhance the NK cell response against cancer. In this review we report on the currently published documentation of the role for Siglec-7 and Siglec-9 receptors on NK cells and their ligands expressed by tumor cells. We also discuss the strategies currently explored to target Siglec-7, Siglec-9 and the sialylated tumor cell surface as well as the impact abrogation of these interactions have on NK cell cytotoxicity against several cancer types.

Learning to liaise: using medication administration role-play to develop teamwork in undergraduate nurses

Aim: To describe undergraduate nursing students' situational awareness and understanding of effective liaison and collaboration within the nursing team during interrupted medication administration.Background: Medication errors related to interruptions are a major problem in health care, impacting on patient morbidity and mortality and increasing the burden of related costs. Effective liaison, teamwork and situation awareness are requisite skills for nurses to facilitate the safe management of interruptions during medication administration.Method: A role-play simulation was offered to 528 second-year undergraduate Bachelor of Nursing students. Qualitative written reflective responses were subsequently collected and subject to thematic analysis to derive themes.Results: Participants (451:528) reported an improved understanding of an unfamiliar and challenging situation that required cooperation and collaboration amongst the nursing team to improve outcomes.Conclusion(s): This simulation exposed undergraduate nurses with limited clinical experience to a situation otherwise unavailable to them. The skills required to engage in effective liaison and teamwork in dynamic situations are vital elements in achieving quality care and must begin to be taught at an undergraduate level.

Characterization and Use of TurboLuc Luciferase as a Reporter for High-Throughput Assays

Luciferase-based reporter assays are powerful tools for monitoring gene expression in cells because of their ultrasensitive detection capacity and wide dynamic range. Here we describe the characterization and use of a luciferase reporter enzyme derived from the marine copepod Metridia luciferase family, referred to as TurboLuc luciferase (TurboLuc). To develop TurboLuc, the wild-type luciferase was modified to decrease its size, increase brightness, slow luminescent signal decay, and provide for efficient intracellular expression. To determine the enzyme susceptibility to compound inhibition and judge the suitability of using of TurboLuc as a reporter in screening assays, purified TurboLuc enzyme was screened for inhibitors using two different compound libraries. No inhibitors of this enzyme were identified in a library representative of typical diverse low molecular weight (LMW) compounds using a purified TurboLuc enzyme assay supporting that such libraries will show very low interference with this enzyme. We were able to identify a few inhibitors from a purified natural product library which can serve as useful tools to validate assays using TurboLuc. In addition to the inhibitor profile for TurboLuc we describe the use of this reporter in cells employing miniaturized assay volumes within 1536-well plates. TurboLuc luciferase is the smallest luciferase reporter enzyme described to date (16 kDa), shows bright luminescence and low interference by LMW compounds, and therefore should provide an ideal reporter in assays applied to high-throughput screening.

Pondering practice: Enhancing the art of reflection

AIMS AND OBJECTIVES

The aim of this study was to describe the effect that immersive simulation experiences and guided reflection can have on the undergraduate nurses' understanding of how stressful environments impact their emotions, performance and ability to implement safe administration of medications.

BACKGROUND

Patient safety can be jeopardised if nurses are unsure of how to appropriately manage and respond to interruptions. Medication administration errors are a major patient safety issue and often occur as a consequence of ineffective interruption management. The skills associated with medication administration are most often taught to, and performed by, undergraduate nurses in a controlled environment. However, the clinical environment in which nurses are expected to administer medications is often highly stressed and nurses are frequently interrupted.

DESIGN/METHODS

This study used role-play simulation and written reflections to facilitate deeper levels of student self-awareness. A qualitative approach was taken to explore students' understanding of the effects of interruptions on their ability to undertake safe medication administration. Convenience sampling of second-year undergraduate nursing students enrolled in a medical-surgical subject was used in this study. Data were obtained from 451:528 (85.42%) of those students and analysed using thematic analysis.

RESULTS

Students reported increasing consciousness and the importance of reflection for evaluating performance and gaining self-awareness. They described self-awareness, effective communication, compassion and empathy as significant factors in facilitating self-efficacy and improved patient care outcomes.

CONCLUSIONS

Following a role-play simulation experience, student nurses reported new knowledge and skill acquisition related to patient safety, and new awareness of the need for empathetic and compassionate care during medication administration. Practicing medication administration in realistic settings adds to current strategies that aim to reduce medication errors by allowing students to reflect on and in practice and develop strategies to ensure patient safety.

RELEVANCE TO CLINICAL PRACTICE

Experiencing clinical scenarios within the safety of simulated environments, offers undergraduate student nurses an opportunity to reflect on practice to provide safer, more empathetic and compassionate care for patients in the future.

Calm to chaos: Engaging undergraduate nursing students with the complex nature of interruptions during medication administration

AIMS AND OBJECTIVES

To describe undergraduate student nurse responses to a simulated role-play experience focussing on managing interruptions during medication administration.

BACKGROUND

Improving patient safety requires that we find creative and innovative methods of teaching medication administration to undergraduate nurses in real-world conditions. Nurses are responsible for the majority of medication administrations in health care. Incidents and errors associated with medications are a significant patient safety issue and often occur as a result of interruptions. Undergraduate nursing students are generally taught medication administration skills in a calm and uninterrupted simulated environment. However, in the clinical environment medication administration is challenged by multiple interruptions.

DESIGN/METHODS

A qualitative study using convenience sampling was used to examine student perceptions of a simulated role-play experience. Data were collected from 451 of a possible 528 student written reflective responses and subject to thematic analysis.

RESULTS

Students reported an increased understanding of the impacts of interruptions while administering medications and an improved awareness of how to manage disruptions. This study reports on one of three emergent themes: "Calm to chaos: engaging with the complex nature of clinical practice."

CONCLUSIONS

Interrupting medication administration in realistic and safe settings facilitates awareness, allows for students to begin to develop management strategies in relation to interruption and increases their confidence. Students were given the opportunity to consolidate and integrate prior and new knowledge and skills through this role-play simulation.

Electronic bulletin board distributed questionnaires for exploratory research

The use of electronic bulletin boards is increasing dramat ically ; they are now a significant source of opinion and experience-related commentary from a wide variety of people over a large range of topics. As such, they are a major information resource and potentially suitable as a vehicle for questionnaire distribution. To date, there has been no formal discussion of this vehicle - a deficiency this paper attempts to address. It discusses the advantages and disadvantages of this medium, and compares it against the other possible alternatives. We believe this comparison shows that the medium has a great deal to offer and a wide degree of applicability, especially within the area of exploratory research.

The main deficiency with the medium is that it poten tially suffers from a large-scale self-selection bias. To inves tigate this, we have conducted a questionnaire study through this medium, and subsequently replicated it using a traditional mail distribution approach. We believe that this experiment provides evidence that, for populations without a sampling frame, the effect is of a similar magni tude for both bulletin board distributed and mail distrib uted surveys. We conclude that surveys using this new medium are valid, given the above restriction.

Nursing Education on Women’s Health Care in Australia, Japan, South Korea, and Thailand

Only within the last 3 decades have a select number of countries addressed issues surrounding the all-inclusive health and well-being of women. This factor has had a major influence on nursing education within these countries and the subsequent development of curricula. Because the preparation of nurses is pivotal in shaping a society’s health care agenda, this article compares and contrasts demographic characteristics, curricular frameworks, the role of the nurse, quality control of nursing curricula, and the focus of nursing courses related to women’s health care among the countries of Australia, Japan, South Korea, and Thailand. Recommendations based on infant mortality rates, life expectancy, leading causes of death, and country-based health care issues are provided to inform and guide the future focus of nursing education courses on women’s healthcare within these countries.

Perceptions and Experiences of Heart Disease: A Literature Review and Identification of a Research Agenda in Older Women

BACKGROUND

Following diagnosis of heart disease women have poorer health related outcomes compared with men. Nursing science lacks well-evaluated interventions to address the specific rehabilitative needs of older women with heart disease. This paper seeks to inform the development of nursing intervention studies by a review of published studies on the experiences and rehabilitative needs of older women with heart disease.

METHODS

The CINAHL, MEDLINE, FAMILY and PsychINFO databases were searched, identifying literature published from 1982 and written in English. Keywords used were women, old* (old, older) women, elderly women and: heart disease, heart failure, cardiac and rehabilitation. Hand searching of nursing and medical textbooks also occurred. These searches resulted in over 120 articles that met the criteria of describing experiences, perceptions, psychological responses and support rehabilitative needs of older women.

RESULTS

Older women present with symptoms that are different from those derived from a male-dominated research agenda and further there is a paucity of data related to evaluation of interventions tailored to the needs of women. Key themes emerging from the literature review include not only that older women compared with men have a poorer prognosis and experience greater disability moreover they: (1). are at a higher risk of psychosocial distress; (2). have a greater need for instrumental support and social support; (3). have an altered perception of risk; and (4). demonstrate the need for specific rehabilitation programs, tailored to their needs.

CONCLUSION

Future research should develop and evaluate intervention studies that better meet the unique needs of older women with heart disease. Particular emphasis needs to be on psychosocial aspects, given evidence that identify these are major concerns for women.

Developing resilience: Stories from novice nurse academics

BACKGROUND

It is acknowledged that novice nurse academics face many challenges on commencement of their new role. Most are recruited from the clinical arena, with little understanding of the academic triumvirate of teaching, research and service. They struggle with role expectation and experience feelings of isolation and anxiety.

AIM

The aim of this paper is to report on an exploration of 14 new nurse academics from two major nursing education institutions as they utilised and developed resilience building strategies.

METHOD

The paper is drawn from a qualitative study that sought to see the world through the eyes of the participants through storytelling. Data was collected using semi-structured, conversational style interviews. Interviews were audio recorded and revealed themes that captured resilience strategies.

RESULTS

These themes were: Developing supportive collegial relationships; Embracing positivity; and Reflection and transformative growth. The first theme, developing supportive relationships, provides insight into the mentoring process and the relationships developed with peers and colleagues. The second theme, embracing positivity, describes the factors that assisted them to face the adversity and challenges in the new role. The final theme, reflection and transformative growth, demonstrated participants' reflecting on difficult situations and demonstrating the ability to learn from the experiences and move forward.

CONCLUSIONS

The strategies utilised by the participants in this study were key factors in the development of resilience which assisted in the transition from clinical nurse to academic. These strategies were often tacit and it is imperative that in a time of acute nurse academic shortages where retention is paramount, that employing organisations support employees and contribute to resilience development. Education on resilience building strategies is fundamental for all new academics and is essential in the transition from clinical nurse to academic.

The consequences of English language testing for international health professionals and students: An Australian case study

AIM

To discuss the perceptions about the International English Language Testing System (IELTS) and its impact on migration and practice of migrant health professionals in Australia.

METHODS

Thematic analysis of interviews with 14 health industry participants and 35 migrated health professionals in Australia.

RESULTS AND DISCUSSION

Language testing is a barrier to health professional registration for migrant health workers in Australia. While two English language tests are recognised by the registration authorities in Australia, it is the International English Language Testing System that is most commonly used. This paper reports that study participants had underlying negative perceptions of the International English Language Testing System which they report, affect their move to Australia. These negative perceptions are caused by: frustration due to changes to processes for migration and registration; challenges regarding the structure of IELTS including timing of when test results expire, scoring requirements, cost, and suitability; and the resulting feelings of inadequacy caused by the test itself.

CONCLUSION

This study has shown that some respondents have experienced difficulties in relation to the International English Language Testing System as part of their migration process. It was found that there is very little research into the effectiveness of the IELTS as it is currently administered for overseas health care professionals. Several recommendations are provided including areas for further research.

Distilling the Antecedents and Enabling Dynamics of Leader Moral Courage: A Framework to Guide Action

Intelligent, robust and courageous nursing leadership is essential in all areas of nursing, including mental health. However, in the nursing leadership literature, the theoretical discourse regarding how leaders recognise the need for action and make the choice to act with moral purpose is currently limited. Little has been written about the cognitions, capabilities and contextual factors that enable leader courage. In particular, the interplay between leader values and actions that are characterised as good or moral remains underexplored in the nursing leadership literature. In this article, through a discursive literature synthesis we seek to distill a more detailed understanding of leader moral courage; specifically, what factors contribute to leaders' ability to act with moral courage, what factors impede such action, and what factors do leaders need to foster within themselves and others to enable action that is driven by moral courage. From the analysis, we distilled a multi-level framework that identifies a range of individual characteristics and capabilities, and enabling contextual factors that underpin leader moral courage. The framework suggests leader moral courage is more complex than often posited in theories of leadership, as it comprises elements that shape moral thought and conduct. Given the complexity and challenges of nursing work, the framework for moral action derived from our analysis provides insight and suggestions for strengthening individual and group capacity to assist nurse leaders and mental health nurses to act with integrity and courage.

Aesthetic Leadership: Its Place in the Clinical Nursing World

Clinical leadership has been identified as crucial to positive patient/client outcomes, across all clinical settings. In the new millennium, transformational leadership has been the dominant leadership style and in more recent times, congruent leadership theory has emerged to explain clinical leadership in nursing. This article discusses these two leadership models and identifies some of the shortcomings of them as models for clinical leadership in nursing. As a way of overcoming some of these limitations, aesthetic leadership is proposed as a style of leadership that is not antithetical to either model and reflects nursing's recognition of the validity of art and aesthetics to nursing generally. Aesthetic leadership is also proposed as a way to identify an expert clinical leader from a less experienced clinical leader, taking a similar approach to the way Benner (1984) has theorised in her staging of novice to expert clinical nurse.

Coronary heart disease in Aboriginal communities: Towards a model for self-management

Coronary heart disease (CHD) is one of the main causes of death and disability in the Aboriginal population, and is the major cause of the twenty-year gap in life expectancy of Aboriginal and non-Aboriginal Australians. This paper explores Aboriginal health in relation to CHD, and suggests self-management as a culturally acceptable therapeutic and sustainable ideology from which positive outcomes may be achieved.

Globalisation as we enter the 21st century: Reflections and directions for nursing education, science, research and clinical practice

The events of September 11th, 2001 in the United States and the Bali bombings of October 2002 are chastening examples of the entangled web of the religious, political, health, cultural and economic forces we experience living in a global community. To view these forces as independent, singular, linearly deterministic entities of globalisation is irrational and illogical. Understanding the concept of globalisation has significant implications not only for world health and international politics, but also the health of individuals. Depending on an individual's political stance and world-view, globalisation may be perceived as an emancipatory force, having the potential to bridge the chasm between rich and poor or, in stark contrast, the very essence of the divide. It is important that nurses appreciate that globalisation does not pertain solely to the realms of economic theory and world politics, but also that it impacts on our daily nursing practice and the welfare of our patients. Globalisation and the closer interactions of human activity that result, have implications for international governance, policy and theory development as well as nursing education, research and clinical practice. Nurses, individually and collectively, have the political power and social consciousness to influence the forces of globalisation to improve health for all. This paper defines and discusses globalisation in today's world and its implications for contemporary nursing education, science, research and clinical practice.

Australian women and heart disease: Trends, epidemiological perspectives and the need for a culturally competent research agenda

Heart disease commonly manifests as acute coronary syndromes (unstable angina pectoris, or myocardial infarction) and heart failure (HF). These conditions are major causes of morbidity and mortality in Australia and internationally. Australian faces particular challenges in health care delivery given the cultural and ethnic diversity of society and unique issues related to rurality. These factors have significant implications for health care delivery. Following an acute cardiac event women have poorer outcomes: higher mortality rates, higher incidence of complications and greater psychological morbidity compared with men. Language barriers, socioeconomic factors, psychological trauma related to migration and alternate health seeking behaviors and varying perceptions of risk are likely to impact adversely on health outcomes. Self-management in chronic cardiovascular disease underscores the importance of models of care that incorporate aspects related to self-care and promotion of adherence to primary and secondary prevention initiatives. Implicit in this statement is the inclusion of the individual in negotiating and developing their care plan. Therefore health professionals need to be aware of the patient's needs, values, beliefs and health seeking behaviours. These factors are strongly influenced by culture and ethnicity. The cultural diversity of Australian society mandates cultural competence in health care. This paper presents an overview of nursing science related to women and heart disease in Australia and suggests directions for culturally-competent research and development and evaluation of models of care to improve health outcomes for all Australians.

A case for consideration of cultural diversity in heart failure management ‐ Part 1: Rationale for the DISCOVER Study

Heart failure is a condition increasing in prevalence and responsible for high health care utilization, morbidity and mortality. Randomised controlled trials of nurse-coordinated interventions have determined self-care and the incorporation of the patient and their family in care planning as critical elements of service delivery. Coping with a chronic illness, such as heart failure, forces the individual to adjust to changed physical, social and emotional functioning and to modify their lifestyle accordingly. Clinicians increasingly use models of care that focus care delivery on the community setting. In order to develop strategies to assist patients and their families with self-care it is important that clinicians understand the health-care seeking behaviours of all individuals targeted in the community. Australia is a culturally diverse nation, yet evaluations of models of care have been undertaken largely in individuals from predominately Anglo-Celtic origins. The end result of this approach is failure to understand the full range of diverse perspectives that individuals hold that can have an impact on self-care behaviours. Consideration of cultural diversity should extend beyond language to a broader appreciation of cultural values, health seeking beliefs and engagement of culturally unique communities. The 'Understanding the cultural experiences of individuals with chronic heart failure (CHF) in South East Health (DISCOVER) Study' seeks to uncover information on the health patterns, information needs and the adjustment process for overseas-born individuals with heart failure. Such information will assist clinicians to tailor health care service delivery and ensure the delivery of appropriate, quality care. This manuscript provides the background, rationale and methods for this study.