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In spite of numerous observations that government organizations have high levels of organizational goal ambiguity that exert major influences on their other characteristics, few researchers have measured goal ambiguity and tested these frequent assertions. In previous research, we developed measures of four dimensions of goal ambiguity: mission comprehension ambiguity, directive goal ambiguity, evaluative goal ambiguity, and priority goal ambiguity. Confirming hypotheses developed from the literature on public organizations, the latter three variables showed relations to such organizational characteristics as organizational age, financial publicness (proportion of funding from government allocations), and regulatory status. This article reports a second analytical step of examining the relations between the goal ambiguity dimensions and indicators of organizational performance based on responses to the 2000 National Partnership for Reinventing Government Survey of federal employees. The performance variables included managerial effectiveness, customer service orientation, productivity, and work quality. Regression analyses with numerous control variables found that directive, evaluative, and priority goal ambiguity related negatively to managerial effectiveness. All four performance indicators showed significant negative relationships with evaluative goal ambiguity and directive goal ambiguity. The results provide further evidence of the viability of the new measures of goal ambiguity, support theory-based but previously untested hypotheses, and further indicate the feasibility and value of analyzing goal ambiguity of government organizations.

Observations that government organizations have particularly high levels of organizational goal ambiguity, and that this goal ambiguity has major influences on their other characteristics, abound in the literature on public bureaucracy. Few researchers, however, have developed quantified measures of goal ambiguity and tested these frequent assertions with large samples of government organizations. We develop measures of four dimensions of goal ambiguity: mission comprehension ambiguity, directive goal ambiguity, evaluative goal ambiguity, and priority goal ambiguity. Confirming hypotheses developed from the literature on public organizations, the last three variables show relations to organizational age, financial publicness (proportion of funding from government allocations), competing demands, policy problem complexity, and regulatory status. The success of the measures of goal ambiguity demonstrates the feasibility of measuring the concept and conducting empirical tests of observations that are often repeated without such testing, and will support further theoretical and methodological development of this important topic.

The article focuses on sterilization technique by gamma rays in hospitals in New Zealand. The concept of pre-sterilized medical disposables has made a considerable impact on the medical and nursing world in the last fifteen years. The sterilization techniques in vogue in New Zealand hospitals up to ten years ago involved multiple steam sterilization apparatus of all sizes and types, randomly distributed through all wards and departments. Several major advantages of gamma ray sterilization are immediately obvious. Because sterility is ensured and because the pack is disposable cross-infection is eliminated. Noise in wards arising in part from the use of conventional metal trays and instruments is eliminated.

Chronic kidney disease (CKD) is a common long-term condition and is associated with increased mortality and a reduction in healthy years of life. Early identification and appropriate treatment of CKD can reduce these risks. The inclusion of CKD in any discussions with people about other long-term health conditions such as cardiovascular disease and diabetes mellitus is also essential. All nurses need to understand the risks associated with CKD so that they can develop the confidence to routinely discuss the condition with patients and support them to improve their health., Competing Interests: None declared, (© 2023 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Objective: Patient-reported outcomes (PROs) can provide critical information concerning the impact of a disease on an individual. Mobile technology to collect PRO data in an electronic format (ePRO) allows for frequent assessment in the person's regular environment. The goal of this study was to assess the compliance with a phone application (app) and validate ePRO information in individuals with systemic lupus erythematosus (SLE)., Methods: A smartphone app that collects ePRO data from various clinical instruments was developed. Information was collected by both an ePRO and a paper-administered instrument as part of a multicenter randomized interventional clinical trial of patients meeting American College of Rheumatology (ACR) criteria for the classification of SLE. To determine agreement between PRO information collected in the different formats, intraclass correlation coefficients (ICCs), paired Student's t tests, and Bland-Altman plots were evaluated. Compliance and Cronbach's alpha were also assessed as a measure of survey reliability., Results: For the 62 subjects from diverse ancestral backgrounds, compliance with ePRO completion was high (more than 75%). Cronbach alpha values for PROs indicated moderate to high survey reliability. The vast majority (73.4%) of ICC values were indicative of good to excellent reliability between measurement methods. Bland-Altman plots verified method agreement, and 87% of pairwise t tests yielded an insignificant difference between information collected with the different administration methods., Conclusion: The excellent compliance and the high level of consistency between data collected by paper and that collected by electronic methods indicate that the app provides a reliable means of cataloging real-time changes in PROs in SLE patients., (© 2021 The Authors. ACR Open Rheumatology published by Wiley Periodicals LLC on behalf of American College of Rheumatology.)

Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.

Introduction: This paper analyses the important enablers, barriers and impacts of country-wide implementation of integrated health and social care in Scotland. It offers insights for other systems seeking to advance similar policy and practice., Description: Landmark legislation was based on a shared vision and narrative about improving outcomes for people and communities. Implementation has involved coordination of multiple policies and interventions for different life stages, care groups, care settings and local context within a dynamic and complex system., Discussion: Relational and citizen led approaches are critical for success, but it takes time to build trusting relationships, influence organisational and professional cultures and cede power. Assessing national impacts is challenging and progress at a national level can seem slower than local experience suggests, due in part to the relative immaturity of national datasets for community interventions. Five years on there are many examples of innovation and positive outcomes despite increasing demographic, workforce, and financial challenges. However, inequalities continue to increase., Conclusion: Realising the true value from integration will require a stronger focus on place-based prevention and early intervention to achieve a fairer Scotland where everybody thrives. Solidarity, equity, and human rights must guide the next phase of Scotland's story., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2021 The Author(s).)

Background: An innovative Community Kidney Service has been running since 2016 in four health regions in East London, United Kingdom. This paper focuses on the patient education (self-management) programme within the service., Objective: To understand the experiences of people with stage 1-3b chronic kidney disease invited to individual or group education sessions. To assess the usefulness of the programme's educational resources to primary care nurses., Design: A mixed-method project. A steering group involving patients shaped both survey and interview questions., Participants: Paper surveys (n = 266) were sent to patients 7-19 months after they had attended. Semi-structured interviews were undertaken with patients who returned the survey and indicated they were willing to be interviewed (n = 9). Survey links were sent electronically to primary care nurses., Results: Fifty-four surveys were returned from patients. The education session increased self-reported knowledge about kidney disease and two-thirds of patients reported making lifestyle changes. Analysis of interview data identified recognition of kidney disease, motivation to change and reliance on "experts" as key themes. Surveys were returned from 21 nurses. Most were aware of the community kidney service but only one-third had used the education resources with their patients., Conclusion: Secondary care nursing involvement in primary care-based education for people with kidney disease is rare in the United Kingdom and internationally. This educational intervention, developed with patients, supports people to make changes that have the potential to reduce progression of kidney disease and our findings have significance for other teams working in chronic kidney disease management., (© 2020 European Dialysis and Transplant Nurses Association/European Renal Care Association.)

Many nations use ecological compensation policies to address negative impacts of development projects and achieve No Net Loss (NNL) of biodiversity and ecosystem services. Yet, failures are widely reported. We use spatial simulation models to quantify potential net impacts of alternative compensation policies on biodiversity (indicated by native vegetation) and two ecosystem services (carbon storage, sediment retention) across four case studies (in Australia, Brazil, Indonesia, Mozambique). No policy achieves NNL of biodiversity in any case study. Two factors limit their potential success: the land available for compensation (existing vegetation to protect or cleared land to restore), and expected counterfactual biodiversity losses (unregulated vegetation clearing). Compensation also fails to slow regional biodiversity declines because policies regulate only a subset of sectors, and expanding policy scope requires more land than is available for compensation activities. Avoidance of impacts remains essential in achieving NNL goals, particularly once opportunities for compensation are exhausted.

A global goal of no net loss of natural ecosystems or better has recently been proposed, but such a goal would require equitable translation to country-level contributions. Given the wide variation in ecosystem depletion, these could vary from net gain (for countries where restoration is needed), to managed net loss (in rare circumstances where natural ecosystems remain extensive and human development imperative is greatest). National contributions and international support for implementation also must consider non-area targets (for example, for threatened species) and socioeconomic factors such as the capacity to conserve and the imperative for human development.

Background: The UK national chronic kidney disease (CKD) audit in primary care shows diagnostic coding in the electronic health record for CKD averages 70%, with wide practice variation. Coding is associated with improvements to risk factor management; CKD cases coded in primary care have lower rates of unplanned hospital admission., Aim: To increase diagnostic coding of CKD (stages 3-5) and primary care management, including blood pressure to target and prescription of statins to reduce cardiovascular disease risk., Design and Setting: Controlled, cross-sectional study in four East London clinical commissioning groups (CCGs)., Method: Interventions to improve coding formed part of a larger system change to the delivery of renal services in both primary and secondary care in East London. Quarterly anonymised data on CKD coding, blood pressure values, and statin prescriptions were extracted from practice computer systems for 1-year pre- and post-initiation of the intervention., Results: Three intervention CCGs showed significant coding improvement over a 1 year period following the intervention (regression for post-intervention trend P <0.001). The CCG with highest coding rates increased from 76-90% of CKD cases coded; the lowest coding CCG increased from 52-81%. The comparison CCG showed no change in coding rates. Combined data from all practices in the intervention CCGs showed a significant increase in the proportion of cases with blood pressure achieving target levels (difference in proportion P <0.001) over the 2-year study period. Differences in statin prescribing were not significant., Conclusion: Clinically important improvements to coding and management of CKD in primary care can be achieved by quality improvement interventions that use shared data to track and monitor change supported by practice-based facilitation. Alignment of clinical and CCG priorities and the provision of clinical targets, financial incentives, and educational resource were additional important elements of the intervention., (© British Journal of General Practice 2019.)

Colorectal cancer remains a leading source of cancer mortality worldwide. Initial response is often followed by emergent resistance that is poorly responsive to targeted therapies, reflecting currently undruggable cancer drivers such as KRAS and overall genomic complexity. Here, we report a novel approach to developing a personalized therapy for a patient with treatment-resistant metastatic KRAS-mutant colorectal cancer. An extensive genomic analysis of the tumor's genomic landscape identified nine key drivers. A transgenic model that altered orthologs of these nine genes in the Drosophila hindgut was developed; a robotics-based screen using this platform identified trametinib plus zoledronate as a candidate treatment combination. Treating the patient led to a significant response: Target and nontarget lesions displayed a strong partial response and remained stable for 11 months. By addressing a disease's genomic complexity, this personalized approach may provide an alternative treatment option for recalcitrant disease such as KRAS-mutant colorectal cancer.

In head and neck cancer (HNC), couple-based interventions may be useful for facilitating treatment completion, patient rehabilitation, and improving both partners' quality of life. With the goal of identifying targets for future interventions, we conducted a qualitative study to understand patient and spouse unmet needs and relationship challenges during curative radiotherapy for HNC. Semistructured interviews were conducted with six HNC patients (83% male) and six spouses (83% female) within 6 months of completing treatment. Interviews were audiotaped and transcribed using grounded theory analysis. Patients and spouses identified several unmet needs including better preparation regarding the severity of physical side effects, a clearer timeline for recovery, and strategies for dealing with their own and each other's emotional reactions. Caregiver's unmet needs included balancing competing roles/responsibilities, making time for self-care, and finding effective strategies for encouraging patient's self-care. Eighty-three percent of spouses and all patients reported increased conflict during treatment. Other relationship challenges included changes in intimacy and social/leisure activities. Findings suggest that couple-based interventions that emphasize the importance of managing physical and psychological symptoms through the regular practice of self-care routines may be beneficial for both patients and spouses. Likewise, programs that teach spouses ways to effectively motivate and encourage patients' self-care may help minimize conflict and help couples navigate HNC treatment and recovery together as a team.

Background: Exposure to musculoskeletal ultrasound (MSUS) is now a mandatory component of physical medicine and rehabilitation (PM&R) residency training. However, reports on the extent of the implementation and efficacy of MSUS education are lacking in the literature., Objective: To determine the extent to which PM&R residencies are implementing MSUS education., Design: Cross-sectional., Setting: Institutional., Participants: Thirty-six of the 78 United States PM&R residency programs accredited by the Accreditation Council for Graduate Medical Education., Methods: All 78 programs were solicited with an online survey via the residency program director and coordinator in July 2014. The 25 questions on the survey were aimed at determining program MSUS educational characteristics and their effectiveness., Main Outcome Measures: Description of teaching methods used for MSUS, residency demographics, characteristics of MSUS faculty expertise, and faculty-perceived competency in MSUS examinations and procedures among residents. Data were analyzed using both descriptive statistics and tests for independence to identify correlations between program characteristics and resident MSUS competency., Results: A response was received from 36 of the 78 residency programs (46.2%). Of the 36 residency programs that responded, 97.2% provide exposure to MSUS (a figure that drops to 44.9% when nonrespondents are included); 61% had mandatory MSUS training (28.2% when including nonrespondents); and 44.4% had a formal curriculum (20.5% when including nonrespondents). The most common MSUS educational tools used were lecture (88.9%), outpatient clinic (86.1%), and hands-on workshops (86.1%). Sixty-one percent of responding programs evaluate residents with formal assessment tools. Overall, faculty at 38.8% and 44.4% of programs believed that at least 50% of residents who graduate are competent in diagnostic and interventional MSUS, respectively. These rates were significantly associated with the use of formal assessment., Conclusion: MSUS education is growing in PM&R, but many programs still have not adopted a formal educational curriculum. Formal assessment to evaluate resident MSUS skills significantly improves faculty-perceived MSUS competency., (Copyright © 2016 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Background: Poor recognition of and response to acute illness in hospitalized patients continues to cause significant harm despite the implementation of safety strategies such as early warning scores. Patients and their relatives may be able to contribute to their own safety by speaking up about changes in condition, but little is known about the factors that influence this. This study examined the experiences and views of patients and their relatives to determine the potential for involvement in promoting their own safety., Methods: This data set is drawn from a wider ethnographic study of the management of the acutely ill patient in hospital. Thirteen patients and seven relatives from two medical settings in two UK NHS Trusts were interviewed. Thematic analysis identified factors likely to influence patients' and their relatives' ability to contribute to the management of deterioration., Results: All patients interviewed had experienced their acute illness within the context of a long-term health problem. Speaking up was influenced by the ability to recognize changes in clinical condition, self-monitoring, confidence and trust, and culture and system of health care. When patients or relatives did raise concerns, health-care staff had a mediating effect on their comfort with and the effectiveness of speaking up., Implications: Safety strategies based on patient involvement must take account of the complexities of acute illness. Those that promote partnership may be more acceptable to patients, their families and staff than those that promote challenging behaviour and may ultimately prove to be most safe and effective., (© 2013 Blackwell Publishing Ltd.)

African forest elephants- taxonomically and functionally unique-are being poached at accelerating rates, but we lack range-wide information on the repercussions. Analysis of the largest survey dataset ever assembled for forest elephants (80 foot-surveys; covering 13,000 km; 91,600 person-days of fieldwork) revealed that population size declined by ca. 62% between 2002-2011, and the taxon lost 30% of its geographical range. The population is now less than 10% of its potential size, occupying less than 25% of its potential range. High human population density, hunting intensity, absence of law enforcement, poor governance, and proximity to expanding infrastructure are the strongest predictors of decline. To save the remaining African forest elephants, illegal poaching for ivory and encroachment into core elephant habitat must be stopped. In addition, the international demand for ivory, which fuels illegal trade, must be dramatically reduced.

The rapid disruption of tropical forests probably imperils global biodiversity more than any other contemporary phenomenon. With deforestation advancing quickly, protected areas are increasingly becoming final refuges for threatened species and natural ecosystem processes. However, many protected areas in the tropics are themselves vulnerable to human encroachment and other environmental stresses. As pressures mount, it is vital to know whether existing reserves can sustain their biodiversity. A critical constraint in addressing this question has been that data describing a broad array of biodiversity groups have been unavailable for a sufficiently large and representative sample of reserves. Here we present a uniquely comprehensive data set on changes over the past 20 to 30 years in 31 functional groups of species and 21 potential drivers of environmental change, for 60 protected areas stratified across the world’s major tropical regions. Our analysis reveals great variation in reserve ‘health’: about half of all reserves have been effective or performed passably, but the rest are experiencing an erosion of biodiversity that is often alarmingly widespread taxonomically and functionally. Habitat disruption, hunting and forest-product exploitation were the strongest predictors of declining reserve health. Crucially, environmental changes immediately outside reserves seemed nearly as important as those inside in determining their ecological fate, with changes inside reserves strongly mirroring those occurring around them. These findings suggest that tropical protected areas are often intimately linked ecologically to their surrounding habitats, and that a failure to stem broad-scale loss and degradation of such habitats could sharply increase the likelihood of serious biodiversity declines.

Introduction: Rapid response systems (RRSs) have been introduced to facilitate effective 'rescue' of seriously ill patients on hospital wards. While research has demonstrated some benefit, uncertainty remains regarding impact on patient outcomes. Little is known about the relationship between social contexts and the application of the RRS., Design: This comparative case study of the RRS within the medical services of two UK hospitals used ethnographic methods over a 12-month period in 2009, including observation (ward work and shadowing medical staff = 150 h), interviews with doctors, ward and critical care nurses, healthcare assistants, safety leads and managers (n=35), documentary review and analysis of routine data. Data were analysed using NVivo software., Results: The RRS reduced variability in recording, recognition and response behaviour. The RRS formalised understandings of deterioration and provided a mandate for escalating care across professional and hierarchical boundaries. However, markers of deterioration not assimilated into risk scores were marginalised and it was harder for staff to escalate care without the 'objective evidence' provided by the score. Contextual features (eg, leadership, organisational culture and training) shaped implementation, utilisation and impact of the RRS. Reporting and feedback of audit data enabled learning about 'selected' escalation work on the wards. Difficulties with referral upwards and across medical boundaries were reported by junior medical staff., Conclusion: Locating a RRS within a pathway of care for the acutely ill patient illustrates the role of these safety strategies within the social organisation of clinical work. There is a need to broaden the focus of inquiry from detection and initiation of escalation (where the strategies are principally directed) towards team response behaviour and towards those medical response practices which to date have escaped scrutiny and monitoring.

Introduction: Rapid response systems (RRSs) have been introduced to facilitate effective 'rescue' of seriously ill patients on hospital wards. While research has demonstrated some benefit, uncertainty remains regarding impact on patient outcomes. Little is known about the relationship between social contexts and the application of the RRS., Design: This comparative case study of the RRS within the medical services of two UK hospitals used ethnographic methods over a 12-month period in 2009, including observation (ward work and shadowing medical staff = 150 h), interviews with doctors, ward and critical care nurses, healthcare assistants, safety leads and managers (n=35), documentary review and analysis of routine data. Data were analysed using NVivo software., Results: The RRS reduced variability in recording, recognition and response behaviour. The RRS formalised understandings of deterioration and provided a mandate for escalating care across professional and hierarchical boundaries. However, markers of deterioration not assimilated into risk scores were marginalised and it was harder for staff to escalate care without the 'objective evidence' provided by the score. Contextual features (eg, leadership, organisational culture and training) shaped implementation, utilisation and impact of the RRS. Reporting and feedback of audit data enabled learning about 'selected' escalation work on the wards. Difficulties with referral upwards and across medical boundaries were reported by junior medical staff., Conclusion: Locating a RRS within a pathway of care for the acutely ill patient illustrates the role of these safety strategies within the social organisation of clinical work. There is a need to broaden the focus of inquiry from detection and initiation of escalation (where the strategies are principally directed) towards team response behaviour and towards those medical response practices which to date have escaped scrutiny and monitoring.