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BACKGROUND: Repeated application of foundational science (FS) during medical reasoning results in encapsulation of knowledge needed to develop clinical expertise. Despite proven benefit of educating learners using a FS framework to anchor clinical decision making, how FS is integrated on clinical rotations has not been well characterized. This study examines how and when FS discussion occurs on internal medicine teaching rounds. MATERIAL AND METHODS: We performed a convergent mixed method study. Six internal medicine teams at a quaternary hospital were observed during rounds and team members interviewed. Transcripts were analyzed using thematic analysis. Descriptive statistics provided a summary of the observations. RESULTS: Our study revealed that rounds used a teacher-centered model where FS knowledge was transmitted as pearls external to the clinical context. FS content arose primarily when the patient was complex. Barriers preventing FS discussion were lack of time and perceived lack of personal FS knowledge. CONCLUSION: Our study describes scenarios that commonly elicit discussion of FS on inpatient medicine rounds highlighting a 'transmission' model of FS knowledge. We suggest a learner-centered model that engages students in the practice of integrating FS into clinical reasoning.

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Some internal medicine residency program directors have expressed concerns that their third-year residents may have been subjected to inappropriate communication during the 2016 fellowship recruitment season. The authors sought to study applicants' interpersonal communication experiences with fellowship programs. Many respondents indicated that they had been asked questions that would constitute violations of the National Residency Matching Program (NRMP) Communications Code of Conduct agreement, including how they plan to rank specific programs. Moreover, female respondents were more likely to have been asked questions during interview experiences about other programs to which they applied, and about their family plans. Post-interview communication policies were not made clear to most applicants. These results suggest ongoing challenges for the internal medicine community to improve communication with applicants and uniform compliance with the NRMP communications code of conduct during the fellowship recruitment process.

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AIM: To identify the facilitators and barriers for health-care organizations to sustain Magnet Recognition, the exemplar of a professional practice environment and quality care. BACKGROUND: Recognition as a Magnet Hospital is the gold standard for acknowledging excellence in nursing. However, limited evidence exists to inform nursing management practices for sustainability. METHOD: This qualitative study was conducted using a national convenience sample of 15 Chief Nursing Officers of Magnet Recognized hospitals in the USA. RESULTS: Key macrosystem facilitators included executive management and leadership themes about quality, people, education, and the nurse executive's commitment and intent. Barriers were executive management turnover and financial challenges. Infrastructure supports and resources for empowerment and quality and unit leadership practices were found to be essential for quality outcomes. The key theme at the microsystem level was moving nursing practice to managing outcomes from tasks; barriers were challenges with unit management turnover and development. CONCLUSIONS: Multiple factors at system levels were found to contribute to sustainability. Further research is needed on the concept of sustainability. IMPLICATIONS FOR NURSING MANAGEMENT: The findings contribute to executives' armamentarium to inform management practice for the design of evidenced based organizational systems and programs for nursing excellence.

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The professional practice of registered nurses (RNs) and their professional role competence are key variables that have an impact on quality and patient safety. Organizations in which RNs practice must have the capacity to fully support the professional role of those RNs in exercising their legitimate power derived through nurse licensing laws and professional standards and ethics. The interplay of individual RN practice and organizational practice, and measurement thereof, are the essence of organizational capacity. Two models are discussed that tie together the attributes of healthy workplace environments and provide the structure to guide and sustain organizational capacity.

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Leaders are bombarded with healthy workplace articles and advice. This article outlines a strategy for laying the foundation for healthy patient care workplaces at the pivotal unit level. This process facilitates the nursing unit staff to create and implement a shared vision for staff working relationships. Fourteen acute care hospital units, all participants in a healthy workplace intervention, were selected for this analysis because they chose team behavioral norms as a top priority to begin to implement their vision for a desired future for their units, a healthy workplace. These units developed specific team behavioral norms for their expectations of each other. The findings revealed 3 major norm themes and attributes: norms for effective communication, positive attitude, and accountability. Attributes of each norm are described to assist nurses to positively influence their core unit work culture.

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Hemolysis presents as acute or chronic anemia, reticulocytosis, or jaundice. The diagnosis is established by reticulocytosis, increased unconjugated bilirubin and lactate dehydrogenase, decreased haptoglobin, and peripheral blood smear findings. Premature destruction of erythrocytes occurs intravascularly or extravascularly. The etiologies of hemolysis often are categorized as acquired or hereditary. Common acquired causes of hemolytic anemia are autoimmunity, microangiopathy, and infection. Immune-mediated hemolysis, caused by antierythrocyte antibodies, can be secondary to malignancies, autoimmune disorders, drugs, and transfusion reactions. Microangiopathic hemolytic anemia occurs when the red cell membrane is damaged in circulation, leading to intravascular hemolysis and the appearance of schistocytes. Infectious agents such as malaria and babesiosis invade red blood cells. Disorders of red blood cell enzymes, membranes, and hemoglobin cause hereditary hemolytic anemias. Glucose-6-phosphate dehydrogenase deficiency leads to hemolysis in the presence of oxidative stress. Hereditary spherocytosis is characterized by spherocytes, a family history, and a negative direct antiglobulin test. Sickle cell anemia and thalassemia are hemoglobinopathies characterized by chronic hemolysis.

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