Nursing Home Staff with Children: Unique Needs Among Single and Partnered Parents.

BACKGROUND AND OBJECTIVES: Nursing home (NH) staff job dissatisfaction and turnover are associated with lower care quality. However, little is known about the impact of being single on workplace experiences. Guided by the Job Demands-Control-Support Model, we compared job satisfaction, turnover intention, and psychological distress for single and partnered parents working in NHs. RESEARCH DESIGN AND METHODS: Employee and manager data from the 2011-12 wave of the Work Family Health Network study were combined (N=1,144) to define parents with complete data (N=586). Bivariate tests and multivariate regressions clustering observations within NHs were used. RESULTS: Most single parents (n=190, 32%) were nursing assistants (NAs) (n=142, 74.74%) or licensed practical nurses (LPNs) (n=29, 15.26%). Compared to partnered parents, single parents were similar on turnover intention and job satisfaction, but they were more likely to report distress (OR=1.79, 95% CI 1.09, 2.94) observed only among NAs (OR=2.08, 95% CI 1.12, 3.85). Psychological distress was associated with greater turnover intent (ß =0.02, p<.05) among NAs and LPNs, yet only among single parents (ß =0.04, p<.01). Distress was more likely with higher family-to-work conflict (OR= 1.67, 95% CI 1.18, 2.36) and work-to-family conflict (OR=1.60, 95% CI 1.20, 2.14) among licensed nurses, yet the distress-work-family conflict associations were only significant for partnered parent nurses. DISCUSSION AND IMPLICATIONS: Supporting NH staff depends upon knowing their parental, relationship, and occupational status. Additional research is needed to understand and develop strategies to mitigate psychological distress and increase resources particularly among NA single parents employed in NHs.

Piloting the role of the chief well-being officer in Veterans Health Administration: The auspicious start.

INTRODUCTION: Emerging evidence from private sector hospitals indicates that a chief well-being officer (CWO) can be an impactful role to lead organizational burnout mitigation efforts in health care systems. A descriptive process evaluation was conducted to learn about facilitators and barriers of integrating this role within the Veterans Health Administration (VA). A pilot intervention inclusive of three domains-culture of well-being, efficiency of practice, and personal resilience-was implemented. METHOD: Eight VA medical centers and two regional network offices received 18 months of implementation support from October 2021 to March 2023. Appointed CWOs were tasked with implementing key interventions in at least two work units at each location. Administrative records were used to track implementation progress. Surveys were administered to participating work units pre- and postintervention to assess changes in key measures. Qualitative interviews elicited information about intervention implementation including barriers and facilitators. RESULTS: Not formally hiring CWOs in the role resulted in limited time to work on intervention implementation. This was insufficient and it impacted their ability to truly function in the role. Several work units experienced multiple challenges and were unable to implement the full intervention. Despite these challenges, when examining work unit changes, improvements in culture of health and well-being and change readiness were observed. CONCLUSION: The results support the importance of a formalized CWO role; however, findings highlight important factors that must be addressed for successful integration of role to drive intervention effectiveness. Comprehensive interventions addressing both system- and individual-level drivers of burnout show promise for improving VA workforce well-being but warrant further study. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A Mixed Methods Study Exploring Patient Safety Culture at Four VHA Hospitals.

BACKGROUND: Patient safety culture (PSC) fosters an environment of trust where people are encouraged to share information to promote psychological safety. To measure PSC, the Veteran's Health Administration (VHA) developed a PSC survey consisting of 20 items administered to all VHA employees. The survey comprises four scales: (1) risk identification and Just Culture, (2) error transparency and mitigation, (3) supervisor communication and trust, and (4) team cohesion and engagement. Our objective was to compare the PSC survey data to qualitative data regarding high reliability organization (HRO) implementation from four purposively selected VHA hospitals to assess how it manifests and converges. METHODS: Qualitative data focused on understanding HRO implementation efforts were collected from key informants between 2019 and 2020 at 4 of the 18 VHA HRO implementation hospitals. To explore the extent and manifestation of each of the PSC scales among the 4 sites, we combined the qualitative data with the PSC survey data from each hospital using a joint display. RESULTS: Survey responses were significantly different between the 4 hospitals for all 4 PSC scales. Of the 20 PSC survey items, 12 (60.0%) significantly differed across the 4 hospitals. For example, we saw cross-hospital differences in the following survey items: "We are given feedback about changes put into place based on event reports" and "We take the time to identify and assess risks to patient safety." Qualitative data supported manifestations for 80.0% (16/20) of PSC individual survey items among hospitals. CONCLUSION: The authors found that the qualitative data manifestations were well aligned with the VHA PSC scales, but relationships were not always consistent between data sources. Further research is necessary to elucidate these relationships.

Equity in Digital Mental Health Interventions in the United States: Where to Next?

Health care technologies have the ability to bridge or hinder equitable care. Advocates of digital mental health interventions (DMHIs) report that such technologies are poised to reduce the documented gross health care inequities that have plagued generations of people seeking care in the United States. This is due to a multitude of factors such as their potential to revolutionize access; mitigate logistical barriers to in-person mental health care; and leverage patient inputs to formulate tailored, responsive, and personalized experiences. Although we agree with the potential of DMHIs to advance health equity, we articulate several steps essential to mobilize and sustain meaningful forward progression in this endeavor, reflecting on decades of research and learnings drawn from multiple fields of expertise and real-world experience. First, DMHI manufacturers must build diversity, equity, inclusion, and belonging (DEIB) processes into the full spectrum of product evolution itself (eg, product design, evidence generation) as well as into the fabric of internal company practices (eg, talent recruitment, communication principles, and advisory boards). Second, awareness of the DEIB efforts-or lack thereof-in DMHI research trials is needed to refine and optimize future study design for inclusivity as well as proactively address potential barriers to doing so. Trials should incorporate thoughtful, inclusive, and creative approaches to recruitment, enrollment, and measurement of social determinants of health and self-identity, as well as a prioritization of planned and exploratory analyses examining outcomes across various groups of people. Third, mental health care advocacy, research funding policies, and local and federal legislation can advance these pursuits, with directives from the US Preventive Services Taskforce, National Institutes of Health, and Food and Drug Administration applied as poignant examples. For products with artificial intelligence/machine learning, maintaining a "human in the loop" as well as prespecified and adaptive analytic frameworks to monitor and remediate potential algorithmic bias can reduce the risk of increasing inequity. Last, but certainly not least, is a call for partnership and transparency within and across ecosystems (academic, industry, payer, provider, regulatory agencies, and value-based care organizations) to reliably build health equity into real-world DMHI product deployments and evidence-generation strategies. All these considerations should also extend into the context of an equity-informed commercial strategy for DMHI manufacturers and health care organizations alike. The potential to advance health equity in innovation with DMHI is apparent. We advocate the field's thoughtful and evergreen advancement in inclusivity, thereby redefining the mental health care experience for this generation and those to come.

Workplace Bullying Experiences of Nurses From Diverse Sexual Orientation and Gender Identity Groups.

AIM: To examine nurse workplace bullying relative to diverse sexual orientation and gender identity groups. DESIGN: Observational cross-sectional study. METHODS: Using an annual organisational satisfaction survey from 2022, we identified free-text comments provided by nurses (N = 25,337). We identified and themed comments for specific bullying content among unique respondents (n = 1432). We also examined close-ended questions that captured organisational constructs, such as job satisfaction and burnout. We looked at differences by comparing diverse sexual orientation and gender identity groups to the majority using both qualitative and quantitative data. RESULTS: For the free-text comments, themed categories reflected the type of bullying, the perpetrator and perceived impact. Disrespect was the most frequent theme with supervisors being the primary perpetrator. The reported bullying themes and workplace perceptions differed between nurses in the diverse gender identity and sexual orientation group compared to other groups. Nurses who reported bullying also reported higher turnover intent, burnout, lower workplace civility, more dissatisfaction and lower self-authenticity. CONCLUSION: Diverse sexual orientation and gender identity groups are understudied in the nurse bullying research, likely because of sensitivities around identification. Our design enabled anonymous assessment of these groups. We suggest practices to help alleviate and mitigate the prevalence of bullying in nursing. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution. IMPACT: We examined differences in perceptions of nurse bullying between diverse sexual orientation and gender identity groups compared to majority groups. Group differences were found both for thematic qualitative content and workplace experience ratings with members of minority groups reporting less favourable workplace experiences. Nurse leaders and staff can benefit from learning about best practices to eliminate bullying among this population. REPORTING METHOD: STROBE guidelines for cross-sectional observational studies.

Glycated Hemoglobin A1c Time in Range and Dementia in Older Adults With Diabetes.

Importance: Individuals with diabetes commonly experience Alzheimer disease and related dementias (ADRD). Factors such as hypoglycemia, hyperglycemia, and glycemic variability have been associated with increased risk of ADRD. Traditional glycemic measures, such as mean glycated hemoglobin A1c (HbA1c), may not identify the dynamic and complex pathophysiologic factors in the association between diabetes and ADRD. The HbA1c time in range (TIR) is a previously developed measure of glycemic control that expresses HbA1c stability over time within specific ranges. This measure may inform the current understanding of the association between glucose levels over time and ADRD incidence. Objective: To examine the association between HbA1c TIR and incidence of ADRD in older veterans with diabetes. Design, Setting, and Participants: The study sample for this cohort study was obtained from administrative and health care utilization data from the Veterans Health Administration and Medicare from January 1, 2004, to December 31, 2018. Veterans 65 years or older with diabetes were assessed. Participants were required to have at least 4 HbA1c tests during the 3-year baseline period, which could start between January 1, 2005, and December 31, 2014. Data analysis was conducted between July and December 2023. Main Outcomes and Measures: Hemoglobin A1c TIR was calculated as the percentage of days during baseline in which HbA1c was in individualized target ranges based on clinical characteristics and life expectancy, with higher HbA1c TIR viewed as more favorable. The association between HbA1c TIR and ADRD incidence was estimated. Additional models considered ADRD incidence in participants who were above or below HbA1c target ranges most of the time. Results: The study included 374 021 veterans with diabetes (mean [SD] age, 73.2 [5.8] years; 369 059 [99%] male). During follow-up of up to 10 years, 41 424 (11%) developed ADRD. Adjusted Cox proportional hazards regression models showed that lower HbA1c TIR was associated with increased risk of incident ADRD (HbA1c TIR of 0 to <20% compared with ≥80%: hazard ratio, 1.19; 95% CI, 1.16-1.23). Furthermore, the direction of out-of-range HbA1c levels was associated with incident ADRD. Having greater time below range (≥60%, compared with ≥60% TIR) was associated with significantly increased risk (hazard ratio, 1.23; 95% CI, 1.19-1.27). Findings remained significant after excluding individuals with baseline use of medications associated with hypoglycemia risk (ie, insulin and sulfonylureas) or with hypoglycemia events. Conclusions and Relevance: In this study of older adults with diabetes, increased HbA1c stability within patient-specific target ranges was associated with a lower risk of ADRD. Lower HbA1c TIR may identify patients at increased risk of ADRD.

"For the first time I am seriously fighting burnout": clinician experiences with a challenging electronic health record transition.

Objectives: The Department of Veterans Affairs (VA) is transitioning from its legacy electronic health record (EHR) to a new commercial EHR in a nationwide, rolling-wave transition. We evaluated clinician and staff experiences to identify strategies to improve future EHR rollouts. Materials and Methods: We completed a convergent mixed-methods formative evaluation collecting survey and interview data to measure and describe clinician and staff experiences. Survey responses were analyzed using descriptive statistics; interview transcripts were coded using a combination of a priori and emergent codes followed by qualitative content analysis. Qualitative and quantitative findings were compared to provide a more comprehensive understanding of participant experience. Employees of specialty and primary care teams at the first nationwide EHR transition site agreed to participate in our study. We distributed surveys at 1-month pre-transition, 2 months post-transition, and 10 months post-transition to each of the 68 identified team members and completed longitudinal interviews with 30 of these individuals totaling 122 semi-structured interviews. Results: Interview participants reported profoundly disruptive experiences during the EHR transition that persisted at 1-year post implementation. Survey responses indicated training difficulties throughout the transition, and sharp declines (P ≤ .05) between pre- and post-go-live measures of EHR usability and increase in EHR burden that were perceived to be due in part to system inefficiencies, discordant positive messaging that initially ignored user challenges, and inadequate support for and attention to ongoing EHR issues. Participants described persistent high levels of stress associated with these disruptions. Discussion: Our findings highlight strategies to improve employee experiences during EHR transitions: (1) working with Oracle Cerner to resolve known issues and improve usability; (2) role-based training with opportunities for self-directed learning; (3) peer-led support systems and timely feedback on issues; (4) messaging that responds to challenges and successes; and (5) continuous efforts to support staff with issues and address clinician and staff stress and burnout. Conclusion: Our findings provide relevant strategies to navigate future EHR transitions while supporting clinical teams.

Study protocol of a systematic review and metaanalysis of stress and burnout among general surgery residents.

Introduction: Chronic workplace stress and burnout are impediments to physicians' professional fulfillment, healthcare organizations' efficiency, and patient care quality/safety. General surgery residents are especially at risk due to the complexity of their training. We report the protocol of a metaanalysis of chronic stress and burnout among Accreditation Council for Graduate Medical Education (ACGME)-affiliated general surgery residents in the era after duty-hour reforms, plus downstream effects on their health and clinical performance. Methods: The proposed systematic review and metaanalysis (PROSPERO registration CRD42021277626) will synthesize/pool data from studies of chronic stress and burnout among general surgery residents at ACGME-affiliated programs. The timeframe under review is subdivided into three intervals: (a) after the 2003 duty-hour restrictions but before 2011 reforms, (b) after the 2011 reforms but before the coronavirus pandemic, and (c) the first 3 years after the pandemic's outbreak. Only studies reporting outcomes based on validated instruments will be included. Qualitative studies, commentaries/editorials, narrative reviews, and studies not published in English will be excluded. Multivariable analyses will adjust for sample characteristics and the methodological quality of included studies. Conclusions: The metaanalysis will yield evidence reflecting experiences of North American-based general surgery residents in the years after ACGME-mandated duty-hour restructuring.

Longitudinal Assessment of Seasonal Impacts and Depression Associations on Circadian Rhythm Using Multimodal Wearable Sensing: Retrospective Analysis.

BACKGROUND: Previous mobile health (mHealth) studies have revealed significant links between depression and circadian rhythm features measured via wearables. However, the comprehensive impact of seasonal variations was not fully considered in these studies, potentially biasing interpretations in real-world settings. OBJECTIVE: This study aims to explore the associations between depression severity and wearable-measured circadian rhythms while accounting for seasonal impacts. METHODS: Data were sourced from a large longitudinal mHealth study, wherein participants' depression severity was assessed biweekly using the 8-item Patient Health Questionnaire (PHQ-8), and participants' behaviors, including sleep, step count, and heart rate (HR), were tracked via Fitbit devices for up to 2 years. We extracted 12 circadian rhythm features from the 14-day Fitbit data preceding each PHQ-8 assessment, including cosinor variables, such as HR peak timing (HR acrophase), and nonparametric features, such as the onset of the most active continuous 10-hour period (M10 onset). To investigate the association between depression severity and circadian rhythms while also assessing the seasonal impacts, we used three nested linear mixed-effects models for each circadian rhythm feature: (1) incorporating the PHQ-8 score as an independent variable, (2) adding seasonality, and (3) adding an interaction term between season and the PHQ-8 score. RESULTS: Analyzing 10,018 PHQ-8 records alongside Fitbit data from 543 participants (n=414, 76.2% female; median age 48, IQR 32-58 years), we found that after adjusting for seasonal effects, higher PHQ-8 scores were associated with reduced daily steps (ß=-93.61, P<.001), increased sleep variability (ß=0.96, P<.001), and delayed circadian rhythms (ie, sleep onset: ß=0.55, P=.001; sleep offset: ß=1.12, P<.001; M10 onset: ß=0.73, P=.003; HR acrophase: ß=0.71, P=.001). Notably, the negative association with daily steps was more pronounced in spring (ß of PHQ-8 × spring = -31.51, P=.002) and summer (ß of PHQ-8 × summer = -42.61, P<.001) compared with winter. Additionally, the significant correlation with delayed M10 onset was observed solely in summer (ß of PHQ-8 × summer = 1.06, P=.008). Moreover, compared with winter, participants experienced a shorter sleep duration by 16.6 minutes, an increase in daily steps by 394.5, a delay in M10 onset by 20.5 minutes, and a delay in HR peak time by 67.9 minutes during summer. CONCLUSIONS: Our findings highlight significant seasonal influences on human circadian rhythms and their associations with depression, underscoring the importance of considering seasonal variations in mHealth research for real-world applications. This study also indicates the potential of wearable-measured circadian rhythms as digital biomarkers for depression.

Management of Depression in Adults: A Review.

Importance: Approximately 9% of US adults experience major depression each year, with a lifetime prevalence of approximately 17% for men and 30% for women. Observations: Major depression is defined by depressed mood, loss of interest in activities, and associated psychological and somatic symptoms lasting at least 2 weeks. Evaluation should include structured assessment of severity as well as risk of self-harm, suspected bipolar disorder, psychotic symptoms, substance use, and co-occurring anxiety disorder. First-line treatments include specific psychotherapies and antidepressant medications. A network meta-analysis of randomized clinical trials reported cognitive therapy, behavioral activation, problem-solving therapy, interpersonal therapy, brief psychodynamic therapy, and mindfulness-based psychotherapy all had at least medium-sized effects in symptom improvement over usual care without psychotherapy (standardized mean difference [SMD] ranging from 0.50 [95% CI, 0.20-0.81] to 0.73 [95% CI, 0.52-0.95]). A network meta-analysis of randomized clinical trials reported 21 antidepressant medications all had small- to medium-sized effects in symptom improvement over placebo (SMD ranging from 0.23 [95% CI, 0.19-0.28] for fluoxetine to 0.48 [95% CI, 0.41-0.55] for amitriptyline). Psychotherapy combined with antidepressant medication may be preferred, especially for more severe or chronic depression. A network meta-analysis of randomized clinical trials reported greater symptom improvement with combined treatment than with psychotherapy alone (SMD, 0.30 [95% CI, 0.14-0.45]) or medication alone (SMD, 0.33 [95% CI, 0.20-0.47]). When initial antidepressant medication is not effective, second-line medication treatment includes changing antidepressant medication, adding a second antidepressant, or augmenting with a nonantidepressant medication, which have approximately equal likelihood of success based on a network meta-analysis. Collaborative care programs, including systematic follow-up and outcome assessment, improve treatment effectiveness, with 1 meta-analysis reporting significantly greater symptom improvement compared with usual care (SMD, 0.42 [95% CI, 0.23-0.61]). Conclusions and Relevance: Effective first-line depression treatments include specific forms of psychotherapy and more than 20 antidepressant medications. Close monitoring significantly improves the likelihood of treatment success.

Measuring algorithmic bias to analyze the reliability of AI tools that predict depression risk using smartphone sensed-behavioral data.

AI tools intend to transform mental healthcare by providing remote estimates of depression risk using behavioral data collected by sensors embedded in smartphones. While these tools accurately predict elevated symptoms in small, homogenous populations, recent studies show that these tools are less accurate in larger, more diverse populations. In this work, we show that accuracy is reduced because sensed-behaviors are unreliable predictors of depression across individuals; specifically the sensed-behaviors that predict depression risk are inconsistent across demographic and socioeconomic subgroups. We first identified subgroups where a developed AI tool underperformed by measuring algorithmic bias, where subgroups with depression were incorrectly predicted to be at lower risk than healthier subgroups. We then found inconsistencies between sensed-behaviors predictive of depression across these subgroups. Our findings suggest that researchers developing AI tools predicting mental health from behavior should think critically about the generalizability of these tools, and consider tailored solutions for targeted populations.

Differential temporal utility of passively sensed smartphone features for depression and anxiety symptom prediction: a longitudinal cohort study.

While studies show links between smartphone data and affective symptoms, we lack clarity on the temporal scale, specificity (e.g., to depression vs. anxiety), and person-specific (vs. group-level) nature of these associations. We conducted a large-scale (n = 1013) smartphone-based passive sensing study to identify within- and between-person digital markers of depression and anxiety symptoms over time. Participants (74.6% female; M age = 40.9) downloaded the LifeSense app, which facilitated continuous passive data collection (e.g., GPS, app and device use, communication) across 16 weeks. Hierarchical linear regression models tested the within- and between-person associations of 2-week windows of passively sensed data with depression (PHQ-8) or generalized anxiety (GAD-7). We used a shifting window to understand the time scale at which sensed features relate to mental health symptoms, predicting symptoms 2 weeks in the future (distal prediction), 1 week in the future (medial prediction), and 0 weeks in the future (proximal prediction). Spending more time at home relative to one's average was an early signal of PHQ-8 severity (distal ß = 0.219, p = 0.012) and continued to relate to PHQ-8 at medial (ß = 0.198, p = 0.022) and proximal (ß = 0.183, p = 0.045) windows. In contrast, circadian movement was proximally related to (ß = -0.131, p = 0.035) but did not predict (distal ß = 0.034, p = 0.577; medial ß = -0.089, p = 0.138) PHQ-8. Distinct communication features (i.e., call/text or app-based messaging) related to PHQ-8 and GAD-7. Findings have implications for identifying novel treatment targets, personalizing digital mental health interventions, and enhancing traditional patient-provider interactions. Certain features (e.g., circadian movement) may represent correlates but not true prospective indicators of affective symptoms. Conversely, other features like home duration may be such early signals of intra-individual symptom change, indicating the potential utility of prophylactic intervention (e.g., behavioral activation) in response to person-specific increases in these signals.

The Impact of Involvement in Whole Health System for Veterans or Participating in It for Oneself on Job Attitudes in VA Employees.

OBJECTIVE: The aim of the study is to examine how involvement in the Whole Health System of care, clinically and personally (through employee-focused activities), would affect employee satisfaction, engagement, burnout, and turnover intent in the Veterans Health Administration. METHODS: Multivariate logistic regression analysis of cross-sectional survey from Veterans Health Administration employees was used to determine the influence of Whole Health System involvement and Employee Whole Health participation on job attitudes. RESULTS: Whole Health System involvement was associated higher job satisfaction, higher levels of engagement, lower burnout, and lower turnover intent. A similar pattern of results was identified when looking specifically at Employee Whole Health participation and associated job attitudes. CONCLUSIONS: Employees who are either directly involved in delivering Whole Health services to veterans or who have participated in Whole Health programming for their own benefit may experience a meaningful positive impact on their well-being and how they experience the workplace.

Measuring algorithmic bias to analyze the reliability of AI tools that predict depression risk using smartphone sensed-behavioral data.

AI tools intend to transform mental healthcare by providing remote estimates of depression risk using behavioral data collected by sensors embedded in smartphones. While these tools accurately predict elevated depression symptoms in small, homogenous populations, recent studies show that these tools are less accurate in larger, more diverse populations. In this work, we show that accuracy is reduced because sensed-behaviors are unreliable predictors of depression across individuals: sensed-behaviors that predict depression risk are inconsistent across demographic and socioeconomic subgroups. We first identified subgroups where a developed AI tool underperformed by measuring algorithmic bias, where subgroups with depression were incorrectly predicted to be at lower risk than healthier subgroups. We then found inconsistencies between sensed-behaviors predictive of depression across these subgroups. Our findings suggest that researchers developing AI tools predicting mental health from sensed-behaviors should think critically about the generalizability of these tools, and consider tailored solutions for targeted populations.

A Digital Intervention to Promote Self-Management Self-Efficacy Among Community-Dwelling Individuals With Stroke: Pilot Randomized Controlled Trial.

BACKGROUND: Digital interventions provided through smartphones or the internet that are guided by a coach have been proposed as promising solutions to support the self-management of chronic conditions. However, digital intervention for poststroke self-management is limited; we developed the interactive Self-Management Augmented by Rehabilitation Technologies (iSMART) intervention to address this gap. OBJECTIVE: This study aimed to examine the feasibility and initial effects of the iSMART intervention to improve self-management self-efficacy in people with stroke. METHODS: A parallel, 2-arm, nonblinded, randomized controlled trial of 12-week duration was conducted. A total of 24 participants with mild-to-moderate chronic stroke were randomized to receive either the iSMART intervention or a manual of stroke rehabilitation (attention control). iSMART was a coach-guided, technology-supported self-management intervention designed to support people managing chronic conditions and maintaining active participation in daily life after stroke. Feasibility measures included retention and engagement rates in the iSMART group. For both the iSMART intervention and active control groups, we used the Feasibility of Intervention Measure, Acceptability of Intervention Measure, and Intervention Appropriateness Measure to assess the feasibility, acceptability, and appropriateness, respectively. Health measures included the Participation Strategies Self-Efficacy Scale and the Patient-Reported Outcomes Measurement Information System's Self-Efficacy for Managing Chronic Conditions. RESULTS: The retention rate was 82% (9/11), and the engagement (SMS text message response) rate was 78% for the iSMART group. Mean scores of the Feasibility of Intervention Measure, Acceptability of Intervention Measure, and Intervention Appropriateness Measure were 4.11 (SD 0.61), 4.44 (SD 0.73), and 4.36 (SD 0.70), respectively, which exceeded our benchmark (4 out of 5), suggesting high feasibility, acceptability, and appropriateness of iSMART. The iSMART group showed moderate-to-large effects in improving self-efficacy in managing emotions (r=0.494), symptoms (r=0.514), daily activities (r=0.593), and treatments and medications (r=0.870), but the control group showed negligible-to-small effects in decreasing self-efficacy in managing emotions (r=0.252), symptoms (r=0.262), daily activities (r=0.136), and treatments and medications (r=0.049). In addition, the iSMART group showed moderate-to-large effects of increasing the use of participation strategies for management in the home (r=0.554), work (r=0.633), community (r=0.673), and communication activities (r=0.476). In contrast, the control group showed small-to-large effects of decreasing the use of participation strategies for management in the home (r=0.567), work (r=0.342, community (r=0.215), and communication activities (r=0.379). CONCLUSIONS: Our findings support the idea that iSMART was feasible to improve poststroke self-management self-efficacy. Our results also support using a low-cost solution, such as SMS text messaging, to supplement traditional therapeutic patient education interventions. Further evaluation with a larger sample of participants is still needed. TRIAL REGISTRATION: ClinicalTrials.gov 202004137; https://clinicaltrials.gov/study/NCT04743037?id=202004137&rank=1.

Standardizing Patient Safety Event Reporting between Care Delivered or Purchased by the Veterans Health Administration (VHA).

BACKGROUND: Increasing community care (CC) use by veterans has introduced new challenges in providing integrated care across the Veterans Health Administration (VHA) and CC. VHA's well-recognized patient safety program has been particularly challenging for CC staff to adopt and implement. To standardize VHA safety practices across both settings, VHA implemented the Patient Safety Guidebook in 2018. The authors compared national- and facility-level trends in VHA and CC safety event reporting post-Guidebook implementation. METHODS: In this retrospective study using patient safety event data from VHA's event reporting system (2020-2022), the research team examined trends in patient safety events, adverse events, close calls (near misses), and recovery rates (ratio of close calls to adverse events plus close calls) in VHA and CC using linear regression models to determine whether the average changes in VHA and CC safety events at the national and facility levels per quarter were significant. RESULTS: A total of 499,332 safety events were reported in VHA and CC. Although VHA patient safety event trends were not significant (p > 0.05), there was a significant negative trend for adverse events (p = 0.02) and positive trends for close calls (p = 0.003) and recovery rates (p = 0.004). In CC there were significant negative trends for patient safety events and adverse events (p = 0.02) and a significant positive trend for recovery rates (p = 0.03). There was less variation in VHA than in CC facilities with significant decreases (for example, interquartile ranges in VHA and CC were 0.03 vs. 0.05, respectively). CONCLUSION: Fluctuations in different safety events over time were likely due to the disruption of care caused by COVID-19 as well as organizational factors. Notably, the increases in recovery rates reflect less staff focus on harmful events and more attention to close calls (preventable events). Although safety practice adoption from VHA to CC was feasible, additional implementation strategies are needed to sustain standardized safety reporting across settings.

Longitudinal associations of daily affective dynamics with depression, generalized anxiety, and social anxiety symptoms.

BACKGROUND: Low average affect, measured using ecological momentary assessment (EMA), has been consistently linked with depression, generalized anxiety, and social anxiety, supporting trait-like negative affect as a shared underlying feature. However, while theoretical models of emotion regulation would also implicate greater variability in daily affect in these conditions, empirical evidence linking EMA of mood variability with affective disorders is mixed. We used multilevel modeling to test relationships of daily mood and mood variability with depression, generalized anxiety, and social anxiety symptoms. METHODS: Participants (N = 1004; 72.31 % female; Mage = 40.85) responded to EMA of mood 2-3×/day and completed measures of depression (PHQ-8), generalized anxiety (GAD-7), and social anxiety (SPIN) every three weeks. RESULTS: Lower mean affect predicted all symptoms at both the between-person (PHQ-8: ß = -0.486, p < 0.001; GAD-7: ß = -0.429, p < 0.001; SPIN: ß = -0.284, p < 0.001) and within-person (PHQ-8: ß = -0.219, p < 0.001; GAD-7: ß = -0.196, p < 0.001; SPIN: ß = -0.049, p < 0.001) levels. Similarly, at the between-person level, greater affective variability was linked with all three clinical symptoms (PHQ-8: ß = 0.617, p < 0.001; GAD-7: ß = 0.703, p < 0.001; SPIN: ß = 0.449, p < 0.001). However, within-person, affective variability related to depression (ß = 0.144, p < 0.001) and generalized anxiety (ß = 0.150, p < 0.001), but not social anxiety (ß = 0.006, p = 0.712). LIMITATIONS: The COVID-19 pandemic lockdown period occurred midway through the study. CONCLUSION: Findings point to common and specific emotion dynamics that characterize affective symptoms severity, with implications for affective monitoring in a clinical context.

LiveWell, a smartphone-based self-management intervention for bipolar disorder: Intervention participation and usability analysis.

BACKGROUND: Understanding how individuals utilize and perceive digital mental health interventions may improve engagement and effectiveness. To support intervention improvement, participant feedback was obtained and app use patterns were examined for a randomized clinical trial evaluating a smartphone-based intervention for individuals with bipolar disorder. METHODS: App use and coaching engagement were examined (n = 124). Feedback was obtained via exit questionnaires (week 16, n = 81) and exit interviews (week 48, n = 17). RESULTS: On average, over 48 weeks, participants used the app for 4.4 h and engaged with the coach for 3.9 h. Participants spent the most time monitoring target behaviors and receiving adaptive feedback and the least time viewing self-assessments and skills. Participants reported that the daily check in helped increase awareness of target behaviors but expressed frustration with repetitiveness of monitoring and feedback content. Participants liked personalizing their wellness plan, but its use did not facilitate skills practice. App use declined over time which participants attributed to clinical stability, content mastery, and time commitment. Participants found the coaching supportive and motivating for app use. LIMITATIONS: App engagement based on viewing time may overestimate engagement. The delay between intervention delivery and the exit interviews and low exit interview participation may introduce bias. CONCLUSION: Utilization patterns and feedback suggest that digital mental health engagement and efficacy may benefit from adaptive personalization of targets monitored combined with adaptive monitoring and feedback to support skills practice and development. Increasing engagement with supports may also be beneficial.