Impact of a peer-support programme to improve loneliness and social isolation due to COVID-19: does adding a secure, user friendly video-conference solution work better than telephone support alone? Protocol for a three-arm randomised clinical trial.

INTRODUCTION: The COVID-19 pandemic has forced the implementation of physical distancing and self-isolation strategies worldwide. However, these measures have significant potential to increase social isolation and loneliness. Among older people, loneliness has increased from 40% to 70% during COVID-19. Previous research indicates loneliness is strongly associated with increased mortality. Thus, strategies to mitigate the unintended consequences of social isolation and loneliness are urgently needed. Following the Obesity-Related Behavioural Intervention Trials model for complex behavioural interventions, we describe a protocol for a three-arm randomised clinical trial to reduce social isolation and loneliness. METHODS AND ANALYSIS: A multicentre, outcome assessor blinded, three-arm randomised controlled trial comparing 12 weeks of: (1) the HOspitals WoRking in Unity ('HOW R U?') weekly volunteer-peer support telephone intervention; (2) 'HOW R U?' deliver using a video-conferencing solution and (3) a standard care group. The study will follow Consolidated Standard of Reporting Trials guidelines.We will recruit 24-26 volunteers who will receive a previously tested half day lay-training session that emphasises a strength-based approach and safety procedures. We will recruit 141 participants ≥70 years of age discharged from two participating emergency departments or referred from hospital family medicine, geriatric or geriatric psychiatry clinics. Eligible participants will have probable baseline loneliness (score ≥2 on the de Jong six-item loneliness scale). We will measure change in loneliness, social isolation (Lubben social network scale), mood (Geriatric Depression Score) and quality of life (EQ-5D-5L) at 12-14 weeks postintervention initiation and again at 24-26 weeks. ETHICS AND DISSEMINATION: Approval has been granted by the participating research ethics boards. Participants randomised to standard care will be offered their choice of telephone or video-conferencing interventions after 12 weeks. Results will be disseminated through journal publications, conference presentations, social media and through the International Federation of Emergency Medicine. TRIAL REGISTRATION NUMBER: NCT05228782.

Improving patient-centered care for HIV and mental illness: exploring hospital and community integration through education.

Current models of care delivery are failing patients with complexity, like those living with HIV, mental illness and other psychosocial challenges. These patients often require resource-intensive personalized care across hospital and community settings, but available supports can be fragmented and challenging to access and navigate. To improve this, the authors created a program to enhance integrated, trauma-informed care through an innovative educational role for a HIV community caseworker embedded in an academic HIV Psychiatry clinic, called the Mental Health Clinical Fellowship. Through qualitative interviews with 21 participants (patients, physicians, clinicians and Mental Health Clinical Fellows) from October 2020-March 2023, the authors explore how implementation of this program affects patient experiences and satisfaction with care. Patients described their care experiences as less stigmatizing, more accessible, holistic and coordinated. They often attributed this to the integration between fellow and psychiatrist, and specifically the accessible stance of community organizations embedded within a hospital, which helped build trust. Interchangeable and integrated support by caseworker and psychiatrist improved patient engagement in psychiatric management and patient satisfaction with their care. Cross-context and cross-disciplinary care provision that includes providers from community and hospital working directly together to deliver care can improve care for patients with significant complexity.

The relationship between moral distress, burnout, and considering leaving a hospital job during the COVID-19 pandemic: a longitudinal survey.

BACKGROUND: Previous research suggests that moral distress contributes to burnout in nurses and other healthcare workers. We hypothesized that burnout both contributed to moral distress and was amplified by moral distress for hospital workers in the COVID-19 pandemic. This study also aimed to test if moral distress was related to considering leaving one's job. METHODS: A cohort of 213 hospital workers completed quarterly surveys at six time-points over fifteen months that included validated measures of three dimensions of professional burnout and moral distress. Moral distress was categorized as minimal, medium, or high. Analyses using linear and ordinal regression models tested the association between burnout and other variables at Time 1 (T1), moral distress at Time 3 (T3), and burnout and considering leaving one's job at Time 6 (T6). RESULTS: Moral distress was highest in nurses. Job type (nurse (co-efficient 1.99, p < .001); other healthcare professional (co-efficient 1.44, p < .001); non-professional staff with close patient contact (reference group)) and burnout-depersonalization (co-efficient 0.32, p < .001) measured at T1 accounted for an estimated 45% of the variance in moral distress at T3. Moral distress at T3 predicted burnout-depersonalization (Beta = 0.34, p < .001) and burnout-emotional exhaustion (Beta = 0.38, p < .008) at T6, and was significantly associated with considering leaving one's job or healthcare. CONCLUSION: Aspects of burnout that were associated with experiencing greater moral distress occurred both prior to and following moral distress, consistent with the hypotheses that burnout both amplifies moral distress and is increased by moral distress. This potential vicious circle, in addition to an association between moral distress and considering leaving one's job, suggests that interventions for moral distress may help mitigate a workforce that is both depleted and burdened with burnout.

Relationship between three aspects of resilience-adaptive characteristics, withstanding stress, and bouncing back-in hospital workers exposed to prolonged occupational stress during the COVID-19 pandemic: a longitudinal study.

BACKGROUND: The term resilience is used to refer to multiple related phenomena, including: (i) characteristics that promote adaptation to stressful circumstances, (ii) withstanding stress, and (iii) bouncing back quickly. There is little evidence to understand how these components of resilience are related to one another. Skills-based adaptive characteristics that can respond to training (as opposed to personality traits) have been proposed to include living authentically, finding work that aligns with purpose and values, maintaining perspective in the face of adversity, managing stress, interacting cooperatively, staying healthy, and building supportive networks. While these characteristics can be measured at a single time-point, observing responses to stress (withstanding and bouncing back) require multiple, longitudinal observations. This study's aim is to determine the relationship between these three aspects of resilience in hospital workers during the prolonged, severe stress of the COVID-19 pandemic. METHODS: We conducted a longitudinal survey of a cohort of 538 hospital workers at seven time-points between the fall of 2020 and the spring of 2022. The survey included a baseline measurement of skills-based adaptive characteristics and repeated measures of adverse outcomes (burnout, psychological distress, and posttraumatic symptoms). Mixed effects linear regression assessed the relationship between baseline adaptive characteristics and the subsequent course of adverse outcomes. RESULTS: The results showed significant main effects of adaptive characteristics and of time on each adverse outcome (all p < .001). The size of the effect of adaptive characteristics on outcomes was clinically significant. There was no significant relationship between adaptive characteristics and the rate of change of adverse outcomes over time (i.e., no contribution of these characteristics to bouncing back). CONCLUSIONS: We conclude that training aimed at improving adaptive skills may help individuals to withstand prolonged, extreme occupational stress. However, the speed of recovery from the effects of stress depends on other factors, which may be organizational or environmental.

Randomized trial of personalized psychological feedback from a longitudinal online survey and simultaneous evaluation of randomized stepped wedge availability of in-person peer support for hospital staff during the COVID-19 pandemic.

OBJECTIVE: We tested if automated Personalized Self-Awareness Feedback (PSAF) from an online survey or in-person Peer Resilience Champion support (PRC) reduced emotional exhaustion among hospital workers during the COVID-19 pandemic. METHOD: Among a single cohort of participating staff from one hospital organization, each intervention was evaluated against a control condition with repeated measures of emotional exhaustion at quarterly intervals for 18 months. PSAF was tested in a randomized controlled trial compared to a no-feedback condition. PRC was tested in a group-randomized stepped-wedge design, comparing individual-level emotional exhaustion before and after availability of the intervention. Main and interactive effects on emotional exhaustion were tested in a linear mixed model. RESULTS: Among 538 staff, there was a small but significant beneficial effect of PSAF over time (p = .01); the difference at individual timepoints was only significant at timepoint three (month six). The effect of PRC over time was non-significant with a trend in the opposite direction to a treatment effect (p = .06). CONCLUSIONS: In a longitudinal assessment, automated feedback about psychological characteristics buffered emotional exhaustion significantly at six months, whereas in-person peer support did not. Providing automated feedback is not resource-intensive and merits further investigation as a method of support.

"It's Complicated": Using Education to Bridge Essential Care Between Hospital and Community for Complex Patients with HIV.

OBJECTIVE: For the most complex patients, like those with HIV and mental illness, integrated care occurs across diverse community and hospital contexts. There is a need for cross-discipline and cross-context educational opportunities for diverse providers to learn integrated care skillsets in real practice settings. The authors developed a Continuing Professional Development (CPD) experience for frontline case workers to be embedded in a hospital-based HIV psychiatry clinic that aims to enhance collaborative skills across hospital and community settings, called the Mental Health Clinical Fellowship. METHODS: Through qualitative pre- and post-interviews with 16 participants from October 2020 to October 2021, the authors explored patient, physician, clinician, resident learner, and the Mental Health Clinical Fellow's learning experiences and the impact on patient care. RESULTS: Preliminary findings elucidate some common challenges providers experience in providing care to this complex population, including facing uncertainty of diagnosis and management, and not having enough time or resources to navigate this uncertainty. The opportunity to work and learn across disciplines through the fellowship reduced challenges, and also facilitated adaptive expertise development. CONCLUSIONS: Cross-context and cross-discipline education opportunities facilitate perspective-sharing and enhanced ability to develop adaptive expertise in caring for complex populations. There is also promise for improving care and decreasing fragmentation because of the educational experience.

Providers' perspectives on implementing resilience coaching for healthcare workers during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic severely exacerbated workplace stress for healthcare workers (HCWs) worldwide. The pandemic also magnified the need for mechanisms to support the psychological wellbeing of HCWs. This study is a qualitative inquiry into the implementation of a HCW support program called Resilience Coaching at a general hospital. Resilience Coaching was delivered by an interdisciplinary team, including: psychiatrists, mental health nurses allied health and a senior bioethicist. The study focuses specifically on the experiences of those who provided the intervention. METHODS: Resilience Coaching was implemented at, an academic hospital in Toronto, Canada in April 2020 and is ongoing. As part of a larger qualitative evaluation, 13 Resilience Coaches were interviewed about their experiences providing psychosocial support to colleagues. Interviews were recorded, transcribed, and analyzed for themes by the research team. Interviews were conducted between February and June 2021. RESULTS: Coaches were motivated by opportunities to support colleagues and contribute to the overall health system response to COVID-19. Challenges included finding time within busy work schedules, balancing role tensions and working while experiencing burnout. CONCLUSIONS: Hospital-based mental health professionals are well-positioned to support colleagues' wellness during acute crises and can find this work meaningful, but note important challenges to the role. Paired-coaches and peer support among the coaching group may mitigate some of these challenges. Perspectives from those providing support to HCWs are an important consideration in developing support programs that leverage internal teams.

Trends in burnout and psychological distress in hospital staff over 12 months of the COVID-19 pandemic: a prospective longitudinal survey.

BACKGROUND: The mental health effects of healthcare work during the COVID-19 pandemic have been substantial, but it is not known how long they will persist. This study aimed to determine if hospital workers' burnout and psychological distress increased monotonically over 1 year, during which waves of case numbers and hospitalizations waxed and waned, or followed some other pattern. METHODS: A prospective longitudinal survey was conducted at four time-points over 1 year in a cohort of 538 hospital workers and learners, which included validated measures of burnout (emotional exhaustion scale of Maslach Burnout Inventory) and psychological distress (K6). Repeated measures ANOVA tested changes over time and differences between subjects by occupational role, age and ethnic group. The direction and magnitude of changes over time were investigated by plotting rates of high scores (using cut-offs) at each time-point compared to case rates of COVID-19 in the city in which the study took place. RESULTS: There were significant effects of occupational role (F = 11.2, p < .001) and age (F = 12.8, p < .001) on emotional exhaustion. The rate of high burnout was highest in nurses, followed by other healthcare professionals, other clinical staff, and lowest in non-clinical staff. Peak rates of high burnout occurred at the second or third measurement point for each occupational group, with lower rates at the fourth measurement point. Similarly to the results for emotional exhaustion, rates of high psychological distress peaked at the spring 2021 measurement point for most occupational groups and were higher in nurses than in other healthcare professionals. CONCLUSIONS: Neither emotional exhaustion nor psychological distress was rising monotonically. Burnout and psychological distress were consistently related to occupational role and were highest in nurses. Although emotional exhaustion improved as the case rate of COVID-19 decreased, rates of high emotional exhaustion in nurses and other healthcare professionals remained higher than was typically measured in hospital-based healthcare workers prior to the pandemic. Ongoing monitoring of healthcare workers' mental health is warranted. Organizational and individual interventions to support healthcare workers continue to be important.

Resilience coaching for healthcare workers: Experiences of receiving collegial support during the COVID-19 pandemic.

OBJECTIVE: To explore experiences of receiving collegial support from the department of psychiatry at an acute care hospital during the COVID-19 pandemic. METHOD: The Resilience Coaching program launched in April 2020, with the aim of offering a timely response to supporting psychosocial needs of healthcare workers (HCWs), leveraging collegial relationships and mental health training to offer support. Twenty-four HCWs were interviewed about their experiences receiving support from resilience coaches. RESULTS: Participants reported that Resilience Coaching offered hospital staff opportunities for connection, encouragement to attend to personal wellness, and avenues to learn practical skills to assist with coping. Coaching also assisted HCWs in accessing clinical mental health support when that was requested by staff. CONCLUSIONS: Resilience Coaching is a model for supporting colleagues in an acute care hospital during a pandemic. It is generally regarded positively by participants. Further study is warranted to determine how best to engage some occupational subcultures within the hospital, and whether the model is feasible for other healthcare contexts.

An Academic Health Sciences Centre's Strategy to Enhance Nurse Resilience and Psychological Safety.

The rapid cadence of change and the fear of acquiring and spreading COVID-19 - coupled with moral distress exacerbated by fulfilling one's duty to care under extremely challenging conditions - continue to impact nurses' coping ability, resilience and psychological safety globally (McDougall et al. 2020). This paper provides an overview of how an academic health sciences centre (AHSC) has responded to the evolving waves of the COVID-19 pandemic. Specifically, we share our context and the strategies we used to build and enhance nurse resilience and psychological safety at the organizational, clinical team and individual levels. This is followed by a description of our nurses' achievements amid the pandemic.

Psychological impact of the COVID-19 pandemic on hospital workers over time: Relationship to occupational role, living with children and elders, and modifiable factors.

OBJECTIVE: The COVID-19 pandemic is expected to have a sustained psychological impact on healthcare workers. We assessed individual characteristics related to changes in emotional exhaustion and psychological distress over time. METHODS: A survey of diverse hospital staff measured emotional exhaustion (Maslach Burnout Inventory) and psychological distress (K6) in Fall 2020 (T1) and Winter 2021 (T2). Relationships between occupational, personal, and psychological variables were assessed using repeated measures ANOVA. RESULTS: Of 539 T1 participants, 484 (89.9%) completed T2. Emotional exhaustion differed by occupational role (F = 7.3, p < .001; greatest in nurses), with increases over time in those with children (F = 8.5, p = .004) or elders (F = 4.0, p = .047). Psychological distress was inversely related to pandemic self-efficacy (F = 110.0, p < .001), with increases over time in those with children (F = 7.0, p = .008). Severe emotional exhaustion occurred in 41.1% (95%CI 36.6-45.4) at T1 and 49.8% (95%CI 45.4-54.2) at T2 (McNemar test p < .001). Psychological distress occurred in 9.7% (95%CI 7.1-12.2) at T1 and 11.6% (95%CI 8.8-14.4) at T2 (McNemar test p = .33). CONCLUSIONS: Healthcare workers' psychological burden is high and rising as the pandemic persists. Ongoing support is warranted, especially for nurses and those with children and elders at home. Modifiable protective factors, restorative sleep and self-efficacy, merit special attention.

The Relationship Between Childhood Adversity and Other Aspects of Clinical Complexity in Psychiatric Outpatients.

Childhood abuse, neglect, and loss are common in psychiatric patients, and the relationship between childhood adversity and adult mental illness is well known. However, beyond diagnoses that are specifically trauma-related, such as posttraumatic stress disorder, there has been little research on how childhood adversity contributes to complex presentations that require more intensive treatment. We examined the relationship between childhood adversity and other contributors to clinical complexity in adult outpatients seeking mental health assessment. In a cross-sectional study, patients completed standard measures of psychological distress and functional impairment. Psychiatrists completed an inventory of clinical complexity, which included childhood abuse, neglect, and loss. Of 4,903 patients seen over 15 months, 1,315 (27%) both consented to research and had the measure of complexity completed. Childhood abuse or neglect was identified in 474 (36.0%) and significant childhood loss in 236 (17.9%). Correcting for multiple comparisons and controlling for psychiatric diagnosis, age, and sex, patients with childhood abuse or neglect were significantly more likely to also have 11 of 31 other indices of clinical complexity, with odds ratios ranging from 1.7 to 5.0. Both childhood abuse or neglect and childhood loss were associated with greater overall complexity (i.e., more indices of complexity, χ2 = 136 and 38 respectively, each p < .001). Childhood abuse and neglect (but not childhood loss) were significantly associated with psychological distress (Kessler Psychological Distress Scale [K10] score, F = 6.2, p = .01) and disability (World Health Organization Disability Assessment Scale 2.0 [WHODAS 2.0] score, F = 5.0, p = .03). Childhood abuse and neglect were associated with many characteristics that contribute to clinical complexity, and thus to suboptimal outcomes to standard, guideline-based care. Screening may alert psychiatrists to the need for intensive, patient-centered, and trauma-informed treatments. Identifying childhood adversity as a common antecedent of complexity may facilitate developing transdiagnostic programs that specifically target sources of complexity.

A Hospital Partnership with a Nursing Home Experiencing a COVID-19 Outbreak: Description of a Multiphase Emergency Response in Toronto, Canada.

Nursing homes have become "ground zero" for the coronavirus disease 2019 (COVID-19) epidemic in North America, with homes experiencing widespread outbreaks, resulting in severe morbidity and mortality among their residents. This article describes a 371-bed acute-care hospital's emergency response to a 126-bed nursing home experiencing a COVID-19 outbreak in Toronto, Canada. Like other healthcare system responses to COVID-19 outbreaks in nursing homes, this hospital-nursing home partnership can be characterized in several phases: (1) engagement, relationship, and trust building; (2) environmental scan, team building, and immediate response; (3) early-phase response; and (4) stabilization and transition period. J Am Geriatr Soc 68:1376-1381, 2020.

Proactive Psychiatry Intervention Using a Nurse-Led Behavioral Response Model for Hospitalized Patients With Behavioral Disturbances.

BACKGROUND: The health care sector has one of the highest rates of workplace violence, putting staff at risk and impeding care. To deliver quality health care, staff need targeted resources. This article describes a program to improve staff safety and reduce barriers to care for patients with behavioral disturbances. PROGRAM DESCRIPTION: A nurse-led behavioral response team was created to identify high-risk patients and offer prompt targeted interventions. The Behavioral Optimization and Outcomes Support Team (BOOST) was implemented in November 2012, in conjunction with a proactive model of care, enabling psychiatric intervention. Advanced practice nurses in psychiatry respond to requests from staff on medical/surgical units to assist with management of behavioral disturbances. METHODS: Consultation and intervention data were reviewed, and staff satisfaction surveys were completed to evaluate the program. RESULTS: The program has contributed to staff feeling more supported and safer at work. There has also been a reduction in staff's experience of perceived burden in the care of patients with behavioral disturbances although they are caring for more of these patients. CONCLUSIONS: Although violence risk in health care continues to be a significant issue, programs to intervene early can be effective in supporting staff to minimize these risks.

Geriatric Delirium Care: Using Chart Audits to Target Improvement Strategies.

BACKGROUND: Our hospital identified delirium care as a quality improvement target. Baseline characterization of our delirium care and deficits was needed to guide improvement efforts. METHODS: Two inpatient units were selected: 1) A general internal medicine unit with a focus on geriatrics, and 2) a surgical unit. Retrospective chart audits were conducted for all patients over age 50 admitted during a one-month period to compare delirium care with best practice guideline (BPG) recommendations, and to determine the incidence of missed cases of delirium and negative outcomes in patients with delirium. The aim was to gather local data to prioritize improvement efforts and mobilize stakeholders. RESULTS: 186 charts were reviewed: 17 patients had physician-diagnosed delirium, 21 patients had missed delirium, and 148 patients had no delirium. Compliance with delirium BPGs was variable, but generally poor. There was a trend towards missed delirium and physician-diagnosed delirium being associated with greater odds of having above-median length of stay and lower odds of discharge home compared to no delirium diagnosis. CONCLUSION: Overall, the chart audits confirmed delirium underrecognition and poor adherence to best practices in delirium management. Granular analysis of this data was used to mobilize stakeholders and prioritize improvement plans.

A mixed-methods systematic review protocol to examine the use of physical restraint with critically ill adults and strategies for minimizing their use.

BACKGROUND: Critically ill patients frequently experience severe agitation placing them at risk of harm. Physical restraint is common in intensive care units (ICUs) for clinician concerns about safety. However, physical restraint may not prevent medical device removal and has been associated with negative physical and psychological consequences. While professional society guidelines, legislation, and accreditation standards recommend physical restraint minimization, guidelines for critically ill patients are over a decade old, with recommendations that are non-specific. Our systematic review will synthesize evidence on physical restraint in critically ill adults with the primary objective of identifying effective minimization strategies. METHODS: Two authors will independently search from inception to July 2016 the following: Ovid MEDLINE, CINAHL, Embase, Web of Science, Cochrane Library, PROSPERO, Joanna Briggs Institute, grey literature, professional society websites, and the International Clinical Trials Registry Platform. We will include quantitative and qualitative study designs, clinical practice guidelines, policy documents, and professional society recommendations relevant to physical restraint of critically ill adults. Authors will independently perform data extraction in duplicate and complete risk of bias and quality assessment using recommended tools. We will assess evidence quality for quantitative studies using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach and for qualitative studies using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) guidelines. Outcomes of interest include (1) efficacy/effectiveness of physical restraint minimization strategies; (2) adverse events (unintentional device removal, psychological impact, physical injury) and associated benefits including harm prevention; (3) ICU outcomes (ventilation duration, length of stay, and mortality); (4) prevalence, incidence, patterns of use including patient and treatment characteristics and chemical restraint; (5) barriers and facilitators to minimization; (6) patient, family, and healthcare professional perspectives; (7) professional society-endorsed recommendations; and (8) evidence gaps and research priorities. DISCUSSION: We will use our systematic review findings to produce updated guidelines on physical restraint use for critically ill adults and to develop a professional society-endorsed position statement. This will foster patient and clinician safety by providing clinicians, administrators, and policy makers with a tool to promote minimal and safe use of physical restraint for critically ill adults. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015027860.

Choosing Wisely? Let's Start with Working Wisely.

There is an increasing emphasis on quality and, relatedly, cost-effectiveness as it relates to the delivery of health care. Choosing Wisely is an initiative adopted by numerous specialties with the goal of starting a dialogue about efficient use of health care resources. People need to be able to access care to have an opportunity to choose wisely. There is a considerable amount of evidence that access to care is poor for specialty mental health care, particularly access to psychiatrists. Consequently, we suggest that psychiatrists and the broader mental health system need to consider working wisely, and in our paper outline key issues (for example, implementation of wait times and objective measures of need in a centralized referral management system; incorporation of performance indicators with longitudinal monitoring for continuous quality improvement) that need to be addressed to develop a mental health system that would allow people to access care to choose wisely.