Leading through the COVID-19 pandemic: Experiences of UK Executive Nurse Directors.

AIM: To explore the challenges experienced by Executive Nurse Directors during the COVID-19 pandemic, and to inform future nursing leadership strategies. DESIGN: A qualitative research project involving interviews with 21 Executive Nurse Directors from England and Wales. METHODS: Participants were purposively sampled and recruited through Chief Nursing Officers and nursing leadership networks. Semi-structured interviews were conducted and recorded online via Teams. Braun and Clarke's approach to thematic reflexive analysis was applied to data analysis. RESULTS: Executive Nurse Directors played a critical role during the COVID-19 pandemic. Six themes are explored: tensions, and adaptive response to personal leadership styles; uncertainty and support at the board level; responding to national political decision-making; the personal and emotional impact of the role and the sources of effective support; the voice and public profile of nursing; lessons learnt and strategies for future leadership development. Enablers of decision-making included effective multidisciplinary working, freedom from normal organizational constraints, support for innovation, and the development of stronger bonds with colleagues. Barriers to decision-making included limited knowledge of the virus and its impact and lack of guidance, particularly at a national level. Priorities, strategies and actions for recovery include recognizing the emotional impact of being in a high-level decision-making role, protecting staff from burnout and understanding the long-term implications of pandemic work for nurse leaders. CONCLUSION: Future strategies for nursing leadership during public health, national and global emergencies are recommended. IMPACT: This study contributes to the literature exploring the Executive Nurse Director role and their experiences of leading through the COVID-19 pandemic, and identifies priorities, strategies and actions for recovery and learning for the future of senior leadership. REPORTING METHOD: The study adhered to the Consolidated Criteria for Reporting Qualitative Research. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Experiences of health professionals towards using mobile electrocardiogram (ECG) technology: A qualitative systematic review.

OBJECTIVES: To identify and explore the experiences of health professionals towards using mobile electrocardiogram (ECG) technology. INTRODUCTION: Mobile technology is increasingly being incorporated into healthcare systems, and when implemented well, has the potential to revolutionise the way in which care is delivered. The uptake of mobile ECG technology enables health professionals to record and transmit ECGs electronically, at the point of care. It is important to explore both the impact of this technology and staff experiences to help understand how readily it is accepted and how effectively it is used in practice. There is a paucity of knowledge and understanding from primary healthcare providers and a lack of qualitative evidence offering insight into the monitoring and use of mobile ECG technology. Therefore, this review adds to the available body of knowledge by giving insight from the perspectives of health professionals on its use. METHODS: TRIP, CINAHL, MEDLINE, Scopus and sources of grey literature were searched for eligible studies. Databases were searched from their inception dates, with a restriction on studies written in English. The results of the search are presented in a PRISMA flow diagram. Two reviewers independently screened studies and assessed methodological quality in accordance with JBI methodology for systematic reviews of qualitative evidence. Data were extracted from the included studies and meta-aggregation methodology adopted to identify categories and create synthesised findings related to the healthcare professionals' experiences. RESULTS: A total of six studies were included, which resulted in 18 findings and five categories. Three synthesised findings were generated: Quick, easy and feasible in both urban and remote settings; Increased accessibility of AF screening opportunities for all; Enhanced support in staff resources, time and technology are required. The level of confidence of synthesised findings varied from low to moderate according to ConQual. CONCLUSIONS: This systematic review synthesised the experiences of healthcare professionals using mobile ECG technology. The methodological quality of the included studies was high, and findings indicated healthcare professionals (HCPs) generally found mobile ECG technology simple, quick, easy to use and non-invasive. Enablers regarding mobile ECG technology were time, workload, and remuneration for improved interoperability with current systems and sustainability for screening long term. Data on the experiences of HCPs came from studies capturing mainly proactive, lower-risk patients; therefore, this review was unable to demonstrate if there are any differences between the experiences of HCPs working in primary care settings, such as GP practices/pharmacies, and those working remotely in the community. This highlights a gap in provision for those patients requiring HCPs to record an ECG in their own home. RELEVANCE TO CLINICAL PRACTICE: The experiences of HCPs towards using Mobile ECG technology in practice is quick, easy and feasible in both urban and remote settings. HCPs and organisations should consider identifying key staff as "change champions" and use change/leadership models to support the integration (with current workflows), transformation, and evaluation of mobile ECG technology in their practice setting. HCPs and providers using mobile ECG technology should ensure it prioritises at-risk individuals and includes the "housebound" population.

Patients' perspectives of recovery after COVID-19 critical illness: An interview study.

BACKGROUND: Critical illness is a traumatic experience, often resulting in post-intensive care syndrome, affecting people's physical, psychological, emotional, and social well-being. The early recovery period is associated with increased risk, negatively impacting longer-term outcomes. AIMS: The aims of this study were to understand the recovery and rehabilitation needs of people who survive a COVID-19 critical illness. STUDY DESIGN: An exploratory descriptive qualitative interview study with 20 survivors of COVID-19 critical illness from two community-based healthcare settings in London, England. Data collection took place September 2020-April 2021, at least 1 month after hospital discharge by telephone or virtual platform. Data were subjected to inductive thematic analysis and mapped deductively to the three core concepts of self-determination theory: autonomy, competence and relatedness. RESULTS: Three key themes emerged: traumatic experience, human connection and navigating a complex system. Participants described how societal restrictions, fear and communication problems caused by the pandemic added to their trauma and the challenge of recovery. The importance of positive human connections, timely information and support to navigate the system was emphasized. CONCLUSIONS: Whilst findings to some extent mirror those of other qualitative pre-pandemic studies, our findings highlight how the uncertainty and instability caused by the pandemic add to the challenge of recovery affecting all core concepts of self-determination (autonomy, competence, relatedness). RELEVANCE TO CLINICAL PRACTICE: Understanding survivors' perspectives of rehabilitation needs following COVID-19 critical illness is vital to delivery of safe, high-quality care. To optimize chances of effective recovery, survivors desire a specialist, co-ordinated and personalized recovery pathway, which reflects humanized care. This should be considered when planning future service provisions.

Nursing and values-based leadership: A literature review.

AIM: To explore literature that supports an understanding of values-based leadership in nursing. BACKGROUND: Understanding values-based leadership in nursing means understanding several leadership theories such as authentic, servant and congruent leadership. EVALUATION: Electronic databases were systematically searched to locate studies with the terms values-based, authentic, servant and congruent leadership. The literature was assessed with the Joanna Briggs Institute Critical Appraisal Tools and the Preferred Reporting Items for Systematic Reviews and meta-analysis approach and a thematic analysis. KEY ISSUES: Existing evidence focuses on specific perspectives within three dominant leadership approaches under the umbrella of values-based leadership: authentic, servant and congruent leadership. Limited literature suggests that values-based leadership can support professional collaboration, enhanced trust and voice for nurses, support for staff well-being, empowerment, job satisfaction, patient-focused outcomes and quality care. CONCLUSIONS: A dearth of empirical literature concerning values-based leadership and nursing exists. Evidence suggests that authentic, servant and congruent leadership correlate with values-based leadership theories and core nursing values. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers should recognize the potential benefits of a values-based leadership approach for staff well-being, enhanced professional collaboration and the nurses voice, improved insight into clinical leadership attributes and improvements in quality patient care.

What factors influence midwives to provide obstetric high dependency care on the delivery suite or request care be escalated away from the obstetric unit? Findings of a focus group study.

BACKGROUND: In the United Kingdom, midwives will engage in discussions with the multidisciplinary team as to whether they can provide Obstetric High Dependency Care (OHDC) on the Delivery Suite or whether a woman's care should be escalated to the critical care team. This study aimed to explore the question: What factors influence midwives to provide OHDC or request care be escalated away from the obstetric unit in hospitals remote from tertiary referral centres? METHODS: Focus groups were undertaken with midwives (n = 34) across three obstetric units in England, with annual birth rates ranging from 1500 to 5000 per annum, in District General Hospitals. Three scenarios in the form of video vignettes of handover were used as triggers for the focus groups. Scenario 1; severe pre-eclampsia, physiologically unstable 2; major postpartum haemorrhage requiring invasive monitoring 3; recent admission of woman with chest pain receiving facial oxygen and requiring continuous electrocardiogram (ECG) monitoring. Two focus groups were conducted in each of the obstetric units with experienced midwives. Data were analysed using a qualitative framework approach. RESULTS: Factors influencing midwives' care escalation decisions included the care environment, a woman's diagnosis and fetal or neonatal factors. The overall plan of care including the need for ECG and invasive monitoring were also influential factors. Midwives in the smallest obstetric unit did not have access to the facilities for OHDC provision. Midwives in the larger obstetric units provided OHDC but identified varying degrees of skill and sometimes used 'workarounds' to facilitate care provision. Midwifery staffing levels, skill mix and workload were also influential. Some differences of opinion were evident between midwives working in the same obstetric units as to whether OHDC could be provided and the support they would enlist to help them provide it. Reliance on clinical guidelines appeared variable. CONCLUSIONS: Findings indicate that there may be inequitable OHDC provision at a local level. Organisationally robust systems are required to promote safe, equitable OHDC care including skills development for midwives and precise escalation guidelines to minimise workarounds. Training for midwives must include strategies that prevent skills fade.

Neurocognitive and Metacognitive Profiles of Intact Social Cognition in Prolonged Schizophrenia.

Social cognition (SC) appears to contribute to long-term outcomes in schizophrenia; however, little is known about whether different forms of SC are supported by the same cognitive processes. Accordingly, we examined the relationship of two domains of SC: emotion recognition (ER), using the Bell-Lysaker Emotion Recognition Test, and social inference (SI), using the Social Attribution Task-Multiple Choice, to measures of neurocognition, metacognition, theory of mind (ToM), and symptoms. Participants were 72 adults with schizophrenia in a nonacute phase. Multivariate analysis of variance and univariate analysis of variance revealed participants with intact ER had better neurocognition (MATRICS Consensus Cognitive Battery [MCCB]), metacognition (Metacognition Assessment Scale-Abbreviated), ToM (The Hinting Task), and higher emotional discomfort symptoms than participants with impaired scores. Participants with intact SI had higher MCCB visual and verbal learning and SC scores. Stepwise regressions revealed neurocognition and metacognition uniquely contribute to ER performance. Results suggest ER and SI are differentially related to cognitive processes.

Metacognitive Reflection and Insight Therapy for Schizophrenia: Case Study of a Patient With a Co-Occurring Substance Use Disorder.

Decrements in metacognitive functioning, or the ability to form complex and integrated representations of oneself and others, have been identified as a core feature of schizophrenia. These deficits have been observed to be largely independent of the severity of psychopathology and neurocognitive functioning and are linked to poor outcomes for those with the disorder. This study is a case illustration of the efficacy of metacognitive reflection and insight therapy (MERIT) in increasing the metacognitive capacity of an individual diagnosed as having co-occurring schizophrenia and a substance use disorder during three years of individual therapy. The eight elements of MERIT, which promote metacognitive growth, are presented as they apply to the present case. Case conceptualization, outcomes, and prognosis are also presented. These eight elements enabled the patient to move from a state of gross disorganization-unable to identify his thoughts or present them in a linear fashion-to one in which he was able to develop increasingly complex ideas about himself and others and integrate this understanding into a richer sense of himself, of his psychological challenges, and of the role that substance use played in his life. Results of the study also illustrate the foundational necessity of self-reflectivity in order to facilitate understanding of the mind of others and the relationship between psychological pain and the emergence of disorganization.

The experience and expression of anger in posttraumatic stress disorder: the relationship with metacognition.

BACKGROUND: Anger experience and expression are a common issue in those experiencing PTSD. However, it remains unclear what variables affect anger and its expression in PTSD. AIMS: To explore the relationships of synthetic forms of metacognition and metacognitive beliefs with anger experience and expression in PTSD, independent of the effects hyperarousal and depression symptoms. METHOD: Participants were 51 veterans with diagnosed with PTSD. Metacognition was assessed using the Metacognition Assessment Scale-Abbreviated (MAS-A) and the Metacognitions Questionnaire (MCQ). Depression, PTSD symptom severity, and seven domains of anger expression were also assessed. RESULTS: Correlations showed after controlling for overall levels of hyperarousal, higher MAS-A total scores were related to lower levels of State Anger, Feeling Angry, Expressing Anger Physically, and Anger Expression in. Lower MCQ scores were related to lower State anger, Expressing anger verbally, and Expressing anger physically. Higher levels of depression were related to higher levels of Trait anger, Expressing anger physically, Anger expression out, and Anger expression in. Multiple regressions suggested that the MAS-A and MCQ predicted unique portions of the variance in anger experience and expression. CONCLUSIONS: Metacognitive deficits may affect anger experience and expression in those with PTSD and may be an important treatment target.

Action learning can support leadership development for undergraduate and postgraduate nurses.

Leadership skills are embedded in the undergraduate nursing curriculum and are essential for post-registration nurses. One way to support the development of these skills is to use the action learning and critical action learning approaches, which can be implemented in both the academic environment and the clinical setting. The process of action learning promotes collaborative multidisciplinary working and affords time for reflection and professional development, in turn supporting the process of applying for revalidation. Developing a nursing workforce with a high level of emotional intelligence can support decision-making, resilience and build confidence. These qualities are crucial not only for delivering safe patient care and promoting innovation in quality improvement, but are essential for personal development and individual career progression.

Metacognition moderates the relationship between dysfunctional self-appraisal and social functioning in prolonged schizophrenia independent of psychopathology.

OBJECTIVES: Both dysfunctional self-appraisal and metacognitive deficits, or impairments in the ability to form complex and integrated ideas about oneself and others, may contribute to social deficits in schizophrenia. Little is known, however, about how they interact with each other. In this study, we examined the hypothesis that both higher metacognition and more positive self-appraisal are necessary for increased social functioning. METHODS: Concurrent assessments of self-appraisal, metacognition, and social functioning were gathered from 66 adults with schizophrenia in a non-acute phase of disorder. Three forms of self-appraisal were used: self-esteem, hope and self-efficacy. Metacognition was assessed using the Metacognitive Assessment Scale-Abbreviated, and social functioning with the Quality of Life Scale. Measures of psychopathology, neurocognition and social cognition were also gathered for use as potential covariates. RESULTS: A single index of self-appraisal was generated from subjecting the assessments of self-appraisal to a principal components analysis. Linear regression analyses revealed that after controlling for severity of psychopathology, metacognition moderated the effect of the self-appraisal factor score upon social functioning. A median split of metacognition and the self-appraisal index yielded four groups. ANCOVA analyses revealed that participants with higher levels of metacognition and more positive self-appraisal had greater capacities for social relatedness than all other participants, regardless of levels of positive and negative symptoms. Correlational analyses revealed that metacognition but not self-appraisal was related to the frequencies of social contact independent of the effects of psychopathology. Assessments of social cognition and neurocognition were not significantly linked with social dysfunction. CONCLUSION: Greater social functioning is made possible by a combination of both more positive self-appraisals and greater metacognitive capacity. Individuals with schizophrenia who struggle to relate to others may benefit from interventions which address both their beliefs about themselves and their capacity for metacognition.

Metacognitive capacity as a predictor of insight in first-episode psychosis.

Impaired insight is common in the first episode of psychosis (FEP). Although considerable research has examined the factors that are associated with impaired insight in chronic psychosis, less is known about the factors that underlie and sustain poor insight in FEP. Impaired metacognition, or the ability to form integrated representations of self and others, is a promising potential contributor to poor insight in FEP. To explore this possibility, the authors assessed insight and metacognition in 40 individuals with FEP and then examined the relationship between these areas and social cognition domains, neurocognitive domains, and psychotic symptoms. Correlation analyses revealed that improved insight was associated with higher metacognition, better vocabulary and Theory of Mind scores, and fewer symptoms. The domain of metacognitive mastery also predicted clinical insight. Results support the need to develop an integrative therapeutic approach focused on improving metacognition, hence addressing poor insight in FEP.

Deficits in Metacognitive Capacity Are Related to Subjective Distress and Heightened Levels of Hyperarousal Symptoms in Adults With Posttraumatic Stress Disorder.

Among persons with posttraumatic stress disorder (PTSD), the severity of symptoms and concurrent distress are not fully explained by trauma severity. Interest has consequently arisen in the psychological processes that cause distress and heighten PTSD symptoms. This study accordingly sought to examine whether differences in metacognitive capacity are related to levels of emotional distress, avoidance/numbing, and hyperarousal. Participants were 48 adults with a confirmed diagnosis of PTSD. Comparison groups included 51 adults with HIV and 183 with schizophrenia. Metacognition, emotion recognition, depression, and emotional distress and levels of avoidance/numbing and hyperarousal were assessed concurrently using the Metacognition Assessment Scale-Abbreviated, the Bell Lysaker Emotion Recognition Test, the Beck Depression Inventory, and the Clinician-Administered PTSD Scale. Results revealed that the PTSD group had better ratings of overall metacognitive capacity than the schizophrenia group and specifically poorer levels of metacognitive mastery, or the ability to use metacognitive knowledge to respond to challenges, than the HIV group. Within the PTSD group, poorer metacognitive mastery was linked with greater distress and higher hyperarousal when depression was controlled for statistically. Emotion recognition was not linked with distress or symptom severity. Results are consistent with models in which symptom severity in PTSD is related to the extent to which persons can use knowledge of themselves and others to find ways to respond to distress that match their own unique needs.

Anhedonia in prolonged schizophrenia spectrum patients with relatively lower vs. higher levels of depression disorders: associations with deficits in social cognition and metacognition.

This study has sought to explore whether there are at least two subtypes of anhedonia in schizophrenia: one closely linked with depression and another that occurs in the absence of depression which is related to a general paucity of internal experience. Participants were 163 adults with schizophrenia who completed assessments of depression, anhedonia, executive functioning, positive and negative symptoms, social cognition and metacognition. A cluster analysis based on participants' depression and anhedonia symptom scores produced three groups: High Depression/High Anhedonia (n=52), Low Depression/Low Anhedonia (n=52), and Low Depression/High Anhedonia (n=59). An ANCOVA and post hoc comparisons controlling for positive and negative symptoms found that the Low Depression/High Anhedonia group had poorer metacognition and social cognition than other groups. These findings point to the possibility of a subtype of anhedonia in schizophrenia, one occurring in the relative lesser levels of depression, and tied to deficits in the ability to think about oneself and others.

Using the MMPI-2-RF to discriminate psychometrically identified schizotypic college students from a matched comparison sample.

This study investigates the extent to which the Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF) profiles of 52 individuals making up a psychometrically identified schizotypes (SZT) sample could be successfully discriminated from the protocols of 52 individuals in a matched comparison (MC) sample. Replication analyses were performed with an additional 53 pairs of SZT and MC participants. Results showed significant differences in mean T-score values between these 2 groups across a variety of MMPI-2-RF scales. Results from discriminant function analyses indicate that schizotypy can be predicted effectively using 4 MMPI-2-RF scales and that this method of classification held up on replication. Additional results demonstrated that these MMPI-2-RF scales nominally outperformed MMPI-2 scales suggested by previous research as being indicative of schizophrenia liability. Directions for future research with the MMPI-2-RF are suggested.

Metacognition as a Transdiagnostic Determinant of Recovery in Schizotypy and Schizophrenia Spectrum Disorders.

The term schizotypy refers to the latent personality organization that is thought to underpin the liability to develop schizophrenia and associated disorders. Metacognition, or the ability to understand and form increasingly complex and integrated ideas of oneself, others, and one's community, has been proposed to be an important transdiagnostic construct across schizophrenia spectrum disorders and a range of both clinical and non-clinical manifestations of schizotypy. In this paper, we review evidence that deficits in metacognition are present in individuals with relatively high levels of schizotypy and that these deficits are related to symptomology, function, and quality of life. We address the idea that decrements in metacognition may also contribute to the progression from schizotypy to more severe manifestations, while the amelioration of these deficits may enhance aspects of recovery, including the ability to form an integrated sense of self, others, and the wider world. We also review the following two recovery-oriented psychotherapies that target metacognition to promote recovery in individuals with clinical manifestations of schizotypy: Evolutionary Systems Therapy for Schizotypy (ESTS) and Metacognitive Reflection and Insight Therapy (MERIT).

Relational Work Is the Work: Virtual Healthcare Transformation for Rural, Remote and First Nations Communities in British Columbia.

The healthcare crisis across unceded First Nations' territories in rural, remote and Indigenous communities in British Columbia (BC) is marked by persistent barriers to accessing care and support close to home. This commentary describes an exceptional story of how technology, trusted partnerships and relationships came together to create an innovative suite of virtual care programs called "Real-Time Virtual Support" (RTVS). We describe key approaches, learnings and future considerations to improve the equity of healthcare delivery for rural, remote and First Nations communities. The key lessons include the following: (1) moving beyond a biomedical model - the collaboration framework for health service design incorporated First Nations' perspective on health and wellness; (2) relational work is the work - the RTVS collaboration was grounded in building connections and relationships to prioritize cultivating trust in the partnership over specific outputs; and (3) aligning to the core values of co-creation - working from a commitment to do things differently and applying an inclusive approach of engagement to integrate perspectives across different sectors and interest groups.

Valuing the emotions of leadership learning experience in nursing education.

AIM: This paper argues that a greater understanding of the role of emotions in experiencing leadership, the impact of role models and cultures of the workplace and profession, may enable further development for effective leadership development at undergraduate level and beyond. BACKGROUND: Leadership has gained prominence as a necessary skill in nursing literature and policy, linking its importance to patient safety, working cultures, resilience and emotional labour globally. Viewed as essential in many undergraduate nursing programmes and a requirement by professional regulators, there is a globally agreed acceptance of its importance. Despite this, the focus on evaluating and researching the effectiveness of leadership learning and through experiences of students in contexts of learning remain limited. This paper presents a discussion on the importance of experiences of leadership, exploring the emotional impact and how enabling reflexivity and critical analysis can be integrated in education. An approach is proposed for nursing education where the emotional impact of experiencing leadership is given significance. Experiences of leadership in practice and educational learning in higher education should allow students to reflect and conceptualise experience, aligning educational contexts of learning. Acknowledgement of emotional experience and pragmatism provides opportunity to strengthen evidence and knowledge and establish leadership as a concept of value in the profession from an early stage. DESIGN: A critical theoretical discussion paper METHODS: Based on a narrative inquiry study, drawing on theory and philosophies of emotions in education and leadership from 1907 to 2023 RESULTS: Acknowledgement of emotional experience and pragmatism provides opportunity to strengthen evidence and establish leadership as a concept of value in the profession from an early stage. CONCLUSIONS: Placing value on the experience of leadership by reflexivity and pragmatic, experiential approaches to learning can align educational contexts of learning and focus on effective leadership learning for the nursing profession. TWEETABLE ABSTRACT: Pragmatic approaches and reflexivity rationalise emotional experiences of leadership and encourage critical thinking and learning.