The consequences of emotionally evocative patient behaviors on emergency nurses' patient assessments and handoffs: An experimental study using simulated patient cases.

BACKGROUND: Engaging with human emotions is an integral but poorly understood part of the work of emergency healthcare providers. Patient factors (e.g., irritable behavior; mental illness) can evoke strong emotions, and evidence suggests that these emotions can impact care quality and patient safety. Given that nurses play a critical role in providing high quality care, efforts to identify and remedy factors that may compromise care are needed. Yet to date, few experiments have been conducted. OBJECTIVE: To examine the effects of emotionally evocative patient behavior as well as the presence of mental illness on emergency nurses' emotions, patient assessments, testing advocacy, and written handoffs. DESIGN: Experimental vignette research. SETTING: Online experiment distributed via email between October and December 2020. PARTICIPANTS: Convenience sample of 130 emergency nurses from seven hospitals in the Northeastern United States and one hospital in the mid-Atlantic region in the United States. METHODS: Nurses completed four multimedia computer-simulated patient encounters in which patient behavior (irritable vs. calm) and mental illness (present vs. absent) were experimentally varied. Nurses reported their emotions and clinical assessments, recommended diagnostic tests, and provided written handoffs. Tests were coded for whether the test would result in a correct diagnosis, and handoffs were coded for negative and positive patient descriptions and the presence of specific clinical information. RESULTS: Nurses experienced more negative emotions (anger, unease) and reported less engagement when assessing patients exhibiting irritable (vs. calm) behavior. Nurses also judged patients with irritable (vs. calm) behavior as more likely to exaggerate their pain and as poorer historians, and as less likely to cooperate, return to work, and recover. Nurses' handoffs were more likely to communicate negative descriptions of patients with irritable (vs. calm) behavior and omit specific clinical information (e.g., whether tests were ordered, personal information). The presence of mental illness increased unease and sadness and resulted in nurses being less likely to recommend a necessary test for a correct diagnosis. CONCLUSIONS: Emergency nurses' assessments and handoffs were impacted by patient factors, particularly irritable patient behavior. As nurses are central to the clinical team and experience regular, close contact with patients, the effects of irritable patient behavior on nursing assessments and care practices have important implications. We discuss potential approaches to address these ill effects, including reflexive practice, teamwork, and standardization of handoffs. TWEETABLE ABSTRACT: Simulated experimental study found that despite having received identical clinical information, emergency nurses believed that patients displaying irritable behaviours were less likely to return to work soon and were less likely to recover than patients who displayed calm behaviour.

Influence of comorbid depression and diagnostic workup on diagnosis of physical illness: a randomized experiment.

OBJECTIVES: Patients with mental illness are less likely to receive the same physical healthcare as those without mental illness and are less likely to be treated in accordance with established guidelines. This study employed a randomized experiment to investigate the influence of comorbid depression on diagnostic accuracy. METHODS: Physicians were presented with an interactive vignette describing a patient with a complex presentation of pernicious anemia. They were randomized to diagnose either a patient with or without (control) comorbid depression and related behaviors. All other clinical information was identical. Physicians recorded a differential diagnosis, ordered tests, and rated patient likeability. RESULTS: Fifty-nine physicians completed the study. The patient with comorbid depression was less likeable than the control patient (p=0.03, 95 % CI [0.09, 1.53]). Diagnostic accuracy was lower in the depression compared to control condition (59.4 % vs. 40.7 %), however this difference was not statistically significant χ2(1)=2.035, p=0.15. Exploratory analyses revealed that patient condition (depression vs. control) interacted with the number of diagnostic tests ordered to predict diagnostic accuracy (OR=2.401, p=0.038). Accuracy was lower in the depression condition (vs. control) when physicians ordered fewer tests (1 SD below mean; OR=0.103, p=0.028), but there was no difference for physicians who ordered more tests (1 SD above mean; OR=2.042, p=0.396). CONCLUSIONS: Comorbid depression and related behaviors lowered diagnostic accuracy when physicians ordered fewer tests - a time when more possibilities should have been considered. These findings underscore the critical need to develop interventions to reduce diagnostic error when treating vulnerable populations such as those with depression.

A Qualitative Study of Emergency Physicians' and Nurses' Experiences Caring for Patients With Psychiatric Conditions and/or Substance Use Disorders.

STUDY OBJECTIVE: Patients with psychiatric conditions and/or substance use disorders (SUDs) frequently seek care in emergency departments (EDs), where providing care for these populations can involve considerable challenges. This study aimed to develop a comprehensive data-driven model of the complex challenges and unique dynamics associated with caring for these populations in the ED, as well as the effect on patient care quality. METHODS: We conducted a preplanned topical analysis of grounded theory data obtained from semistructured interviews with 86 ED physicians and nurses from 8 hospitals in the Northeastern USA. Participants provided detailed descriptions of their experiences and challenges in caring for patients with psychiatric conditions and/or SUDs. We identified themes inductively using constant comparative analysis and developed a grounded model of physicians' and nurses' perceptions of challenges, biases, and effects on patient care. RESULTS: Emergency physicians and nurses described emotional, diagnostic, and logistical challenges that patients with psychiatric conditions and/or SUDs present. These challenges are magnified by existing health care system issues and social structures, which fuel and reinforce negative attitudes, expectations, and biases. In combination, these processes create negative health care experiences for patients, physicians, and nurses and can adversely affect patient care quality and ED staff well-being. CONCLUSION: Our findings uncover a cyclical process whereby challenges and biases associated with patients with psychiatric conditions and/or SUDs can reciprocally threaten patient care quality. Systemic changes and localized interventions are urgently needed to mitigate challenges, reduce bias, improve patient care, and improve physicians' and nurses' experiences in the ED.

COVID-19 related negative emotions and emotional suppression are associated with greater risk perceptions among emergency nurses: A cross-sectional study.

Background: As the COVID-19 pandemic began, frontline nurses experienced many emotions as they faced risks relevant to both patients (e.g., making errors resulting in patient harm) and themselves (e.g., becoming infected with COVID-19). Although emotions are often neglected in the patient safety literature, research in affective science suggests that emotions may significantly impact nurses' perceptions of risk, which can have downstream consequences. Further, the use of chronic emotion regulation strategies that are known to differ in adaptability and effectiveness (i.e., emotional suppression, reappraisal) can impact risk perceptions. Objective: To investigate the relationship between nurses' emotional experiences in response to the pandemic and their estimates of how likely they would be to experience adverse outcomes related to both patients and themselves within the next six months. Additionally, we investigated the extent to which the use of suppression and reappraisal processes to manage emotions are associated with these risk perceptions. Design: Cross-sectional survey. Setting: Online survey distributed via email to emergency nurses at eight hospitals in the northeastern United States during fall 2020. Participants: 132 emergency nurses (M age = 37.05; 81.1% Female; 89.4% White). Methods: Nurses reported the extent to which they experienced a variety of positive (e.g., hope, optimism) and negative (e.g., fear, sadness) emotions in response to the COVID-19 pandemic, and reported their perceptions of risk to both patients and themselves. Nurses also completed the Emotion Regulation Questionnaire, a measure of chronic tendencies to engage in emotional suppression and reappraisal. Immediately prior to providing data for this study, nurses completed an unrelated decision-making study. Results: Nurses' negative emotions in response to COVID-19 were associated with greater perceptions of both patient safety risks (b = 0.31, p < .001) and personal risks (b = 0.34, p < .001). The relationships between positive emotions and risk perceptions were not statistically significant (all p values > 0.66). Greater chronic tendencies to suppress emotions uniquely predicted greater perceptions of patient safety risks (b = 2.91, p = .036) and personal risks (b = 2.87, p = .040) among nurses; however, no statistically significant relationships with reappraisal emerged (all p values > 0.16). Conclusions: Understanding factors that influence perceptions of risk are important, given that these perceptions can motivate behaviours that may adversely impact patient safety. Such an understanding is essential to inform the development of interventions to mitigate threats to patient safety that emerge from nurses' negative emotional experiences and their use of different emotion regulation strategies. Tweetable abstract: Covid-related negative emotions and emotional suppression are associated with greater patient and personal risk perceptions among emergency nurses @lindamisbell @Nathan_Huff_1.

Perspectives of Emergency Clinicians About Medical Errors Resulting in Patient Harm or Malpractice Litigation.

This cross-sectional study analyzes responses to a survey about medical error outcomes completed by emergency department attending physicians and advanced practice clinicians.

Stigmatizing attitudes toward Disruptive Mood Dysregulation Disorder (DMDD) in parents vs. non-parents: Effects of medication and genetic etiology.

Stigmatizing attitudes toward children with psychopathology represent a barrier to treatment and well-being, yet almost no research has investigated what contributes to these attitudes. This study examines the effects of medication treatment and genetic etiology on stigmatizing attitudes toward a relatively new and controversial disorder-Disruptive Mood Dysregulation Disorder (DMDD). Participants (159 parents, 225 non-parents) completed a vignette study on Amazon's Mechanical Turk (MTurk) in which a child displayed behaviors consistent with DMDD. The child was described as either taking psychiatric medication or not, and the vignette described the child's condition as either genetic or did not mention etiology. Participants who were parents reported greater stigma when the etiology (genetic prime vs. no prime) matched the perceived appropriate treatment (medication vs. no medication). Among parents, a child treated with medication who had a genetic disorder, and a child who was not treated with medication and for whom genetic etiology was not primed, were most stigmatized. No differences emerged among non-parents. These findings highlight the importance of considering multiple factors (parental status, congruence between treatment and perceived disorder etiology) when investigating mental health stigma and underscore the need to further investigate such nuances to inform anti-stigma interventions.

Quiet Ego Intervention Enhances Flourishing by Increasing Quiet Ego Characteristics and Trait Emotional Intelligence: A Randomized Experiment.

The quiet ego-a personality construct characterized by empathy, inclusivity, non-defensiveness, and growth-mindedness in self-other relations-correlates positively with varied health markers. There is also emerging evidence that quiet-ego-based interventions may have a positive impact on health-related outcomes. However, no research has examined whether such interventions promote psychological flourishing and through what mechanisms. We addressed this gap with a randomized longitudinal experiment, hypothesizing that a quiet ego contemplation would improve participants' flourishing and that the link between the intervention and flourishing would be mediated by higher trait emotional intelligence (EI). Using Amazon MTurk, we randomly assigned 75 participants to a 3-session intervention or control condition. As hypothesized, participants in the intervention condition reported higher trait EI scores that, in turn, elevated their flourishing. Results extend the causal benefits of brief quiet ego interventions to psychological flourishing. Given the study's context during the COVID-19 pandemic, the findings may have implications for mitigating the negative impact of the pandemic. Supplementary Information: The online version contains supplementary material available at 10.1007/s10902-022-00560-z.

Affective influences on clinical reasoning and diagnosis: insights from social psychology and new research opportunities.

Psychological research consistently demonstrates that affect can play an important role in decision-making across a broad range of contexts. Despite this, the role of affect in clinical reasoning and medical decision-making has received relatively little attention. Integrating the affect, social cognition, and patient safety literatures can provide new insights that promise to advance our understanding of clinical reasoning and lay the foundation for novel interventions to reduce diagnostic errors and improve patient safety. In this paper, we briefly review the ways in which psychologists differentiate various types of affect. We then consider existing research examining the influence of both positive and negative affect on clinical reasoning and diagnosis. Finally, we introduce an empirically supported theoretical framework from social psychology that explains the cognitive processes by which these effects emerge and demonstrates that cognitive interventions can alter these processes. Such interventions, if adapted to a medical context, hold great promise for reducing errors that emerge from faulty thinking when healthcare providers experience different affective responses.

A qualitative investigation of the impact of coronavirus disease 2019 (COVID-19) on emergency physicians' emotional experiences and coping strategies.

STUDY OBJECTIVE: Throughout the coronavirus disease 2019 (COVID-19) pandemic, emergency physicians in the United States have faced unprecedented challenges, risks, and uncertainty while caring for patients in an already vulnerable healthcare system. As such, the pandemic has exacerbated high levels of negative emotions and burnout among emergency physicians, but little systematic qualitative work has documented these phenomena. The purpose of this qualitative investigation was to study emergency physicians' emotional experiences in response to COVID-19 and the coping strategies that they employed to navigate the pandemic. METHODS: From September 2020 to February 2021, we conducted semistructured interviews with 26 emergency physicians recruited from 2 early COVID-19 epicenters: New York City and the Metro Boston region. Interviews, coding, and analyses were conducted using a grounded theory approach. RESULTS: Emergency physicians reported heightened anxiety, empathy, sadness, frustration, and anger during the pandemic. Physicians frequently attributed feelings of anxiety to medical uncertainty around the COVID-19 virus, personal risk of contracting the virus and transmitting it to family members, the emergency environment, and resource availability. Emergency physicians also discussed the emotional effects of policies prohibiting patients' family members from entering the emergency department (ED), both on themselves and patients. Sources of physician anger and frustration included changing policies and rules, hospital leadership and administration, and pay cuts. Some physicians described an evolving, ongoing coping process in response to the pandemic, and most identified collective discussion and processing within the emergency medicine community as an effective coping strategy. CONCLUSIONS: Our findings underscore the need to investigate the effects of physicians' pandemic-related emotional stress and burnout on patient care. Evidence-based interventions to support emergency physicians in coping with pandemic-related trauma are needed.

Emotionally evocative patients in the emergency department: a mixed methods investigation of providers' reported emotions and implications for patient safety.

BACKGROUND: Emergency department (ED) physicians and nurses frequently interact with emotionally evocative patients, which can impact clinical decision-making and behaviour. This study introduces well-established methods from social psychology to investigate ED providers' reported emotional experiences and engagement in their own recent patient encounters, as well as perceived effects of emotion on patient care. METHODS: Ninety-four experienced ED providers (50 physicians and 44 nurses) vividly recalled and wrote about three recent patient encounters (qualitative data): one that elicited anger/frustration/irritation (angry encounter), one that elicited happiness/satisfaction/appreciation (positive encounter), and one with a patient with a mental health condition (mental health encounter). Providers rated their emotions and engagement in each encounter (quantitative data), and reported their perception of whether and how their emotions impacted their clinical decision-making and behaviour (qualitative data). RESULTS: Providers generated 282 encounter descriptions. Emotions reported in angry and mental health encounters were remarkably similar, highly negative, and associated with reports of low provider engagement compared with positive encounters. Providers reported their emotions influenced their clinical decision-making and behaviour most frequently in angry encounters, followed by mental health and then positive encounters. Emotions in angry and mental health encounters were associated with increased perceptions of patient safety risks; emotions in positive encounters were associated with perceptions of higher quality care. CONCLUSIONS: Positive and negative emotions can influence clinical decision-making and impact patient safety. Findings underscore the need for (1) education and training initiatives to promote awareness of emotional influences and to consider strategies for managing these influences, and (2) a comprehensive research agenda to facilitate discovery of evidence-based interventions to mitigate emotion-induced patient safety risks. The current work lays the foundation for testing novel interventions.

What do emergency department physicians and nurses feel? A qualitative study of emotions, triggers, regulation strategies, and effects on patient care.

BACKGROUND: Despite calls to study how healthcare providers' emotions may impact patient safety, little research has addressed this topic. The current study aimed to develop a comprehensive understanding of emergency department (ED) providers' emotional experiences, including what triggers their emotions, the perceived effects of emotions on clinical decision making and patient care, and strategies providers use to manage their emotions to reduce patient safety risks. METHODS: Employing grounded theory, we conducted 86 semi-structured qualitative interviews with experienced ED providers (45 physicians and 41 nurses) from four academic medical centres and four community hospitals in the Northeastern USA. Constant comparative analysis was used to develop a grounded model of provider emotions and patient safety in the ED. RESULTS: ED providers reported experiencing a wide range of emotions in response to patient, hospital, and system-level factors. Patients triggered both positive and negative emotions; hospital and system-level factors largely triggered negative emotions. Providers expressed awareness of possible adverse effects of negative emotions on clinical decision making, highlighting concerns about patient safety. Providers described strategies they employ to regulate their emotions, including emotional suppression, distraction, and cognitive reappraisal. Many providers believed that these strategies effectively guarded against the risk of emotions negatively influencing their clinical decision making. CONCLUSION: The role of emotions in patient safety is in its early stages and many opportunities exist for researchers, educators, and clinicians to further address this important issue. Our findings highlight the need for future work to (1) determine whether providers' emotion regulation strategies are effective at mitigating patient safety risk, (2) incorporate emotional intelligence training into healthcare education, and (3) shift the cultural norms in medicine to support meaningful discourse around emotions.

Do emotional control beliefs lead people to approach positive or negative situations? Two competing effects of control beliefs on emotional situation selection.

Control beliefs are widely acknowledged to play a critical role in self-regulation and well-being, but their impact on decisions to approach or avoid situations that vary in emotional valence remains unclear. We propose that two contradictory, yet equally intuitive, predictions can be made about the impact of control beliefs on emotional situation selection. On the one hand, control beliefs might encourage individuals to initiate proactive emotion regulatory efforts, helping people select positive situations. On the other hand, control beliefs might promote a sense of confidence in one's ability to manage emotions once they arise, helping people select negative situations. We propose that both effects occur via different mechanisms and suppress one another: control beliefs facilitate (1) positivity engagement by enhancing awareness of opportunities to regulate emotions, and (2) negativity engagement by enhancing confidence in one's ability to handle negative situations. We found support for this framework in four studies. Consistent with our hypotheses, control beliefs (measured in Studies 1-3 and manipulated in Study 4) exerted two simultaneous and competing effects on emotional situation selection (assessed via self-report measures in Studies 1 and 2 and behaviorally in Studies 3 and 4) via the proposed mechanisms, and evidence of suppression was found. New opportunities for research on control beliefs, emotion regulation, and motivation are discussed. (PsycINFO Database Record

The impact of negative emotions on self-concept abstraction depends on accessible information processing styles.

Research suggests that anger promotes global, abstract processing whereas sadness and fear promote local, concrete processing (see Schwarz & Clore, 2007 for a review). Contrary to a large and influential body of work suggesting that specific affective experiences are tethered to specific cognitive outcomes, the affect-as-cognitive-feedback account maintains that affective experiences confer positive or negative value on currently dominant processing styles, and thus can lead to either global or local processing (Huntsinger, Isbell, & Clore, 2014). The current work extends this theoretical perspective by investigating the impact of discrete negative emotions on the self-concept. By experimentally manipulating information processing styles and discrete negative emotions that vary in appraisals of certainty, we demonstrate that the impact of discrete negative emotions on the spontaneous self-concept depends on accessible processing styles. When global processing was accessible, individuals in angry (negative, high certainty) states generated more abstract statements about themselves than individuals in either sad (Experiment 1) or fearful (Experiment 2; negative, low certainty) states. When local processing was made accessible, however, the opposite pattern emerged, whereby individuals in angry states generated fewer abstract statements than individuals in sad or fearful states. Together these studies provide new insights into the mechanisms through which discrete emotions influence cognition. In contrast to theories assuming a dedicated link between emotions and processing styles, these results suggest that discrete emotions provide feedback about accessible ways of thinking, and are consistent with recent evidence suggesting that the impact of affect on cognition is highly context-dependent. (PsycINFO Database Record

The Impact of Affect on Out-Group Judgments Depends on Dominant Information-Processing Styles: Evidence From Incidental and Integral Affect Paradigms.

Two studies tested the affect-as-cognitive-feedback model, in which positive and negative affective states are not uniquely associated with particular processing styles, but rather serve as feedback about currently accessible processing styles. The studies extend existing work by investigating (a) both incidental and integral affect, (b) out-group judgments, and (c) downstream consequences. We manipulated processing styles and either incidental (Study 1) or integral (Study 2) affect and measured perceptions of out-group homogeneity. Positive (relative to negative) affect increased out-group homogeneity judgments when global processing was primed, but under local priming, the effect reversed (Studies 1 and 2). A similar interactive effect emerged on attributions, which had downstream consequences for behavioral intentions (Study 2). These results demonstrate that both incidental and integral affect do not directly produce specific processing styles, but rather influence thinking by providing feedback about currently accessible processing styles.

The affective control of thought: malleable, not fixed.

Despite decades of research demonstrating a dedicated link between positive and negative affect and specific cognitive processes, not all research is consistent with this view. We present a new overarching theoretical account as an alternative-one that can simultaneously account for prior findings, generate new predictions, and encompass a wide range of phenomena. According to our proposed affect-as-cognitive-feedback account, affective reactions confer value on accessible information processing strategies (e.g., global vs. local processing) and other responses, goals, concepts, and thoughts that happen to be accessible at the time. This view underscores that the relationship between affect and cognition is not fixed but, instead, is highly malleable. That is, the relationship between affect and cognitive processing can be altered, and often reversed, by varying the mental context in which it is experienced. We present evidence that supports this account, along with implications for specific affective states and other subjective experiences. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

Who am I?: The influence of affect on the working self-concept.

Two experiments investigated the impact of affect on the working self-concept. Following an affect induction, participants completed the twenty statements test (TST) to assess their working self-concepts. Participants in predominantly happy and angry states used more abstract statements to describe themselves than did participants in predominantly sad and fearful states. Evaluations of the statements that participants generated (Experiment 2) demonstrate that these effects are not the result of (1) participants describing positively and negatively valenced information at different levels of abstraction, or (2) valence-based affective priming. Further, half of the participants in Experiment 2 were led to attribute their affect to the manipulation prior to completing the TST. This manipulation eliminated the influence of affect on the working self-concept. Taken together, these results are consistent with theory and research on the informative functions of affect.

Sometimes happy people focus on the trees and sad people focus on the forest: context-dependent effects of mood in impression formation.

Research indicates that affect influences whether people focus on categorical or behavioral information during impression formation. One explanation is that affect confers its value on whatever cognitive inclinations are most accessible in a given situation. Three studies tested this malleable mood effects hypothesis, predicting that happy moods should maintain and unhappy moods should inhibit situationally dominant thinking styles. Participants completed an impression formation task that included categorical and behavioral information. Consistent with the proposed hypothesis, no fixed relation between mood and processing emerged. Whether happy moods led to judgments reflecting category-level or behavior-level information depended on whether participants were led to focus on the their immediate psychological state (i.e., current affective experience; Studies 1 and 2) or physical environment (i.e., an unexpected odor; Study 3). Consistent with research on socially situated cognition, these results demonstrate that the same affective state can trigger entirely different thinking styles depending on the context.