Inspiring, Recruiting, and Retaining the Health-Care Workforce: What Will it Take?

The U.S. health-care system, the costliest in the world, is facing an exodus of nurses and other healthcare workers. The growth of corporate medicine has contributed to clinician stress and burnout, and has created conditions that have eroded autonomy. Reform is needed that creates cultures in which healthcare providers have agency to make decisions that impact their practice and all aspects of patient care. Massive change is needed to inspire, recruit, and retain the health-care workforce.

Integrative Nursing: A Framework for Whole-Person Mental Health Care.

The incidence of mental illness continues to increase since the start of the COVID-19 pandemic (Mental Health America, 2022). Demand for mental health services has grown, and providers report being "unable to meet the demand" or having an increase in wait times for access to care (American Psychological Association, 2022, para. 1). Due to this increase in demand, more patients are seeking mental health care from their primary care providers. Over the past decade, integrative models of care have been expanding into mental health care (Lake, 2017). Integrative Nursing is a strategy for improving the quality of care provided to patients seeking care for mental health diagnoses, as well as those with a goal of increasing mental health and wellbeing. This article proposes that Integrative Nursing can serve as a framework for providing whole-person mental health care.

Integrative Nursing and the ANA Scope and Standards of Practice: Expanding the Reach of Nursing for Families and Society.

The American Nurses Association's (ANA) recently published 4th edition of the Scope and Standards of Practice provides authoritative guidance on actions and behaviors that all registered nurses are expected to perform competently, regardless of role, population, specialty, or setting. The newly defined scope emphasizes the art and science of caring, compassionate presence, and the expectation that nurses be advocates for all, recognizing the connections of all humanity. It also makes frequent reference to whole-person care and highlights the importance of mindfulness by inviting nurses to reflect on how they can incorporate mindfulness and other integrative therapies into their self-care and professional practice. A new standard explicitly states that advanced practice registered nurses should have the competency to prescribe evidence-based traditional and integrative treatments, therapies, and procedures that are compatible with the consumer's cultural preferences, norms, and abilities. Integrative Nursing is aligned with the ANA Scope and Standards of Practice and provides a useful framework for practice that expands the reach of nursing across clinical and community settings and patient populations. In this article, exemplars highlight how Integrative Nursing is being implemented in clinical settings and nursing education programs.

A Randomized Trial of 21 Days of Loving Kindness Meditation for Stress Reduction and Emotional Well-being Within an Online Health Community for Patients, Family, and Friends Experiencing a Cancer Health Journey.

Objectives: CaringBridge (CB) is an online health community for people undergoing challenging health journeys. Loving Kindness Meditation (LKM) is a systemized mind-body approach developed to increase loving acceptance and has previously been reported to increase resilience in the face of adversity. Materials and Methods: Results of a randomized controlled trial of immediate compared with deferred 21-day LKM intervention in an online community are reported. The deferred group received LKM intervention after a waiting period of 3 weeks. Inclusion criteria were >18 years old, ability to understand English, willingness to participate in a mind-body practice, and use of CB for a cancer journey. Change in perceived stress, self-compassion, social connectedness and assurance, and compassionate love scales from baseline to 21 days was assessed. Results: Of the 979 participants included in the study, 649 (66%) provided 3-week follow-up data and 330 (49%) self-reported engaging in the LKM practice 5 or more days/week. Participants in the immediate LKM group reported medium effect size improvement in stress (0.4), self-compassion (0.5), and social connectedness (0.4) compared with the deferred LKM group. Changes in perceived stress and self-compassion were larger in magnitude and increased with more frequent engagement in LKM. Conclusions: The immediate LKM group showed improvements in stress, self-compassion, and social connectedness compared with the deferred control group. Differential study retention rates by treatment arm and self-reported engagement in LKM subject the results to selection bias. Future research of similar interventions within online health communities might pay greater attention to promoting intervention adherence and engaging a more diverse economic and racial/ethnic population. ClinicalTrials.gov (NCT05002842).

Evaluating Systemized Nomenclature of Medicine Clinical Terms Coverage of Complementary and Integrative Health Therapy Approaches Used Within Integrative Nursing, Health, and Medicine.

The use of complementary and integrative health therapy strategies for a wide variety of health conditions is increasing and is rapidly becoming mainstream. However, little is known about how or if complementary and integrative health therapies are represented in the EHR. Standardized terminologies provide an organizing structure for health information that enable EHR representation and support shareable and comparable data; which may contribute to increased understanding of which therapies are being used for whom and for what purposes. Use of standardized terminologies is recommended for interoperable clinical data to support sharable, comparable data to enable the use of complementary and integrative health therapies and to enable research on outcomes. In this study, complementary and integrative health therapy terms were extracted from multiple sources and organized using the National Center for Complementary and Integrative Health and former National Center for Complementary and Alternative Medicine classification structures. A total of 1209 complementary and integrative health therapy terms were extracted. After removing duplicates, the final term list was generated via expert consensus. The final list included 578 terms, and these terms were mapped to Systemized Nomenclature of Medicine Clinical Terms. Of the 578, approximately half (48.1%) were found within Systemized Nomenclature of Medicine Clinical Terms. Levels of specificity of terms differed between National Center for Complementary and Integrative Health and National Center for Complementary and Alternative Medicine classification structures and Systemized Nomenclature of Medicine Clinical Terms. Future studies should focus on the terms not mapped to Systemized Nomenclature of Medicine Clinical Terms (51.9%), to formally submit terms for inclusion in Systemized Nomenclature of Medicine Clinical Terms, toward leveraging the data generated by use of these terms to determine associations among treatments and outcomes.

Voices of Nurses During the Covid-19 Pandemic: A Call to Action.

The Covid-19 pandemic is having a significant impact on the well-being of nurses and has exacerbated long-standing issues of stress and burnout. Expecting or hoping that nurses will recover quickly or bounce back from the stress and deep trauma of the pandemic is not realistic. Each nurse has a story, and while these stories may have similar themes, they are all different. It is important to reflect on our stories, identify the myriad of emotions we are experiencing, and find ways to work through our feelings. Ignoring, denying, or suppressing feelings does not serve us well in the long run. Stifling negative emotions does not make them go away. A Call to Action is needed to address the impact of the pandemic, clinician burnout, and systemic racism on health-care organizations and educational institutions. Strategies are identified that will support personal and organizational well-being.

Frontolimbic alpha activity tracks intentional rest BCI control improvement through mindfulness meditation.

Brain-computer interfaces (BCIs) are capable of translating human intentions into signals controlling an external device to assist patients with severe neuromuscular disorders. Prior work has demonstrated that participants with mindfulness meditation experience evince improved BCI performance, but the underlying neural mechanisms remain unclear. Here, we conducted a large-scale longitudinal intervention study by training participants in mindfulness-based stress reduction (MBSR; a standardized mind-body awareness training intervention), and investigated whether and how short-term MBSR affected sensorimotor rhythm (SMR)-based BCI performance. We hypothesize that MBSR training improves BCI performance by reducing mind wandering and enhancing self-awareness during the intentional rest BCI control, which would mainly be reflected by modulations of default-mode network and limbic network activity. We found that MBSR training significantly improved BCI performance compared to controls and these behavioral enhancements were accompanied by increased frontolimbic alpha activity (9-15 Hz) and decreased alpha connectivity among limbic network, frontoparietal network, and default-mode network. Furthermore, the modulations of frontolimbic alpha activity were positively correlated with the duration of meditation experience and the extent of BCI performance improvement. Overall, these data suggest that mindfulness allows participant to reach a state where they can modulate frontolimbic alpha power and improve BCI performance for SMR-based BCI control.

Professional development in integrative health through an interprofessional online course in clinical settings.

BACKGROUND: Although there is mounting clinical and cost-effectiveness evidence supporting integrative healthcare (IH), a significant knowledge gap hinders widespread adoption by health professionals. INTERVENTION: Foundations in Integrative Health (FIH), a 32-h online competency-based interprofessional course to address this knowledge gap. METHODS: The course was pilot-tested by an interprofessional sample of providers in various clinical settings as professional and staff development. OUTCOME MEASURES: Prior to and following the course, participants completed an IH knowledge test, an IH self-efficacy self-assessment, and validated measures of burnout, wellness behaviors, and attitudes toward IH, interprofessional teams, and patient involvement. Evaluation surveys were administered following each unit and the course. RESULTS: Thirty-one percent of the participants (n = 214/690) completed the course. Pre/post course improvements were found in IH knowledge, IH self-efficacy, attitudes towards IH and interprofessional teams, and several wellness behaviors. The course was positively evaluated with 81% of the participants indicating interest in applying IH principles in their practice and 92% reported that the course enhanced their clinical experience. CONCLUSION: This study demonstrates the outcomes of a multi-site, online IH curriculum offered to a diverse group of health professionals in various clinical settings. This course may allow clinical settings to offer an interprofessional, IH curriculum even with limited on-site faculty expertise.

Mindfulness Improves Brain-Computer Interface Performance by Increasing Control Over Neural Activity in the Alpha Band.

Brain-computer interfaces (BCIs) are promising tools for assisting patients with paralysis, but suffer from long training times and variable user proficiency. Mind-body awareness training (MBAT) can improve BCI learning, but how it does so remains unknown. Here, we show that MBAT allows participants to learn to volitionally increase alpha band neural activity during BCI tasks that incorporate intentional rest. We trained individuals in mindfulness-based stress reduction (MBSR; a standardized MBAT intervention) and compared performance and brain activity before and after training between randomly assigned trained and untrained control groups. The MBAT group showed reliably faster learning of BCI than the control group throughout training. Alpha-band activity in electroencephalogram signals, recorded in the volitional resting state during task performance, showed a parallel increase over sessions, and predicted final BCI performance. The level of alpha-band activity during the intentional resting state correlated reliably with individuals' mindfulness practice as well as performance on a breath counting task. Collectively, these results show that MBAT modifies a specific neural signal used by BCI. MBAT, by increasing patients' control over their brain activity during rest, may increase the effectiveness of BCI in the large population who could benefit from alternatives to direct motor control.

Impact of an Online Nutrition Course to Address a Gap in Medical Education: A Feasibility Study.

BACKGROUND AND OBJECTIVES: Nutrition is a foundation of health, yet there is a deficiency of nutrition training in graduate medical education. The purpose of this feasibility study was to assess the impact of a brief online clinical nutrition course on medical residents' knowledge and attitudes related to the role of nutrition in clinical practice. METHODS: Medical residents from two institutions took a 3-hour, online, self-paced and interactive clinical nutrition course that reviewed macronutrients, evidence-based dietary patterns, a rapid nutrition assessment, and motivational interviewing. We administered surveys of nutrition knowledge and attitudes at three time points: (1) just prior to taking the online course, (2) immediately following, and (3) 3 months after course completion. RESULTS: Seventy-six residents enrolled in the study and 47 (62%) completed the online course and postcourse surveys. For residents who completed the study, the summated nutrition knowledge scores assessed both immediately after taking the course and 3 months later showed significant improvement (P<.001). Three months after completing the course, residents were more likely to believe it was their role to personally provide detailed nutrition information to patients (P=.045) and to endorse the view that a healthy diet is important for self-care (P<.001). The estimated time residents spent counseling patients on nutrition did not change after the intervention. CONCLUSION: This feasibility study demonstrated the potential of a 3-hour, online, self-paced nutrition course administered to medical residents to result in a significant and sustained increase in nutrition knowledge and positive attitudes about the role of nutrition in clinical practice.

Nursing Theory in the Quest for the Sustainable Development Goals.

The 17 United Nations Sustainable Development Goals (SDG) are intended to promote a safe, healthy, and equitable world by the year 2030. Nurses are at the forefront of realizing the 2030 agenda through concerned citizenship and professional leadership. Nursing theory informs knowledge development and theory-guided practice essential for nurses working in all domains and in all nations. Although all extant nursing theories are relevant, a select few are discussed in detail to make explicit the links between theory and SDG realization. Middle-range theories are also valuable in helping to contextualize nursing practice through the lens of the SDGs. The SDGs address five themes - People, Planet, Peace, Prosperity, and Partnership - and theory remains vital to ensure nurses working in all settings are equipped to meet the needs of humanity and the world, now and in the future.

Introducing integrative primary health care to an interprofessional audience: Feasibility and impact of an asynchronous online course.

BACKGROUND: Although there is mounting clinical and cost-effectiveness evidence supporting integrative healthcare (IH), a significant knowledge gap hinders widespread adoption by primary care professionals. INTERVENTION: Based on IH competencies developed by an interprofessional team and a needs assessment, a 32-h online interprofessional IH course, Foundations in Integrative Health, was developed. Trainees learn to conduct an IH assessment and how patients are assessed and treated from the diverse professions in integrative primary care. METHODS: The course was pilot-tested with educational program trainees, faculty and clinical staff at graduate level primary care training programs (primary care residencies, nursing, pharmacy, public health, behavioral health, and licensed complementary and IH programs). OUTCOME MEASURES: Prior to and following the course, participants completed an IH knowledge test, an IH efficacy self-assessment, and validated measures of IH attitudes, interprofessional learning, provider empathy, patient involvement, resiliency, self-care, wellness behaviors, and wellbeing. Evaluation surveys were administered following each unit and the course. RESULTS: Almost one-half (n = 461/982, 47%) completed the course. Pre/post course improvements in IH knowledge, IH self-efficacy, IH attitudes, interprofessional learning, provider empathy, resiliency, self-care, several wellness behaviors, and wellbeing were observed. The course was positively evaluated with most (93%) indicating interest in applying IH principles and that the course enhanced their educational experience (92%). CONCLUSION: This study demonstrates the feasibility and effectiveness of a multi-site, online curriculum for introducing IH to a diverse group of primary care professionals. Primary care training programs have the ability to offer an interprofessional, IH curriculum with limited on-site faculty expertise.

Randomized Trial of Mindfulness-Based Stress Reduction in Cardiac Patients Eligible for Cardiac Rehabilitation.

Currently, exercise-based cardiac rehabilitation (CR) is the only recommended secondary prevention strategy for cardiac patients that attempts to tackle stress and psychosocial wellbeing, but it is under-utilized and lacks a comprehensive curriculum for this purpose; hence there is a critical gap to address psychosocial needs of cardiac patients after an event. Mindfulness-based stress reduction (MBSR) has shown benefits in the general population but its role in cardiac patients is not clear. We conducted a pilot randomized controlled trial (RCT) of MBSR in CR-eligible cardiac patients during their initial year of recovery. Patients were allocated 2:1 (intervention:control) to an 8-week MBSR group intervention or usual care. Standard measures of depression, anxiety, perceived stress, health related quality of life (HRQOL), blood pressure, biomarkers (lipids, HbA1c, CRP) and 24-hour Holter monitoring were obtained at baseline, 3- and 9-months post-randomization. Sub-group analyses were performed for participants with at least mild depression (PHQ-9 ≥ 5). 47 patients [mean age 58.6 years; 38% female; 77% white] were enrolled in 2 cohorts. 87% of MBSR patients completed the intervention; study retention was >95% at each follow-up visit. At 3 months, compared to controls, MBSR patients showed improvements in depression [p = 0.01] and anxiety [p = 0.04] with a similar trend in HRQOL [p = 0.06]. The MBSR group showed greater improvement or less worsening of most CV risk factors, with an attenuation of treatment effects at 9 months. Participants with at PHQ-9 scores ≥5 at baseline showed greater improvement in psychosocial and CV outcomes, that persisted at 9 months. MBSR is a safe and well received secondary prevention strategy. This pilot RCT provides preliminary evidence of MBSR's potential to improve short term psychosocial well-being in cardiac patients during their first year of recovery.

Why and How Should We Integrate Biomarkers into Complex Trials? A Discussion on Paradigms and Clinical Research Strategies.

BACKGROUND: Research in complementary and alternative medicine (CAM) encounters a variety of challenges, such as potentially synergistic, multimodal, and complex interventions which are often dependent on the relationship between practitioner and patient, on specific settings, and on patients' individual preferences, expectations, beliefs, and motivations. Moreover, patients seeking CAM care often suffer from chronic disease conditions, and multiple symptoms and/or pathologies. On the other hand, CAM interventions are often challenged as being solely dependent on subjective and nonspecific factors without biologically based mechanisms of action. If we agree that biomarkers as outcomes are important for the understanding of CAM interventions, a hypothesis- and strategy-driven process for the selection of the most appropriate biomarkers is needed. METHODS: This paper presents the results of an expert panel on how to integrate biomarkers in whole system research of an interdisciplinary workshop on research methodology in CAM held in November 2012. RESULTS: The following main CAM research challenges were identified: (a) finding appropriate biomarkers, which are able to picture the complex pathophysiological pathways and likewise complex interventions under study; (b) integrating these biomarkers into clinical trials in CAM; and (c) identifying the biomarkers specific to the particular CAM intervention being applied. CONCLUSION: The paper provides a disease/condition/symptom- and intervention-driven strategy regarding how to identify the outcomes of interest and possible related biomarkers. The research approach presented here allows the selected biomarkers to be grounded in conventional physiology/pathophysiology as well as complementary and alternative concepts, including traditional systems of medicine. The goal is to provide researchers in the field with a framework on how to integrate biomarkers into complex trials.

Outcomes of a Gratitude Practice in an Online Community of Caring.

OBJECTIVES: CaringBridge (CB) is a web-based social network where people share information, enlist support, and access resources following a difficult diagnosis; it can also be used to disseminate supportive self-care tools, such as a gratitude practice, for its users. Gratitude practices are shown to reduce stress and fear, improve sleep, and increase positive emotions and overall well-being. The purpose of this article was to report the findings of a brief gratitude intervention delivered to CB users. Design, setting/location, subjects: This is a nonrandomized, prospective, pre- and post-evaluation study in an online community. Inclusion criteria were adults 18 years or older, English literate, willingness to participate in a mind-body practice, and active users of CB: patient, caregiver, or visitor to a site. INTERVENTIONS: Participants were engaged in a daily, 21-day brief gratitude practice and were given weekly automated reminders to do their practice. OUTCOME MEASURES: Outcomes included perceived stress, gratitude, social connectedness, and social assurance scales. Paired t tests were used to assess changes in outcomes; multivariate regression models were used to assess the relationship between the frequency of gratitude practice and change in outcomes. RESULTS: Follow-up data were collected from 882/1598 participants, and nearly 70% self-reported engaging in the gratitude practice five or more days/week. Participants reported statistically significant improvement in all outcomes with small standardized effect sizes for gratitude (0.39), social connectedness (0.24), and social assurance (0.10). Changes in perceived stress (-0.73) were larger in magnitude and increased with more frequent practice. CONCLUSIONS: Among this online community, there was a high level of engagement with a brief gratitude practice, and improvements in stress, gratitude, and social support were observed. This design did not control for changes in outcomes that may be due to time trends, placebo or contextual effects, regression to the mean, or selection bias.

Implementing Integrative Nursing in a Pediatric Setting.

Pediatric blood and marrow transplantation (BMT) is one of the most challenging allopathic treatments a patient and family can be faced with. A large Midwest academic health center, and leader in pediatric BMT, made the decision in 2013 to incorporate integrative nursing as the care delivery model. Nurses trained in advanced nursing practice and specialized in integrative health and healing performed a deep-dive needs assessment, national benchmarking, a comprehensive review of the literature, and ultimately designed a comprehensive integrative program for pediatric patients and their families undergoing BMT. Four years after implementation, this paper discusses lessons learned, strengths, challenges and next phases of the program, including a research agenda. The authors conclude that it is feasible, acceptable and sustainable to implement a nurse-led integrative program within an academic health center-based pediatric BMT program.

Exploring Older Adults' Strengths, Problems, and Wellbeing Using De-identified Electronic Health Record Data.

As new data sources including individuals' strengths emerge in electronic health records, such data provide whole-person oriented information to generate integrated knowledge for person-centered practice. The purpose of this study is to describe older adults' strengths and problems within a wellbeing context documented by the Omaha System. The Wellbeing Model is employed as a conceptual framework for wellbeing and is operationalized by the Omaha System Problem Classification Scheme. This study has a retrospective, descriptive design using de-identified EHR data of wellbeing assessments including problems, strengths, and signs/symptoms for a convenience sample of 440 assisted-living residents in a Midwest metropolitan area. Descriptive statistics and data visualization were used to summarize and display strength and signs/symptom attributes within wellbeing contexts. The study reveals cutting-edge knowledge regarding older adults' strengths and wellbeing, and creates a platform for further research use of a strength-based ontology in clinical practice and electronic system of documentation.

Reducing diabetes distress and improving self-management with mindfulness.

Stress associated with diabetes makes managing diabetes harder. We investigated whether mindfulness-based stress reduction (MBSR) could reduce diabetes distress and improve management. We recruited 38 participants to complete an MBSR program. Surveys and lab values were completed at baseline and post-intervention. Participants showed significant improvement in diabetes-related distress (Cohen's d -.71, p < .002), psychosocial self-efficacy (Cohen's d .80, p < .001), and glucose control (Cohen's d -.79, p < .001). Significant improvements in depression, anxiety, stress, coping, self-compassion, and social support were also found. These results suggest that MBSR may offer an effective method for helping people better self-manage their diabetes and improve mental health.

Linking the Unitary Paradigm to Policy through a Synthesis of Caring Science and Integrative Nursing.

The principles of integrative nursing and caring science align with the unitary paradigm in a way that can inform and shape nursing knowledge, patient care delivery across populations and settings, and new healthcare policy. The proposed policies may transform the healthcare system in a way that supports nursing praxis and honors the discipline's unitary paradigm. This call to action provides a distinct and hopeful vision of a healthcare system that is accessible, equitable, safe, patient-centered, and affordable. In these challenging times, it is the unitary paradigm and nursing wisdom that offer a clear path forward.

Educational innovations to foster resilience in the health professions.

Stress and burnout of healthcare providers has become a major healthcare issue that has implications for not only workforce projections, but the cost and quality of care and the lives of healthcare providers and their families. Burnout, characterized by loss of enthusiasm for work, feelings of cynicism and a low sense of personal accomplishment is associated with early retirement, alcohol use, and suicidal ideation. Healthcare professional "wellbeing" or "care of the caregiver" is a topic that has not been significantly addressed in the education of healthcare professionals. The culture that has dominated much of education has been one where students have been expected to forego personal needs, endure stressful environments, and emerge from highly competitive and often dysfunctional environments to work in care settings where health and wellbeing is also largely ignored. Three curricular innovations are highlighted that target pre-professional students, students enrolled in health professions education and practicing health care professionals. Strategies are highlighted that both help individuals cultivate resiliency and wellbeing in their personal and professional lives and that address system issues that contribute to unhealthy learning and work environments.