Telehealth Walking Self-Management for Individuals With Amputation: A Qualitative Study of Therapist Perspectives on Adoption.

OBJECTIVE: The aim of this study was to understand therapist-identified factors influencing clinical adoption of a telehealth walking self-management intervention for individuals with lower limb amputation. METHODS: Semi-structured focus groups were completed with actively practicing physical and occupational therapists treating populations that are medically complex. A qualitative explorative design was employed with conventional content analysis and iterative independent parallel coding using 2 analysts. Themes and subthemes were generated with a consensus building process identifying patterns and collapsing codes to represent participant perspectives. RESULTS: Thematic saturation was met after 5 focus groups (24 therapists). Therapists were on average 34 years old and predominantly female (n = 19; 79%) physical therapists (n = 17; 71%). Three primary facilitator and barrier themes were identified for intervention adoption: system, therapist, and person. System considerations included telehealth support and interprofessional care coordination. Therapist facilitators included self-management programming that overlapped with standard of care and personalization methods. However, limited behavioral theory training was a therapist level barrier. Finally, person factors such as patient activation could influence both positively and negatively. Person facilitators included social support and barriers included the complex health condition. CONCLUSION: System, therapist, and person facilitators and barriers must be considered to maximize the adoption of similar telehealth walking self-management interventions and prior to larger scale implementation of the current intervention for individuals with lower limb amputation. IMPACT: A telehealth walking self-management intervention has potential impact for individuals with lower limb amputation and must be considered in terms of optimizing system, therapist, and person level facilitators and barriers to implementation.

Addressing Pandemic Burnout Among Health Care Professionals: Beyond Intrapersonal Wellness Programming.

The COVID-19 pandemic has been distressing to health care professionals, causing significant burnout. Burnout has resulted in notable rates of mental health symptoms and job turnover. Hospitals have incorporated programming to meet the needs of health care professionals. A previously reported intervention at the study institution was a cognitive behavioral narrative writing program to target job-related stress. On the basis of participant feedback, psychoeducational seminars, psychotherapy drop-in sessions, and complementary interventions (mindfulness, yoga, and acupuncture) were also implemented to alleviate stress. This article is an update based on these year 2 augmentations. Participation in brief psychoeducational seminars and acupuncture was high, but engagement in other programming (individual psychotherapy and mindfulness) was poor. Hospitals should consider multimodal approaches to address pandemic-related stress and burnout. In addition to educational seminars, programs that address lasting distress should be offered to health care professionals. Targeting job-related burnout at organizational and systemic levels may ameliorate distress. This article discusses methods of integrating organizational programs into clinics.

Older Veterans' Experiences of a Multicomponent Telehealth Program: Qualitative Program Evaluation Study.

BACKGROUND: There are 8.8 million American veterans aged >65 years. Older veterans often have multiple health conditions that increase their risk of social isolation and loneliness, disability, adverse health events (eg, hospitalization and death), mental illness, and heavy health care use. This population also exhibits low levels of physical function and daily physical activity, which are factors that can negatively influence health. Importantly, these are modifiable risk factors that are amenable to physical therapy intervention. We used a working model based on the dynamic biopsychosocial framework and social cognitive theory to conceptualize the multifactorial needs of older veterans with multiple health conditions and develop a novel, 4-component telehealth program to address their complex needs. OBJECTIVE: This study aims to describe veterans' experiences of a multicomponent telehealth program and identify opportunities for quality and process improvement. We conducted qualitative interviews with telehealth program participants to collect their feedback on this novel program; explore their experience of program components; and document perceived outcomes and the impact on their daily life, relationships, and quality of life. METHODS: As part of a multimethod program evaluation, semistructured interviews were conducted with key informants who completed ≥8 weeks of the 12-week multicomponent telehealth program for veterans aged ≥50 years with at least 3 medical comorbidities. Interviews were audio recorded and transcribed. Data were analyzed by a team of 2 coders using a directed content analysis approach and Dedoose software was used to assist with data analysis. RESULTS: Of the 21 individuals enrolled in the program, 15 (71%) met the inclusion criteria for interviews. All 15 individuals completed 1-hour interviews. A total of 6 main conceptual domains were identified: technology, social networks, therapeutic relationship, patient attributes, access, and feasibility. Themes associated with each domain detail participant experiences of the telehealth program. Key informants also provided feedback related to different components of the program, leading to adaptations for the biobehavioral intervention, group sessions (transition from individual to group sessions and group session dynamics), and technology supports. CONCLUSIONS: Findings from this program evaluation identified quality and process improvements, which were made before rigorously testing the intervention in a larger population through a randomized controlled trial. The findings may inform adaptations of similar programs in different contexts. Further research is needed to develop a deeper understanding of how program components influence social health and longer-term behavior change.

A pilot of a veteran suicide prevention learning collaborative among community organizations: Initial results and outcomes.

INTRODUCTION: Veteran suicide remains an ongoing public health concern in need of fresh, community-based initiatives. The Department of Veterans Affairs (VA) has built an enterprise-wide integrated behavioral health system that has pioneered numerous suicide prevention methods. However, most Veterans receive healthcare outside the VA, from organizations that may not be equipped to address Veteran suicide risk. One solution is implementing a VA/community suicide prevention learning collaborative to support organizations in implementing suicide prevention best practices for Veterans. Although learning collaboratives have a history of supporting improved patient safety in healthcare systems, to our knowledge, none have focused on Veteran suicide prevention. METHOD: The current quality improvement project sought to pilot a VA/community suicide prevention learning collaborative in the broader Denver and Colorado Springs areas with 13 organizations that served, interacted with, or employed Veterans. RESULTS: The collaborative had a large footprint in the region, with organizations interacting with over 24,000 community members and over 5000 Veterans. Organizations implemented 92 Veteran suicide prevention program components within a 16-month period. Overall, the learning collaborative made significant strides in Veteran suicide prevention. CONCLUSION: Findings suggest that this method facilitates rapid implementation of Veteran suicide prevention practices and may be promising for accelerating uptake within communities.

An Evaluation of a Narrative Expressive Writing Program for Nurses During the COVID-19 Pandemic.

OBJECTIVE: This study aimed to evaluate a writing program targeted to reduce stress and improve resilience in nurses during the coronavirus pandemic (COVID-19). BACKGROUND: Occupational hazards often result in poor mental health outcomes. The pandemic highlighted this problem. Because nurses face barriers to accessing support, brief interventions are needed to process stressful events. METHODS: Over 5 weeks, nurses across the United States detailed their COVID-19 experiences through narrative expressive writing. Trained mental health professionals provided confidential feedback. RESULTS: One thousand one hundred three nurses enrolled in the program, with 430 continuing to the 1st session. Approximately 36% who began the program completed all 5 sessions. Feedback suggested high satisfaction with their experience in the program, but no significant changes in perceived levels of stress or resilience were observed. CONCLUSION: Narrative expressive writing is an accessible intervention with the potential to decrease stress. This program is a flexible, personalized model that managers can offer to staff to promote healthy coping strategies.

Brief Narrative Writing Program Implemented in a Neurosurgical Intensive Care Unit During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic has substantially affected health care professionals. Health care professionals have noted increased distress, psychiatric symptoms, and feelings of burnout during this time. Implementation of brief, easy-to-access psychosocial interventions might help health care professionals process stressful events, thus bolstering mental health. One such approach is the narrative expressive writing program, a 5-session cognitive behavioral writing intervention. OBJECTIVES: The narrative expressive writing program was instituted in a neurosurgical intensive care unit during the COVID-19 pandemic. The program was delivered online and guided by a licensed mental health professional. METHODS: Health care professionals completed measures of anxiety, depression, burnout, resilience, and perceived stress before and after completing the narrative expressive writing program. Fifty-eight health care professionals initiated the program; 31 (53% of initiators) completed it. RESULTS: Health care professionals who completed the narrative expressive writing program experienced significant reductions in depressive symptoms and perceived stress (P < .05). CONCLUSIONS: Preliminary data show that narrative expressive writing is an easy-to-access intervention that has the potential to decrease stress and depressive symptoms. Additional research on tailoring or augmenting the narrative expressive writing program may facilitate health care professionals' engagement and address other mental health domains (eg, burnout).

Critical Care Nurse Burnout in Veterans Health Administration: Relation to Clinician and Patient Outcomes.

BACKGROUND: Critical care nurses have a burnout rate among the highest of any nursing field. Nurse burnout may impact care quality. Few studies have considered how temporal patterns may influence outcomes. OBJECTIVE: To test a longitudinal model of burnout clusters and associations with patient and clinician outcomes. METHODS: An observational study analyzed data from annual employee surveys and administrative data on patient outcomes at 111 Veterans Health Administration intensive care units from 2013 through 2017. Site-level burnout rates among critical care nurses were calculated from survey responses about emotional exhaustion and depersonalization. Latent trajectory analysis was applied to identify clusters of facilities with similar burnout patterns over 5 years. Regression analysis was used to analyze patient and employee outcomes by burnout cluster and organizational context measures. Outcomes of interest included patient outcomes (30-day standardized mortality rate and observed minus expected length of stay) for 2016 and 2017 and clinician outcomes (intention to leave and employee satisfaction) from 2013 through 2017. RESULTS: Longitudinal analysis revealed 3 burnout clusters among the 111 sites: low (n = 37), medium (n = 68), and high (n = 6) burnout. Compared with sites in the low-burnout cluster, those in the high-burnout cluster had longer patient stays, higher employee turnover intention, and lower employee satisfaction in bivariate models but not in multivariate models. CONCLUSIONS: In this multiyear, multisite study, critical care nurse burnout was associated with key clinician and patient outcomes. Efforts to address burnout among nurses may improve patient and employee outcomes.

Psychometric Assessment of the Connor-Davidson Resilience Scale for People With Lower-Limb Amputation.

OBJECTIVE: The purpose of this study was to (1) determine the psychometric properties of the 25- and 10-item Connor-Davidson Resilience Scales (CD-RISC25, CD-RISC10) for people with lower-limb amputation (LLA) in middle age or later, and (2) describe relationships of the CD-RISC with biopsychosocial, sociodemographic, and health variables. METHODS: Participants were included if their most recent LLA was 1 or more years prior, if they were independently walking with a prosthesis, and if they were between 45 and 88 years of age (N = 122; mean = 62.5 years of age [SD = 8]; 59.5 [mean = 58] months since LLA; 88.5% male; 82.0% with dysvascular etiology; 68.0% with unilateral transtibial LLA). Psychometric analyses included assessment of skewness, floor and ceiling effects, internal consistency, and agreement between versions. Correlation analyses were used to determine associations between the CD-RISC with disability, perceived functional capacity, falls efficacy, life-space, anxiety, depression, self-efficacy, social support, sociodemographic, and health variables. Additionally, quartiles of participants were identified using CD-RISC25 and CD-RISC10 scores and compared using ANOVA and post-hoc comparisons for disability, perceived functional capacity, falls efficacy, and life-space. RESULTS: Skewness, floor, and ceiling effects of both CD-RISC versions were acceptable. Both versions of the CD-RISC were internally consistent (CD-RISC25: α = .92; CD-RISC10: α = .89). The CD-RISC25 and CD-RISC10 were highly correlated with disability, perceived functional capacity, falls efficacy, anxiety, depression, and self-efficacy (r = 0.52-0.67). CD-RISC25 and CD-RISC10 quartile differences, especially the lowest quartile, were identified for disability, perceived functional capacity, falls efficacy, and life-space. CONCLUSION: The CD-RISC25 and CD-RISC10 have acceptable psychometric properties for use with people who have LLA. CD-RISC scores are associated with clinically relevant biopsychosocial measures targeted by physical therapist intervention following LLA. IMPACT: The CD-RISC may be an appropriate tool to measure resilience following LLA.

Evaluation of an Immunomodulatory Probiotic Intervention for Veterans With Co-occurring Mild Traumatic Brain Injury and Posttraumatic Stress Disorder: A Pilot Study.

Background: US military Veterans returned from Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) with symptoms associated with mild traumatic brain injury [mTBI; i.e., persistent post-concussive (PPC) symptoms] and posttraumatic stress disorder (PTSD). Interventions aimed at addressing symptoms associated with both physical and psychological stressors (e.g., PPC and PTSD symptoms) are needed. This study was conducted to assess the feasibility, acceptability, and safety of a probiotic intervention, as well as to begin the process of evaluating potential biological outcomes. Methods: A pilot randomized controlled trial was implemented among US military Veterans from recent conflicts in Iraq and Afghanistan. Those enrolled had clinically significant PPC and PTSD symptoms. Participants were randomized to intervention (Lactobacillus reuteri DSM 17938) or placebo supplementation (daily for 8 weeks +/- 2 weeks) at a 1:1 ratio, stratified by irritable bowel syndrome status. Thirty-one Veterans were enrolled and randomized (15 to the placebo condition and 16 to the probiotic condition). Results: Thresholds for feasibility, acceptability, and safety were met. Probiotic supplementation resulted in a decrease in plasma C-reactive protein (CRP) concentrations relative to the placebo group that approached statistical significance (p = 0.056). Although during the Trier Social Stress Test (TSST; administered post-supplementation) no between-group differences were found on a subjective measure of stress responsivity (Visual Analog Scale), there was a significantly larger increase in mean heart beats per minute between baseline and the math task for the placebo group as compared with the probiotic group (estimated mean change, probiotic 5.3 [95% Confidence Interval: -0.55, 11.0], placebo 16.9 [11.0, 22.7], p = 0.006). Conclusions: Findings from this trial support the feasibility, acceptability, and safety of supplementation with an anti-inflammatory/immunoregulatory probiotic, L. reuteri DSM 17938, among Veterans with PPC and PTSD symptoms. Moreover, results suggest that CRP may be a viable inflammatory marker of interest. A larger randomized controlled trial aimed at measuring both biological and clinical outcomes is indicated. Clinical Trial Registration: ClinicalTrials.gov, Identifier NCT02723344.

Addressing Burnout Syndrome From a Critical Care Specialty Organization Perspective.

BACKGROUND: Health care specialty organizations are an important resource for their membership; however, it is not clear how specialty societies should approach combating stress and burnout on an organizational scale. OBJECTIVE: To understand the prevalence of burnout syndrome in American Thoracic Society members, identify specialty-specific risk factors, and generate strategies for health care societies to combat burnout. METHODS: Cross-sectional, mixed-methods survey in a sample of 2018 American Thoracic Society International Conference attendees to assess levels of burnout syndrome, work satisfaction, and stress. RESULTS: Of the 130 respondents, 69% reported high stress, 38% met burnout criteria, and 20% confirmed chaotic work environments. Significant associations included sex and stress level; clinical time and at-home electronic health record work; and US practice and at-home electronic health record work. There were no significant associations between burnout syndrome and the selected demographics. Participants indicated patient care as the most meaningful aspect of work, whereas the highest contributors to burnout were workload and electronic health record documentation. Importantly, most respondents were unaware of available resources for burnout. CONCLUSIONS: Health care specialty societies have access to each level of the health system, creating an opportunity to monitor trends, disseminate resources, and influence the direction of efforts to reduce workplace stress and enhance clinician well-being.

Qualitative analysis of resilience characteristics of people with unilateral transtibial amputation.

BACKGROUND: Resilience characteristics are a significant factor in the highly variable rehabilitation outcomes for people in middle age or later with transtibial amputation. OBJECTIVE: The purpose of this study was to describe resilience characteristics meaningful to people with transtibial amputation in middle age or later, who use a prosthesis. METHODS: Semi-structured interviews were conducted, audio recorded, and transcribed with eighteen participants. Interview transcripts were coded and analyzed using a directed content analysis approach, guided by Charney's theory of resilience and Connor-Davidson Resilience Scale scores. RESULTS: Five main resilience characteristics (themes) were identified: coping skills, cognitive flexibility, optimism, skill for facing fear, and social support. Participants with higher resilience scores generally described effective use of coping skills, cognitive flexibility, optimism, skills in facing fears, and social support to attain meaningful goals. In contrast, participants with lower resilience scores discussed passive coping strategies, cognitive rigidity, general pessimism, avoidance of activities due to fear, or social support limitations. CONCLUSION: Coping skills, cognitive flexibility, optimism, skills for facing fear, and social support were identified as meaningful resilience characteristics for people with transtibial amputation in middle age or later. These characteristics can be targeted and enhanced using resilience interventions. Future research should consider these characteristics when designing and testing rehabilitation focused resilience interventions for people with TTA.

Exploratory and Confirmatory Factor Analysis of the Maslach Burnout Inventory to Measure Burnout Syndrome in Critical Care Nurses.

BACKGROUND AND PURPOSE: Burnout syndrome is common in critical care nursing. The Critical Care Societies Collaborative recently released a joint statement and call to action on burnout in critical care professionals. METHODS: We conducted an exploratory factor analysis and confirmatory factor analysis (CFA) of the 22-item MBI. RESULTS: The exploratory factor analysis identified three factors but after questions were removed; we were left with a 2-factor, 10-item abridged version of the MBI-HSS to test with CFA modeling. The CFA indicated conflicting fit indices. CONCLUSIONS: we conducted an exploratory and CFA of the abridged MBI-HSS in critical care nurses from the United States and found the two-factor model was the best fit achieved.

Prevalence of Coping Strategy Training in Nursing School Curricula.

BACKGROUND: Stress and burnout are plaguing critical care nurses across the globe and leading to high levels of turnover. Resilience-building strategies such as mindfulness, self-care, and well-being can help shield nurses from the negative effects of workplace stress. As the first line of defense, nursing schools could provide students with strategies that build resilience; however, little is known about the availability of such resources in nursing education. OBJECTIVES: To determine the prevalence of resources and curricula targeting resilience training and stress reduction at nursing schools across the United States. METHODS: Raters analyzed publicly available college/ university websites and course catalogs of a sample of nursing schools in the United States to determine the availability of resilience resources and curricula. RESULTS: None of the schools surveyed regularly screened their students for burnout syndrome, and only 9% of schools had a formal curriculum that included resilience training. CONCLUSIONS: Training in practices to build resilience and prevent burnout is essentially absent from accredited nursing schools. This highlights an important opportunity to modify existing curricula to include preventative strategies-such as developing positive coping skills- that could mitigate symptoms of workplace stress in future generations of nurses.

Designing a Resilience Program for Critical Care Nurses.

BACKGROUND: Workplace stress can affect job satisfaction, increase staff turnover and hospital costs, and reduce quality of patient care. Highly resilient nurses adapt to stress and use a variety of skills to cope effectively. OBJECTIVE: To gain data on a mindfulness-based cognitive therapy resilience intervention for intensive care unit nurses to see if the intervention program would be feasible and acceptable. METHODS: Focus-group interviews were conducted by videoconference with critical care nurses who were members of the American Association of Critical-Care Nurses. The interview questions assessed the feasibility and acceptability of a mindfulness-based cognitive therapy program to reduce burnout syndrome in intensive care unit nurses. RESULTS: Thirty-three nurses participated in 11 focus groups. Respondents identified potential barriers to program adherence, incentives for adherence, preferred qualifications of instructors, and intensive care unit-specific issues to be addressed. CONCLUSIONS: The mindfulness-based cognitive therapy pilot intervention was modified to incorporate thematic categories that the focus groups reported as relevant to intensive care unit nurses. Institutions that wish to design a resilience program for intensive care unit nurses to reduce burnout syndrome need an understanding of the barriers and concerns relevant to their local intensive care unit nurses.

Factors Affecting Resilience and Development of Posttraumatic Stress Disorder in Critical Care Nurses.

BACKGROUND: Job stress and cumulative exposure to traumatic events experienced by critical care nurses can lead to psychological distress and the development of burnout syndrome and posttraumatic stress disorder. Resilience can mitigate symptoms associated with these conditions. OBJECTIVE: To identify factors that affect resilience and to determine if the factors have direct or indirect effects on resilience in development of posttraumatic stress disorder. METHODS: Data from 744 respondents to a survey mailed to 3500 critical care nurses who were members of the American Association of Critical-Care Nurses were analyzed. Mplus was used to analyze a mediation model. RESULTS: Nurses who worked in any type of intensive care unit other than the medical unit and had high scores for resilience were 18% to 50% less likely to experience post-traumatic stress disorder than were nurses with low scores. Nurses with a graduate degree in nursing were 18% more likely to experience posttraumatic stress disorder than were nurses with a bachelor's degree. CONCLUSION: Because of their effects on resilience, working in a medical intensive care unit and having a graduate degree may influence the development of posttraumatic stress disorder. Future research is needed to better understand the impact of resilience on health care organizations, development of preventive therapies and treatment of posttraumatic stress disorder for critical care nurses, and the most appropriate mechanism to disseminate and implement strategies to address posttraumatic stress disorder.

Accelerating Multisite Research in Nursing Education: Navigating Institutional Review Board Regulatory Issues.

Researchers investigating phenomena in nursing education are increasingly striving to conduct multisite studies. However, designing and managing multisite studies can be costly and time consuming. One complex and costly challenge of multisite studies can be anticipating and navigating the variations in the institutional review board requirements and expectations of different study sites. This article explores issues and regulations around protection of human subjects in multisite studies using the authors' experiences launching the 2016 National Nursing Education Research Network surveys as an exemplar. [J Nurs Educ. 2017;56(2):65-68.].