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

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

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

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

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

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

Adult attachment insecurity and responses to prolonged severe occupational stress in hospital workers during the COVID-19 pandemic.

Background: The stress response includes appraisal of the threat and one's resources, coping (including interpersonal interactions), distress, and recovery. Relationships between patterns of adult attachment and stress response have received little study in the context of prolonged, severe occupational stress, limiting knowledge about how attachment patterns contribute to occupational burnout and recovery. Aim: This study aimed to assess the relationship of adult attachment to aspects of the stress response over time in hospital workers during a pandemic. Methods: This study included 538 hospital workers within a general and a rehabilitation hospital in Toronto, Canada between September 2020 and November 2021. Half, selected at random, completed validated measures of adult attachment, resilience, self-efficacy, coping, interpersonal problems, and various stress outcomes. Attachment insecurity severity was calculated as the vector addition of attachment anxiety and attachment avoidance. Correlations between these measures were determined at individual time-points and temporal patterns of adverse outcomes using repeated-measures ANOVA. Results: All correlations between measures of attachment and resilience or self-efficacy were significant and moderately strong (r = .30-.48), while most correlations with coping strategies were weak (<.20). Attachment avoidance was more strongly correlated with interpersonal problems related to being cold, whereas attachment anxiety was more strongly correlated with problems related to being intrusive, overly-nurturant, exploitable and non-assertive. Attachment insecurity severity was moderately correlated with every dimension of interpersonal problems. A significant main effect of each attachment measure on each stress outcome was found (effects sizes: .18-.26). Attachment insecurity severity was significantly associated with outcome X time interactions for burnout, consistent with greater resilience for those with lower attachment insecurity. Conclusions: Severity of insecure attachment was correlated with each measure of self-appraisal, interpersonal problems, and all measured stress outcomes. Severity of attachment insecurity performed well as a summary attachment measure. Greater security is associated with patterns of recovery that indicate resilience.

Attachment Relationships as Determinants of Physical Health.

Childhood adversity alters the relational world of the child and inhibits the development of secure attachment bonds. The purpose of this article is to survey recent evidence that attachment insecurity has the potential to impair physical health throughout the lifespan. It is proposed that attachment insecurity contributes to disease risk through a range of mechanisms which include (1) disturbances in arousal and recovery within physiological systems that respond to stress; (2) physiological links between the mediators of social relationships, stress, and immunity; (3) links between relationship style and various health behaviors; and (4) disease risk factors that serve as external regulators of dysphoric affect, such as nicotine and alcohol. The evidence for these mechanisms, particularly the evidence that has accumulated since the model was first proposed in 2000, is presented and discussed.

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

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

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

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

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

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

Physicians' knowledge and practices regarding screening adult patients for adverse childhood experiences: a survey.

BACKGROUND: Adverse Childhood Experiences (ACEs) are common and associated with many illnesses. Most physicians do not routinely screen for ACEs. We aimed to determine if screening is related to knowledge or medical specialty, and to assess perceived barriers. METHODS: Physicians in Ontario, Canada completed an online survey in 2018-2019. Data were analyzed in 2019. RESULTS: Participants were 89 family physicians, 46 psychiatrists and 48 other specialists. Participants screened for ACEs "never or not usually" (N = 58, 31.7%), "when indicated" (N = 67, 36.6%), "routinely" (N = 50, 27.3%) or "other" (N = 5, 2.7%). Screening was strongly associated with specialty (Chi2 = 181.0, p < .001). The modal responses were: family physicians - "when indicated" (66.3%), psychiatrists - "routinely" (91.3%), and other specialists - "never or not usually" (77.1%). Screening was not related to knowledge of prevalence of ACEs, or of the link between ACEs and mental health, but was significantly associated with knowing that ACEs are associated with physical health. Knowing that ACEs are linked to stroke, ischemic heart disease, COPD, and diabetes predicted greater screening (Chi2 15.0-17.7, each p ≤ .001). The most prevalent perceived barriers to screening were lack of mental health resources (59.0%), lack of time (59.0%), concern about causing distress (49.7%) and lack of confidence (43.7%). CONCLUSIONS: Enhancing knowledge about ACEs' negative influence on physical illness may increase screening. Efforts to promote screening should address concerns that screening is time-consuming and will increase referrals to mental health resources. Education should focus on increasing confidence with screening and with managing patient distress.

A randomized trial of nurse-administered behavioral interventions to manage anticipatory nausea and vomiting in chemotherapy.

PURPOSE: Chemotherapy side effects diminish quality of life and can lead to treatment delay. Nausea and vomiting can occur prior to chemotherapy because of classical conditioning. We studied the effects of 20-minute behavioral interventions, administered by oncology nurses, of higher intensity (mindfulness relaxation-MR) or lower intensity (relaxing music-RM), on anticipatory nausea and vomiting (ANV). PATIENTS AND METHODS: Patients undergoing chemotherapy for solid tumors were randomized to MR (N = 160), RM (N = 159), or standard care SC (N = 155). Subjects were mostly female (91.8%) and white (86.1%) with breast cancer (85%). Most patients had early stage disease (Stage I: 26%; II: 52.9%; III: 19%; IV: 0.1%). Anticipatory nausea and vomiting were assessed at the midpoint and end of the chemotherapy course using the Morrow Assessment of Nausea and Emesis (MANE). RESULTS: Compared to SC, there was reduced anticipatory nausea at the midpoint of chemotherapy in those receiving MR (OR 0.44, 95% CI 0.20-0.93) and RM (OR 0.40, 95% CI 0.20-0.93), controlling for age, sex, cancer stage, and emetogenic level of chemotherapy. There was no difference between treatment groups in anticipatory nausea at the end of chemotherapy or in anticipatory vomiting and postchemotherapy nausea and vomiting at either time point. CONCLUSION: A brief nurse-delivered behavioral intervention can reduce midpoint ANV associated with chemotherapy.

The prevalence and clinical correlates of adverse childhood experiences in a cross-sectional study of primary care patients with cardiometabolic disease or risk factors.

BACKGROUND: Adverse childhood experiences (ACEs) are associated with risk of poor adult health, including cardiometabolic diseases. Little is known about the correlates of ACEs for adults who have already developed cardiometabolic diseases, or who are at elevated risk. METHODS: Adult primary care patients with cardiometabolic disease (hypertension, diabetes, stroke, angina, myocardial infarction, coronary artery bypass graft, angioplasty) or with a risk factor (obesity, smoking, high cholesterol, family history) were surveyed regarding ACEs, psychological distress, attachment insecurity, quality of life, behavior change goals, stages of change, and attitudes toward potential prevention strategies. RESULTS: Of 387 eligible patients, 74% completed the ACEs survey. Exposure to ACEs was reported by 174 participants (61%). Controlling for age, gender, relationship status and income, number of ACEs was associated with psychological distress (F = 3.7, p = .01), quality of life (F = 8.9, p = .001), attachment anxiety (F = 3.4, p = .02), drinking alcohol most days (F = 4.0, p = .008) and smoking (F = 2.7, p = .04). Greater ACE exposure was associated with less likelihood of selecting diet or physical activity as a behavior change goal (linear-by-linear association p = .009). Stage of change was not associated with ACEs. ACEs exposure was not related to preferred resources for behavior change. CONCLUSIONS: ACEs are common among patients at cardiometabolic risk and are related to quality of life, psychological factors that influence cardiometabolic outcomes and behavior change goals. ACEs should be taken into account when managing cardiometabolic risk in family medicine.

An Internet Resource for Self-Assessment of Mental Health and Health Behavior: Development and Implementation of the Self-Assessment Kiosk.

BACKGROUND: Standardized measurement of physical and mental health is useful for identification of health problems. Personalized feedback of the results can influence health behavior, and treatment outcomes can be improved by monitoring feedback over time. However, few resources are available that are free for users, provide feedback from validated measurement instruments, and measure a wide range of health domains. OBJECTIVE: This study aimed to develop an internet self-assessment resource that fills the identified gap and collects data to generate and test hypotheses about health, to test its feasibility, and to describe the characteristics of its users. METHODS: The Self-Assessment Kiosk was built using validated health measurement instruments and implemented on a commercial internet survey platform. Data regarding usage and the characteristics of users were collected over 54 weeks. The rate of accrual of new users, popularity of measurement domains, frequency with which multiple domains were selected for measurement, and characteristics of users who chose particular questionnaires were assessed. RESULTS: Of the 1435 visits, 441 (30.73%) were visiting for the first time, completed at least 1 measure, indicated that their responses were truthful, and consented to research. Growth in the number of users over time was approximately linear. Users were skewed toward old age and higher income and education. Most (53.9%, 234/434) reported at least 1 medical condition. The median number of questionnaires completed was 5. Internal reliability of most measures was good (Cronbach alpha>.70), with lower reliability for some subscales of coping (self-distraction alpha=.35, venting alpha=.50, acceptance alpha=.51) and personality (agreeableness alpha=.46, openness alpha=.45). The popular questionnaires measured depression (61.0%, 269/441), anxiety (60.5%, 267/441), attachment insecurity (54.2%, 239/441), and coping (46.0%, 203/441). Demographic characteristics somewhat influenced choice of instruments, accounting for <9% of the variance in this choice. Mean depression and anxiety scores were intermediate between previously studied populations with and without mental illness. Modeling to estimate the sample size required to study relationships between variables suggested that the accrual of users required to study the relationship between 3 variables was 2 to 3 times greater than that required to study a single variable. CONCLUSIONS: The value of the Self-Assessment Kiosk to users and the feasibility of providing this resource are supported by the steady accumulation of new users over time. The Self-Assessment Kiosk database can be interrogated to understand the relationships between health variables. Users who select particular instruments tend to have scores that are higher than those found in the general population, indicating that instruments are more likely to be selected when they are salient. Self-selection bias limits generalizability and needs to be taken into account when using the Self-Assessment Kiosk database for research. Ethical issues that were considered in developing and implementing the Self-Assessment Kiosk are discussed.

An Attachment-Based Model of the Relationship Between Childhood Adversity and Somatization in Children and Adults.

OBJECTIVE: An attachment model was used to understand how maternal sensitivity and adverse childhood experiences are related to somatization. METHODS: We examined maternal sensitivity at 6 and 18 months and somatization at 5 years in 292 children in a longitudinal cohort study. We next examined attachment insecurity and somatization (health anxiety, physical symptoms) in four adult cohorts: healthy primary care patients (AC1, n = 67), ulcerative colitis in remission (AC2, n = 100), hospital workers (AC3, n = 157), and paramedics (AC4, n = 188). Recall of childhood adversity was measured in AC3 and AC4. Attachment insecurity was tested as a possible mediator between childhood adversity and somatization in AC3 and AC4. RESULTS: In children, there was a significant negative relationship between maternal sensitivity at 18 months and somatization at age 5 years (B = -3.52, standard error = 1.16, t = -3.02, p = .003), whereas maternal sensitivity at 6 months had no significant relationship. In adults, there were consistent, significant relationships between attachment insecurity and somatization, with the strongest findings for attachment anxiety and health anxiety (AC1, ß = 0.51; AC2, ß = 0.43). There was a significant indirect effect of childhood adversity on physical symptoms mediated by attachment anxiety in AC3 and AC4. CONCLUSIONS: Deficits in maternal sensitivity at 18 months of age are related to the emergence of somatization by age 5 years. Adult attachment insecurity is related to somatization. Insecure attachment may partially mediate the relationship between early adversity and somatization.

Can patients be 'attached' to healthcare providers? An observational study to measure attachment phenomena in patient-provider relationships.

OBJECTIVES: To develop and assess the validity of measures of patients' attachment-related perceptions of experiences with healthcare providers (HCPs). SETTING: Online survey. PARTICIPANTS: 181 people provided consent and 119 completed the survey (66%). Most participants were women (80%). PRIMARY AND SECONDARY OUTCOME MEASURES: Questions were developed to assess possible attachment functions served by an HCP and patients' attachment-related attitudes towards an HCP. Scales were constructed based on exploratory factor analysis. Measures of adult attachment, therapeutic alliance, perceived HCP characteristics and health utilisation were used to validate scales. RESULTS: Possible safe haven and secure base functions served by HCPs were strongly endorsed. A model with good fit (root mean square error of approximation=0.056) yielded 3 factors: 'HCP experienced as supportive and safe' (SUPPORT, α=0.94), 'HCP experienced as aversive' (AVERSE, α=0.86) and 'more and closer contact wanted with HCP' (WANT, α=0.85). SUPPORT was correlated with positive HCP characteristics and not with attachment insecurity. AVERSE was inversely correlated with positive HCP attributes and correlated with attachment insecurity. WANT was unrelated to positive HCP attributes, but correlated with attachment insecurity. Frequency of HCP contact was related to WANT (Kruskal-Wallis=21.9, p<0.001) and SUPPORT (Kruskal-Wallis=13.2, p=0.02), but not to AVERSE (Kruskal-Wallis=1.7, p=0.89). CONCLUSIONS: Patients attribute attachment functions of secure base and safe haven to HCPs. SUPPORT is related to positive appraisal of HCP characteristics; AVERSE is associated with discomfort in the HCP relationship that is related with perceived HCP characteristics and patients' insecure attachment; WANT is associated with unmet needs for connection with an HCP related to insecure attachment, but not to perceived HCP characteristics. These scales may be useful in studying the application of attachment theory to the HCP-patient relationship.

Twelve tips for asking and responding to difficult questions during a challenging clinical encounter.

BACKGROUND: Teaching healthcare providers (HCPs) effective communication skills can be challenging, but is crucial for managing complex patient encounters. AIM: To provide medical trainees strategies for recognizing and understanding problematic interactions. METHODS: The Twelve Tips are based on a study of communication skills teaching with family medicine trainees (n = 26) who received controlled exposure to common clinical difficulties simulated by standardized patients (SPs). The following tips were derived from a thematic analysis of a subset of the transcribed coaching sessions. RESULTS: These tips demonstrate that doctor-patient communication difficulties can arise from any of three sources: the patient's issues, the HCP's misunderstanding or inaccurate responsiveness to an issue, and/or the interaction between the HCP and the patient. These tips are heuristically grouped into two themes: (1) guiding principles to hold in mind and (2) behaviors that can be used to apply these principles. CONCLUSION: We believe that these strategies will help trainees to remain attentive to the patient, the interaction, and their own reactions, to improve the overall clinical encounter.

Improving physician-patient communication through coaching of simulated encounters.

OBJECTIVE: Effective communication between physicians and their patients is important in optimizing patient care. This project tested a brief, intensive, interactive medical education intervention using coaching and standardized psychiatric patients to teach physician-patient communication to family medicine trainees. METHODS: Twenty-six family medicine trainees (9 PGY1, 11 PGY2, 6 fellows) from five university-affiliated hospitals conducted four once-weekly, 30-minute videotaped interviews with "difficult" standardized patients. After each interview, trainees received 1 hour of individual coaching that incorporated self-assessment and skills-teaching from experienced psychiatrists. Two follow-up interviews with standardized patients occurred 1 week and an average of 6 months post-intervention. Trainee self-reported physician-patient communication efficacy was measured as a control 1 month before the intervention; during the month of the intervention; and an average of 6 months after the intervention. Coach-rated physician-patient communication competence was measured each week of the intervention. RESULTS: Improvements in physician-patient communication were demonstrated. Self-efficacy for physician-patient communication improved significantly during the intervention, in contrast to no improvement during the control period (i.e., training-as-usual). This improvement was sustained during the follow-up period. CONCLUSIONS: This innovative educational intervention was shown to be highly effective in improving trainee communication competence and self-efficacy. Future applications of this brief model of physician training have potential to improve communication competence and, in turn, can improve patient care.

A prototype-based model of adult attachment for clinicians.

Models of adult attachment have proven to be useful for understanding illness behavior, stress responses, susceptibility to disease processes, and psychotherapeutic approaches to difficult patients. Two methods of assessing patterns of attachment, using self-report instruments and using techniques such as the Adult Attachment Interview (AAI), are only weakly related and each has drawbacks for clinical use. We have previously assessed commonalities and differences in the descriptions of attachment patterns that emerge from these schools and synthesized them in empirically based attachment prototypes. In this companion article, we describe a prototype-based model of attachment. This model defines dimensions of attachment anxiety and attachment avoidance as composites of particular aspects of internal working models of self and other, behavior in current close relationships, patterns of expression of affect, and narrative coherence. The model emphasizes the clinical importance of the severity of attachment insecurity, defined as a dimension which incorporates problems in the previously listed domains of attachment as well as deficits in mentalizing, self-agency, and resolution of trauma. The model locates the central tendencies of prototypic ("textbook") descriptions of four patterns of attachment (secure, dismissing, preoccupied, and fearful/disorganized) while avoiding definitions of the boundaries between categories of attachment. We compare the prototype-based model to the two most prominent current models of attachment, the 4-category, 2-dimension model derived from self-report methods of assessment and categories of "attachment states of mind" derived from the Adult Attachment Interview. Finally, we discuss limitations of the prototype-based model and areas requiring further research.

The impact of attachment insecurity and sleep disturbance on symptoms and sick days in hospital-based health-care workers.

OBJECTIVE: Adult attachment insecurity is associated with many health outcomes and may be associated with sleep disturbance. The purpose of this study was to test the hypothesis that sleep disturbance mediates the relationship between attachment insecurity and three measures of health (perceived general health, physical symptoms and sick days) in a group that is at high risk of sleep disturbance: hospital based health-care workers. METHODS: One hundred thirty-one nondepressed female hospital workers completed self-report measures of adult attachment, sleep disturbance, depressive symptoms (excluding sleep-related items) and health outcomes. The hypothesis of mediation was tested with sequential regression analyses. RESULTS: Both attachment anxiety and attachment avoidance were significantly associated with impairment in global sleep quality (ρ=.20 and .19, respectively, P<.05) and physical symptoms (ρ=.21 and .19, P<.05). Attachment anxiety was also associated with depressive symptoms (ρ=.33, P<.001) and sick days (ρ=.21, P<.05). For both physical symptoms and sick days, mediation analyses were consistent with global sleep quality acting as a partial mediator of the relationship between attachment anxiety and physical health. Non-sleep-related depressive symptoms were a stronger mediator. CONCLUSIONS: This study corroborates evidence that attachment insecurity is associated with sleep disturbance and extends this association to the occurrence of physical symptoms and time off work due to sickness among workers in a high-stress occupation.

Computer-assisted resilience training to prepare healthcare workers for pandemic influenza: a randomized trial of the optimal dose of training.

BACKGROUND: Working in a hospital during an extraordinary infectious disease outbreak can cause significant stress and contribute to healthcare workers choosing to reduce patient contact. Psychological training of healthcare workers prior to an influenza pandemic may reduce stress-related absenteeism, however, established training methods that change behavior and attitudes are too resource-intensive for widespread use. This study tests the feasibility and effectiveness of a less expensive alternative - an interactive, computer-assisted training course designed to build resilience to the stresses of working during a pandemic. METHODS: A "dose-finding" study compared pre-post changes in three different durations of training. We measured variables that are likely to mediate stress-responses in a pandemic before and after training: confidence in support and training, pandemic-related self-efficacy, coping style and interpersonal problems. RESULTS: 158 hospital workers took the course and were randomly assigned to the short (7 sessions, median cumulative duration 111 minutes), medium (12 sessions, 158 minutes) or long (17 sessions, 223 minutes) version. Using an intention-to-treat analysis, the course was associated with significant improvements in confidence in support and training, pandemic self-efficacy and interpersonal problems. Participants who under-utilized coping via problem-solving or seeking support or over-utilized escape-avoidance experienced improved coping. Comparison of doses showed improved interpersonal problems in the medium and long course but not in the short course. There was a trend towards higher drop-out rates with longer duration of training. CONCLUSIONS: Computer-assisted resilience training in healthcare workers appears to be of significant benefit and merits further study under pandemic conditions. Comparing three "doses" of the course suggested that the medium course was optimal.

Assessing patterns of adult attachment in medical patients.

OBJECTIVE: Patterns of adult attachment affect physical health and yet are unfamiliar to many clinicians. The purpose of this review was to derive descriptions of prototypic patterns of adult attachment that are relevant to health care. METHODS: Observations from attachment research using diverse methods to measure adult attachment were reviewed. A synthetic approach was used to integrate these observations into coherent descriptions of prototypic patterns of attachment. RESULTS: Four patterns of adult attachment (secure, preoccupied, dismissing and fearful) are distinguished by prototypic patterns in intimate relationships, affect regulation, use of social support, trait descriptors, mentalization and narrative coherence. These patterns are linked to health care relationships and health outcomes. CONCLUSION: Prototypic descriptions of patterns of adult attachment may guide clinicians in appreciating individual differences in interpersonal style that affect the health of patients.