Nature-based biopsychosocial resilience: An integrative theoretical framework for research on nature and health.

Nature-based solutions including urban forests and wetlands can help communities cope better with climate change and other environmental stressors by enhancing social-ecological resilience. Natural ecosystems, settings, elements and affordances can also help individuals become more personally resilient to a variety of stressors, although the mechanisms underpinning individual-level nature-based resilience, and their relations to social-ecological resilience, are not well articulated. We propose 'nature-based biopsychosocial resilience theory' (NBRT) to address these gaps. Our framework begins by suggesting that individual-level resilience can refer to both: a) a person's set of adaptive resources; and b) the processes by which these resources are deployed. Drawing on existing nature-health perspectives, we argue that nature contact can support individuals build and maintain biological, psychological, and social (i.e. biopsychosocial) resilience-related resources. Together with nature-based social-ecological resilience, these biopsychosocial resilience resources can: i) reduce the risk of various stressors (preventive resilience); ii) enhance adaptive reactions to stressful circumstances (response resilience), and/or iii) facilitate more rapid and/or complete recovery from stress (recovery resilience). Reference to these three resilience processes supports integration across more familiar pathways involving harm reduction, capacity building, and restoration. Evidence in support of the theory, potential interventions to promote nature-based biopsychosocial resilience, and issues that require further consideration are discussed.

Gardening in Childcare Centers: A Randomized Controlled Trial Examining the Effects of a Garden Intervention on Physical Activity among Children Aged 3-5 Years in North Carolina.

This study examined the effects of a childcare gardening intervention on children's physical activity (PA). Eligible childcare centers were randomly assigned to: (1) garden intervention (n = 5; year 1); (2) waitlist control (n = 5; control year 1, intervention year 2); or (3) control (n = 5; year 2 only) groups. Across the two-year study, PA was measured for 3 days at four data collection periods using Actigraph GT3X+ accelerometers. The intervention comprised 6 raised fruit and vegetable garden beds and a gardening guide with age-appropriate learning activities. The sample included a total of 321 3-5-year-olds enrolled in childcare centers in Wake County, North Carolina, with n = 293 possessing PA data for at least one time point. The analyses employed repeated measures linear mixed models (SAS v 9.4 PROC MIXED), accounting for clustering of the children within the center and relevant covariates (e.g., cohort, weather, outside days, accelerometer wear). A significant intervention effect was found for MVPA (p < 0.0001) and SED minutes (p = 0.0004), with children at intervention centers acquiring approximately 6 min more MVPA and 14 min less sedentary time each day. The effects were moderated by sex and age, with a stronger impact for boys and the youngest children. The results suggest that childcare gardening has potential as a PA intervention.

The effects of school gardens on fruit and vegetable consumption at school: A randomized controlled trial with low-income elementary schools in four U.S. states.

This randomized controlled trial examines the effects of a school garden intervention on children's fruit and vegetable (FV) consumption at school over two years. We randomly assigned schools to the intervention group that received gardens and related curriculum (n = 24) or to the waitlist control group that received gardens and curriculum at the conclusion of the study (n = 22). Children in second, fourth, and fifth grade at baseline (n = 2767) in low-income schools (n = 46) in four U.S. States (Arkansas, Iowa, New York, and Washington) participated. The intervention comprised gardens for each classroom; a curriculum focused on nutrition, plant science, and horticulture, including activities and FV tasting sessions; resources for the school that addressed topics such as soil contamination and food safety; an implementation guide focused on issues related to planning, planting, and maintaining the garden through the year, engaging volunteers, summer gardening, building community capacity, and sustaining the gardening program. FV consumption was measured by photographing lunches before and after children ate, for 2-3 days, at baseline and at each of 3 subsequent periods of data collection during the intervention. FV consumption was calculated using Digital Food Image Analysis. Among children in the intervention, fruit consumption and low-fat vegetable consumption increased from pre-garden baseline to post-garden more than among control group children. Garden intervention fidelity (GIF) also predicted changes in dietary intake, with more robust interventions showing a stronger effect than weaker interventions. GIF-lessons was a particularly potent predictor of change in dietary intake. School gardens modestly increase children's FV consumption at school.

Hands-on childcare garden intervention: A randomized controlled trial to assess effects on fruit and vegetable identification, liking, and consumption among children aged 3-5 years in North Carolina.

Gardening at childcare centers may have a potent influence on young children's learning about fruits and vegetables and their development of healthy dietary behaviors. This randomized controlled trial examined the effect of a garden intervention on fruit and vegetable (FV) identification, FV liking, and FV consumption among 3-5-year-old children enrolled in childcare centers in Wake County, North Carolina, USA. Eligible childcare centers (serving primarily low-income families) were randomly selected and then randomly assigned to one of three groups: (1) intervention; (2) waitlist-control that served as a control in year 1 and received the intervention in year 2; or (3) no-intervention control. From the 15 participating childcare centers, 285 children aged 3-5 years were consented by their parents or guardians to participate. The intervention comprised six standardized, raised, mulched garden beds, planted with warm-season annual vegetables and fruits, and perennial fruits. A Gardening Activity Guide describing 12 age-appropriate, sequential gardening activities was distributed for teachers to lead hands-on gardening activities during the growing season. Data were gathered between Spring 2018 and Fall 2019. FV identification and liking were measured using an age-appropriate tablet-enabled protocol. FV consumption was measured by weighing each child's fruit and vegetable snack tray before and after tasting sessions. Compared to children receiving no-intervention, children who received the garden intervention showed a greater increase in accurate identification of both fruits and vegetables as well as consumption of both fruit and vegetables during the tasting sessions. Consistent with prior research, the effects on fruit consumption were greater than on vegetable consumption. There was no significant effect of the garden intervention on children's FV liking. Garden interventions implemented early in life foster learning about FV and promote healthy eating. Early exposure to gardening may yield a return on investment throughout the lifecourse, impacting healthy diet and associated health outcomes, which are particularly important within disadvantaged communities where children's health is challenged by a host of risk factors. Clinical Trials Registration #NCT04864574 (clinicaltrials.gov).

Research Design, Protocol, and Participant Characteristics of COLEAFS: A Cluster Randomized Controlled Trial of a Childcare Garden Intervention.

Childcare garden interventions may be an effective strategy to increase fruit and vegetable (FV) consumption and physical activity among young children. The objective of this paper is to describe the research design, protocol, outcome measures, and baseline characteristics of participants in the Childcare Outdoor Learning Environments as Active Food Systems ("COLEAFS") study, a cluster randomized controlled trial (RCT) examining the effect of a garden intervention on outcomes related to diet and physical activity. Fifteen childcare centers in low-income areas were randomly assigned to intervention (to receive garden intervention in Year 1), waitlist control (to receive garden intervention in Year 2), and control group (no intervention). The garden intervention comprised six raised beds planted with warm-season vegetables and fruits, and a garden activity booklet presenting 12 gardening activities. FV knowledge and FV liking were measured using a tablet-enabled protocol. FV consumption was measured by weighing FV before and after a snack session. Physical activity was measured using Actigraph GT3x+ worn by children for three consecutive days while at the childcare center. Of the 543 eligible children from the 15 childcare centers, 250 children aged 3-5 years received parental consent, assented, and participated in baseline data collection. By employing an RCT to examine the effect of a garden intervention on diet and physical activity among young children attending childcare centers within low-income communities, this study offers compelling research design and methods, addresses a critical gap in the empirical literature, and is a step toward evidence-based regulations to promote early childhood healthy habits.

Life Course Nature Exposure and Mental Health Outcomes: A Systematic Review and Future Directions.

Recently, an emerging body of literature has examined the relationships between early life nature exposure and mental health in later life; however, no critical synthesis yet exists regarding the extent and strength of these relationships. This study presents the first systematic review of studies in this growing area. Following the PRISMA framework, we searched six databases (i.e., Scopus, Web of Science, MEDLINE, Embase, PsycINFO, and CINAHL); conducted identification, screening, eligibility, and inclusion analyses; and identified a final set of 29 articles. The review set comprises primarily longitudinal studies, with several cross-sectional studies using retrospective measures of childhood nature exposure. The majority of included studies were published between 2016 and 2020 and conducted in Europe and North America. Five domains of mental health outcomes are associated with early-life nature exposure: incidence of mental disorders, psychiatric symptoms and emotions, conduct problems in children, cognitive function, and subjective well-being. The evidence lends support to an overall beneficial role of early nature exposure on mental health, although inconsistencies are reported. Taken together, the evidence does not suggest that exposure at any given life stage is more saliently associated with mental health outcomes than at others. We discuss the validity concerns and methodological remedies and offer directions for future research.

Characteristics of Inpatient Units Associated With Sustained Hand Hygiene Compliance.

OBJECTIVES: Following institution of a hand hygiene (HH) program at an academic medical center, HH compliance increased from 58% to 92% for 3 years. Some inpatient units modeled early, sustained increases, and others exhibited protracted improvement rates. We examined the association between patterns of HH compliance improvement and unit characteristics. METHODS: Adult inpatient units (N = 35) were categorized into the following three tiers based on their pattern of HH compliance: early adopters, nonsustained and late adopters, and laggards. Unit-based culture measures were collected, including nursing practice environment scores (National Database of Nursing Quality Indicators [NDNQI]), patient rated quality and teamwork (Hospital Consumer Assessment of Healthcare Provider and Systems), patient complaint rates, case mix index, staff turnover rates, and patient volume. Associations between variables and the binary outcome of laggard (n = 18) versus nonlaggard (n = 17) were tested using a Mann-Whitney U test. Multivariate analysis was performed using an ordinal regression model. RESULTS: In direct comparison, laggard units had clinically relevant differences in NDNQI scores, Hospital Consumer Assessment of Healthcare Provider and Systems scores, case mix index, patient complaints, patient volume, and staff turnover. The results were not statistically significant. In the multivariate model, the predictor variables explained a significant proportion of the variability associated with laggard status, (R2 = 0.35, P = 0.0481) and identified NDNQI scores and patient complaints as statistically significant. CONCLUSIONS: Uptake of an HH program was associated with factors related to a unit's safety culture. In particular, NDNQI scores and patient complaint rates might be used to assist in identifying units that may require additional attention during implementation of an HH quality improvement program.

Perianesthesia Nurses Pain Management Practices: Findings and Recommendations From a National Descriptive Study of Members of the American Society of Perianesthesia Nurses.

PURPOSE: The purpose of this study was to identify current individual practice of perianesthesia nurses regarding assessment and documentation of pain. DESIGN: Descriptive cross-sectional design using vignette technique. METHODS: Vignettes with questions available via electronic survey offered to attendees of the 2017 American Society of PeriAnesthesia Nurses National Conference. FINDINGS: Total of 1,680 perianesthesia nurses participated; 41.4% reported assessment of pain compared with 36.7% who reported documentation of pain assessment. The numeric (0 to 10) pain intensity score was the most commonly used assessment method. Only 16.4% assessed for and documented pain location, 14.4% assessed for and documented quality of pain. CONCLUSIONS: Pain assessment should include intensity, location, quality, and functional impact. The gap between nurses' practices in assessment and documention of pain may be related to system barriers. Embedding evidence-based best practice within electronic health records may improve both. Prior literature, as well as our findings, indicate these trends (missed documentation and assessment) are more global than only perianesthesia nursing.

Empowering Nurses: Creation of a Peer-Reviewed Journal as a Catalyst for Innovative Nursing Research and Enhancing Evidence-Based Nursing Practice.

An internal peer-reviewed journal was created to promote high-quality nursing practice, improve patient outcomes, and inspire nurses at an academic medical center. The goal of the journal was to increase nurses' utilization of evidence-based practice (EBP). The publication provides a platform that facilitates the dissemination of nursing research and supports the implementation of EBP across the organization.

Initial psychometric testing of the Head and Neck Cancer Patient Self-Management Inventory (HNC-PSMI).

PURPOSE: Head and neck cancer (HNC) and its treatment are associated with significant symptom burden and functional impairment. HNC patients must engage in intensive and complex self-management protocols to minimize acute and late treatment effects. Self-management among HNC patients is understudied due to the limited availability of disease-specific self-management measures. This article describes the initial psychometric testing of the HNC Patient Self-Management Inventory (HNC-PSMI), an instrument that characterizes self-management tasks in the HNC population. METHOD: A cross-sectional survey design was used. One hundred HNC patients completed the HNC-PSMI, the Vanderbilt Head and Neck Cancer Symptom Survey plus General Symptom Survey, and the Profile of Mood States-Short Form. To evaluate the psychometric properties of the HNC-PSMI, the relevance of items, internal consistency of domain item responses, and the direction and strength of associations between domain scores and other measures were examined. RESULTS: There was variability both in the number of self-management tasks performed overall and in each domain as well as in the reported difficulty completing those tasks. Kuder-Richardson values for domains with > 3 items ranged from 0.61 to 0.86. Hypothesized associations were supported. CONCLUSIONS: Overall, the psychometric properties for the HNC-PSMI were acceptable. The HNC-PSMI can be used to advance an understanding of self-management requirements and challenges in HNC patients.

A Comparison of the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) and Pain Assessment in Advanced Dementia Scale (PAINAD).

BACKGROUND: There is currently no gold standard instrument for assessing pain in severely cognitively impaired adults who are unable to provide self-report. AIMS: To determine interrater reliability of the PACSLAC and PAINAD in assessing pain behaviors in patients with the same pain stimulus, determine the consistency of the reliable changes between and within the instruments and assess nurse preference for either instrument. DESIGN: A single-group, within-subjects repeated-measures design was implemented. SETTING: The study took place in a small suburban hospital. PARTICIPANTS/SUBJECTS: Pain levels were observed at 24, 48, and 72 hours postsurgery using two instruments: Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) and Pain Assessment in Advanced Dementia Scale (PAINAD). These instruments were selected because they are among the most commonly recommended tools for clinical use. Interrater reliability was analyzed along with reliable changes in pain for each period, and the study concluded with the nurse raters completing a preference survey. METHODS: A convenience sample of 30 patients was used with a diagnosis of severe dementia rendering the patient unable to reliably express pain, 60+ years of age, recovering from hip fracture surgery. RESULTS: Greater interrater reliability was found for the PACSLAC, with reliable change potentially affected by the type and level of pain medication. The nurses' preference for the tool was split. CONCLUSIONS: The results of this study indicate that the PACSLAC may be the more reliable tool over the PAINAD; however, rater training and familiarity with the tool is critical.

Prevalence and Risk Factors for Opioid-Induced Constipation in an Older National Veteran Cohort.

Objectives: This research describes the prevalence and covariates associated with opioid-induced constipation (OIC) in an observational cohort study utilizing a national veteran cohort and integrated data from the Center for Medicare and Medicaid Services (CMS). Methods: A cohort of 152,904 veterans with encounters between 1 January 2008 and 30 November 2010, an exposure to opioids of 30 days or more, and no exposure in the prior year was developed to establish existing conditions and medications at the start of the opioid exposure and determining outcomes through the end of exposure. OIC was identified through additions/changes in laxative prescriptions, all-cause constipation identification through diagnosis, or constipation related procedures in the presence of opioid exposure. The association of time to constipation with opioid use was analyzed using Cox proportional hazard regression adjusted for patient characteristics, concomitant medications, laboratory tests, and comorbidities. Results: The prevalence of OIC was 12.6%. Twelve positively associated covariates were identified with the largest associations for prior constipation and prevalent laxative (any laxative that continued into the first day of opioid exposure). Among the 17 negatively associated covariates, the largest associations were for erythromycins, androgens/anabolics, and unknown race. Conclusions: There were several novel covariates found that are seen in the all-cause chronic constipation literature but have not been reported for opioid-induced constipation. Some are modifiable covariates, particularly medication coadministration, which may assist clinicians and researchers in risk stratification efforts when initiating opioid medications. The integration of CMS data supports the robustness of the analysis and may be of interest in the elderly population warranting future examination.

Associations between local government expenditures and low birth weight incidence: Evidence from national birth records.

Local governments play an integral role in providing public services to their residents, yet the population health benefits are frequently overlooked, especially when services are outside the traditional health domain. With data from the U.S. Census of Governments and national birth records (spanning from 1992 to 2014), we examined whether local government expenditures on parks and recreation services (PRS) and housing and community development (HCD) predicted county low birth weight outcomes (population incidence and black-white disparities). Hypotheses were tested using bias-corrected county-by-period fixed effects models in a sample of 956 U.S. counties with a total of 3619 observations (observations were defined as three-year pooled estimates), representing 24 million births. Adjusting for prior county low birth weight incidence, levels of total operational, health, and hospital expenditures, and time-varying county sociodemographics, an increase in per capita county PRS expenditures of $50 was associated with 1.25 fewer low birth weight cases per 1000. Change in county HCD expenditures was not associated with low birth weight incidence, and, contrary to hypotheses, neither expenditure type was linked to county black-white disparities. Further examination of the benefits to birth outcomes from increasing parks and recreation services is warranted.

Burnout and Resiliency in Perianesthesia Nurses: Findings and Recommendations From a National Study of Members of the American Society of PeriAnesthesia Nurses.

PURPOSE: Describe prevalence of burnout in perianesthesia nurses, explore risks, mitigating factors. DESIGN: Cross-sectional descriptive. METHODS: Survey containing Maslach Burnout Inventory, Short Form-12, and Social Support and Personal Coping was emailed to American Society of PeriAnesthesia Nurses. Regression analysis examined relationships between burnout and health, social support, personal coping, substance use, and demographics. FINDINGS: Of 2,837 respondents, 18% were currently and 35% were formerly burned out, with lower incidence in those >40 years. Currently burned out nurses had worse health and also perceived a lack of advancement opportunities and organizational investment in the individual. Lower burnout was associated with regular participation in physical (P < .001), creative (P = .004), or mindfulness hobbies (P < .001) and ease in discussing work problems with spouse or partner (P = .001). CONCLUSIONS: Despite burnout nurses' empathy for their patients is maintained. Interests outside of work, personal and work support, healthy work environment, and regular physical activities can improve burnout.

Clinic and park partnerships for childhood resilience: A prospective study of park prescriptions.

INTRODUCTION: Pediatricians need community resources for childhood stress. We examined the association of weekly park visits and resilience amongst children receiving a park prescription at a clinic for low-income families. MATERIALS AND METHODS: A prospective longitudinal clinical trial was conducted amongst children ages 7-17 at a safety-net primary care clinic with measures at zero, one and three months out. Parents reported their child's park visits per week, baseline ACE score, their own stress (PSS10) and coping; children reported resilience (Brief Resiliency Scale) and stress (PSQ8-11 scale). RESULTS: Enrolled children (N = 54; mean (sd) age 10.3 (2.4) years), had a median (IQR) ACE score of 2 (1, 4). Child resilience improved with each one-day increase in weekly park visits (0.04 points, 95% CI 0.01, 0.08) at every level of ACEs. Child stress partially mediated this relationship. CONCLUSION: Parks are a community resource for pediatric resilience; park prescriptions may be a way to deal with pediatric stress.

The hands that cradle: A pilot study of parent adverse childhood experience scores.

The purpose of this study was to gather population-specific data within a pediatric hospital and contribute to understanding the intergenerational continuity of adverse childhood experiences (ACEs). This descriptive study aimed at measuring the ACE scores of parents or caretakers whose child was a suspected victim of abuse or neglect. The "Finding Your ACE Score questionnaire was used to determine participants' scores." Fifteen participants enrolled in the study (N = 15), and 86.7% had exposure to ACEs. Statistical significance was found when comparing ACE scores with reported income levels (p = .051). This study supports previous findings of ACEs being present in a variety of populations, and it presents practice implications for advance practice registered nurses (APRNs) in various practice settings. Findings support that research regarding how to assess and treat ACEs throughout family members is both necessary and difficult. Additional data regarding the intergenerational continuity of ACEs might influence how APRNs deliver family-specific assessment, treatment, and prevention of ACEs throughout generations of family members.

Impact of patient symptoms and caregiving tasks on psychological distress in caregivers for head and neck cancer (HNC).

OBJECTIVE: To determine the association of caregiving task burden and patient symptom burden with psychological distress among caregivers of head and neck cancer (HNC) patients. METHODS: Adults with HNC and their primary caregivers were included. Patient symptom burden was assessed with the Vanderbilt Head and Neck Symptom Survey-2.0. Caregiving task burden was quantified as task number and task difficulty/distress using the HNC Caregiving Task Inventory. Psychological distress was measured with the Profile of Mood States-Short Form. Two-step clustering analysis was conducted for patient symptom burden, caregiving task burden, and psychological distress. Associations of the resultant clusters of task burden and patient symptoms with caregiver distress were tested using logistic regressions. RESULTS: Eighty-nine HNC caregivers and 84 patients were included. Among patients, two clusters of symptom burden were found (51% mod-high, 49% low). Among caregivers, two clusters of caregiving task burden (40% mod-high, 60% low) and caregiver psychological distress (40% mod-high, 60% low) were found. Caregivers with mod-high task numbers and task difficulty/distress reported higher levels of psychological distress. After controlling for caregiver number of tasks, respective difficulty/distress, and patient symptom burden, caregiver perceived task difficulty/distress had the strongest association with caregiver psychological distress (adjusted OR = 3.83; 95% CI, 1.0-14.64; P = 0.049). CONCLUSIONS: Psychological distress in HNC caregivers is associated with caregiving task burden, with caregivers experiencing high task difficulty/distress at greatest risk. Further study of the caregiver and task characteristics leading to psychological distress should inform supportive interventions for HNC patients and caregivers.

Nearby nature buffers the pain catastrophizing - pain intensity relation among urban residents with chronic pain.

Pain catastrophizing is among the strongest predictors of pain intensity. This study examined the role of the nearby natural environment in the experience of pain among community-dwelling adults with chronic pain (N=81) living in New York City and explored the notion that attention may underlie nature's effect. Nearby nature was objectively measured using satellite data. Daily diary data across 14 days was employed to operationalize pain catastrophizing (and subscales: rumination, helplessness, and magnification) and pain intensity. Results indicated that nearby nature buffered the relation between catastrophizing and pain intensity. Moreover, nearby nature moderated the association between pain-related rumination (the most attention-based subscale of pain catastrophizing) and pain intensity, but did not moderate the helplessness-pain intensity or the magnification-pain intensity associations. These results suggest that the mechanism underlying nearby nature's moderating influence involves attention. Practitioners in search of strategies to reduce pain intensity experienced by community-dwelling chronic pain sufferers might look to a community resource: nearby nature.

Cafeteria assessment for elementary schools (CAFES): development, reliability testing, and predictive validity analysis.

BACKGROUND: Strategies to reduce childhood obesity and improve nutrition include creating school food environments that promote healthy eating. Despite well-documented health benefits of fruit and vegetable (FV) consumption, many U.S. school-aged children, especially low-income youth, fail to meet national dietary guidelines for FV intake. The Cafeteria Assessment for Elementary Schools (CAFES) was developed to quantify physical attributes of elementary school cafeteria environments associated with students' selection and consumption of FV. CAFES procedures require observation of the cafeteria environment where preparation, serving, and eating occur; staff interviews; photography; and scoring. METHODS: CAFES development included three phases. First, assessment items were identified via a literature review, expert panel review, and pilot testing. Second, reliability testing included calculating inter-item correlations, internal consistency (Kuder-Richardson-21 coefficients), and inter-rater reliability (percent agreement) based on data collected from 50 elementary schools in low-income communities and 3187 National School Lunch Program participants in four U.S. states. At least 43% of each participating school's students qualified for free- or reduced-price meals. Third, FV servings and consumption data, obtained from lunch tray photography, and multi-level modeling were used to assess the predictive validity of CAFES. RESULTS: CAFES' 198 items (grouped into 108 questions) capture four environmental scales: room (50 points), table/display (133 points), plate (4 points), and food (11 points). Internal consistency (KR-21) was 0.88 (overall), 0.80 (room), 0.72 (table), 0.83 (plate), and 0.58 (food). Room subscales include ambient environment, appearance, windows, layout/visibility, healthy signage, and kitchen/serving area. Table subscales include furniture, availability, display layout/presentation, serving method, and variety. Inter-rater reliability (percent agreement) of the final CAFES tool was 90%. Predictive validity analyses indicated that the total CAFES and four measurement scale scores were significantly associated with percentage consumed of FV served (p < .05). CONCLUSIONS: CAFES offers a practical and low-cost measurement tool for school staff, design and public health practitioners, and researchers to identify critical areas for intervention; suggest low- and no-cost intervention strategies; and contribute to guidelines for cafeteria design, food presentation and layout, and operations aimed at promoting healthy eating among elementary school students.