A Pilot Feasibility Evaluation of a Heart Rate Variability Biofeedback App to Improve Self-Care in COVID-19 Healthcare Workers.

COVID-19 exacerbated burnout and mental health concerns among the healthcare workforce. Due to high work stress, demanding schedules made attuned eating behaviors a particularly challenging aspect of self-care for healthcare workers. This study aimed to examine the feasibility and acceptability of a heart rate variability biofeedback (HRVB) mobile app for improving well-being among healthcare workers reporting elevated disordered eating during COVID-19. We conducted a mixed methods pre-mid-post single-arm pilot feasibility trial (ClinicalTrials.gov NCT04921228). Deductive content analysis of participants' commentary generated qualitative themes. Linear mixed models were used to examine changes in pre- mid- to post-assessment scores on well-being outcomes. We consented 28 healthcare workers (25/89% female; 23/82% Non-Hispanic White; 22/79% nurses) to use and evaluate an HRVB mobile app. Of these, 25/89% fully enrolled by attending the app and device training; 23/82% were engaged in all elements of the protocol. Thirteen (52%) completed at least 10 min of HRVB on two-thirds or more study days. Most participants (18/75%) reported being likely or extremely likely to continue HRVB. Common barriers to engagement were busy schedules, fatigue, and technology difficulties. However, participants felt that HRVB helped them relax and connect better to their body's signals and experiences. Results suggested preliminary evidence of efficacy for improving interoceptive sensibility, mindful self-care, body appreciation, intuitive eating, stress, resilience, and disordered eating. HRVB has potential as a low-cost adjunct tool for enhancing well-being in healthcare workers through positively connecting to the body, especially during times of increased stress when attuned eating behavior becomes difficult to uphold.

Critical Care Nurses' Moral Resilience, Moral Injury, Institutional Betrayal, and Traumatic Stress After COVID-19.

BACKGROUND: Traumatic stress and moral injury may contribute to burnout, but their relationship to institutional betrayal and moral resilience is poorly understood, leaving risk and protective factors understudied. OBJECTIVES: To examine traumatic stress symptoms, moral injury symptoms, moral resilience, and institutional betrayal experienced by critical care nurses and examine how moral injury and traumatic stress symptoms relate to moral resilience, institutional betrayal, and patient-related burnout. METHODS: This cross-sectional study included 121 critical care nurses and used an online survey. Validated instruments were used to measure key variables. Descriptive statistics, regression analyses, and group t tests were used to examine relationships among variables. RESULTS: Of participating nurses, 71.5% reported significant moral injury symptoms and/or traumatic stress. Both moral injury symptoms and traumatic stress were associated with burnout. Regression models showed that institutional betrayal was associated with increased likelihood of traumatic stress and moral injury. Increases in scores on Response to Moral Adversity subscale of moral resilience were associated with a lower likelihood of traumatic stress and moral injury symptoms. CONCLUSIONS: Moral resilience, especially response to difficult circumstances, may be protective in critical care environments, but system factors (eg, institutional betrayal) must also be addressed systemically rather than relying on individual-level interventions to address nurses' needs.

Roles and responsibilities of expert clients in adolescent HIV service delivery in Eswatini: a conventional content analysis.

We aimed to elucidate the specific roles and responsibilities of expert clients in service delivery among adolescents living with HIV in Eswatini, and to provide recommendations for enhancing adolescent service provision among expert clients and similar lay health workers throughout low- and middle-income countries. An exploratory qualitative descriptive methodology using conventional content analysis was used to meet our study aims. We recruited 20 expert clients and 12 key informants (programme managers, programme coordinators and nurses) to participate in semi-structured interviews, and we arranged four focus group discussions among adolescents living with HIV with seven to ten participants per focus group. Adherence counselling in clinical and community settings was considered paramount to the roles and responsibilities of expert clients with regard to adolescent-specific HIV service delivery. The following recommendations were made to enhance expert client service delivery practices among adolescents: (1) training in adolescent developmental, sexual and reproductive needs; (2) training to enhance clinical knowledge and skills; (3) additional work equipment and compensation; and d) more parent and guardian engagement in their work. While expert clients meet the needs of adolescents living with HIV in several capacities, they require additional resources, skills and training to improve their work, especially in the realm of sexual and reproductive health. Future research is needed to evaluate the impact of expert client service delivery on adolescent health outcomes.

Parent experiences during and after adolescent suicide crisis: A qualitative study.

Parents of adolescents who have suicide crises (i.e. suicide attempt and/or significant ideation) are often highly involved in the care management, treatment and preventing future suicides of their children. How they experience these suicide crises, and the period afterward, has not been well studied. The purpose of this study was to understand parents' (defined in this study as any legal guardian of an adolescent taking on a parental role) experience of adolescent suicide crises and its impact on themselves and the family system. Semi-structured interviews were conducted with parents (N = 18) of adolescents who had a suicide crisis in the past 3 years. Thematic analysis was used with a combined inductive-deductive coding approach, drawing from Diamond's conceptualization of family treatment engagement for suicidal youth and iterative close readings of transcripts. Five themes emerged related to parent experience: Trauma of the Experience (subtheme: Feelings of Failure); Living in Fear; Alone and Seeking Connection; Lasting Impact; and A New Normal (subtheme: Turn the Pain to Purpose). Parents experienced these events as traumatic, damaging their sense of self. They experienced long periods of time where fear and loneliness dominated their lives. Recovery was both an individual and a family process, occurring in tandem with, but distinct from, adolescent experiences. Descriptions and illustrative quotes illustrate parent experiences and their understanding of the impact on the family system. Results highlighted that parents require support both for themselves and as caregivers for adolescents around an adolescent's suicide crisis and that family-focused services are vital.

Adolescent suicide risk, firearm access, and family functioning: Screening in primary care.

INTRODUCTION: Suicide is a serious mental health concern and the second leading cause of death for adolescents in the United States. Suicide risk is a complex interaction of social, psychological, and physiological factors. Previous research has identified family functioning as being related to adolescent suicide risk, but it is not well studied in clinical settings. This study uses the Behavioral Health Screen-Primary care (BHS-PC) to examine the relationship between current suicide risk in adolescent and a dysfunctional family environment. METHOD: Adolescents presenting for primary care appointments (n = 6,609; age 14-17) completed the BHS-PC, a broad-based, psychometrically validated screening tool that measures a wide range of adolescent behavioral and mental health concerns. Using data from the BHS-PC, hierarchical logistic regression modeling was used to build and compare models of current suicide risk to determine the effect of including family factors. Fisher's Exact test was utilized to examine the relationship between family functioning and firearm access, a critical factor in youth safety and risk of completing suicide. RESULTS: In the final model, three family functioning related variables were associated with current suicide risk in adolescents: never talking to adult family member about their concerns, witnessing violence in the home, and arguing in the home. In addition, all but one family functioning factor was related to adolescent firearm access. CONCLUSIONS: Family functioning and access to firearms are critical to understanding adolescent suicide risk. Utilizing a holistic approach in primary care to screen for adolescent suicide risk may improve clinical response and linkages to care. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Long Tail of COVID-19: Implications for the Future of Emergency Nursing.

INTRODUCTION: COVID-19 has led to exacerbated levels of traumatic stress and moral distress experienced by emergency nurses. This study contributes to understanding the perspectives of emergency nurses' perception of psychological trauma during COVID-19 and protective mechanisms used to build resilience. METHOD: The primary method was qualitative analysis of semistructured interviews, with survey data on general resilience, moral resilience, and traumatic stress used to triangulate and understand qualitative findings. Analyses and theme development were guided by social identity theory and informed by the middle range theory of nurses' psychological trauma. RESULTS: A total of 14 emergency nurses were interviewed, 11 from one site and 3 from the other. Almost all nurses described working in an emergency department throughout the pandemic as extraordinarily stressful, morally injurious, and exhausting at multiple levels. Although the source of stressors changed throughout the pandemic, the culmination of continued stress, moral injury, and emotional and physical exhaustion almost always exceeded their ability to adapt to the ever-changing landscape in health care created by the pandemic. Two primary themes were identified: losing identity as a nurse and hopelessness and self-preservation. DISCUSSION: The consequences of the pandemic on nurses are likely to be long lasting. Nurses need to mend and rebuild their identity as a nurse. The solutions are not quick fixes but rather will require fundamental changes in the profession, health care organizations, and the society. These changes will require a strategic vision, sustained commitment, and leadership to accomplish.

The Impact of Traumatic Stress, Resilience, and Threats to Core Values on Nurses During a Pandemic.

OBJECTIVE: The aim of this study was to understand the traumatic stress and resilience of nurses who cared for patients with COVID-19. BACKGROUND: Studies have shown a high proportion of healthcare workers are at risk for developing posttraumatic stress disorder after a pandemic. Resilience factors are believed to play an important role in the well-being of healthcare professionals. METHODS: This was a triangulated mixed methods study; a phenomenological qualitative approach with survey data was used to triangulate the findings, and sensemaking was used as the theoretical framework. RESULTS: Four themes emerged from the study: 1) phases of traumatic stress response to perceived threats; 2) honoring their sacrifice; 3) professional self-identity; and 4) sustaining resilience in a stressful work environment. Quantitative results on traumatic stress, general resilience, and moral resilience supported the themes. CONCLUSIONS: The findings will help leaders understand the potential for postpandemic mental health problems and the role of resilience in maintaining well-being.

Barriers to mental health services among college students screened in student health: A latent class analysis.

Background: Almost a third of college students experience significant mental health concerns, but many do not receive adequate services. This study investigated barriers to mental health services among college students screened in a student health center primary care service. Method: Students (N = 1662) presenting for primary care completed mental health screenings and a barrier measure in the student health center of a university. Latent class analysis created barrier profiles. Results: Three barrier profiles were identified (none, logistical, all barriers). Profiles related to gender (p < .001), with logistical/all barrier profiles more likely amongst female students. No significant difference found by race. Students with higher depression scores were more likely to report logistical barriers than no barriers (p < .001). Conclusion: Programs must address multiple barriers to successfully engage students in treatment. Tailored interventions, including in primary care, should assess and respond to individual barriers, not just common ones.

Consumers With Serious Mental Illness Perspectives on Care Integration: Preparation for Integration.

BACKGROUND: Those with serious mental illness (SMI) experience poor health outcomes which may be addressed by the integration of mental health and primary care services. This integration could be enhanced by the inclusion of consumers in the planning process. AIMS: This study sought to bring the voice of the consumer with SMI to assist with the integration of primary care and mental health services. METHODS: Working with a community advisory board in the City of Philadelphia, we carried out a sequential explanatory mixed-methods study. The team conducted 12 focus groups (n=149) and surveys (n = 137) of consumers with SMI about their experiences of the health care system and perspectives on integrated health. Data from surveys and focus groups were analyzed and integrated. RESULTS: Three relevant themes emerged: primary care experiences; health care stigma; and social determinants as barriers to health. Generally, individuals with SMI supported the integration of care, with careful consideration given to social determinants of health, patient privacy, and respect between providers and patients. CONCLUSIONS: Integration may reduce health disparities experienced by individuals with SMI, but the process must be informed by intended consumers. Policymakers and administrators will need to address barriers to care, healthcare stigma, and social determinants of health. Nurses are well placed to inform and lead healthcare integration and overcome the siloing of mental and physical healthcare systems.

Mental Health Burden among Black Adolescents: The Need for Better Assessment, Diagnosis and Treatment Engagement.

This study examines mental health symptoms among Black adolescents who were currently in mental health treatment and those who were not in treatment. The study uses a sample of Black adolescents (N=154) and logistic regression was performed to determine which psychological factors were associated with exhibiting mental health symptoms. Both groups experienced high amounts of trauma exposure history, recent suicidality, substance use, and depressive symptoms. Nearly one in four adolescents in the out of treatment group met diagnostic criteria for anxiety disorders. Implications include better screening for mental health symptoms to ensure Black adolescent have access to mental health treatment.

Psychiatric Medication Changes Associated With Increased Rate of Medical Readmissions in Patients With Serious Mental Illness.

ABSTRACT: To identify the impact of postdischarge psychiatric medication changes on general medical readmissions among patients with serious mental illness (SMI; bipolar disorder, major depressive disorder, and schizophrenia), claims from a 5% national sample of Medicare fee-for-service (FFS) beneficiaries hospitalized between 2013 and 2016 were studied. A total of 165,490 Medicare FFS beneficiaries with SMI 18 years or older with at least 1 year of continuous Medicare enrollment were identified. Within 30 days of discharge from index admission, 47.4% experienced a psychiatric medication change-including 75,892 beneficiaries experiencing a deletion and 55,713 experiencing an addition. After adjusting for potential confounders, those with a medication change experienced an 10% increase in the odds of 30-day readmission (odds ratio, 1.10; SE, 0.019; p < 0.001). Comorbid drug use disorder was also associated with an increased odds of readmission after controlling for other covariates. These findings suggest important factors that clinicians should be aware of when discharging patients with SMI.

Experiences of Hospitalization of Patients With Psychotic Disorders on Medical-Surgical Units: A Thematic Analysis.

BACKGROUND:Individuals with psychotic disorders are more likely to have nonpsychiatric hospitalizations than the general population. Moreover, they experience worse outcomes in terms of rehospitalization, adverse events, in-hospital mortality, and longer length of stay. AIM: A patient-centered understanding of inpatient medical-surgical hospitalization experiences could shed light on disparities in hospital outcomes among individuals with psychotic disorders. METHOD: This article reports findings from Phase 1 (Qualitative) of a mixed methods, exploratory sequential study of nonpsychiatric hospitalizations of patients with psychotic disorders. Patients on medical-surgical units with diagnosed psychotic disorders (n = 20) were interviewed about their experiences of hospitalization, and a thematic analysis was conducted of transcripts, case notes, and setting notes. RESULTS: Five themes emerged from analysis: (1) managing through hard times (subthemes: intense emotions, medically complex with many symptoms, strategies for self-management), (2) ignored and treated unfairly, (3) actively involved in health (subthemes: seeking health education, suggesting changes), (4) appreciation of caring providers, and (5) violence: expected and enacted. Participants connected the difficult nature of their hospitalization experiences with a variety of sources and outcomes, including strong emotions, variable relationships with providers and a struggle to receive health education. CONCLUSIONS: Nurses who care for patients with psychotic disorders in medical-surgical settings can better meet patients' needs by concentrating on relationship building, especially during initial interactions, and helping patients better manage their medical and psychiatric symptoms through both pharmaceutical and nursing interventions.

Non-psychiatric hospitalization length-of-stay for patients with psychotic disorders: A mixed methods study.

OBJECTIVE: Patients with psychotic disorders experience higher rates of chronic and acute non-psychotic diseases and have frequent non-psychiatric hospitalizations which result in both longer and more varied length-of-stay (LoS) than other patients. This study seeks to use a patient-centered perspective to examine LoS. METHODS: This article reports Phase Two of a mixed methods, exploratory sequential study on non-psychiatric hospitalizations for individuals with psychotic disorders. Patients' experiences were used to guide a quantitative analysis of LoS using a general linear model. RESULTS: Medical comorbidities were the patient characteristics which had the largest effect on LoS. Certain processes of care highlighted by patients from Phase One were also associated with longer LoS, including: physical restraints (105%), psychiatric consults (20%) and continuous observation (133%). Only recent in-system outpatient appointments were associated with shorter LoS. Data integration highlighted that factors which were important to patients such as partner support, were not always quantitatively significant, while others like medical comorbidities and use of physical restraints were points of congruence. CONCLUSIONS: Medical comorbidities were highly associated with LoS but processes relating to longer LoS are those that are used to manage symptoms of acute psychosis. Clinicians should develop policies and procedures that address psychosis symptoms effectively during non-psychiatric hospitalizations. Further research is needed to understand which patients with psychotic disorders are at highest risk of extended length-of-stay.

Informed consent and ethical reporting of research in clinical trials involving participants with psychotic disorders.

Informed consent is critical for protecting vulnerable individuals interested in research participation, like those with psychotic disorders (e.g. schizophrenia, schizoaffective disorder, schizophreniform disorder, etc.). Individuals with psychotic disorders may have fluctuating capacity to consent and capacity assessment prior to research participation can help determine decisional status. However, there is little research on how, or if, these assessments are conducted in clinical research. A systematic review of randomized medication or device trials that specifically recruited individuals with psychotic disorders to understand the use and reporting of capacity assessment to consent was conducted. A total of 646 articles were reviewed using a developed questionnaire on ethical reporting of consent practices and capacity assessment. Less than 10% (n = 34; 5.3%) of the studies reported an assessment of capacity to provide informed consent and less than half of those used a standardized assessment. Sixty-four (9.9%) of the articles reported capacity to provide informed consent in the study's inclusion and exclusion criteria. Additionally, 66 (10.2%) of the articles did not provide a statement about institutional review board (IRB) approval; and given the large number of medication and device trials, one out of five articles (n = 134; 20.7%) reported no statement about potential conflicts of interest. Future research should continue to examine these issues and to better understand the benefits and challenges of research participation with psychotic individuals and their decisional capacity in this context.

A Mixed Methods Approach to Identify Cognitive Warning Signs for Suicide Attempts.

This study used a mixed methods approach to examine pathways to suicidal behavior by identifying cognitive warning signs that occurred within 1 day of a suicide attempt. Transcripts of cognitive therapy sessions from 35 patients who attempted suicide were analyzed using a modified grounded theory approach. Cognitive themes emerging from these transcripts included: state hopelessness, focus on escape, suicide as a solution, fixation on suicide, and aloneness. Differences in demographic and baseline diagnostic and symptom data were explored in relation to each cognitive theme. We propose a potential conceptual model of cognitive warning signs for suicide attempts that requires further testing.

Addressing Unmet Sexual Health Needs among Black Adolescents with Mental Illnesses.

Despite advances in HIV epidemiologic and prevention research, adolescents with mental illnesses remain a historically underserved group with respect to human immunodeficiency virus (HIV)/sexually transmitted infection (STI) prevention resources. Black adolescents with mental illnesses in particular are a relatively underserved, hidden population in the field of sexual health. Strategies and guidelines are needed to account for underlying psychopathology among Black adolescents with mental illnesses in ways that current models have yet to address. In this paper, we propose several actionable mechanisms to better integrate HIV/STI and mental health related services and activities for sexual health promotion.

The role of depression in medication adherence among heart failure patients.

The purpose of the study was to explore the association between depression and medication adherence in heart failure (HF) patients. Studies have shown that people with depression are likely to be nonadherent to their prescribed medication treatment. But other studies suggest that nonadherence may be overestimated by people with depression. A total of 244 adults with Stage C HF completed the study. Self-reported medication adherence was obtained using the Basel Assessment of Adherence Scale (BAAS); objective data on medication adherence were collected using the electronic Medication Event Monitoring System (MEMS). Depression was measured via self-report with the Patient Health Questionnaire (PHQ-9). There was a significant difference between depressed and nondepressed participants in self-reported medication nonadherence (p = .008), but not in objectively measured medication nonadherence (p = .72). The depressed sample was 2.3 times more likely to self-report poor medication adherence than those who were nondepressed (p = .006).