The Health Narratives Research Group (HeNReG): A self-direction process offered to help decrease burnout in public health nurse practitioners.

Founded in accordance with 19th century sex roles and public health concerns, nursing evolved as other-directed, dependent on physician-focused diagnosis, prescription decisions, and public health advancements. The result of this other direction is that public health nurse practitioners have endured significant workplace stress resulting in burnout, especially during COVID-19. To help decrease their burnout, nurses require development of self-direction. The Health Narratives Research Group (HeNReG) has the potential to reduce burnout in nurse practitioners by encouraging the development of self-direction. The HeNReG process is presented through historically analyzed documents regarding reducing burnout in health researchers by developing self-direction including: (1) three years of archived year-end feedback results provided by participants, (2) archived participant responses to specific HeNReG-related writing prompts, and (3) a comparison of HeNReG results with the outcomes of resilience programs. The conclusion-the HeNReG offers an effective option for reducing burnout in health researchers that has the potential to decrease nurse practitioner burnout in a way that resilience programs do not. Tailoring the HeNReG process to public health nurses is discussed, inviting future research for reducing burnout in public health nurses.

Increased severity of mental health symptoms among adolescent inpatients during COVID-19.

OBJECTIVE: Prior research suggests that the COVID-19 pandemic has been detrimental to adolescent mental health. However, no research has examined whether the pandemic is associated with increased symptom severity among high-risk youth, such as those hospitalized for a psychiatric crisis. METHOD: Over a four-year period, upon admission to an adolescent psychiatric inpatient unit, youth completed measures of depression (Center for Epidemiologic Studies Depression Scale), feeling like a burden and lack of belongingness (Interpersonal Needs Questionnaire), trauma-related symptoms (Child Trauma Screen), suicidal thoughts and behaviors (Self-Injurious Thoughts and Behaviors Interview Self-Report Version). We compared the severity of these symptoms for patients admitted during the pandemic to the severity for patients admitted to the same unit in the three years before the pandemic. RESULTS: Across most symptoms, youth hospitalized during the pandemic reported increased severity compared to those hospitalized before the pandemic. CONCLUSIONS: Adolescents requiring psychiatric hospitalization during the pandemic reported increased symptom severity compared to adolescents hospitalized on the same inpatient unit in the three years prior to the pandemic.

Social Support and Nonsuicidal Self-injury among adolescent Psychiatric Inpatients.

Cross-sectional studies and prospective studies with long follow-up periods (e.g., years) have shown that lower levels of social support are associated with nonsuicidal self-injury (NSSI) among adolescents. This study examined how short-term changes in social support may contribute to NSSI behavior and whether different sources of support (e.g., friends, family members) provide differential protective effects against NSSI. We examined fluctuations in NSSI and social support perceived from multiple sources among a sample of 118 high-risk adolescents hospitalized for serious self-harm risk. Participants provided daily reports of social support and any self-injurious behavior for the duration of their inpatient treatment (721 total observations, average observations per participant = 6.11). Multi-level models were used to assess variability in social support and how these fluctuations relate to whether or not an individual engages in NSSI. Over one-third of participants reported engaging in NSSI at least once during inpatient hospitalization and self-reported social support varied within person across sources of support (ICC range = 0.68-0.81). Support perceived from family members and inpatient unit staff was inversely associated with NSSI, but no relationship was found between NSSI and support from other patients on the unit or friends outside of the unit. These findings suggest that the protective effects of social support for NSSI vary over short periods of time and that support perceived from adults is particularly relevant among this high-risk clinical sample. This study represents an important step in identifying risk factors to improve the detection and prevention of NSSI among adolescent inpatients.

Examining implicit positive affect toward suicide among suicidal and nonsuicidal adults and adolescents.

OBJECTIVE: The purpose of this study was to examine implicit affect toward suicide (i.e., how good/bad suicide is perceived). Some people might be more likely to think about/choose suicide because they perceive it as a good option (to gain relief) relative to available alternatives. METHOD: Implicit affect toward suicide among adults (N = 72) and adolescents (N = 174) with and without suicidal thoughts was examined using first-person (FP) perspective suicide pictures in the affect misattribution procedure (AMP). RESULTS: Suicidal adults' implicit positive affect toward suicide was associated with STB variables, such as explicit valence (r = 0.34) and arousal (r = 0.44) ratings of suicide pictures, and implicit affect differentiated groups above and beyond explicit valence ratings. Contrary to our hypothesis, suicidal participants did not display higher implicit positive affect toward suicide than nonsuicidal participants. However, suicidal participants displayed consistent implicit affect toward different suicide pictures, whereas nonsuicidal participants evaluated some pictures as more pleasant than others (ORs = 1.92-2.27). CONCLUSIONS: Implicit affect toward suicide may relate to STB, but stimuli characteristics (e.g., color) likely influence the accuracy of assessment with the AMP and should be a focus of future research involving this and other implicit measures.

COVID-19 Limitations on Doodling as a Measure of Burnout.

Pre-COVID-19, doodling was identified as a measure of burnout in researchers attending a weekly, in-person health narratives research group manifesting team mindfulness. Under the group's supportive conditions, variations in doodling served to measure change in participants reported depression and anxiety-internal states directly associated with burnout, adversely affecting healthcare researchers, their employment, and their research. COVID-19 demanded social distancing during the group's 2020/21 academic meetings. Conducted online, the group's participants who chose to doodle did so alone during the pandemic. Whether the sequestering of group participants during COVID-19 altered the ability of doodling to act as a measure of depression and anxiety was investigated. Participants considered that doodling during the group's online meetings increased their enjoyment and attention level-some expressed that it helped them to relax. However, unlike face-to-face meetings during previous non-COVID-19 years, solitary doodling during online meetings was unable to reflect researchers' depression or anxiety. The COVID-19 limitations that necessitated doodling alone maintained the benefits group members saw in doodling but hampered the ability of doodling to act as a measure of burnout, in contrast to previous in-person doodling. This result is seen to correspond to one aspect of the group's change in team mindfulness resulting from COVID-19 constraints.

Fear of sleep and sleep quality mediate the relationship between trauma exposure and suicide attempt in adolescents.

Prior work has established bivariate associations between suicidal thoughts and behaviors, trauma exposure and sleep disturbance broadly. Specifically, this study tested whether fear of sleep and sleep quality mediated the association between trauma exposure and suicide attempt. Participants (N = 100) were adolescents admitted to an inpatient psychiatric program for suicidality. Trauma exposure history was retrieved from admission notes and participants completed self-report surveys assessing sleep quality, fear of sleep and number of suicide attempts within the previous month. Structural equation modelling was used to investigate the relationships between childhood trauma, fear of sleep, sleep quality, and suicide attempt. Path analysis was used to investigate the indirect effects from trauma exposure to suicide attempt through fear of sleep, and sleep quality. Path analysis revealed a significant indirect effect from trauma exposure to suicide attempt through fear of sleep and sleep quality. Our findings suggest that a significant portion of the association between trauma exposure and suicide attempts in adolescence may be explained by the negative impact of trauma exposure on sleep. Fear of sleep may increase the risk of a suicide attempt by negatively impacting sleep quality. Future studies should investigate whether interventions targeting sleep and fear of sleep reduce the association between trauma and suicide attempt.

Positive and negative uses of social media among adolescents hospitalized for suicidal behavior.

INTRODUCTION: There is public concern about potential associations between adolescent social media/smartphone use and risk for suicide. However, no prior studies leverage qualitative methods to explore the experiences of adolescents currently at-risk for suicide. METHODS: This study examined social technology use from the perspectives of adolescents (n = 30; Mage = 16.1 years) currently hospitalized for a recent suicide attempt or severe ideation. We conducted in-depth interviews and coded transcripts using thematic analysis. We had three research questions: What (1) negative and (2) positive experiences do suicidal adolescents report related to their use of social media/smartphones? (3) How do adolescents describe their disconnection from these technologies use during inpatient hospitalization and views on a subsequent return to digital connectivity after discharge? RESULTS AND CONCLUSIONS: Results reveal both positive and negative social technology uses, with most participants reporting mixed (positive and negative) experiences. Negatives/risks included trouble regulating use, stress related to social media metrics, encounters with "triggering" content, hostility and meanness, self-denigrating comparisons, and burdensome friendship expectations. Positives/benefits included social connection, social support, affect-enhancing content, shared interests, and resources for mental health and coping. Overall, the documented risks and benefits of social technology use correspond with established (offline) risk and protective factors for suicidal thoughts and behaviors. Participants generally valued the break from social technologies during hospitalization, and also viewed them as integral to social re-entry and identified related concerns. Future studies should test well-being focused 'digital hygiene' interventions for maximizing potential benefits and minimizing potential harms of social technologies for at-risk adolescents.

Mindfulness Meditation and Anxiety in Adolescents on an Inpatient Psychiatric Unit.

This study presents the impact of chaplain-provided mindfulness meditation (MM) groups on state-anxiety in adolescent inpatients on an acute psychiatric unit, an understudied topic that warrants further research given that anxiety is a demonstrated predictor of suicide attempts in adolescents and the elevated suicide risk of this population. A total of 53 adolescent patients, age 13-19, attended optional 30-minute MM groups while hospitalized for inpatient psychiatric care. State-anxiety was assessed immediately before and after each MM session, and psychiatric symptom severity upon admission was compared between patients choosing to attend MM and those who did not. State-anxiety was found to decrease significantly between pre- and post-MM upon first exposure regardless of patient age, sex, and prior experience with MM. Findings also suggest the possibility that patients experiencing symptoms of psychosis may benefit more from MM as compared to other patients. Admission symptom severity was not found to be an indicator of MM attendance. These findings suggest the possibility that MM could be an effective and relatively immediate transdiagnostic intervention to lower state anxiety in adolescents on an inpatient psychiatric unit and invite further implementation and research by staff chaplains on such units.

Doodling as a Measure of Burnout in Healthcare Researchers.

Burnout adversely affects healthcare researchers, their place of employment, and the production of valuable research. It is directly associated with symptoms of depression and anxiety. Having an easily employed and reliable measure of depression and anxiety in healthcare researchers is important if burnout is to be diminished. Doodling may be one such measure. Doodling became a possible indicator based on unexpected outcomes associated with one diverse and voluntary health narrative research group where doodling was introduced. The result, with respect to casual, self-reported levels of depression and anxiety, ranged from researchers expressing low levels of distress to those revealing clinical diagnoses of depression and anxiety. Changes to doodling execution and content, and their effect on the doodler-metrics previously unmentioned in the literature-hold promise for evaluating depression and anxiety levels of researchers. Maligned in academic settings with increasingly punitive outcomes, doodling should be reassessed as a possible indicator of internal states of distress, dysphoria, depression, and anxiety based on this University of Toronto Health Narratives Research Group result of doodling. Under certain well-defined conditions, variations in doodling may serve as a measure of change in these internal states and, therefore, act as an aid in reducing burnout.

Increase in Suicidal Thinking During COVID-19.

There is concern that the COVID-19 pandemic may cause increased risk of suicide. In the current study, we tested whether suicidal thinking has increased during the COVID-19 pandemic and whether such thinking was predicted by increased feelings of social isolation. In a sample of 55 individuals recently hospitalized for suicidal thinking or behaviors and participating in a 6-month intensive longitudinal smartphone monitoring study, we examined suicidal thinking and isolation before and after the COVID-19 pandemic was declared a national emergency in the United States. We found that suicidal thinking increased significantly among adults (odds ratio [OR] = 4.01, 95% confidence interval [CI] = [3.28, 4.90], p < .001) but not adolescents (OR = 0.84, 95% CI = [0.69, 1.01], p = .07) during the onset of the COVID-19 pandemic. Increased feelings of isolation predicted suicidal thinking during the pandemic phase. Given the importance of social distancing policies, these findings support the need for digital outreach and treatment.

ED Visits and Readmissions After Follow-up for Mental Health Hospitalization.

OBJECTIVES: A national quality measure in the Child Core Set is used to assess whether pediatric patients hospitalized for a mental illness receive timely follow-up care. In this study, we examine the relationship between adherence to the quality measure and repeat use of the emergency department (ED) or repeat hospitalization for a primary mental health condition. METHODS: We used the Truven MarketScan Medicaid Database 2015-2016, identifying hospitalizations with a primary diagnosis of depression, bipolar disorder, psychosis, or anxiety for patients aged 6 to 17 years. Primary predictors were outpatient follow-up visits within 7 and 30 days. The primary outcome was time to subsequent mental health-related ED visit or hospitalization. We conducted bivariate and multivariate analyses using Cox proportional hazard models to assess relationships between predictors and outcome. RESULTS: Of 22 844 hospitalizations, 62.0% had 7-day follow-up, and 82.3% had 30-day follow-up. Subsequent acute use was common, with 22.4% having an ED or hospital admission within 30 days and 54.8% within 6 months. Decreased likelihood of follow-up was associated with non-Hispanic or non-Latino black race and/or ethnicity, fee-for-service insurance, having no comorbidities, discharge from a medical or surgical unit, and suicide attempt. Timely outpatient follow-up was associated with increased subsequent acute care use (hazard ratio [95% confidence interval]: 7 days: 1.20 [1.16-1.25]; 30 days: 1.31 [1.25-1.37]). These associations remained after adjusting for severity indicators. CONCLUSIONS: Although more than half of patients received follow-up within 7 days, variations across patient population suggest that care improvements are needed. The increased hazard of subsequent use indicates the complexity of treating these patients and points to potential opportunities to intervene at follow-up visits.

Predicting Psychiatric Rehospitalization in Adolescents.

Adolescent psychiatric rehospitalizations are common, cause patients and their families severe psychological distress, and use tremendous healthcare resources. This study sought to identify predictors of rehospitalization in 783 adolescents in the 2 year period following psychiatric hospitalization at a major treatment facility in a large urban area. A current diagnosis of posttraumatic stress disorder, greater severity of lifetime suicidal ideation (SI) and stronger treatment alliance prior to hospitalization were associated with a greater likelihood of rehospitalization. Overall, severe lifetime SI was the strongest predictor of rehospitalization; although, within the first 4 months post-discharge, moderate lifetime SI was the strongest predictor. Future research should continue to identify additional factors that may influence rehospitalization, such as the intensity of post-discharge services.

Using Wearable Physiological Monitors With Suicidal Adolescent Inpatients: Feasibility and Acceptability Study.

BACKGROUND: Wearable physiological monitoring devices enable the continuous measurement of human behavior and psychophysiology in the real world. Although such monitors are promising, their availability does not guarantee that participants will continuously wear and interact with them, especially during times of psychological distress. OBJECTIVE: This study aimed to evaluate the feasibility and acceptability of using a wearable behavioral and physiological monitor, the Empatica E4, to continuously assess a group of suicidal adolescent inpatients. METHODS: Participants (n=50 adolescent inpatients) were asked to wear an Empatica E4 on their wrist for the duration of their inpatient stay. In addition to assessing behavioral metadata (eg, hours worn per day), we also used qualitative interviews and self-report measures to assess participants' experience of wearing the monitor. RESULTS: Results supported the feasibility and acceptability of this approach. Participants wore the monitor for an average of 18 hours a day and reported that despite sometimes finding the monitor uncomfortable, they did not mind wearing it. Many of the participants noted that the part of the study they enjoyed most was contributing to scientific understanding, especially if it could help people similar to them in the future. CONCLUSIONS: These findings provide promising support for using wearable monitors in clinical samples in future studies, especially if participants are invested in being part of a research study.

Relevance of the interpersonal theory of suicide in an adolescent psychiatric inpatient population.

The interpersonal theory of suicide (IPTS) has been widely studied in adults, but not adolescent populations at acute risk for suicide. Accordingly, this study aimed to evaluate IPTS clinical utility in a high-risk sample of suicidal adolescent inpatients. We assessed whether constructs of the IPTS (1) are associated with suicidal thoughts and behaviors (STBs) on admission to a psychiatric hospitalization, and (2) prospectively predict suicide attempt (SA) or psychiatric rehospitalization 90 days after discharge. On admission, adolescent patients self-reported recent STBs, perceived burdensomeness (PB), thwarted belongingness (TB), and depression. Parents reported their child's rehospitalization and suicide attempts 90 days after discharge. Generalized linear regression modelling was used to determine how key constructs of the IPTS are associated with STBs prior to admission and whether they prospectively predict SA or rehospitalization 90 days after discharge. IPTS constructs did not predict rehospitalization or SA within 90 days of discharge. Although PB and TB interacted to associate with prehospitalization SI frequency, and PB, TB and NSSI interacted to associate with prehospitalization SA, the nature of these interactions were not as the IPTS predicts. IPTS constructs are relevant proximal predictors of prehospitalization STB in adolescents, but may operate differently than in adults.

Emergency Department Use Following Pediatric Psychiatric Hospitalization.

OBJECTIVE: Emergency department (ED) use has increased disproportionately for pediatric psychiatric care. This study aimed to identify predictors of ED use within 30 days of discharge from a pediatric psychiatric hospitalization. METHODS: ED use was assessed in the 30 days after discharge. Univariate logistic regression modeling identified predictors of ED use, which were used in subsequent multivariate modeling. RESULTS: Greater number of trauma types (odds ratio [OR]=1.92, 95% confidence interval [CI]=1.50-2.45, z=2.67, p=0.008), generalized anxiety disorder (OR=3.20, 95% CI=1.78-5.76, z=1.98, p=.048), and longer length of stay (OR=1.05, 95% CI=1.03-1.07, z=2.74, p=0.006) were associated with increased ED use within 30 days of discharge. CONCLUSIONS: ED use may be an important marker of negative outcomes within 30 days of discharge from pediatric psychiatric hospitalization. Patients with high trauma exposure, anxiety, and acuity marked by increased length of stay may require additional services to prevent unplanned ED use for psychiatric crises.

Unplanned readmissions to acute care from a pediatric postacute care hospital: incidence, clinical reasons, and predictive factors.

OBJECTIVE: To identify the incidence, clinical reasons, and predictive factors for unplanned readmissions to acute care from a pediatric postacute care hospital. METHODS: A retrospective cohort analysis of all discharges between October 1, 2011, and September 30, 2013 (n=298), in 1 pediatric postacute care hospital was conducted. Descriptive statistics were used to summarize the incidence and assess the clinical reasons for all readmissions to an acute care hospital. Logistic regression was used to identify predictive factors of any unplanned readmission to an acute care hospital. RESULTS: Thirty percent of all postacute care hospital discharges were unplanned readmissions to an acute care hospital. The primary clinical reasons for unplanned readmissions to acute care were respiratory decompensation (54%) and infection (20%). Requiring invasive mechanical ventilation, being <1 year of age, and having a postacute care length of stay<30 days were the 3 predictive factors. CONCLUSIONS: This is the first study to examine readmission to acute care from a postacute care hospital and to identify age, length of stay, and dependence on mechanical ventilation as predictive factors. Understanding which children are likely to require an unplanned readmission may allow providers to develop strategies to minimize this occurrence.

Pediatric post-acute care hospital transitions: an evaluation of current practice.

OBJECTIVES: After discharge from an acute care hospital, some children require ongoing care at a post-acute care hospital. Care transitions occur at both admission to the post-acute care hospital and again at discharge to the home/community. Our objective was to report the current practices used during the admission to and discharge from 7 pediatric post-acute care hospitals in the United States. METHODS: Participants from 7 pediatric post-acute care hospitals completed a survey and rated the frequency of use of 20 practices to prepare and support children and their families during both admission to the hospital and at time of discharge to the home/community. For consistency with existing literature, practices were grouped into 4 previously reported categories: assessment, communication, education, and logistics. Descriptive statistics were used to report the frequency of use within practices and between hospitals. RESULTS: Only 2 of 10 admission practices and 3 of 10 discharge practices were reportedly "always" used by all hospitals. Assessment and communication practices were reported to be more frequently used (57%-100% of the time) than education and logistic procedures. Between hospitals, only the reported frequency of use of the discharge practices was statistically significantly different (P = .03). CONCLUSIONS: Variability exists in transition practices among 7 post-acute care pediatric hospitals. This report is the first known to detail the frequency of use of admission and discharge practices for pediatric post-acute care hospitals in the United States.

Limited (6-h) ambulatory blood pressure monitoring is a valid replacement for the office blood pressure by trained nurse clinician in the diagnosis of hypertension.

OBJECTIVE: To assess the ability of limited ambulatory blood pressure monitoring as a valid replacement for office blood pressure measurement done to American Heart Association criteria in diagnosing hypertension. METHODS: In all, 105 adults, who had been referred for limited ambulatory blood pressure monitoring, participated in the study. Limited ambulatory blood pressure monitoring consisted of 6 h of blood pressure measurement while ambulatory at the Mayo Clinic, using a SpaceLabs 90207 (SpaceLabs Medical, Issaquah, Washington, USA) collecting six readings per hour for the period of observation. The study participants gave consent for three additional consecutive office blood pressure measurements, using a validated aneroid device, done to American Heart Association criteria, by a single hypertension nurse specialist. RESULTS: Mean systolic blood pressure by limited ambulatory blood pressure monitoring was 137.9+/-14.2 mmHg and for the nurse, 137.9+/-20.1 mmHg. Mean diastolic blood pressure by limited ambulatory blood pressure monitoring was 81.5+/-9.7 mmHg and for the nurse, 74.3+/-11.9 mmHg. The intermethod difference for systolic blood pressure was 0.03+/-12.5 mmHg and diastolic blood pressure, -7.2+/-8.0 mmHg. Using <140/90 as criteria factor, limited ambulatory blood pressure monitoring and the trained nurse agreed 77% of the time on whether the patient was hypertensive. This agreement increased to 81% if the participant's referral blood pressure was >or=140/90. CONCLUSIONS: Limited ambulatory blood pressure monitoring is an excellent replacement for office blood pressure, done to American Heart Association criteria, in diagnosing hypertension. This avoids issues of variability introduced by the observers, such as digit preference and bias, and increases reproducibility of blood pressure measurements. The appropriate normal value for limited ambulatory blood pressure monitoring is <140/90 mmHg compared with <135/85 mmHg used in 24-h ambulatory blood pressure monitoring.