Psychiatric mental health nurse practitioners experiencing therapeutic alliance while using tele-mental health: A phenomenological study

BACKGROUND

Psychiatric mental health nurse practitioners have rapidly adopted and implemented tele-mental health in their practice; however it is unclear how this modality of care affects the experiential quality of therapeutic alliance, simply defined as the interpersonal working bond between provider and patient.

OBJECTIVE

This study is the first to explore how psychiatric mental health nurse practitioners experience therapeutic alliance while using tele-mental health.

DESIGN

Husserlian phenomenological qualitative study.

PARTICIPANTS

A purposive, convenience sample of 17 American psychiatric mental health nurse practitioners who engaged in tele-mental health care were recruited online and interviewed.

METHODS

Phenomenological interview transcripts recorded and later thematically coded in the qualitative software MaxQDA.

RESULTS

From 1426 individual codes, five major themes and 16 subthemes were discovered. Overall, themes illuminated that psychiatric mental health nurse practitioners could build therapeutic alliance over tele-mental health using inherent interpersonal skills that had to be adapted to the technology. Adaptions included working with patient environmental factors, individual patient considerations, provider ambivalence, and technological observation shifting awareness and communication patterns.

CONCLUSIONS

When adapting for the tele-mental health environment, psychiatric mental health nurse practitioners experienced building and sustaining therapeutic alliance with most patients. Unparalleled aspects of tele-mental health allowed for a fuller clinical picture and logistical convenience to see patients more often with ease for both the provider and patient. However, experiential aspects of therapeutic alliance created during in-person care could not be replaced with tele-mental health. In conclusion, participants concluded that a hybrid care model would enhance therapeutic alliance for most patients.

Social-Ecological Resilience of Indigenous Adolescents in the United States and Canada: A Situation-Specific Nursing Theory

For the past decade, resilience research with American Indian/Alaska Native and First Nations/Métis/Inuit adolescents has improved our understanding of how adolescents overcome mental health challenges. A new situation-specific theory is presented to guide nurses in applying the evidence to their practice with Indigenous adolescents in the United States and Canada. The social-ecological resilience of indigenous adolescents (SERIA) theory was derived from integrating ( a ) existing social-ecological frameworks by Bronfenbrenner, Ungar, and Burnette and Figley, ( b ) findings from a systematic review of 78 studies about resilience factors for mental health of Indigenous adolescents, ( c ) clinical experience, and ( d ) Indigenous knowledge.

Expanding the Health Belief Model for exploring inpatient fall risk perceptions: A methodology paper

AIMS

Inpatient falls among older adults are a relentless problem, and extant inpatient fall prevention research and interventions lack the older adults' perspectives and experiences of their own fall risk in the hospital. Theory-guided research is essential in nursing, and the purpose of this paper was to describe the process of developing a theoretical framework for a phenomenological nursing study exploring older adults' lived experiences of being at risk for falling in the hospital.

METHOD

Based on philosophical nursing underpinnings, the Health Belief Model (HBM) was selected as the theoretical model. The limitations of the model led to expansion of the model with established concepts associated with accidental falls among older adults.

RESULTS

The HBM was selected as the guiding model due to its ability to capture a broad range of perceptions of a health threat. The HBM was expanded with the concepts of embarrassment, independence, fear of falling, dignity and positivity effect. The addition of these concepts made the theoretical framework more applicable to age-related developmental behaviours of older adult and more applicable to nursing research.

CONCLUSION

The Expanded HBM theoretical framework may guide future nursing research to develop fall prevention interventions to decrease fall rates among hospitalized older adults.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Understanding the resilience of children living on an American Indian reservation: A mixed methods participatory study

AIM

To explore the resilience of children, six to thirteen years old, living on a Northern Plains American Indian Reservation using a situation specific nursing theory.

BACKGROUND

American Indian and Alaska Native children experience mental health inequities compared to their white peers, including substance use, suicide, depression, and anxiety. Resilience is a strength of children that can be leveraged to improve their mental health.

DESIGN

A parallel convergent mixed methods design.

METHODS

A community advisory board culturally adapted resilience instruments. During two weeks in summer 2022, forty-seven children/caregiver dyads completed surveys about the child's resilience. Descriptive statistics gave the scores of each child's personal, relational, and total resilience. A subset of 20 children participated in a semi-structured interview.

RESULTS

Children scored high on overall resilience, and higher on the relational subscale than the personal subscale. Caregiver survey scores were not significantly correlated with their child's scores and were higher than the children's scores. Qualitative coding revealed six themes of resilience. Integration of data showed a concordance and expansion of the quantitative data across themes.

CONCLUSION

The children reported high resilience supported by a strong ecosystem of relationships. Resilience, as explained through children's voices, corroborated with findings from the surveys.

IMPLICATIONS FOR NURSING

Findings will help nurses across sectors of primary, secondary, and tertiary care create resilience-enhancing interventions and prevent mental health crises in this community.

IMPACT STATEMENT

This findings from this study will inform local mental health interventions on the Reservation. The study provides a reproducible design to adapt to other Indigenous communities.

PUBLIC CONTRIBUTION

A community advisory board was a partner in every stage of the study. Children and caregivers participated in data collection.

CONTRIBUTION TO THE WIDER CLINICAL COMMUNITY

This research provides knowledge that will further social justice efforts within nursing to promote health equity across diverse populations.

Relying on Myself: The Lived Experience of Being at Risk for Falling in the Hospital Among Older Adults

Inpatient falls are a persistent problem and despite research efforts during the last decade, inpatient fall rates have not significantly decreased. Older adults have an estimated 50% greater inpatient fall rate than younger adults. How older adults perceive their own fall risk affects their adherence to fall prevention recommendations. The aim of this phenomenological study was to gain a deeper understanding of the lived experiences of being at risk for falling in the hospital among older adults aged 65 years and older (N=9). Participants (female=55%, age range=67 – 86) were interviewed twice using video conferencing within two weeks of hospital discharge. The audio-recorded interviews were transcribed, and then analyzed using van Manen’s interpretive phenomenological method. The Health Belief Model expanded with the concepts of independence, fear of falling, embarrassment, dignity, and positivity effect served as the theoretical framework. Five major interpretive themes emerged: Relying on Myself, Managing Balance Problems in an Unfamiliar Environment, Struggling to Maintain Identity, Following the Hospital Rules, and Maintaining Dignity in the Relationships with Nursing Staff. These themes describe how the participants thoughtfully planned their mobilization to avoid falls. This process was influenced by their struggling to remain independent, following the hospital fall prevention rules out of politeness, and experiencing both positive and negative relationships with nursing staff. Hospitalized older adults employed their self-efficacy to manage balance problems in the hospital. These findings have not been previously documented in the literature. Fall prevention interventions supporting hospitalized older adults’ self-management of fall risk are needed.

Barriers and facilitators for adopting a healthy lifestyle among Latina cancer survivors: A qualitative descriptive study

PURPOSE

Cancer is the leading cause of death among Hispanics/Latinos in the USA. Latina cancer survivors experience higher symptom burden than other cancer survivors. A healthy lifestyle can decrease recurrent cancer risk, increase well-being, and may decrease symptom burden in cancer survivors. The purpose of this study was to explore the barriers and facilitators for adopting healthy lifestyle behaviors among Latina cancer survivors.

METHODS

Using the Health Belief Model as the theoretical framework, qualitative descriptive methodology was used for secondary analysis of data from a previously conducted randomized clinical trial. Transcripts from the telephone health coaching calls, analyzed in the original language (English or Spanish), were used for this qualitative analysis.

RESULTS

Intervention telephone call transcript data from Latina cancer survivors (n = 14) were analyzed. Major themes were as follows: Perceived susceptibility to other chronic illnesses, perceived benefits of a healthy lifestyle, and perceived barriers and facilitators of adopting a healthy lifestyle. Lack of knowledge about healthy lifestyle behaviors could prevent participants from adopting a healthy lifestyle; gaining new knowledge about healthy lifestyle behaviors was a facilitator for changing lifestyle. Family responsibility and wearable technology could both prevent and motivate the participants to adopt a healthy lifestyle.

CONCLUSION

Developing culturally appropriate interventions for Latina cancer survivors is vital to decrease symptom burden and health risks, as well as improve health outcomes in this population.

Older adults' perceptions of their fall risk in the hospital: An integrative review

AIMS AND OBJECTIVES

The objectives of this review are to determine what is currently known about older adults' perceptions of their own fall risk in the hospital and associated factors and explore how perceived fall risk in the hospital is assessed.

BACKGROUND

Every year, up to one million patients suffer an accidental fall in the hospital. Despite research efforts during the last decade, inpatient fall rates have not significantly decreased, and about one third of inpatient falls result in injuries. Limited evidence suggests that assessing hospitalised patients' perceptions of their fall risk and engaging them in their own fall prevention can reduce inpatient falls.

DESIGN

An integrative review.

METHODS

An electronic literature search was conducted in the Cumulative Index of Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, Embase, Google Scholar, OpenGrey, ProQuest Dissertations & Theses Global, PsycINFO and PubMed. Data extraction and quality assessments were independently performed by two reviewers. PRISMA guidelines were followed for reporting this review.

RESULTS

Twenty-two studies met the inclusion criteria. The findings suggest that hospitalised older adults inadequately estimate their own fall risk. Most participants did not perceive themselves as at risk for falling in the hospital. Educational and motivational interventions can change the patients' perceptions of their own fall risk in the hospital and engage them in fall prevention. The desire to remain independent and feeling vulnerable were associated with fall risk, and the relationship with nursing staff may affect how hospitalised patients perceive their own fall risk.

CONCLUSIONS

Hospitalised adults, and specifically older adults, do not adequately estimate their own fall risk. Factors associated with these perceptions must be further explored to develop assessment tools and interventions to decrease inpatient fall rates.

RELEVANCE TO CLINICAL PRACTICE

Nurses' understanding and assessment of hospitalised adults' perception of their own fall risk is important to consider for reducing inpatient falls.

Changes in symptoms, sleep, oxidative stress, and inflammatory markers among community-dwelling stroke survivors after a tai chi exercise intervention

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Laurence B. Emmons Research Award

Background

Depression is prevalent among one-third to two-thirds of stroke survivors. Despite the availability of pharmacotherapies and/or psychotherapies, depression persists, even 5-10 years post-stroke, reflecting limited treatment responses and/or adherence to this conventional care. Mind-body interventions are commonly used among adults to ameliorate depressive symptoms, thus we investigated the feasibility of Tai Chi, alongside conventional care, to manage post-stroke depression.

Purpose

Describe changes in symptoms of depression, anxiety and stress, sleep, oxidative stress, and inflammatory markers post-intervention among community-dwelling stroke survivors with depressive symptoms.

Methods

In this feasibility study, a single-group pre-post intervention design was used. Due to COVID-19, participants attended a 1-hour Tai Chi exercise class three times per week for 8 weeks, instead of the planned 12-weeks. Symptoms of depression, anxiety and stress were assessed using standardized questionnaires (Center for Epidemiological Studies Depression scale, CESD; Generalized Anxiety Disorder Assessment; Perceived Stress Scale), objective sleep was assessed via a research-grade triaxial accelerometer (ActiGraph GT9X), and blood samples were taken to assess oxidative stress (plasma superoxide dismutase, SOD)  and inflammatory markers (serum tumor necrosis factor-alpha, interleukin-6, interleukin-10). Pre-post intervention changes were assessed using paired t-tests.

Results

Community-dwelling stroke survivors (N = 11) on average 69.7 ± 9.3 years old, mainly retired (73%, n = 8), married men (55%, n = 6) with >13 years education (91%, n = 10), reporting depression symptoms (CESD = 17.3 ± 11.4) and 55% taking anti-depressant medications, enrolled. The majority of participants reported having an ischemic stroke (82%, n = 9) with hemiparesis (55%, n = 6), but were able to walk 15 feet without assistance (91%, n = 10). After the Tai Chi intervention, we observed significant reductions in symptoms of depression (-5.3 ± 5.9, p = 0.01), anxiety (-2.2 ± 2.4, p = 0.01) and stress (-4.6 ± 4.8, p = 0.01); along with better sleep efficiency (+1.8 ± 1.8, p = 0.01), less wakefulness after sleep onset (-9.3 ± 11.6, p = 0.04), and less time awake (-9.3 ± 11.6, p = 0.04). In addition, there was a 36% decrease in SOD activity (p = 0.02) indicative of a decreased oxidative environment post-intervention; though no significant changes in any of the inflammatory markers were found (all p-values >0.05).

Conclusion

Symptoms of depression, anxiety and stress were observed in these community-dwelling stroke survivors along with sub-optimal sleep. Among community-dwelling stroke survivors, Tai Chi exercise is a feasible intervention that can be used alongside conventional care to manage post-stroke depression and may also aid in reducing symptoms of anxiety and stress, and improve sleep.  Further research is needed with rigorous study designs and larger samples, before widespread recommendations can be made.

Stroke survivors personal efficacy beliefs and outcomes expectations of tai chi exercise: a qualitative descriptive study

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Laurence B. Emmons Research Award

Background

Strokes are a leading cause of serious long-term disability, often compounded by post-stroke depression. Prior Tai Chi research conducted among stroke survivors has focused mainly on physical functioning yet understanding the potential benefits and challenges of participating in Tai Chi exercise during stroke recovery is limited. Social Cognitive Theory and Complex Systems Biology provided the theoretical framework to examine stroke survivors’ personal efficacy beliefs, behaviour (Tai Chi intervention), and outcome expectations (Figure 1).

Purpose

To describe community-dwelling stroke survivors’ experiences of being in an 8-week Tai Chi intervention, including any benefits or challenges they had, and allow the participants to offer any suggestions for improving how the Tai Chi classes were structured.

Methods

A qualitative descriptive approach was used, with focus group interview data collected from stroke survivors after participation in a Tai Chi intervention. Due to COVID-19, the focus group interview was conducted via on-line video conferencing. The interview was audio-recorded, then transcribed using an online transcription service. Content analysis of the de-identified transcript was conducted using online analysis software with a priori codes based on the theoretical framework, and inductive codes that were added during the analysis process. The transcript was coded independently by two researchers and discussed until consensus was reached. Lincoln and Guba’s criteria were followed to ensure trustworthiness of the data.

Results

Community-dwelling stroke survivors (n = 7) participating in the focus group interviews were on average 68 years old, mainly retired (71%, n = 5), married women (57%, n = 4) with >13 years education (86%, n = 6), reporting depression symptoms (Center for Epidemiological Studies-Depression = 15.9 ± 9.6) with 43% (n = 3) taking anti-depressant medications. The major findings are summarized according to three major themes: Personal Efficacy Beliefs, Tai Chi Intervention Active Ingredients and Outcome Expectations. Personal Efficacy Beliefs centered on the participants’ ability to do the Tai Chi movements. The Tai Chi Intervention Active Ingredients experienced during the classes were evident, apart from ‘natural freer breathing’ which was not discussed or described. Outcome Expectations centered on the physical, mental, and social benefits experienced, challenges encountered, and suggestions for improving the Tai Chi classes.

Conclusion

Social Cognitive Theory underscored stroke survivors’ personal efficacy beliefs, behaviour, and outcome expectations. While Complex Systems Biology highlighted the active ingredients of Tai Chi intervention they experienced. Participation in the 8-week Tai Chi intervention led to perceived holistic (physical, mental, social) benefits post-stroke.

National Internet-Based Survey of the Use, Barriers, Reasons and Beliefs of Mind-Body Practices During the Early Months of the COVID-19 Pandemic

The purpose of this study was to learn about the use, barriers, reasons and beliefs regarding mind-body practices among adults living in the United States during the beginning months of the 2019 novel coronavirus disease (COVID-19) pandemic. An on-line survey was developed following the Checklist for Reporting Results of Internet e-Surveys (CHERRIES) guidelines and using the online survey software program, Qualtrics_®^XM, platform. Pilot testing of the survey was conducted for usability and functionality. The final 24-item survey was distributed via email and social media. A total of 338 adults responded to the survey, with 68.8% indicating that they participated in mind-body activities since the start of the pandemic. Physical activity was the most frequently (61.5%, n = 227) used mind-body practice. Further, 2 of the common barriers to engaging in mind-body practices were lack of motivation and wandering mind. Frequently listed reasons for using mind-body practices were to promote health, reduce stress and relaxation. Respondents believed that mind-body practices resulted in less stress. These findings may be applicable for reducing psychological stress related to the pandemic, as the pandemic continues to impact many areas of the United States.

Embarrassment experienced by older adults in relation to accidental falls: A concept analysis

Embarrassment is commonly felt by older adults experiencing a fall, and embarrassment may cause older adults to adopt maladaptive behaviors by not implementing fall prevention strategies. Clarifying the concept of embarrassment for nursing and defining the concept as it relates to accidental falls and fall prevention among older adults was conducted using Walker and Avant's eight-step concept analysis process. The proposed definition of embarrassment experienced by older adults in relation to accidental falls is: The feeling of physical discomfort and exposure in a social situation due to the loss of control and self-esteem, as well as the inconsistency between one's personal identity as an independent and dignified person and the accidental fall or near fall behavior that threatens independence and dignity leading to emotional distress. Nurses recognizing older adults' potential fall-related embarrassment may increase older adults' adherence to fall prevention strategies and improve health outcomes.

Wearable sensor-based in-home assessment of gait, balance, and physical activity for discrimination of frailty status: baseline results of the Arizona frailty cohort study

BACKGROUND

Frailty is a geriatric syndrome resulting from age-related cumulative decline across multiple physiologic systems, impaired homeostatic reserve, and reduced capacity to resist stress. Based on recent estimates, 10% of community-dwelling older individuals are frail and another 41.6% are prefrail. Frail elders account for the highest health care costs in industrialized nations. Impaired physical function is a major indicator of frailty, and functional performance tests are useful for the identification of frailty. Objective instrumented assessments of physical functioning that are feasible for home frailty screening have not been adequately developed.

OBJECTIVE

To examine the ability of wearable sensor-based in-home assessment of gait, balance, and physical activity (PA) to discriminate between frailty levels (nonfrail, prefrail, and frail).

METHODS

In an observational cross-sectional study, in-home visits were completed in 125 older adults (nonfrail: n=44, prefrail: n=60, frail: n=21) living in Tucson, Ariz., USA, between September 2012 and November 2013. Temporal-spatial gait parameters (speed, stride length, stride time, double support, and variability of stride velocity), postural balance (sway of hip, ankle, and center of mass), and PA (percentage of walking, standing, sitting, and lying; mean duration and variability of single walking, standing, sitting, and lying bouts) were measured in the participant's home using validated wearable sensor technology. Logistic regression was used to assess the most sensitive gait, balance, and PA variables for identifying prefrail participants (vs. nonfrail). Multinomial logistic regression was used to identify variables sensitive to discriminate between three frailty levels.

RESULTS

Gait speed (area under the curve, AUC=0.802), hip sway (AUC=0.734), and steps/day (AUC=0.736) were the most sensitive parameters for the identification of prefrailty. Multinomial regression revealed that stride length (AUC=0.857) and double support (AUC=0.841) were the most sensitive gait parameters for discriminating between three frailty levels. Interestingly, walking bout duration variability was the most sensitive PA parameter for discriminating between three frailty levels (AUC=0.818). No balance parameter discriminated between three frailty levels.

CONCLUSION

Our results indicate that unique parameters derived from objective assessment of gait, balance, and PA are sensitive for the identification of prefrailty and the classification of a subject's frailty level. The present findings highlight the potential of wearable sensor technology for in-home assessment of frailty status.

Wearable sensor-based in-home assessment of gait, balance, and physical activity for discrimination of frailty status: baseline results of the Arizona frailty cohort study

BACKGROUND

Frailty is a geriatric syndrome resulting from age-related cumulative decline across multiple physiologic systems, impaired homeostatic reserve, and reduced capacity to resist stress. Based on recent estimates, 10% of community-dwelling older individuals are frail and another 41.6% are prefrail. Frail elders account for the highest health care costs in industrialized nations. Impaired physical function is a major indicator of frailty, and functional performance tests are useful for the identification of frailty. Objective instrumented assessments of physical functioning that are feasible for home frailty screening have not been adequately developed.

OBJECTIVE

To examine the ability of wearable sensor-based in-home assessment of gait, balance, and physical activity (PA) to discriminate between frailty levels (nonfrail, prefrail, and frail).

METHODS

In an observational cross-sectional study, in-home visits were completed in 125 older adults (nonfrail: n=44, prefrail: n=60, frail: n=21) living in Tucson, Ariz., USA, between September 2012 and November 2013. Temporal-spatial gait parameters (speed, stride length, stride time, double support, and variability of stride velocity), postural balance (sway of hip, ankle, and center of mass), and PA (percentage of walking, standing, sitting, and lying; mean duration and variability of single walking, standing, sitting, and lying bouts) were measured in the participant's home using validated wearable sensor technology. Logistic regression was used to assess the most sensitive gait, balance, and PA variables for identifying prefrail participants (vs. nonfrail). Multinomial logistic regression was used to identify variables sensitive to discriminate between three frailty levels.

RESULTS

Gait speed (area under the curve, AUC=0.802), hip sway (AUC=0.734), and steps/day (AUC=0.736) were the most sensitive parameters for the identification of prefrailty. Multinomial regression revealed that stride length (AUC=0.857) and double support (AUC=0.841) were the most sensitive gait parameters for discriminating between three frailty levels. Interestingly, walking bout duration variability was the most sensitive PA parameter for discriminating between three frailty levels (AUC=0.818). No balance parameter discriminated between three frailty levels.

CONCLUSION

Our results indicate that unique parameters derived from objective assessment of gait, balance, and PA are sensitive for the identification of prefrailty and the classification of a subject's frailty level. The present findings highlight the potential of wearable sensor technology for in-home assessment of frailty status.