Well-Being Domains in U.S. Military Veterans: Identifying Modifiable Factors to Promote Whole Health

The U.S. Department of Veterans Affairs is actively transitioning away from a disease-centric model of healthcare to one that prioritizes disease prevention and the promotion of overall health and well-being. Described as Whole Health, this initiative aims to provide personalized, values-centered care that optimizes physical, behavioral, spiritual, and socioeconomic well-being. To inform this initiative, we analyzed cross-sectional data from a nationally representative sample of primarily older U.S. military veterans to estimate levels of well-being across these domains, and identify sociodemographic, military, and potentially modifiable health and psychosocial correlates of them. Results revealed that, overall, veterans reported high domain-specific well-being (average scores ranging from 6.7 to 8.3 out of 10), with the highest levels in the socioeconomic domain and lowest in the physical domain. Several modifiable factors, including purpose in life, resilience, and social support, were strongly associated with the examined well-being domains. Interventions targeting these constructs may help promote well-being among U.S. veterans.

Hope during somber times: a defining moment

In addition to the diverse educational materials the National Cancer Institute provides to patients, caregivers, and health-care professionals, the NCI maintains an online dictionary that provides concise definitions of terms used in modern oncology. The dictionary is regarded as a valuable data reserve because it is updated frequently and employs language that facilitates comprehension among lay users and professionals alike. In this commentary, we call attention to the absence of the word hope as an entry in this important digital resource. Moreover, we propose not only including the concept of hope in this vital reference text but also basing its meaning on C. R. Snyder's model of "hope theory," which stresses the importance of 3 entities: goals, pathways thinking, and agency. Finally, we argue that hope can be taught as a skill to relevant stakeholders (eg, patients, caregivers, and health-care professionals) through brief workshops that have recently been expanded from in-person encounters to virtual platforms revolving around a user-friendly mobile app called "Hopetimize."

The Ethics of Hope-A Moral Imperative for Oncologists

This Viewpoint suggests that giving patients with terminal cancer unrealistic hope based only on cure is ethically inferior to redirecting patients toward noncurative goals and noncancer-related hope.

Feeling hopeful: development and validation of the trait emotion hope scale

While prominent measures of hope are largely cognitive in nature, many scholars and laypeople view hope primarily as an emotion. Although Snyder's Elaborated Hope Theory attempts to theoretically balance these two perspectives, no measure yet exists of hope as a purely emotional process, only as a cognitive process. Overlooking the emotional features of hope limits our ability to more fully and precisely understand this construct. As such, across three studies (N = 2,900), we develop and validate the Trait Emotion Hope Scale (TEHS). In Study 1, we report on item development and piloting of the TEHS, examining internal consistency as well as convergent and discriminant validity. Study 2 includes an exploratory factor analysis (EFA) and further examines internal consistency and construct validity. Finally, in Study 3 we report a confirmatory factor analysis (CFA) to cross-validate the factor structure identified in Study 2 in a large, international sample. Importantly, we find that the TEHS accounts for significant unique variance beyond cognitive hope, indicating that the two constructs are distinct and not redundant. Taken together, these three studies demonstrate that the TEHS is psychometrically sound and provides a valid measure for those interested in examining hope as an emotion in their research.

Purpose in life protects against the development of suicidal thoughts and behaviors in U.S. veterans without a history of suicidality: A 10-year, nationally representative, longitudinal study

OBJECTIVES

To determine the incidence of suicidal ideation and suicide attempts (STBs) in veterans without an endorsed history of STBs and identify baseline predictors of these outcomes over a 10-year period.

METHODS

Population-based prospective cohort study of 2307 US military veterans using five waves of the 2011-2021 National Health and Resilience in Veterans Study. Baseline data were collected in 2011, with follow-up assessments conducted 2-(2013), 4-(2015), 7-(2018), and 10-years (2021) later.

RESULTS

In total, 10.1 % (N = 203) of veterans endorsed incident suicidal ideation (SI) over the 10-year period and 3.0 % (N = 55) endorsed an incident suicide attempt (SA). Multivariable regression analyses revealed the following baseline predictors of incident SI: lower annual household income, current posttraumatic stress disorder, current alcohol use disorder (AUD), disability with activities of daily living (i.e., ADLs) or instrumental activities of daily living (i.e., IADLs), lower perceived social support, lower community integration, and lower purpose in life. Current AUD, greater cumulative trauma burden, and lower purpose in life at baseline were predictive of incident SA. Relative importance analyses revealed that lower purpose in life was the strongest predictor of both incident SI and SA.

CONCLUSIONS

Psychosocial determinants of health, such as purpose in life, may be more reliable predictors of incident suicidal thoughts and behaviors than traditional risk factors (e.g., psychiatric distress; history of SA) in those without a history of STBs. Evidence-based interventions that facilitate purpose in life and feelings of connectedness and belonging should be examined as possible treatments for STBs.

Identifying significant correlates of purpose in life in older US military veterans: results from the national health and resilience in veterans study

OBJECTIVE

Perceived purpose in life (PIL) has been linked to a broad range of adverse physical, mental, and cognitive outcomes. However, limited research has examined factors associated with PIL that can be targeted in prevention and treatment efforts in aging populations at heightened risk of adverse outcomes. Using data from predominantly older US veterans, we sought to identify important correlates of PIL.

METHODS

Cross-sectional data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 4069 US military veterans (Mage = 62.2). Elastic net and relative importance analyses were conducted to evaluate sociodemographic, military, health, and psychosocial variables that were strongly associated with PIL.

RESULTS

Of the 39 variables entered into an elastic net analysis, 10 were identified as significant correlates of PIL. In order of magnitude, these were resilience (18.7% relative variance explained [RVE]), optimism (12.1%), depressive symptoms (11.3%), community integration (10.7%), gratitude (10.2%), loneliness (9.8%), received social support (8.6%), conscientiousness (8.5%), openness to experience (5.4%), and intrinsic religiosity (4.7%).

CONCLUSIONS

Several modifiable psychosocial factors emerged as significant correlates of PIL in US military veterans. Interventions designed to target these factors may help increase PIL and mitigate risk for adverse health outcomes in this population.

Suicidal Thoughts and Behaviors in Older U.S. Military Veterans: Results From the National Health and Resilience in Veterans Study

OBJECTIVE

To identify the prevalence and correlates associated with suicidal thoughts and behaviors (STBs) in a nationally representative sample of older (55+) US military veterans.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study (N = 3,356; mean age = 70.6). Self-report measures of past-year suicidal ideation (SI), lifetime suicide plan, lifetime suicide attempt(s), and future suicide intent were examined in relation to sociodemographic, neuropsychiatric, trauma, physical health, and protective factors.

RESULTS

A total of 6.6% (95% CI = 5.7%-7.8%) of the sample endorsed past-year SI, 4.1% (CI = 3.3%-5.1%) a lifetime suicide plan, 1.8% (CI = 1.4%-2.3%) a lifetime suicide attempt, and 0.9% (CI = 0.5%-1.3%) future suicide intent. Higher levels of loneliness and lower levels of purpose in life were most strongly associated with past-year SI; lifetime history of major depressive disorder with suicide plan and suicide attempt; and frequency of past-year SI and more negative expectations regarding emotional aging with future suicide intent.

CONCLUSION

These findings provide the most up-to-date nationally representative prevalence estimates of STBs among older military veterans in the United States. Several modifiable vulnerability factors were found to be associated with suicide risk in older US military veterans, suggesting that these factors may be targets for intervention in this population.

The Relationships of Hope, Optimism, and Academic Motivation With GPA Among University Students in Hong Kong

Research demonstrates the relationship between dispositional hope and GPA, but mixed results regarding the relationship between dispositional optimism and GPA. Hope and optimism also have been shown to predict academic motivation. However, no study has yet investigated all of these factors together, and most research concerns only Western samples. In a cross-sectional sample of 129 Hong Kong university students, we administered measures of internal hope (hope regarding one's own capabilities), external-family hope (hope derived from family), optimism, and intrinsic and extrinsic academic motivation. We found significant zero-order correlations between internal hope and GPA, but not between external-family hope nor optimism and GPA. Mediation analyses showed that internal hope directly related to GPA, and did not appear mediated by academic motivation. Given our findings, future studies testing hope-based interventions in similar samples may be warranted. We discuss implications for culturally adapting hope interventions.

Feasibility and acceptability of an online intervention to enhance hopefulness among oncology professionals

BACKGROUND

Patients prefer medical communication including both hopefulness and realism, though health-care professional (HCPs) struggle to balance these. Providers could thus benefit from a detailed personal understanding of hope, allowing them to model and convey it to patients. Additionally, given that hope is associated with lower levels of burnout, HCPs may benefit from tools designed to enhance their own personal hopefulness. Several investigators have proposed offering HCPs interventions to augment hope. We developed an online workshop for this purpose.

METHODS

Feasibility and acceptability of the workshop were assessed in members of the SWOG Cancer Research Network. Three measures were used: the Was-It-Worth-It scale, a survey based on the Kirkpatrick Training Evaluation Model, and a single item prompting participants to rate the degree to which they believe concepts from the workshop should be integrated into SWOG studies.

RESULTS

Twenty-nine individuals signed up for the intervention, which consisted of a single 2-hour session, and 23 completed measures. Results from Was-It-Worth-It items indicate that nearly all participants found the intervention relevant, engaging, and helpful. Mean ratings for Kirkpatrick Training Evaluation Model items were high, ranging from 6.91 to 7.70 on 8-point scales. Finally, participants provided a mean rating of 4.44 on a 5-point scale to the item "To what degree do you believe it may be useful to integrate concepts from this workshop into SWOG trials/studies?"

CONCLUSIONS

An online workshop to enhance hopefulness is feasible and acceptable to oncology HCPs. The tool will be integrated into SWOG studies evaluating provider and patient well-being.

Purpose in life and physical health in older U.S. military veterans: Cross-sectional results from the National Health and Resilience in Veterans Study

General population studies suggest purpose in life (PIL) is associated with a number of positive outcomes, including better mental and physical health. At present, however, scarce research has examined how PIL relates to these outcomes in veterans. The goal of this study was to determine the current prevalence of different levels of PIL and their associations with reported physical health in a nationally representative sample of predominantly older U.S. veterans. Cross-sectional data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study (N = 4069; M_(age) = 62.2). Veterans were classified into low, average, and high PIL. Self-report assessments were administered to assess physical health conditions and physical functioning. Results showed most veterans endorsed average PIL (71.7%), while 16.0% endorsed low PIL and 12.3% endorsed high PIL. Low PIL was associated with lower overall self-reported health and physical and cognitive functioning, as well as higher bodily pain, somatic symptoms, and physical role limitations (Cohen's d = 0.06-0.77). Low PIL was also associated with elevated rates of several physical health conditions, including sleep disorders, as well as obesity and disability with activities of daily living (i.e., ADLs) or instrumental activities of daily living (i.e., IADLs). These results suggest low PIL is associated with physical health difficulties, and underscore the importance of assessing and monitoring PIL, and evaluating whether interventions to promote PIL may help improve physical health and vice versa.

Hope and cancer

Two models of hope have predominated in the literature pertaining to cancer-Snyder's "Hope Theory" and Herth's hope model-both of which have produced brief self-report measures. Growing evidence demonstrates that hope, as operationalized in these models, is associated with a number of psychological variables in individuals with cancer, including depression, distress, coping, symptom burden, and posttraumatic growth. Emerging evidence also suggests that hope may predict probability of survival in advanced cancer. Surveys show that patients and families generally prefer healthcare communication that authentically conveys prognosis; such communication is not associated with decreased hope, but may actually foster hope. Finally, several interventions have been developed to enhance hope in people with cancer, which generally demonstrate medium effects.

Development of a measure of clinicians' self-efficacy for medical communication (SEMC)

OBJECTIVES

Studies of clinician-patient communication have used varied, ad hoc measures for communication efficacy. We developed and validated the Self-Efficacy for Medical Communication (SEMC) scale as a standard, quantitative measure of clinician-reported skills in communicating difficult news.

METHODS

Using evidence-based scale development guidelines, we created two 16-item forms of the SEMC, one assessing communication with patients and one assessing communication with families. Clinicians providing oncological care in four organisations were invited to participate and provided consent. Participant demographics, responses to the SEMC items and responses to convergent and discriminant measures (those expected to relate strongly and weakly to the SEMC) were collected online. We performed analyses to determine the convergent and discriminant validity of the SEMC as well as its reliability and factor structure.

RESULTS

Overall, 221 oncology clinicians (including physicians, residents, fellows, medical students, nurses, nurse practitioners and physician assistants) participated. The patient and family forms both demonstrated high internal consistency reliability (alpha=0.94 and 0.96, respectively) and were strongly correlated with one another (r=0.95, p<0.001). Exploratory factor analysis demonstrated that the SEMC measures a unitary construct (eigenvalue=9.0), and its higher mean correlation with convergent (r=0.46) than discriminant (r=0.22) measures further supported its validity.

CONCLUSIONS

Our findings support the SEMC's validity and reliability as a measure of clinician-rated communication skills regarding conducting difficult conversations with patients and families. It provides a useful standard tool for future research in oncology provider-patient serious illness communication.

Dispositional hope as a potential outcome parameter among patients with advanced malignancy: An analysis of the ENABLE database

BACKGROUND

Hopefulness, whether inherently present (dispositional hope) or augmented (by enhancement techniques), may affect outcomes. This study was performed to determine the association of dispositional hope with survival among patients diagnosed with advanced cancer.

METHODS

Data from ENABLE (Educate, Nurture, Advise, Before Life Ends), a palliative care intervention, were reanalyzed to determine the association of higher dispositional hope and patient survival. This was a secondary analysis of data combined from the ENABLE II and ENABLE III randomized controlled trials (RCTs) with respect to dispositional hope and survival. A dispositional hope index was created from 3 hope items from 2 validated baseline questionnaires. Dispositional hope and survival data were collected during the 2 RCTs. In ENABLE II, participants were randomly assigned to the ENABLE intervention or to usual care. In ENABLE III, participants were randomly assigned to receive the intervention immediately or 12 weeks after enrollment.

RESULTS

In all, 529 persons were included in Cox proportional hazards regression analyses to model the effects of dispositional hope on survival. An initial analysis without covariates yielded a significant effect of hope (Wald statistic, 8.649; hazard ratio, 0.941; confidence interval, 0.904-0.980; P = .003), such that higher dispositional hope was associated with longer survival. In a subsequent analysis that included all covariates, the effect of dispositional hope approached statistical significance (Wald statistic, 2.96; hazard ratio, 0.933; confidence interval, 0.863-1.010; P = .085).

CONCLUSIONS

Higher levels of dispositional hope were associated with longer survival in patients with advanced cancer. Prospective trials are needed to determine the effects of dispositional and augmented hope on the outcomes of patients with advanced cancer.

Hope-enhancement workshops in the SWOG Cancer Research Network: Feasibility of an online intervention

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Background: Research shows that healthcare professionals’ personal hopefulness is associated with burnout and life satisfaction, highlighting the value of hope-enhancement interventions. Feldman and Dreher developed a single-session hope intervention, but this has been used rarely with oncology professionals, and only in in-person format (Shah, Ferguson, Corn et al.). Given SWOG Cancer Research Network’s commitment to assessing hope-enhancement approaches and the need for online interventions given COVID-19, we report a feasibility study of a virtual hope workshop in SWOG members. Methods: The workshop was a single 2-hour session delivered live via Zoom to 6-8 participants at a time. The workshop comprises 3 components: A brief lecture on hope and two exercises—a “hope mapping” exercise (aided by a smartphone app created for the workshop) and a hope visualization exercise—both designed to build hope for a life goal of each participant’s choosing. 29 SWOG members participated. A link to post-workshop measures was sent to participants, which they were given a week to complete. Measures included Thanarajasingamet al’s 5-item Was-it-Worth-it (WIWI) measure; Kirkpatrick’s 4-item Training Evaluation Model (TEM; reaction, learning, behavior, results); and an item assessing the degree to which participants believe concepts from the workshop should be integrated into SWOG studies. Results: In all, 25 participants (86%) completed measures. Participants were physicians (n = 8), nurses (n = 4), patient advocates (n = 3), research staff (n = 3), and others (n = 7); mostly female (n = 17), mostly white (n = 18), with a mean age of 55.5 (SD = 13.95). Results for the WIWI items are as follows: “Was it worthwhile to participate in the Hope Workshop?” (23 Yes, 2 No/Undecided/Missing Answer); “If you had to do over, would you participate in the Hope Workshop again?” (22 Yes, 3 No/Undecided/Missing Answer); “Would you recommend participating in the Hope Workshop to others?” (22 Yes, 3 No/Undecided/Missing Answer). Two additional items on the WIWI asked participants to rate on a 3-point scale the degree to which they believe their quality of life had increased due to the workshop (M = 2.52, SD =.51) and their overall experience in the workshop (M = 2.70, SD =.64). Ratings for Kirkpatrick’s TEM items likewise were high, ranging from 6.91 (SD = 1.31) to 7.70 (SD =.70) on an 8-point scale. Finally, participants gave a mean rating of 4.44 (SD =.59) on a 5-point scale to the item “To what degree do you believe it may be useful to integrate concepts from this workshop into SWOG trials/studies?” Conclusions: It is feasible to implement hope-enhancement workshops in an online platform that includes a smartphone app. Data obtained from two validated tools (WIWI instrument and Kirkpatrick’s TEM) attest to an array of positive outcomes. Participants also overwhelmingly advocated integrating hope concepts into SWOG’s research.

Development and validation of the self-efficacy for medical communication scale

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Background: Most studies of clinician-patient communication use scales created ad hoc with unknown validity. To provide a standard measure for future studies, we developed and validated a new scale of clinician-reported skills in communicating difficult news: the Self-Efficacy for Medical Communication (SEMC) scale. Methods: Using evidence-based scale development guidelines, we created 16 items sampling a range of communication skills, including “Disclose difficult news in manageable chunks, so the patient is not overwhelmed,” and “Determine how to present information based on the patient’s emotional state.” Items are rated on Likert scales from 1 ( cannot do at all) to 10 ( highly certain can do). We constructed two forms—one assessing communication with patients and one with family—using identical items but replacing “patient” with “family/caregiver.” We examined the convergent and discriminant validity of the SEMC (correlations with similar and dissimilar measures) as well as its reliability and factor structure. A total of 221 clinicians working in oncology settings (physicians, nurses, medical students) completed measures online. Convergent measures included medical communication items from past studies; the Self-Perceived Communication Competence Scale to measure communication ability outside the medical realm; and the General Self-Efficacy and Occupational Self-Efficacy scales to measure overall self-efficacy/confidence. Discriminant measures included the Ten Item Personality Inventory to measure personality factors; the Maslach Burnout Inventory to measure job burnout; and the Satisfaction with Life Scale to measure well-being. Finally, the Marlowe-Crowne Social Desirability (MCSD) scale measured motivation to “look good” in responding to survey questions. Results: Mean scores were similar for the patient (126.36) and family (127.09) forms (max score 160), both with excellent reliability ( alphas =.94,.96, respectively). Because these forms were almost perfectly correlated ( r =.95, p <.001), we used only the patient form in subsequent analyses. Factor analysis demonstrated that the SEMC measures a unitary construct ( eigenvalue = 9.0). Its mean correlation was higher with convergent ( r =.46) than discriminant measures ( r =.22), supporting its validity. Moreover, its correlation with the MCSD was small ( r =.28) and no larger than between the MCSD and other measures, indicating minimal social-desirability effects. Finally, no differences emerged for gender or profession; higher scores did correlate with age ( r =.29, p <.001) and years working in oncology ( r =.18, p =.01). Conclusions: Our findings support the SEMC’s validity and reliability. Scores on the patient and family forms were similar, indicating that either may be used. The SEMC provides a useful tool for measuring clinician-rated communication skills in future research, ultimately allowing standardization across studies.

Hope, Burnout, and Life Satisfaction: An Intriguing Trinity Among Investigators of the SWOG Cancer Research Network

PURPOSE

Although hope has been explored in patients, few studies have investigated hopefulness in health care professionals. We surveyed oncology professionals within the SWOG Cancer Research Network, exploring relationships among personal hopefulness, social support, work stress, burnout, and life satisfaction. We hypothesized that hope would mediate the relationships between these other variables and life satisfaction.

METHODS

SWOG members were randomly selected for an online survey containing measures of hope, social support, work stress, burnout, and satisfaction with life. Of 1,000 invitees, 226 responded.

RESULTS

We tested a multiple mediational model using Hayes' bootstrapping approach (ie, PROCESS v3.4). As hypothesized, hope partially mediated the relationships between burnout and life satisfaction as well as between social support and life satisfaction. In particular, hopefulness was associated with lower burnout (-0.23; P = .005), greater social support (0.23; P = .005), and greater life satisfaction (0.50; P < .001). Work stress was associated with greater burnout (0.57; P < .001) but was not associated with general life satisfaction. Finally, social support was associated with lower burnout (-0.16; P = .005) and greater life satisfaction (0.24; P < .001).

CONCLUSION

Our results suggest that hope may mitigate the effects of burnout. The combination of hope and social support may prove helpful for reducing burnout and improving life satisfaction. Single-session hope-enhancement interventions incorporating both hope and social support have previously been shown to increase hope and well-being in non-health care professionals. Such interventions for health care providers warrant further study.

Hoping to Pass: Randomized Trial of a One-Time Hope Intervention on Standardized Exam Passing Rates in BSN Students

BACKGROUND: National standardized nursing exams serve as critical measures of student readiness for practice and carry significant consequences for students and academic institutions. Educational interventions that can enhance a student's performance increase the probability of academic success. Previous studies link hope to grade point average in college students and on standardized exam (SE) scores in nursing students, yet it is not clear if hope can be increased utilizing a one-time intervention in ways that produce lasting benefits for passing SEs. AIMS: Aim 1 tested the efficacy of a one-time hope intervention on increasing SE passing rates among BSN nursing students. Aim 2 examined the role of the interventions, selected state-mechanism variables, and trait characteristics in predicting SE passing. METHOD: This comparative-effectiveness trial utilized a randomized, controlled, multiple-cohort experimental design to compare a one-time 90-minute hope intervention to an attention-matched progressive muscle relaxation intervention on SE passing scores among BSN nursing students. RESULTS: Levels of hope briefly increased following the hope intervention. Both interventions demonstrated short-term improvement in state-level psychosocial indicators but did not affect SE scores. Among trait and mechanism factors, only academic self-efficacy was linked with passing SEs. CONCLUSIONS: This study demonstrated that a single-session hope intervention can increase short-term hope. In this sample of 292 BSN students, there was no statistically significant long-term effect on passing SEs; however, this study may lay the groundwork for future interventions investigating booster sessions, or how to modify the intervention for struggling students.

A hopefulness survey of SWOG members: Relationships among hope, job stress, and burnout

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Background: Hope is a cognitive, goal-directed phenomenon that is measurable. It is “a cognitive set that is based on a reciprocally-derived sense of successful agency (goal-directed determination) and pathways (planning to meet goals).” Although hope has been explored in patients, few studies have investigated hope in physicians and other healthcare providers. Low hope has been shown to predict work burnout in other professions. This survey in the SWOG Cancer Research Network tests the relationships among hope, work stress, burnout, and general satisfaction with life. Methods: SWOG members randomly selected and invited to participate by email linked to a 10-minute online survey consisting of the following: The Adult Hope Scale, Satisfaction with Life Scale, demographic questionnaire, and items assessing burnout, work stress, and general social support. Of 1000 invitees, 226 responded to the survey, including physicians ( n = 77) and RNs ( n = 46). Results: On average, respondents reported relatively high work stress ( M = 3.59 out of 5). Levels of work stress were positively associated with burnout ( r = .58, p < .001), but not with general satisfaction with life ( r = .11, p = .08). Hope levels were negatively associated with burnout ( r = -.21, p = .003) and positively associated with satisfaction with life ( r = .58, p < .001). Consistent with past research showing that people with greater availability of general social support suffer from lower rates of burnout and experience higher levels of psychological well-being, we found that social support was negatively associated with burnout ( r = -.18, p = .007) and positively associated with life satisfaction ( r = .38, p < .001). In addition, we tested a meditational model using Hayes’ bootstrapping approach via the PROCESS macro in SPSS. In this model, hope partially mediated the relationships between social support and both burnout and life satisfaction. In the model, job stress also predicted burnout, but, as in the previous correlational analysis, had no relationship with general life satisfaction. Conclusions: Our cross-sectional results suggest that hope may mitigate the effects of burnout. Our data indicate that the particular combination of social support and hope may prove helpful for reducing job burnout and increasing general satisfaction with life. Single-session hope-enhancement workshops that incorporate both of these elements have been shown to increase hope and psychological well-being in non-medical populations. Such interventions for healthcare professionals warrant further study.

Relationship between clinical work intensity, hopefulness and well-being among medical oncologists

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Background: Oncology providers’ well-being particularly concerns administrators, as projections suggest a shortfall in number of providers available to care for an increasing cancer survivor population. This pilot study solicited medical oncologists’ ratings on Clinical Work Intensity (CWI), well-being, and hope constructs: agency (goal-directed determination) and pathways (planning ways to meet goals), to understand relationships between clinical work intensity, hopefulness and well-being. Methods: Eleven providers (8 = MD and 3 = NP) practicing in three distinct community-based oncology sites completed the CWI measure, NASA-TLX, immediately following an office visit, for 20 separate visits. Each provider also completed one well-being index and one Adult Hope Scale that included agency and pathways subscales after the 20 visits. Lower well-being scores indicated higher well-being; higher hope scores indicated greater hopefulness. Results: Clinical work intensity positively correlates with well-being (Spearman rho = 0.16; p = 0.02). Clinical work intensity was inversely related to the total hopefulness score (Spearman rho = -0.25; p < 0.001) and Hope construct subcomponents of perceived pathway to goal achievement (Spearman rho = -0.24; p < 0.001), and determination to meet goals (agency) (Spearman rho = -0.15; p < 0.001). Favorable provider well-being was also related to agency (Spearman rho = -0.71; p < 0.0001). Conclusions: Higher provider-rated work intensity in sampled clinical encounters correlates, albeit weakly, with less favorable well-being scores. Higher CWI also correlates with lower hope scale scores. Thus, providers’ perceptions of their mental workload in clinical care are potentially related to their sense of well-being and hopefulness. Results also suggest provider determination to meet goals (agency) is also reflected in sense of well-being. These findings support further investigation using larger, more diverse samples to affirm observed relationships. Future research may also elucidate intervention targets through which to abate provider distress portending burnout. Insights gleaned from future work may inform improvements to the work life of oncology care providers.

The science of hope

Hope is a contextual term that has different connotations depending on the setting. We analyse the concept of hope with respect to its applicability for oncology. We review studies that present hope as a direct or secondary mediator of outcome. We posit that an individual's level of hope is often determined by innate personality characteristics and environmental factors, but can also be physiologically influenced by immune modulators, neurotransmitters, affective states, and even the underlying disease process of cancer. We argue that hope can be a therapeutic target and review evidence showing the effects of hope-enhancing therapies. Given the potential for hope to alter oncological outcomes in patients with cancer and the opportunity for improvement in quality of life, we suggest further research directions in this area.

Hope and Physical Exercise: The Contributions of Hope, Self-Efficacy, and Optimism in Accounting for Variance in Exercise Frequency

We examine the relationship of hope with exercise using Snyder’s hope model, which defines hope as a combination of goal-directed planning (pathways) and motivation (agency). We surveyed 102 participants online via Amazon MTurk. The Adult Hope Scale and Goal-Specific Hope Scale assessed general hope and hope regarding exercise. The Leisure-Time Exercise Questionnaire assessed frequency of exercise and of any activity “long enough to work up a sweat.” We also measured optimism, exercise self-efficacy, depression, anxiety, and stress. Because hope emphasizes planning and motivation (both likely needed in fitness regimens), we expected it to relate to exercise frequency after controlling for these other variables. Indeed, exercise goal-specific hope was correlated with frequency of exercise and activity long enough to sweat, though general hope was not. This relationship held after controlling for all other variables. Future research may be useful in investigating causality, including whether hope-based interventions result in increased exercise engagement.

Does Family Cohesion Predict Children's Effort? The Mediating Roles of Sense of Coherence, Hope, and Loneliness

The degree of cohesion and support within families has often been considered a predictor of students' effort-investment and success in school. The objectives of this study are to examine the roles of personal factors (i.e., sense of coherence and hopeful thinking) as well as interpersonal factors (i.e., loneliness) in mediating the relationship between family cohesion and effort. The sample consists of 1719 elementary school children (781 boys and 938 girls) from the fifth and six grades (mean age = 10.25, SD = 0.70) of 29 elementary schools in central Israel. Students answered study questionnaires in the middle of their academic year. Analyses utilizing hierarchical multiple regression and Hayes' bootstrapping approach (PROCESS; Preacher & Hayes, 2008) were used. The results support the distinctive contribution of family cohesion and the mediating roles of sense of coherence and hope (as protective factors) as well as loneliness (as a risk factor) in predicting students' school effort. This study has important educational implications, emphasizing the value of promoting hopeful thinking and coping with loneliness in helping students to thrive in their studies.

Stepwise Psychosocial Palliative Care: A New Approach to the Treatment of Posttraumatic Stress Disorder at the End of Life

Although evidence-based therapies for Posttraumatic Stress Disorder (PTSD) exist for physically healthy populations, these often do not adequately address PTSD in dying patients. Particularly because these interventions require 8-16 weekly sessions, and the median stay in U.S. hospices is 17.5 days (National Hospice and Palliative Care Organization [NHPCO], 2015 ), there is a potentially serious timing mismatch. Moreover, these treatments may temporarily increase trauma symptoms (Nishith, Resick, & Griffin, 2002 ), resulting in some patients dying in greater distress than had they not received care. The Stepwise Psychosocial Palliative Care (SPPC) model presented in this article compensates for these difficulties by embracing a palliative care approach to PTSD. Although it utilizes techniques drawn from existing PTSD interventions, these are re-ordered and utilized in a time-responsive, patient-centered manner that takes into account prognosis, fatigue, and logistical concerns. The SPPC approach is further considered with respect to existing social work palliative care competencies (Gwyther et al., 2005 ) and a case study is used to demonstrate its application.

A focused intervention for 1st-year college students: promoting hope, sense of coherence, and self-efficacy

Many students experience elevated psychological distress during their 1st year at college. Within the salutogenic paradigm (A. Antonovsky, 1987), sense of coherence (SOC), self-efficacy, and hope (in terms of hope theory; C. R. Snyder, 2002) are considered as protective factors in the demanding academic system. Study goals were to examine the outcomes of a focused workshop for 43 students, targeting the promotion of hope, sense of coherence, and self-efficacy for enhancing students' academic adjustment as expressed through their grades. Results revealed an effect over the 3 measurement time-points (before the workshop, immediately after it, and after 1 month), as well as the interactions of time and hope levels. Although their mean grades were not statistically different before the intervention, students who achieved higher levels of hope following the workshop got higher grades in the semester following the intervention. SOC and self-efficacy scores were significantly related both to hope levels after 1 month and to mean grades. The implications of this study for promoting a hopeful orientation in educational systems are discussed, and future interventional research is suggested.

Can suicide be ethical? A utilitarian perspective on the appropriateness of choosing to die

In his article in the current issue of Death Studies, "Can Suicide be a Good Death?" David Lester argues that each person should determine whether suicide is appropriate for him or her in relative isolation from the opinions of others. In the present article, I use a utilitarian ethical perspective to critique this assertion. According to utilitarianism, the "goodness" of an action is judged by its impact not only on the individual, but also upon others. As such, I review research demonstrating that suicide has harmful emotional, interpersonal, and economic effects upon individuals and society. Ultimately, the rightness or wrongness of choosing to commit suicide cannot be determined in isolation from the broader consequences of this choice.

Hope in Cognitive Psychotherapies: On Working With Client Strengths

The field of psychology, which is traditionally rooted in the study and treatment of psychological disorders and pathology, recently has begun to embrace an examination of individual, as well as societal, strengths and virtues. This subspecialty within psychology, known as positive psychology, can be defined as the attempt to understand the characteristics and processes that contribute to optimal functioning, flourishing, and resiliency. The purpose of the present article is to draw a link between traditional psychology and positive psychology using the example of the positive psychological construct of hope. Specifically, we explore the ways in which hope theory can be incorporated into traditional forms of cognitive therapy for symptom reduction and elimination. First, the theory of hope (Snyder, 1994) is introduced and the concept of hopeful thought is defined. Next, we explore the distinction between Snyder’s definition of hope and Beck’s definition of hopelessness (Beck, Weissman, Lester, & Trexler, 1974). Finally, we present possible strategies for utilizing hope concepts in cognitive therapies. Studying individuals with high levels of hope has resulted in a wealth of information about the ways these individuals overcome obstacles and find multiple ways to the goals that they have set for themselves. Integrating these lessons into empirically based treatments for symptom reduction is likely to result in a synergy that utilizes the most sound aspects of both traditional psychology and positive psychology.

"False" hope

"False" hope is condemned in the literature on the grounds that it reflects the counterproductive use of: (a) expectations based on illusions rather than reality, (b) inappropriate goals, and (c) poor strategies to reach desired goals. Snyder, Harris, et al.'s (1991) hope theory involving self-referential thoughts about finding routes to desired goals (pathways) and the motivation to use those routes (agency) is used as a framework for examining these three criticisms of false hope. It is concluded that the presently available evidence does not support any of the false-hope criticisms. The implications of hope-related issues for the applied clinical arena are discussed.

The umbilical coiling index

OBJECTIVE

Our purpose was to objectively quantitate umbilical vascular coiling.

STUDY DESIGN

In this prospective study the umbilical cords and delivery records of 100 consecutive liveborn neonates were studied. The umbilical coiling index of each cord was determined by dividing the total number of complete umbilical vascular coils by the umbilical cord length (in centimeters). The obstetric history, intrapartum fetal heart rate tracing, and pregnancy outcome of each fetus were evaluated without knowledge of the umbilical coiling index.

RESULTS

The mean umbilical coiling index was 0.21 +/- 0.07 (SD) coils per centimeter. The 100 values were normally distributed. Among those whose umbilical coiling index values fell < or = 10th percentile, there was a significantly greater incidence of karyotypic abnormalities (p = 0.04), meconium staining (p = 0.03), and operative intervention for fetal distress (p = 0.03). There was a significantly greater incidence of moderate or severe variable fetal heart rate decelerations for those whose umbilical coiling index value was either < or = 10th percentile (0.1 coils per centimeter) or > 90th percentile (0.3 coils per centimeter) (p = 0.03).

CONCLUSION

The umbilical coiling index may have utility for objectively describing the degree of umbilical vascular coiling.

Amnioinfusion among women attempting vaginal birth after cesarean delivery

Eighteen of 901 women (2%) attempting vaginal birth after cesarean delivery (VBAC) received amnioinfusion. No untoward effects occurred in the subjects or their fetuses. We conclude that, though amnioinfusion in the setting of a VBAC attempt is needed only infrequently, it appears to be a reasonable intrapartum management option. The usual safeguards for a VBAC attempt should be followed.

Unexplained displacement of ipsilateral ovary and fallopian tube

During routine laparoscopy, the right fallopian tube and ovary were noted to be displaced. Ovarian and fallopian tube tissue were found on biopsy of adjacent omentum. The most probable cause is asymptomatic torsion of the right adnexum; therefore, evaluation of the renal system with intravenous pyelogram is probably not necessary.

Congenital depression of the fetal skull

One hundred forty-seven cases of congenital skull depression are analyzed, including two presented by the authors, and a review of the literature follows. A management plan emphasizing a conservative approach is outlined.

Computed tomographic evaluation of surgical clip artifact: tissue phantom and experimental animal assessment

Surgical clips in postoperative patients create streak artifact on computed tomographic (CT) studies which often significantly degrade image quality. We have evaluated three types of surgical clips: tantalum, stainless steel, and titanium in a phantom and animal model to assess their relative CT artifact. Tantalum clips showed the greatest artifact, stainless steel intermediate, and titanium the least artifact. Artifact could be reduced with the use of faster scan times. The type of clip used may enter into surgical decision making depending upon the need for high resolution scanning to detect small pathological processes in the area of surgical clips.

Comparison of tests for the diagnosis of spontaneous encephalitozoonosis in rabbits

The effectiveness of immunofluorescence, complement fixation, microagglutination serologic tests, intradermal skin test, and detection of histologic lesions were compared for use in diagnosis of spontaneous encephalitozoonosis in rabbits. The India ink and microbead agglutination reactions were compared with immunofluorescence and complement fixation by testing 11 single or pooled sera. Serologic tests correlated best with each other and less well with intradermal tests or presence of lesions. Immunofluorescence, India ink reaction and microbead agglutination were equally useful in detecting antibodies to Encephalitozoon cuniculi. The intradermal test correlated best with the presence of detectable lesions.

Growth, kidney disease, and longevity of Syrian hamsters (Mesocricetus auratus) fed varying levels of protein

Male and female hamsters were fed natural ingredient diets containing 6, 12, 18, or 24% protein. Differences in growth rate, feed consumption, kidney weight, serum chemistry (total protein, serum creatinine, blood urea nitrogen), and longevity were analyzed. The kidneys were examined microscopically and graded according to the severity of nephritis. The 6% protein diet resulted in the lowest frequency of nephritis, but the animals were significantly smaller and had shorter life spans than the remaining groups. The 12% protein diet initially promoted slower growth than 18 or 24% protein, but the differences in body weight eventually became insignificant. The 12% protein diet resulted in a higher frequency of nephritis than 6% protein, but lower than 18 or 24% protein. The 18 and 24% protein diets promoted the most rapid early growth as well as the highest frequency and most severe kidney lesions. Uremia did not appear to be a major cause of death. Longevity did not differ significantly among hamsters of either sex fed 12, 18, or 24% protein diets.