A Stress Management App Intervention for Cancer Survivors: Design, Development, and Usability Testing

Background: Distress is prevalent in cancer survivors. Stress management interventions can reduce distress and improve quality of life for cancer patients, but many people with cancer are unfortunately not offered or able to attend such in-person stress management interventions. Objective: The objective of this study was to develop an evidence-based stress management intervention for patients living with cancer that can be delivered electronically with wide reach and dissemination. This paper describes the design and development process of a technology-based stress management intervention for cancer survivors, including the exploration phase, intervention content development, iterative software development (including design, development, and formative evaluation of low- and high-level prototypes), and security and privacy considerations. Methods: Design and development processes were iterative and performed in close collaboration with key stakeholders (N=48). In the exploration phase, identifying needs and requirements for the intervention, 28 participants gave input, including male and female cancer survivors (n=11) representing a wide age range (31-81 years) and cancer diagnoses, healthcare providers (n=8) including psychosocial oncology experts, and eHealth experts (n=9) including information technology design and developers. To ensure user involvement in each phase various user-centered design and service design methods were included, such as interviews, usability testing, and think aloud processes. Overall, participants were involved usability testing in the software development and formative evaluation phase, including cancer survivors (n=6), healthy volunteers (n=7), health care providers (n=2), and eHealth experts (n=5). Intervention content was developed by stress management experts based on well-known cognitive behavioral stress management strategies and adjusted to electronic format through multiple iterations with stakeholders. Privacy and security issues were considered throughout. Results: The design and development process identified a variety of stakeholder requirements. Cancer survivors preferred stress management through a mobile app rather than through a personal computer (PC) and identified usefulness, easy access, user friendliness, use of easily understandable language, and many brief sections rather than longer ones as important components of the intervention. These requirements were also supported by recommendations from health care providers and eHealth experts. The final intervention was named StressProffen and the hospital Privacy and Security Protection Committee was part of the final intervention approval to also ensure anchoring in the hospital organization. Conclusions: Interventions, even evidence-based, have little impact if not actively used. This study illustrates how user-centered design and service design can be applied to identify and incorporate essential stakeholder aspects in the entire design and development process. In combination with evidence-based concepts, this process facilitated development of a stress management intervention truly designed for the end users, in this case, cancer survivors. Trial Registration: ClinicalTrials.gov NCT02939612; https://clinicaltrials.gov/ct2/show/NCT02939612 (Archived at WebCite at http://www.webcitation.org/71l9HcfcB

Implementation strategies to enhance the implementation of eHealth programs for patients with chronic illnesses: realist systematic review

Background: There is growing evidence of the positive effects of electronic health (eHealth) interventions for patients with chronic illness, but implementation of such interventions into practice is challenging. Implementation strategies that potentially impact implementation outcomes and implementation success have been identified. Which strategies are actually used in the implementation of eHealth interventions for patients with chronic illness and which ones are the most effective is unclear. Objective: This systematic realist review aimed to summarize evidence from empirical studies regarding (1) which implementation strategies are used when implementing eHealth interventions for patients with chronic illnesses living at home, (2) implementation outcomes, and (3) the relationship between implementation strategies, implementation outcomes, and degree of implementation success. Methods: A systematic literature search was performed in the electronic databases MEDLINE, Embase, PsycINFO, Scopus, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library. Studies were included if they described implementation strategies used to support the integration of eHealth interventions into practice. Implementation strategies were categorized according to 9 categories defined by the Expert Recommendations for Implementing Change project: (1) engage consumers, (2) use evaluative and iterative strategies, (3) change infrastructure, (4) adapt and tailor to the context, (5) develop stakeholder interrelationships, (6) use financial strategies, (7) support clinicians, (8) provide interactive assistance, and (9) train and educate stakeholders. Implementation outcomes were extracted according to the implementation outcome framework by Proctor and colleagues: (1) acceptability, (2) adoption, (3) appropriateness, (4) cost, (5) feasibility, (6) fidelity, (7) penetration, and (8) sustainability. Implementation success was extracted according to the study authors’ own evaluation of implementation success in relation to the used implementation strategies. Results: The implementation strategies management support and engagement, internal and external facilitation, training, and audit and feedback were directly related to implementation success in several studies. No clear relationship was found between the number of implementation strategies used and implementation success. Conclusions: This is the first review examining implementation strategies, implementation outcomes, and implementation success of studies reporting the implementation of eHealth programs for patients with chronic illnesses living at home. The review indicates that internal and external facilitation, audit and feedback, management support, and training of clinicians are of importance for eHealth implementation. The review also points to the lack of eHealth studies that report implementation strategies in a comprehensive way and highlights the need to design robust studies focusing on implementation strategies in the future.publishedVersio

Integrating Top-down and Bottom-up Requirements in eHealth Development:The Case of a Mobile Self-compassion Intervention for People with Newly Diagnosed Cancer

Background: Psychosocial eHealth interventions for people with cancer are promising in reducing distress; however, their results in terms of effects and adherence rates are quite mixed. Developing interventions with a solid evidence base while still ensuring adaptation to user wishes and needs is recommended to overcome this. As most models of eHealth development are based primarily on examining user experiences (so-called bottom-up requirements), it is not clear how theory and evidence (so-called top-down requirements) may best be integrated into the development process. Objective: This study aims to investigate the integration of top-down and bottom-up requirements in the co-design of eHealth applications by building on the development of a mobile self-compassion intervention for people with newly diagnosed cancer. Methods: Four co-design tasks were formulated at the start of the project and adjusted and evaluated throughout: explore bottom-up experiences, reassess top-down content, incorporate bottom-up and top-down input into concrete features and design, and synergize bottom-up and top-down input into the intervention context. These tasks were executed iteratively during a series of co-design sessions over the course of 2 years, in which 15 people with cancer and 7 nurses (recruited from 2 hospitals) participated. On the basis of the sessions, a list of requirements, a final intervention design, and an evaluation of the co-design process and tasks were yielded. Results: The final list of requirements included intervention content (eg, major topics of compassionate mind training such as psychoeducation about 3 emotion systems and main issues that people with cancer encounter after diagnosis such as regulating information consumption), navigation, visual design, implementation strategies, and persuasive elements. The final intervention, Compas-Y, is a mobile self-compassion training comprising 6 training modules and several supportive functionalities such as a mood tracker and persuasive elements such as push notifications. The 4 co-design tasks helped overcome challenges in the development process such as dealing with conflicting top-down and bottom-up requirements and enabled the integration of all main requirements into the design. Conclusions: This study addressed the necessary integration of top-down and bottom-up requirements into eHealth development by examining a preliminary model of 4 co-design tasks. Broader considerations regarding the design of a mobile intervention based on traditional intervention formats and merging the scientific disciplines of psychology and design research are discussed

Aspects of uptake, use and effectiveness of eHealth interventions for self-management support and patient-provider communication

The prevalence and burden of chronic diseases, including cancer, are escalating worldwide. New models of care are needed to meet this challenge. eHealth has a great potential to support patients self-management and communication with health care providers. However, a number of barriers to achieve the full benefits of eHealth have been reported. The aim of this dissertation was to address gaps related to the uptake, use and effectiveness of eHealth interventions. This study used a multi-method approach, employing both qualitative and quantitative methods including interviews with nurses, secondary analyses of longitudinal data and a randomized controlled trial with patient reported outcomes. The Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework was used as the conceptual framework in this dissertation. The study shows that a Web-based self-management system can be an important contributor in providing health care for breast cancer patients in terms of reducing symptom distress, anxiety and depression scores. A secure e-mail component alone contributed to reduced depression scores, which indicates that secure e-mail is an important part of multi-component systems and can also effectively be offered as a stand-alone service. This is promising, as depression is highly prevalent and debilitating among cancer patients. An e-mail service is much easier to develop and to implement widely than more complex multi-component solutions. Despite the concerns identified in the literature regarding health care providers being flooded by messages, only modest use was observed in these studies, indicating e-mail as manageable to integrate in routine care. Further, this study revealed that different user characteristics are associated with different use patterns of Web-based self-management support systems. Secure e-mail and self-management advice were highly accessed components among patients with low levels of social support combined with high illness burden, suggesting that patients with these characteristics may find such tools particularly useful. This information is important in order to target Web-based support systems to different patient groups. Finally, the results suggest that, from nurses’ perspectives, integration of an interactive tailored assessment tool in clinical practice offers many benefits for communication and enhancement of patient-centered care. However, to reap these benefits, use of such tools must receive equal priority to other routines and require sufficient time and competence. In summary, through materials from three different studies and use of multiple methods, this dissertation adds to the knowledge about the uptake, use and effectiveness of eHealth interventions in real life settings. The results and knowledge gained are important to the design of support systems that are better tailored to the individual and the context of use

Gender and ethnicity's influence on first-year nursing students' educational motivation and career expectations: A cross-sectional study.

Aim Given the apparent link between gender and ethnicity, and the diversity and career opportunities in nursing, this study examined gender and ethnicity's influence on first-year nursing students' educational motivation and career expectations. Design Cross-sectional. Methods Through bootstrapped linear regressions, we analysed data on 504 Norwegian first-year nursing students' self-reported educational motivation and career expectations, from the StudData survey at the Centre for the Study of Professions (SPS) at Oslo Metropolitan University (OsloMet). Results The sample consisted of 67 (13%) male and 437 (87%) female nursing students. Female students were more motivated compared to male students by professional interest and to pursue a specialization, less likely to assume leadership positions in the future, and more likely to prioritize family and pursue positions in the traditional nursing field. In total, 425 (84%) respondents stated a Norwegian background. Respondents who stated that both of their parents were born in a country other than Norway made up the 79 (16%) students of immigrant background. Those with immigrant backgrounds were more motivated than other students by income, status and flexible working hours and less likely to pursue a specialization or future employment in the nursing fiel

Comparing Effects in Regular Practice of E-Communication and Web-Based Self-Management Support Among Breast Cancer Patients: Preliminary Results From a Randomized Controlled Trial

Background: While Web-based interventions have been shown to assist a wide range of patients successfully in managing their illness, few studies have examined the relative contribution of different Web-based components to improve outcomes. Further efficacy trials are needed to test the effects of Web support when offered as a part of routine care. Objective: Our aim was to compare in regular care the effects of (1) an Internet-based patient provider communication service (IPPC), (2) WebChoice, a Web-based illness management system for breast cancer patients (IPPC included), and (3) usual care on symptom distress, anxiety, depression, (primary outcomes), and self-efficacy (secondary outcome). This study reports preliminary findings from 6 months’ follow-up data in a 12-month trial Methods: We recruited 167 patients recently diagnosed with breast cancer and undergoing treatment from three Norwegian hospitals. The nurse-administered IPPC allowed patients to send secure e-messages to and receive e-messages from health care personnel at the hospital where they were treated. In addition to the IPPC, WebChoice contains components for symptom monitoring, tailored information and self-management support, a diary, and communication with other patients. A total of 20 care providers (11 nurses, 6 physicians, and 3 social workers) were trained to answer questions from patients. Outcomes were measured with questionnaires at study entry and at study months 2, 4, and 6. Linear mixed models for repeated measures were fitted to compare effects on outcomes over time. Results: Patients were randomly assigned to the WebChoice group (n=64), the IPPC group (n=45), or the usual care group (n=58). Response rates to questionnaires were 73.7% (123/167) at 2 months, 65.9 (110/167) at 4 months, and 62.3% (104/167) at 6 months. Attrition was similar in all study groups. Among those with access to WebChoice, 64% (41/64) logged on more than once and 39% (25/64) sent e-messages to care providers. In the IPPC group, 40% (18/45) sent e-messages. Linear mixed models analyses revealed that the WebChoice group reported significantly lower symptom distress (mean difference 0.16, 95% CI 0.06-0.25, P=.001), anxiety (mean difference 0.79, 95% CI 0.09-1.49, P=.03), and depression (mean difference 0.79, 95% CI 0.09-1.49, P=.03) compared with the usual care group. The IPPC group reported significant lower depression scores compared with the usual care group (mean difference 0.69, 95% CI 0.05-1.32, P=.03), but no differences were observed for symptom distress or anxiety. No significant differences in self-efficacy were found among the study groups. Conclusions: In spite of practice variations and moderate use of the interventions, our results suggest that offering Web support as part of regular care can be a powerful tool to help patients manage their illness. Our finding that a nurse-administered IPPC alone can significantly reduce depression is particularly promising. However, the multicomponent intervention WebChoice had additional positive effects. © Elin Børøsund, Milada Cvancarova, Shirley M Moore, Mirjam Ekstedt, Cornelia M Ruland. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 18.12.2014. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included

Helsepersonells forventninger til e-konsultasjon - en kvalitativ studie

Bakgrunn: Digitale tjenester har potensial til å erstatte og effektivisere områder av helsetjenesten, redusere helseutfordringene samfunnet står overfor, samt gi pasienten bedre muligheter til å medvirke i egne behandlingsvalg. Stadig flere pasienter får tilbud om digital pasientportal og e-konsultasjon i tillegg til, eller i stedet for, tradisjonelle konsultasjoner på sykehus. Tilbudet i en digital pasientportal varierer, men i hovedsak får pasienter tilgang til egne helseopplysninger og mulighet til å kommunisere asynkront med sine behandlere. Hensikt: Hensikten med studien er å utforske helsepersonells forventninger til å implementere og bruke asynkron, tekstbasert e-konsultasjon i en digital pasientportal ved poliklinisk oppfølging av pasienter med en alvorlig kronisk sykdom. Metode: Studien har et utforskende kvalitativt design, der vi gjennomførte ni semistrukturerte, individuelle intervjuer av helsepersonell som skulle ta i bruk e-konsultasjon. Utvalget besto av sykepleiere (n = 4) og leger (n = 5). Materialet ble analysert med tematisk innholdsanalyse. Resultat: Hovedtemaene som kom frem i analysen, var følgende: Seleksjon av pasienter, Faglig forsvarlig helsehjelp og Reorganisering av praksis. Informantene mente at pasienter som får tilbud om oppfølging via e-konsultasjon, må selekteres. Pasientene må oppfylle visse kriterier, spesielt ha tilstrekkelige norskkunnskaper, digitale ferdigheter og høy grad av helsekompetanse og - informasjonsforståelse. Informantene var bekymret for hvorvidt tekstbasert ekonsultasjon ivaretar krav om faglig forsvarlighet, ettersom muligheten til å observere og gjøre kliniske undersøkelser reduseres. Selv om e-konsultasjon kan være egnet til å effektivisere det daglige arbeidet, forventet informantene at en innføring vil endre rutiner og kreve en reorganisering av praksis. Konklusjon: Helsepersonell er opptatt av hvorvidt e-konsultasjon sikrer faglig forsvarlig helsehjelp, samtidig som de forventer at den kan endre praksis og organiseringen av helsetjenesten. Det bør derfor være en viktig prioritet fremover å lytte til helsepersonell både når digitale tjenester implementeres, brukes og utvikles videre, for å sikre at det ytes faglig forsvarlig helsehjelp

Nurses' experiences of using an interactive tailored patient assessment tool one year past implementation

BACKGROUND: Despite evidence of benefits, integration of patient-centered communication in clinical practice is challenging. Interactive tailored patient assessment (ITPA) tools can contribute to a more patient-centered care approach. However, little research has examined the impact of such tools on nursing care once they have been implemented. OBJECTIVE: To explore nurses' experiences of the benefits of and barriers to using an ITPA called Choice, in cancer care one year after its implementation. METHODS: This investigation is a part of a larger study examining the use of Choice in cancer care. Four focus group interviews were conducted with 20 nurses experienced in using the Choice application. The data were analyzed using qualitative content analysis. RESULTS: Three themes and nine sub-themes emerged: (1) "Choice as facilitator for shared understanding and engagement in patients' own care," with three sub-themes: preparing both patient and nurse for communication, shared engagement in care planning, and giving the patients a voice; (2) "enhancing the patients' strengths," with two sub-themes: releasing patient's internal strengths and confirming "normalcy" for the patient; and (3) "new challenges for the nurse," with four sub-themes: organizational challenges, interactions with technology, a need for training in communication skills, and new ethical challenges. CONCLUSIONS: Findings suggest that, from nurses' perspectives, integration of ITPAs such as Choice in clinical practice offers many benefits that can contribute to patient-centered care. However, to reap these benefits, use of such tools must receive equal priority as other routines, and require sufficient time, space and competence. Choice also challenged nurses' professional roles and created dilemmas such as nurses' ambivalence regarding patients' levels of disclosure of sensitive issues and the nurses' ability to respond to them. Although patient-centered care is advocated as model for good clinical practice, this is not always internalized. Tools such as Choice may help to make such a shift happen.QC 20140123</p

Therapists’ experiences with mentalization-based treatment for avoidant personality disorder

Recent research points to significant mentalizing difficulties in individuals with avoidant personality disorder (AvPD). A mentalization-based approach in psychotherapy with avoidant patients is emerging. The aim of this study is to contribute to an understanding of the therapeutic issues such work might entail with our research questions being: a) What are therapists’ experiences of using mentalization-based treatment (MBT) to treat patients with an AvPD diagnosis? and b) What do therapists perceive as therapeutic challenges when conducting MBT with avoidant patients? Semi-structured, in-depth interviews were conducted with six therapists from a MBT team treating patients with AvPD. The data were analyzed using thematic analysis. Two main themes emerged. The first ‘Scarcity of explicit personal narratives’ encompasses ‘Engaging the withdrawn patient’ and ‘Capitalizing on the treatment structure’. The second main theme – ‘On being a patient’ - incorporates ‘Stimulating but emotionally challenging work’ and ‘Making use of experience with other therapeutic approaches’. Participants’ responses about their experience suggests that MBT targets much of the AvPD core pathology. The use of some techniques, however, warrants active consideration, and there may be a need to adjust MBT treatment for use with AvPD patients. Our study reveals more nuances in therapists’ emotional reactions than earlier reported. Future studies should investigate the effect of MBT on AvPD patients and examine treatment processes and interventions that may facilitate change

Video as an alternative to in-person consultations in outpatient renal transplant recipient follow-up: a qualitative study

Background Renal transplant recipients have to see a nephrologist for regular follow-up for the rest of their lives. To reduce the burden for the patients, video consultation can be an alternative to traditional in-person hospital consultations. The aim of the current study was, from the perspectives of patients and health care providers, to investigate the perceived benefits and challenges of using video consultations in outpatient renal transplant recipient follow-up. Methods Patients (i.e., renal transplant recipients; n = 18) alternated between regular in-person follow-up consultations and video consultations. Patients and health care providers were then invited to participate in semi-structured interviews. The interviews were analyzed using thematic analysis. Results Patients interviewed (n = 15) were median 53 years old (range 37–64) and 53% female. The video consultation solution used in the study turned out to have major technical deficiencies. Despite the technical challenges, however, the majority of the patients reported appreciating being able to alternate between video and in-person hospital consultations. Main benefits reported included not needing to travel to the hospital and thereby saving time, less focus on being chronically ill and potential economic benefits for patients and society. The health care providers (n = 3) also valued the benefits provided by the use of video consultations, but described the reoccurring technical challenges as disruptive. The fact that patients were in a stable phase of their health condition and already had an established, trusting relationship with their nephrologist, acted as facilitators for success. Possible challenges and harms described included concerns related to security, confidentiality and interruptions, as well as the potential need for physical examinations. Conclusions Benefits from using video consultations as an alternative to in-person consultations may outweigh potential technological challenges for patients as well as health care providers. A long-lasting mutually trusting relationship between patient and provider may be an important prerequisite for the experienced benefits of using video consultation. Findings also indicate that starting such care delivery changes in a small-scale, with a few selected patients in a stable phase of their condition, may be an important factor for success