Emotion regulation moderates the association between COVID-19 stress and mental distress: findings on buffering, exacerbation, and gender differences in a cross-sectional study from Norway

Background: Maintaining good mental health is important during a crisis. However, little attention has been given to how people achieve this, or how they evaluate emotions associated with stressors, such as the COVID-19 pandemic. This study aims to (1) investigate whether emotion regulation, in particular cognitive reappraisal and suppression, moderates the relationship between COVID-19 stress and general mental distress and (2) examine gender differences in the interrelations between COVID-19 stress, emotion regulation, and mental distress. Methods: Data from a population in Norway (n = 1.225) were collected using a cross-sectional survey during the early months of the COVID-19 pandemic. Emotion regulation was measured using the Emotion Regulation Questionnaire Scale (ERQ), COVID-19 stress with the COVID-19 Stress Scale, and mental distress with the Patient Health Questionnaire 4 (PHQ-4). Moderation analyses were conducted using the PROCESS macro for SPSS. Results: There was a strong association between COVID-19 stress and general mental distress (r = 0.61). The moderation analyses showed substantial moderation effects of cognitive reappraisal and suppression on the relationship between COVID-19 stress and mental distress. Cognitive reappraisal served as a buffer (p = 0.001) and suppression (p = 0.002) exacerbated the relation between COVID-19 stress and mental distress. Men had higher scores of suppression (p < 0.001), and women had higher scores of cognitive reappraisal (p = 0.025). The buffering effect of cognitive reappraisal presented itself only in women (p < 0.001), while the exacerbation effect of suppression appeared only in men (p < 0.001). Conclusion: The current study suggests that COVID-19 pandemic-related stress is easier to deal with for those who have the tendency to cognitively reappraise. In contrast, suppression is associated with symptoms of depression and anxiety. The prevention of mental distress can be supported by guiding people about the importance of using healthy emotion regulation strategies, as well as helping them to become more aware of the way they interpret and regulate their emotions. Gender differences in emotion regulation suggest gender awareness, e.g., tailored programs for men and women.publishedVersio

Improvements in Patient Monitoring in the Intensive Care Unit: Survey Study

Background: Due to demographic change and, more recently, coronavirus disease (COVID-19), the importance of modern intensive care units (ICU) is becoming apparent. One of the key components of an ICU is the continuous monitoring of patients' vital parameters. However, existing advances in informatics, signal processing, or engineering that could alleviate the burden on ICUs have not yet been applied. This could be due to the lack of user involvement in research and development. Objective: This study focused on the satisfaction of ICU staff with current patient monitoring and their suggestions for future improvements. We aimed to identify aspects of monitoring that interrupt patient care, display devices for remote monitoring, use cases for artificial intelligence (AI), and whether ICU staff members are willing to improve their digital literacy or contribute to the improvement of patient monitoring. We further aimed to identify differences in the responses of different professional groups. Methods: This survey study was performed with ICU staff from 4 ICUs of a German university hospital between November 2019 and January 2020. We developed a web-based 36-item survey questionnaire, by analyzing a preceding qualitative interview study with ICU staff, about the clinical requirements of future patient monitoring. Statistical analyses of questionnaire results included median values with their bootstrapped 95% confidence intervals, and chi-square tests to compare the distributions of item responses of the professional groups. Results: In total, 86 of the 270 ICU physicians and nurses completed the survey questionnaire. The majority stated they felt confident using the patient monitoring equipment, but that high rates of false-positive alarms and the many sensor cables interrupted patient care. Regarding future improvements, respondents asked for wireless sensors, a reduction in the number of false-positive alarms, and hospital standard operating procedures for alarm management. Responses to the display devices proposed for remote patient monitoring were divided. Most respondents indicated it would be useful for earlier alerting or when they were responsible for multiple wards. AI for ICUs would be useful for early detection of complications and an increased risk of mortality; in addition, the AI could propose guidelines for therapy and diagnostics. Transparency, interoperability, usability, and staff training were essential to promote the use of AI. The majority wanted to learn more about new technologies for the ICU and required more time for learning. Physicians had fewer reservations than nurses about AI-based intelligent alarm management and using mobile phones for remote monitoring. Conclusions: This survey study of ICU staff revealed key improvements for patient monitoring in intensive care medicine. Hospital providers and medical device manufacturers should focus on reducing false alarms, implementing hospital alarm standard operating procedures, introducing wireless sensors, preparing for the use of AI, and enhancing the digital literacy of ICU staff. Our results may contribute to the user-centered transfer of digital technologies into practice to alleviate challenges in intensive care medicine. Trial registration: ClinicalTrials.gov NCT03514173; https://clinicaltrials.gov/ct2/show/NCT03514173

Clinical Requirements of Future Patient Monitoring in the Intensive Care Unit: Qualitative Study

BACKGROUND: In the intensive care unit (ICU), continuous patient monitoring is essential to detect critical changes in patients' health statuses and to guide therapy. The implementation of digital health technologies for patient monitoring may further improve patient safety. However, most monitoring devices today are still based on technologies from the 1970s. OBJECTIVE: The aim of this study was to evaluate statements by ICU staff on the current patient monitoring systems and their expectations for future technological developments in order to investigate clinical requirements and barriers to the implementation of future patient monitoring. METHODS: This prospective study was conducted at three intensive care units of a German university hospital. Guideline-based interviews with ICU staff-5 physicians, 6 nurses, and 4 respiratory therapists-were recorded, transcribed, and analyzed using the grounded theory approach. RESULTS: Evaluating the current monitoring system, ICU staff put high emphasis on usability factors such as intuitiveness and visualization. Trend analysis was rarely used; inadequate alarm management as well as the entanglement of monitoring cables were rated as potential patient safety issues. For a future system, the importance of high usability was again emphasized; wireless, noninvasive, and interoperable monitoring sensors were desired; mobile phones for remote patient monitoring and alarm management optimization were needed; and clinical decision support systems based on artificial intelligence were considered useful. Among perceived barriers to implementation of novel technology were lack of trust, fear of losing clinical skills, fear of increasing workload, and lack of awareness of available digital technologies. CONCLUSIONS: This qualitative study on patient monitoring involves core statements from ICU staff. To promote a rapid and sustainable implementation of digital health solutions in the ICU, all health care stakeholders must focus more on user-derived findings. Results on alarm management or mobile devices may be used to prepare ICU staff to use novel technology, to reduce alarm fatigue, to improve medical device usability, and to advance interoperability standards in intensive care medicine. For digital transformation in health care, increasing the trust and awareness of ICU staff in digital health technology may be an essential prerequisite

Creation of an Evidence-Based Implementation Framework for Digital Health Technology in the Intensive Care Unit: Qualitative Study

Background: Digital health technologies such as continuous remote monitoring and artificial intelligence–driven clinical decision support systems could improve clinical outcomes in intensive care medicine. However, comprehensive evidence and guidelines for the successful implementation of digital health technologies into specific clinical settings such as the intensive care unit (ICU) are scarce. We evaluated the implementation of a remote patient monitoring platform and derived a framework proposal for the implementation of digital health technology in an ICU. Objective: This study aims to investigate barriers and facilitators to the implementation of a remote patient monitoring technology and to develop a proposal for an implementation framework for digital health technology in the ICU. Methods: This study was conducted from May 2018 to March 2020 during the implementation of a tablet computer–based remote patient monitoring system. The system was installed in the ICU of a large German university hospital as a supplementary monitoring device. Following a hybrid qualitative approach with inductive and deductive elements, we used the Consolidated Framework for Implementation Research and the Expert Recommendations for Implementing Change to analyze the transcripts of 7 semistructured interviews with clinical ICU stakeholders and descriptive questionnaire data. The results of the qualitative analysis, together with the findings from informal meetings, field observations, and previous explorations, provided the basis for the derivation of the proposed framework. Results: This study revealed an insufficient implementation process due to lack of staff engagement and few perceived benefits from the novel solution. Further implementation barriers were the high staff presence and monitoring coverage in the ICU. The implementation framework includes strategies to be applied before and during implementation, targeting the implementation setting by involving all ICU stakeholders, assessing the intervention’s adaptability, facilitating the implementation process, and maintaining a vital feedback culture. Setting up a unit responsible for implementation, considering the guidance of an implementation advisor, and building on existing institutional capacities could improve the institutional context of implementation projects in the ICU. Conclusions: Implementation of digital health in the ICU should involve a thorough preimplementation assessment of the ICU’s need for innovation and its readiness to change, as well as an ongoing evaluation of the implementation conditions. Involvement of all stakeholders, transparent communication, and continuous feedback in an equal atmosphere are essential, but leadership roles must be clearly defined and competently filled. Our proposed framework may guide health care providers with concrete, evidence-based, and step-by-step recommendations for implementation practice, facilitating the introduction of digital health in intensive care. Trial Registration: ClinicalTrials.gov NCT03514173; https://clinicaltrials.gov/ct2/show/NCT0351417

Sense of coherence, mental well-being and perceived preoperative hospital and surgery related stress in surgical patients with malignant, benign, and no neoplasms

Background: This prospective, cross-sectional, observational study examined associations between sense of coherence (SOC), mental well-being, and perceived preoperative hospital and surgery related stress of surgical patients with malignant, benign, and no neoplasms. The objective was to assess a putative association between SOC and preoperative stress, and to test for a statistical mediation by mental well-being. Method: The sample consisted of 4918 patients from diverse surgical fields, of which 945 had malignant neoplasms, 333 benign neoplasms, and 3640 no neoplasms. For each subsample, we conducted simple mediation analyses to test an indirect effect of SOC on preoperative stress mediated by mental well-being. The models were adjusted for age, gender, and essential medical factors. Results: Patient groups did not differ significantly regarding degrees of SOC and mental well-being (SOC, M [SD]: 12.31 [2.59], 12.02 [2.62], 12.18 [2.57]; mental well-being M [SD]: 59.26 [24.05], 56.89 [22.67], 57.31 [22.87], in patients with malignant, benign, and without neoplasms, respectively). Patients without neoplasms reported significantly lower stress (4.19 [2.86], M [SD]) than those with benign (5.02 [3.03], M [SD]) and malignant neoplasms (4.99 [2.93], M [SD]). In all three mediation models, SOC had significant direct effects on stress, with higher SOC being associated with lower stress (- 0.3170 [0.0407], - 0.3484 [0.0752], - 0.2919 [0.0206]; c' [SE], p < 0.001 in patients with malignant, benign, and without neoplasms, respectively). In patients with malignant neoplasms and without neoplasms, SOC showed small indirect effects on stress that were statistically mediated by well-being. Higher SOC was related to higher well-being, which in turn was related to lower stress. In patients with benign neoplasms, however, no significant indirect effects of SOC were found. Conclusions: SOC was directly associated with lower perceived hospital and surgery related stress, over and above the direct and mediation effects of mental well-being. Because the data are cross-sectional, conclusions implying causality cannot be drawn. Nevertheless, they indicate important relationships that can inform treatment approaches to reduce elevated preoperative stress by specifically addressing low SOC

Perceived Severity of Stressors in the Intensive Care Unit: A Systematic Review and Semi-Quantitative Analysis of the Literature on the Perspectives of Patients, Health Care Providers and Relatives

The aim of this study was to synthesize quantitative research that identified ranking lists of the most severe stressors of patients in the intensive care unit, as perceived by patients, relatives, and health care professionals (HCP). We conducted a systematic literature search in PubMed, MEDLINE, EMBASE, PsycInfo, CINAHL, and Cochrane Library from 1989 to 15 May 2020. Data were analyzed with descriptive and semi-quantitative methods to yield summarizing ranking lists of the most severe stressors. We synthesized the results of 42 prospective cross-sectional observational studies from different international regions. All investigations had assessed patient ratings. Thirteen studies also measured HCP ratings, and four studies included ratings of relatives. Data indicated that patients rate the severity of stressors lower than HCPs and relatives do. Out of all ranking lists, we extracted 137 stressor items that were most frequently ranked among the most severe stressors. After allocation to four domains, a group of clinical ICU experts sorted these stressors with good to excellent agreement according to their stress levels. Our results may contribute to improve HCPs' and relatives' understanding of patients' perceptions of stressors in the ICU. The synthesized stressor rankings can be used for the development of new assessment instruments of stressors

The role of therapist rotation and patient characteristics for the working mechanisms of the Outpatient Long-term Intensive Therapy for Alcoholics (OLITA)

Die vorliegende Arbeit umfasst zwei Originalartikel, die sich mit den Wirksamkeitsprozessen der Ambulanten Langzeit-Intensivtherapie für Alkoholkranke (ALITA) beschäftigen.Die Therapeutenrotation ist seit 10 Jahren ein zentrales Therapieelement von ALITA. Die Beteiligung mehrerer gleichermaßen verantwortlicher Therapeuten bei der Behandlung psychisch kranker Menschen wurde bislang kaum als eigenständiger Therapieansatz betrachtet. Der Artikel analysiert die Therapeutenrotation aus theoretischer und klinischer Perspektive.Die Arbeit stellt die derzeit einzige internationale Übersichtsarbeit zur Rolle der therapeutischen Beziehung in der Suchttherapie dar und bietet darüber hinaus einen Überblick über die wichtigsten Forschungsarbeiten zur therapeutischen Beziehung in der allgemeinen Psychotherapie. Desweiteren wird die Literatur zum historischen Vorläufer der Therapeutenrotation, der multiplen Psychotherapie nach Alfred Adler, referiert.Von der Bedeutung der therapeutischen Allianz für die Behandlung suchtkranker Menschen und der Wirksamkeit der Multiplen Psychotherapie ausgehend, diskutiert die vorliegende Arbeit die Therapeutenrotation als einen wesentlichen Wirkfaktor von ALITA. Dabei werden potentielle Vorteile und Nachteile für die Patienten und Therapeuten berücksichtigt, und es wird versucht, die Bedingungen eines erfolgreichen Einsatzes dieses Therapieelementes zu identifizieren. Im Rahmen einer Prozessanalyse wird die konkrete Anwendung der Therapeutenrotation bei ALITA beschrieben. Abschließend werden neue Anwendungsgebiete der Therapeutenrotation diskutiert.FragestellungEs ist noch unerforscht, wie sich komorbide psychiatrische Störungen während der Suchttherapie verändern. Die vorliegende Studie untersucht zwei Fragestellungen: (1) den Verlauf komorbider Achse-I-Störungen bei chronisch alkoholkranken Patienten unter kontrollierter Abstinenz während der zwei Therapiejahre von ALITA; (2) den prädiktiven Wert von komorbiden Achse-I-Störungen und Achse-II-Störungen bei der Vorhersage des Rückfallgeschehens während eines Vier-Jahreszeitraumes.Es wurden umfassende psychiatrische, suchtassoziierte und soziodemographische Variablen von 89 Patienten zu Behandlungsbeginn (t1), nach sechs Monaten (t2), nach 12 Monaten (t3) und nach 24 Monaten (t4) erhoben. Abstinenz und Substanzkonsum wurden durch regelmäßige Analyse von Urin- und Blutproben während des gesamten Vier-Jahreszeitraumes überprüft. Die statistische Auswertung der Daten erfolgte mit speziellen nonparametrischen Tests für Langzeituntersuchungen an kleinen Stichproben und mit Überlebensanalysen.Zu Therapiebeginn wiesen 61.8% der Patienten mindestens eine Achse-I-Störung und 63.2% mindestens eine Achse-II-Störung (d.h. Persönlichkeitsstörung) auf. Die Häufigkeit von Achse-I-Störungen sank von t1 (59.0%), über t2 (38.5%), t3 (28.2%) zu t4 (12.8%) (p<.0001). Angststörungen remittierten eher langsam von t1 (43.6%) zu t3 (20.5%, p=.0086). Affektive Störungen fielen durch einen frühen Rückgang zwischen t1 (23.1%) und t2 (5.1%, p=.0387) auf, zeigten jedoch einen leichten Wiederanstieg zu t3 (10.3%). Während des vierjährigen Untersuchungszeitraumes betrug die kumulative Wahrscheinlichkeit, nicht rückfällig zu werden, .59. Zwei Prädiktoren haben einen starken negativen Einfluss auf die Abstinenzwahrscheinlichkeit: die Anzahl früherer stationärer Entgiftungsbehandlungen (p=.0013) und das Vorliegen von mindestens einer Persönlichkeitsstörung (p=.0106).Die vorliegende Studie zeigt einen deutlichen Rückgang komorbider Achse-I-Störungen bei abstinenten chronisch alkoholkranken Patienten während der langfristigen und umfassenden Behandlung bei ALITA. Im Gegensatz zu Achse-I-Störungen, die keinen prädiktiven Gehalt für den langfristigen Rückfallverlauf aufweisen, können komorbide Persönlichkeitsstörungen und die Anzahl an früheren Entgiftungen das Rückfallgeschehen im vierjährigen Untersuchungszeitraum klar vorhersagen.This thesis comprises two articles which are concerned with the process and outcome research on the Outpatient Long-term Intensive Therapy for Alcoholics.For nine years, the so-called 'therapist rotation' has been a central part of OLITA, the Outpatient Longterm Intensive Therapy for Alcoholics. Thus far, the participation of several equally responsible therapists in the treatment of a patient has rarely been seen as a specific therapeutic approach. The present paper analyses the 'therapist rotation' from a theoretical and clinical perspective.This article contains the only internationally available review on the role of therapeutic alliance in the treatment of substance use disorders. In addition, it offers an overview of the most important studies on therapeutic relationship in general psychotherapy. The literature on multiple psychotherapy which may be seen as the precedent of the 'therapist rotation' is surveyed.Based on the efficacy of multiple psychotherapy and the importance of the therapeutic alliance in the treatment of substance use disorders, the present work discusses the 'therapist rotation' as an essential factor for the success of OLITA. It considers both, potential advantages and disadvantages for patients and therapists and tries to identify conditions under which this approach appears to promote therapeutic interactions. Finally, the implementation of 'therapist rotation' into OLITA is described including the theoretical background of the program itself and the treatment procedure. New areas of application for the 'therapist rotation' are discussed.ObjectiveIt is far from clear how comorbidity changes during alcoholism treatment. This study investigates (1) the course of comorbid Axis I disorders in chronic alcoholics over 2 years of controlled abstinence in the Outpatient Long-term Intensive Therapy for Alcoholics (OLITA), and (2) the effect of comorbid Axis I and II disorders in this group of patients on subsequent drinking outcome over a 4-year follow-up.This prospective treatment study evaluates psychiatric, addiction associated and sociodemographic variables of 89 severely affected chronic alcohol dependent patients on admission (t1), month 6 (t2), 12 (t3) and 24 (t4). Drinking outcomes have been assessed by regular urine and blood analyses during a 4-year follow-up. Statistical data analysis was carried out with specific nonparametric tests for comparing repeated measures data with small sample sizes and with survival analyses.On admission, 61.8% of the patients met criteria for a comorbid Axis I disorder, 63.2% for a comorbid personality disorder. Axis I disorders remit from t1 (59.0% ill), t2 (38.5%), t3 (28.2%) to t4 (12.8%) (p<.0001). Anxiety disorders remit more slowly from t1 (43.6%) to t3 (20.5%, p=.0086), whereas mood disorders remit early between t1 (23.1%) and t2 (5.1%, p=.0387) with a slight transient increase at t3 (10.3%). During the 4-year follow-up, the cumulative probability of not having relapsed amounts to .59. Two predictors have a strong negative impact on abstinence probability: number of inpatient detoxifications (p=.0013) and personality disorders (p=.0106).The present study demonstrates a striking remission of comorbid Axis I disorders upon abstinence during comprehensive long-term outpatient alcoholism treatment. The presence of an Axis II rather than an Axis I disorder on admission strongly predicts drinking outcome over a 4-year follow-up