“We hope that NanO2 will be a drug that will successfully provide additional oxygen to parts of the brain region that are at risk, but not yet dead. We hope to provide a much-needed stroke therapy to the stroke population," ~ Helena Morrison, PhD, RN

The benefits for those with ischemic stroke could be substantial. “There is a saying that the American Heart and Stroke Association has adapted from Ben Franklin, ‘Time is Brain,’” Dr. Morrison says, referencing the famous ‘Time is Money’ aphorism. “This means that the more time that the brain does without oxygen, the more damage is done to the brain. We hope that NanO2 will be a drug that will successfully provide additional oxygen to parts of the brain region that are at risk, but not yet dead. We hope to provide a much-needed stroke therapy to the stroke population.”

Drs. Morrison and Unger hypothesize that the compromised brain tissue will be smaller in a preclinical cohort that receives the NanO2 treatment when compared to the cohort that will not receive the treatment. “In this case, the preclinical model is one of temporary ischemia, meaning that we model not just ischemic stroke but also the reperfusion, or reestablishment of blood flow, that could occur due to pharmacological or surgical interventions,” Dr. Morrison says. “Previous studies have examined the effect of this drug with ischemic stroke without reperfusion and these investigators illustrated a positive effect, meaning that the brain injury was decreased.”

Dr. Morrison joined the study after UArizona Nursing colleague Leslie Ritter, PhD, RN, FAAN, recommended her to Dr. Unger because of her substantial experience and skills with the pre-clinical model necessary for the study. As Co-PI, Dr. Morrison will handle the nuts and bolts of the study, partnering with NuvOx to shape the study design and the drug supply. The bulk of the clinical work will take place in the Morrison Lab located at UArizona Nursing.

“Tobacco use is one of the leading causes of disease and death in the world. This study will be the first of its kind to test the efficacy of a guided imagery, integrative intervention delivered entirely remotely. There is tremendous potential to reach smokers wherever they are, whenever they’re ready," ~ Judith Gordon, PhD, UArizona Nursing Associate Dean for Research

“Tobacco use is one of the leading causes of disease and death in the world,” said study lead Judith Gordon, PhD, associate dean for research and professor in the UArizona College of Nursing, which is part of UArizona Health Sciences. “This study will be the first of its kind to test the efficacy of a guided imagery, integrative intervention delivered entirely remotely. There is tremendous potential to reach smokers wherever they are, whenever they’re ready.”

An interdisciplinary team of researchers will partner with tobacco quitlines and community organizations in Arizona, New York and West Virginia to recruit 1,200 participants randomized to receive either an integrative intervention or an active control tobacco cessation program. The interventions differ in content, but both programs use nicotine replacement therapy to reduce withdrawal symptoms. 

The study builds on Dr. Gordon’s previous research, which found that both the integrative and control interventions have potential to be effective. In the prior study, protocols were successfully delivered to participants, who adhered to those protocols and stayed with the intervention throughout the process.

Dr. Gordon’s current team will use the same study procedures, protocols, databases, training materials and surveys to test the efficacy of the integrative intervention in a much larger group of people. The expanded partnerships with quitlines and community agencies also will ensure a more representative sample of smokers in the new study.

“We expanded it to include Arizona, which has a high Hispanic/Latino population, New York and West Virginia. West Virginia has the highest tobacco use rates in the U.S.,” Dr. Gordon said. “New York State is highly diverse and has the largest state-run quitline in the U.S.” 

While generally successful, quitlines reach only a small fraction of smokers nationwide. Dr. Gordon chose to develop and test an integrative approach that could expand the appeal of cessation programs to people who may not be interested in the standard cognitive behavioral method. Dr. Gordon hopes the expanded options will resonate with a greater number of smokers. 

“The directors of the quitlines we’re partnering with are excited about adding another option to their services,” Dr. Gordon said. “They hope it will be a new way to motivate people who wouldn’t normally call a quitline. Given the fact that there are still millions of smokers worldwide, if you can get those people to quit, you’re going to greatly improve not only their health and wellbeing but also the health and wellbeing of people who are exposed to their secondhand tobacco smoke. There’s enormous potential for improving public health.”

“Nurses in our pain study were going to incredible lengths to be able to deliver the best care for their patients regardless of the consequences for their own health and life outside of work," ~ Jessica Rainbow, PhD, RN

The two-year study, which started in July, builds on Dr. Rainbow’s prior research, which found that nurses were suffering from significant pain that was impacting their work. That pilot study suggests that nurses, as the largest group of health care providers, care for patients who are using cannabis, and that nurses are using cannabis in conjunction with other substances as treatment for their own pain.

“I hypothesize that nurses are using cannabis and other substances to cope with their work, and that these are often used to recover rather than prior to attending work,” Dr. Rainbow said. “Nurses in our pain study were going to incredible lengths to be able to deliver the best care for their patients regardless of the consequences for their own health and life outside of work.”  
 

Prior studies have found that nurses have similar rates of substance use as the general population and are at risk for substance abuse due to access, stress and attitudes toward substance use. The COVID-19 pandemic has increased stress, anxiety, depression, fatigue and burnout among nurses. These conditions have all been linked to substance use in past studies; however, the impact of the pandemic on nurse cannabis and other substance use is currently unknown. 

The new study will address these gaps by exploring nurse use of cannabis in addition to other substance use. Dr. Rainbow, along with Shawn Gallagher, PhD, PMHCNS-BC, APRN-BC, FNP-BC, a professor in the College of Nursing, and Alicia M. Allen, PhD, MPH, an assistant professor in the UArizona College of Medicine – Tucson and member of the UArizona Health Sciences Comprehensive Pain and Addiction Center, will examine the potential impact on patient care through both a cross-sectional survey and one-on-one interviews with nurses who self-report using cannabis. 

“This study will involve a large confidential survey and interviews with a subset of survey respondents who use cannabis,” Dr. Rainbow said, adding that questions will include measures of nurse substance use and some free-response questions. “As part of the survey, we will ask participants to complete a schedule of the prior week and include when they worked and when they used substances.”

The findings of this study may provide valuable information about how nurses are currently using cannabis and other substances, and the potential impact of use on patient care. These data can inform the development of cannabis use regulations, and diversion and educational programs for nurses in this changing state and federal landscape.

The study aligns with the National Council of State Boards of Nursing Center for Regulatory Excellence’s research priorities of “impact of legalized marijuana” and “substance use disorders in nursing.” 

“The National Council of State Boards of Nursing is interested in nurse cannabis use because of the changes in cannabis legalization across the United States and the implications for state boards of nursing,” Dr. Rainbow said. “Our findings may guide future regulations, and hopefully interventions, to address any work-related issues that are leading to nurse substance use in a way that impacts patient care and is detrimental to their own health.

“For my research,” she added, “this will guide what kind of work system interventions I build to improve the work lives and health of nurses.”

Dr. Rainbow’s research seeks to improve systems, such as hospitals, to improve nurse health and safety, which will ultimately improve the patient care they provide. 

“The synergistic approach in training psychiatric nurse practitioner doctoral students together with psychology doctoral interns will prepare them to provide integrated care within teams. In doing so, it leverages the expertise of the College of Nursing and the College of Medicine – Tucson in our shared missions,” ~ Sara Edmund, DNP, RN, FNP-C, PMHNP-BC

“This program will have a tremendous impact on the preparation of mental health professionals working in community clinical settings,” Dr. Edmund said. “The synergistic approach in training psychiatric nurse practitioner doctoral students together with psychology doctoral interns will prepare them to provide integrated care within teams. In doing so, it leverages the expertise of the College of Nursing and the College of Medicine – Tucson in our shared missions."

Each cohort will experience 12-month longitudinal tracks that align with the purpose of the program and the trainee’s professional interests.

“The increased prevalence of mental illness and needs for both prevention and treatment are outpacing the current availability of licensed mental health professionals,” Dr. Karp said. “This award responds to this dual crisis by training mental health professionals from different disciplines to provide effective team-based care. Our unique approach to multidisciplinary education and training puts the University of Arizona Health Sciences in the vanguard for improving access to behavioral health care.”

For each track, trainees will be integrated into the partner site’s care team to learn best practices in multidisciplinary care. Focus areas at the partner sites include child and adolescent mental health, rural and underserved areas, substance use, and late-life mental health. With the current and anticipated effects of the COVID-19 pandemic in mind, training in telehealth will be prioritized.

“There is a great need to respond to the paucity of health care providers prepared to care for those with mental illness in Arizona and nationally,” said UArizona College of Nursing Dean Ki Moore, PhD, RN, FAAN. “The Behavioral Health Workforce Education and Training program will serve as a major education and training platform for a cohort of psychiatric mental health nurse practitioners and PhD-level psychologists who are committed to training in underserved and culturally diverse areas with high levels of poverty, substance use, adverse childhood experiences and an alarming increase in suicides compared to 2019.”

“Data Science needs to be something that we address in every course and is familiar to students because they learn about it over and over again throughout courses, but in different perspectives, so that when they inevitably need to evaluate a large data set for their research question, they are equipped to understand all the dimensions of working with big data," ~ Kimberly Shea, PhD, RN, CHPN

Dr. Shea and her colleagues created the Data Science Curriculum Organizing Model (DSCOM) to guide a comprehensive review of PhD education that will enable data science to be addressed within the individual courses throughout the program. The DSCOM represents concepts and constructs, and their relationships which are essential to a comprehensive understanding of data science. By transforming the terminology and applicability of multidisciplinary data science models into the DSCOM, Dr. Shea’s team found that application of the DSCOM identified areas for threading into core course curriculum, as well as gaps that require additional content. Bottom line: the DSCOM is an effective tool to guide curriculum development and evaluation towards the preparation of nurse scientists with knowledge of data science.

“The ubiquitous presence of technology continually generates vast quantities of data that necessitate leaders within the health care system understand data science,” Dr. Shea and her co-authors wrote in their article. “As the foundation of the health care system, nurses must have a working knowledge of technology generated data. Data science is more than just understanding numbers used for analysis. Data support evidence-based practice and nurse scientists must thoroughly understand the complexities of data science in order to use advanced analysis techniques to build knowledge for providers.”

“In our college we have a remarkable group of informatics scholars and data science is one of the components or interests of informatics,” Dr. Shea explains, noting how retired UArizona Nursing Professor Anne Rosenfeld’s interest in expanding Nursing’s focus on integrating data science into graduate-level curriculum provided the inspiration for the project. “We wanted to see how we might look at integrating data science into our PhD curriculum.”

Dr. Shea and colleagues found that there was ample room for data science to be integrated throughout the College’s courses. “It's not just one course, it's possible within every course,” she says, “because it [data science] applies to every course and every bit of what we teach in today’s [PhD] programs and potentially in the DNP.” However in the article, they only apply the DSCOM to the core courses in the PhD program.

“We decided to use a course mapping technique, taking from all the syllabi and objectives in all of the core courses,” Dr. Shea explains. “We then applied our model to evaluating those syllabi to discover the overlaps and gaps.”

The concept mapping technique was a concerted effort that was painstaking.  Dr. Shea says. “In short, we evaluated constructs [Domain, Ethics, Theory, Technical, Analytics and Dissemination] for matches and then gathered information about concepts within the constructs and found that there were opportunities for insertion, overlaps and gaps that needed to be filled.”  The course mapping identified that there were 123 matches and 3 large gaps within the existing curriculums.

The next step will be to take what has been learned and implement it into the UArizona Nursing’s upper division course work – and hopefully disseminate use of the model to other nursing schools. Dr. Shea hopes that by sharing the team’s research and conclusions, others will learn the methodology without having to conduct their own intensive evaluations of the academic literature on the subject.

“Ultimately it can be used by nursing colleges and schools throughout the United States and abroad to realize that data science is much bigger than just getting a data set and using statistics” she says, noting that the DSCOM can be accurately used to apply, disseminate, and analyze gaps in the curriculum of other institutions. “It [data science] is our future of evaluating outcomes and needs to be something that we address in every course and is familiar to students because they learn about it over and over again throughout courses, but in different perspectives, so that when they inevitably need to evaluate a large data set for their research question, they are equipped to understand all the dimensions of working with big data.”

“This multi-sensory infant massage is low-cost, easy to learn, and can be applied as soon as the baby’s born. The mother applies the infant massage, but any caretaker or clinician can easily teach it," ~ Aleeca Bell, PhD, RN, CNM

This intervention has been researched for 30 years in primarily pre-term infants in the NICU, but Dr. Bell’s study will focus on full-term healthy babies.  “We want to promote positive mother-infant interaction, but there’s limited research to show us what works in a cost-effective way,” she says. “This multi-sensory infant massage is low-cost, easy to learn, and can be applied as soon as the baby’s born. The mother applies the infant massage, but any caretaker or clinician can easily teach it.”

The scientific literature demonstrates that higher oxytocin levels in blood and saliva are associated with better mother-infant synchrony, but a unique element of Dr. Bell’s study is that it looks in greater detail at the oxytocin pathway to determine epigenetic effects (i.e., how oxytocin is regulated). “In this RCT, we hypothesized that moms with a history of early life adversity will demonstrate lower mother-infant synchrony due in part to a dysregulated oxytocin system,” Dr. Bell says. “We theorize that our intervention will lead to greater mother-infant synchrony and a better functioning oxytocin system.”

During the three-month intervention, participating mothers will give the 15-minute infant massage daily, because three months is the earliest that mother-infant synchrony can be reliably measured. More than just a massage, the technique is geared toward teaching new moms how to engage with their infant. There will also be a control group who will come to all the study sessions to donate blood and answer questionnaires, but they will receive an educational intervention about safe infant care.

The moms and babies will be videotaped during their interactions, after which video coders will complete the painstaking process of micro-coding behaviors. “We use a highly rigorous method that only requires three minutes of video recorded behavior to measure frame-by-frame the mother’s and the baby’s gaze, affect, touch and speech,” Dr. Bell says. She points out that most researchers who study mother-infant interactions use a more subjective method where coders are trained to reliably examine segments of recordings to rate the quality of that interaction. “Another unique aspect of the study is that it’s a very objective, quantitative way to measure behavior,” she says. 

Currently, Dr. Bell is hiring staff for the project, but she hopes to begin recruiting participants in January. Though the recruitment sites have yet to be determined, Dr. Bell has already set in place a raft of safety guidelines to make the process safer during the COVID-19 pandemic. Recruiting will be done over the phone versus in person and when participants do need to come to the College for study visits, masks and social distancing will be required. Appointment times will also be limited and staggered to avoid waiting room interactions as much as possible.

Once this study is completed, Dr. Bell hopes to enhance her research with further inquiries. One extension is to follow vulnerable mother-infant dyads for a longer period of time to ascertain broader biobehavioral health outcomes, and to determine epigenetic effects of the massage in the infant. Another goal is to enable clinicians to implement teaching the infant massage, testing at multiple sites, so that it can eventually become standard of care.

Dr. Bell, who practiced as a Certified Nurse Midwife for seven years prior to entering academia, has an unwavering commitment to improve the wellbeing of mothers and babies in the perinatal period. She seeks to promote a positive birth experience for women and encourage optimal mother-infant interaction. “The same passion I had as a clinician is what drives my research,” she says. “As a clinician I wanted to promote physiologic birth and to help moms and babies get off to a great start – to help them fall in love with each other. These are the same desires that drive my research questions.”

College of Nursing research takes a comprehensive approach

Nurses are trained to address the person, the environment, and well-being, and the research in the college typically incorporates these, Dr. Loescher said.

“We look at it through a little bit different lens than a physician or a pharmacist. We're really looking at health in a broader context,” said Dr. Loescher, who noted she is pleased to see other health care fields have begun to move in a more holistic direction, too. One of the most difficult challenges in health care is to change human behavior, both Dr. Loescher and Dr. Gordon said, and much of the college’s research work touches on ways to promote positive behavioral changes. For example, Tracy Crane, PhD, an assistant professor in Nursing, Public Health and Nutrition Sciences, is studying the impact of lifestyle behaviors, such as changes to diet, physical activity, sleep and tobacco use, on health outcomes for cancer survivors.

“Most of these projects show the synergy that happens between practice and research,” said Dr. Gordon. “Our PhD students are nurses who have practiced and who have been working in various areas, and they’ve generated questions that we answer through the research process, which generates more questions.”

Nursing research includes basic and behavioral sciences, and beyond

“We have researchers who are looking at the effect of stroke on brain microglia, all the way to questions such as ‘How do we better provide tobacco cessation treatments to cancer patients at the UArizona Cancer Center?’ and everything in between,” Dr. Gordon said.

The science comes together just as it does in other colleges, in a variety of settings, including laboratories and community engagement programs.

“We have two core labs. One is a biological core lab that does basic wet lab assays looking at biological markers in our research. We also have a behavioral applied clinical science lab that provides space and facilities for doing in-person behavioral research across all our domains,” Dr. Gordon said. “Much of our research takes place in community settings. We recruit participants through health centers, community centers, and social media.”

College of Nursing research is as diverse as the researchers are

College of Nursing faculty is comprised of both nurses and scientists from other fields, creating a rich environment for team science. Faculty and students in the PhD program who come from a nursing career bring myriad life and work experience to the study of human health, and that makes the research that comes out of the college equally diverse. Those from other fields bring their expertise to enrich research and education.

Drs. Loescher and Gordon are prime examples.

Dr. Loescher began her career as an ICU nurse, then moved into oncology and eventually worked at the University of Arizona Cancer Center. She then earned her PhD from the College of Nursing, and now oversees the PhD program along with conducting cancer prevention behavioral research.

Dr. Gordon is representative of those with other professional backgrounds. Dr. Gordon’s health care background is in behavioral psychology. Before that, she worked in IT and theater. She pulled all of that together when she worked with students studying computer science to create the See Me Serene mobile phone app to study guided meditation for stress reduction and smoking cessation.

“I like to describe the research in the College of Nursing as research done by nurses and other experts about nursing and, primarily, about how to improve health, health care and health equity,” said Dr. Gordon.

College of Nursing research embraces teamwork

Nurses are trained to be collaborative in the clinical environment, which translates to being collaborative in their research pursuits, said Dr. Gordon.

“We have so many connections to so many different fields, and I think it stems from an attitude of recognizing that there are different members of the team that bring different expertise, and together it creates this really positive synergy,” Dr. Gordon said.

Zhanette Coffee, FNP-BC, MSN, APRN, a nursing PhD student, is a prime example. She is studying integrative health approaches for patients with opioid use disorder and chronic pain. The study is a collaboration with researchers at the College of Pharmacy and the Comprehensive Pain and Addiction Center.

Dr. Gordon and Dr. Loescher are both members of the University of Arizona Cancer Center and have worked on cancer prevention strategies. They say that College of Nursing faculty are involved in many kinds of health research with many collaborators.

“I think you'll find that a lot of the research we do may be perceived as something else besides nursing because we have so many team players,” Dr. Loescher said. Dr. Gordon agrees, “What this shows is the important contribution that the College of Nursing makes to team science and to improving health.”

Additional examples of ongoing research in the College of Nursing:

• Terry A. Badger, PhD, RN, FAAN, chair of the division of community and systems health science: innovative ways to reduce psychological distress among cancer survivors and their caregivers, through telephone and app-based interventions
• Aleeca Bell, PhD, RN, CNM, associate professor: integrative intervention for improving the maternal-child bond in order to improve health outcomes and long-term educational and other outcomes, among first-time, low income mothers.
• PhD student Ottilie Rung: testing the feasibility of integrative health intervention alternate nostril breathing to reduce biopsychosocial stress in pregnant women who are victims of intimate partner violence.
• PhD student Elizabeth Johnson: testing a USB wristband device worn by pediatric cancer patients that houses clinical trial information to be accessed by providers in critical care and emergency situations.
• PhD student Cristina Rivera Carpenter: studying wellness among Diné women in Navajo Nation border towns using a methodology that integrates mainstream Western qualitative methodology with Indigenous methodologies.
• PhD student Carrie Langley: studying the factors that facilitate and inhibit the use of community-based transitional support services by adults with mental illness post release from jail.

“Skin cancer is the most common cancer in the US and costs about $8.1 billion annually to manage. Massage therapists trained to properly communicate skin cancer risk reduction information to their clients ultimately could contribute to decreased skin cancer incidence and management costs,”  ~ Lois J Loescher, PhD, RN, FAAN

Because of their eyes-on-the-skin observation and client-centered communication, MTs are uniquely positioned to promote skin cancer risk reduction. During a typical full body massage, MTs have a full view of each anatomical area of a client’s body, allowing the opportunity to visualize skin cancer risk factors such as sunburn, tanning lines, high mole counts, or suspicious lesions. Additionally, clients typically see their MTs more often and for longer durations than their primary care provider and are more likely to discuss health promotion offering greater opportunities for communication and encouragement of effective skin cancer risk reduction behaviors.

Some MTs receive education about skin cancer while completing licensing and certification training; however, there is no national standard for the extent of inclusion in massage therapy curricula. To help fill this gap, Dr. Loescher and her team developed an e-training intervention with two purposes: to inform MTs about skin cancer risk reduction and to train MTs how to have positive client-focused conversations about skin cancer risk reduction without compromising their scope of practice.

Dr. Loescher’s team utilized the DecisionSim™ online platform in the e-training intervention. The team developed five virtual cases (simulations), each highlighting different components of a conversation within the context of a massage client visit. Each case contained between four and seven decision points for the participant to apply knowledge. The five cases were seamlessly integrated into the learning management system (LMS) to directly follow the e-training modules, allowing staff to monitor participant status and case completion.

To test the efficacy of the e-training, Dr. Loescher and her team recruited 80 MTs practicing in the state of Arizona. Participants demonstrated high rates of success with the training, which significantly improved their skin cancer knowledge and attitudes and comfort with delivering risk reduction information with their clients. A majority of MTs found the simulations useful and worth including in the training of future MTs. Dr. Loescher and her team concluded that adding decision simulation technology to e-training modules was useful not only to assess participant knowledge and skills, but also to assess e-training content and delivery for improvement. This innovative, practical application of simulation technology may be useful in a wide variety of health promotion and disease prevention contexts across disciplines and populations of study.

As for the future, Dr. Loescher’s team is planning on further testing of the e-training in a larger sample of massage therapists in sunbelt states in the US.

Adding fuel to this fire, the COVID-19 pandemic has exacerbated these issues. “Before the COVID-19 pandemic, the suffering of nurses from suboptimal well-being and burnout was normalized in healthcare,” adds Littzen. “According to Arundhati Roy, COVID-19 is a portal, and we have the choice to decide what we leave behind. Now is the time we acknowledge that the normalization of suffering in nurses is unacceptable, and together we need to create work environments that enable all nurses to thrive in the new post-pandemic world.”

Dr. Rainbow and Littzen are both conducting IRB-approved research studies that will describe the experiences of our frontline nurses prior to, and during, the COVID-19 pandemic. Dr. Rainbow’s study is utilizing a voicemail box to collect recordings of the experiences of nurses and others working in healthcare during the pandemic. Anyone working in a healthcare setting in the United States during the pandemic is eligible to call the study voicemail box (1 833 624 0707) and leave a message detailing their experiences. Dr. Rainbow describes the inspiration for her study as, “Listening to nurses and other providers  talk about working during COVID-19 made me interested in capturing recordings of these experiences to figure out how we can intervene to improve the healthcare work environment and also to catalogue this time in our history.” Participants can access the consent form with study information online or contact Dr. Rainbow for more information.

"Now is the time we acknowledge that the normalization of suffering in nurses is unacceptable, and together we need to create work environments that enable all nurses to thrive in the new post-pandemic world," ~ Chloe Littzen, MSN, RN, AE-C, PhD Candidate

Littzen is doing this in her dissertation study titled, “Young Adult Nurse Work-Related Well-Being, Contemporary Practice Worldview, Resilience, and Co-Worker Support,” where she inquired about the role of COVID-19 in nurses work-related well-being. 

Littzen and Dr. Rainbow both plan to use their study findings to guide future interventions that will improve the healthcare work environment and nurse well-being. Dr. Rainbow says. “My goals in creating this study were to understand the different experiences of different healthcare providers and those working in healthcare settings during the pandemic. This will help us improve readiness for future pandemics and build interventions to improve the healthcare work environment.”  In the meantime, they reached out to nurses and other health care workers with a series of questions designed to garner their feelings about such subjects as how leadership can help nurses during this time, as well as how the public can improve the situation. “I kept getting asked by my non-healthcare friends how they can support nurses and other providers during the pandemic and what nurses are doing to cope during this difficult time, so I thought it was important to ask nurses and share that information,” Dr. Rainbow said. Littzen and Dr. Rainbow asked nurses on social media what they would like the public and healthcare leaders to know as well as how nurses are coping with the increased stress of working during a pandemic. Here is how nurses responded:

Following is a breakdown of the results that were garnered from the informal Twitter survey, as well as contact information for nurses seeking more information and support.

• The pandemic is on the verge of breaking the nursing workforce, and to a larger extent, healthcare at large.

  The COVID-19 pandemic has strapped healthcare organizations for resources, both tangibly and financial. Nurses feel the squeeze of this lack of resources, and they are doing their best to make sure patients do not suffer. But this can only last for so long, and nurses will ultimately reach a breaking point. They will either leave their jobs once hiring freezes end or they can travel, or leave nursing altogether. Prior to COVID, the turnover rate among nurses was 15.9% in the United States.

For a snapshot of breaking point, Dr. Rainbow and Littzen asked in their informal Twitter survey, “Have you thought about leaving your job, or nursing completely during the pandemic?” Of the 44 participants, 39% selected “leaving my job” 18% selected “leaving nursing,” with only 43% selecting “neither.” Only time can tell if and when this comes to fruition, but 57% of respondents are demonstrating this breaking point.

• What can nursing leadership do to support their nurses during the pandemic?

  Nurses know that leadership is maxed out, but they do not feel as if leadership is being honest with them. 

  Expressing concerns about nursing leadership, one participant stated:

  “They need to be honest... If there is a shortage of PPE, be honest about it, don't try to make us believe using the same N95 for days is "safe"... needless to say, trust has plummeted (sic).”

  In the Twitter survey, nurses also expressed concern about the post-traumatic effects from the pandemic that are on the horizon for them.

  One nurse stated:

  “A greater recognition of the effects that bearing witness to such extensive death and loss will have on providers in the coming days... I see so much PTSD in the near future.”

  While data is lacking on the occurrence of post-traumatic stress related to the pandemic, leadership needs to proactively prepare for the potential of post-traumatic stress for their frontline nurses.

  One nurse described this experience to nursing leadership, and offered some suggestions to help frontline nurses:

  “The worry from working directly with Covid patients can be overwhelming sometimes. Worry about taking it home to family. Worrying about family who lost jobs or gotten sick. Wondering how long these altered work environments will keep up. I think what so many people want right now is to feel safe and valued and heard in some way. We don’t want to be in the dark about decisions that will impact us. I think team of social workers and chaplains should be employed to support staff around the hospital on every shift.”
   

• How can the public help support nurses during the pandemic?

  Nurses want the public to understand that they are doing everything they can to help their patients and families. But they are tired, and their bandwidth is maxed out.

  In describing her experience being a frontline nurse, one participant stated:

  “We’re tired. Frustrated and over begging people to do the right thing. We’re doing the best we can, one second we’re heroes, the next villains for asking people to wear a mask. But we continue to fight. Because mask or no mask we will care for those in their sickest hour”

  Nurses want the public to remember that nurses are human too. They have children, and some have multiple jobs. Nurses need the public to be more understanding of who they are as humans, and grant them flexibility, grace, and forgiveness when things don’t go as planned.
   

• What have nurses been doing to help their well-being and burnout during the pandemic?

  Nurses have been trying out a variety of creative self-care strategies to help enhance their well-being and prevent burnout during the pandemic. Many of these strategies are mind-body focused activities such as meditation, yoga, and journaling. One resource that many nurses have recommended is the Calm app. Dr. Judith Gordon, UArizona Nursing Associate Dean, Research, has also developed an app, “See Me Serene,” an app that uses Guided Imagery to address the negative health effects of social isolation by reducing stress and anxiety.

  One nurse described:

  “I started Calm several weeks ago, and it has been a significant quality of life enhancer. I do guided meditation at least 1xa day...”

Nurses have also been reconnecting with nature by going for walks or hikes outside and gardening. Others have prioritized sleep including naps, hydrating, eating healthy balanced meals, and making sure they make time for creative hobbies such as cooking or baking. Some nurses know they haven’t been doing the best job managing their well-being and burnout, but they are actively practicing grace towards themselves during this difficult time. 

Dr. Rainbow and Littzen hope to expand on the understanding of the impact of COVID-19 on nurses from their two ongoing studies. The participation of more nurses in this research will help improve readiness for  future pandemics and build interventions to improve the healthcare work environment.
 

While social media can provide connections with others, social isolation removes people from nature and the outdoors. People who cannot go outdoors may experience increased stress and anxiety as a result.  Although technologies exist to provide immersive experiences (e.g., virtual reality), they require specialized equipment and are expensive. The vast majority of Americans across age, race/ethnicity, and socioeconomic status own smartphones; and of those, most use mobile apps. Dr. Gordon’s project addresses this stress by offering a mobile app that delivers a Guided Imagery intervention.

Guided imagery is a proven method that uses enhanced visualization to help people deal with stressful situations, including social isolation. More than just visual images, guided Imagery involves imagining sights, sounds, tastes, smells, tactile senses, and the emotions you feel in a particular situation. Dr. Gordon and her colleagues have used Guided Imagery successfully to help people make positive lifestyle changes, like quitting smoking, eating healthfully, and getting more exercise. Guided Imagery also has been shown to be effective at reducing chronic pain and anxiety.

"Using a simple mHealth app to deliver Guided Imagery audio files will provide endless possibilities for simulating outdoor experiences for the millions of Americans experiencing social isolation," ~ Judith Gordon, PhD, UArizona Nursing Associate Dean, Research

“Using a simple mHealth app to deliver Guided Imagery audio files will provide endless possibilities for simulating outdoor experiences for the millions of Americans experiencing social isolation,” Dr. Gordon said.

The See Me Serene app provides users with immersive, vivid, nature experiences designed to reduce stress and anxiety related to social isolation. The app will be a more affordable and scalable solution than Virtual Reality, which requires expensive and specialized equipment. “See Me Serene allows users to select from at least 50 different audio files, each describing a different outdoor experience. The app also contains links to mental health resources that are available 24/7,” Dr. Gordon said.

The goals of the See Me Serene research project are to pilot test the app with 100 participants. Participants will provide self-report survey data and will be tested for cortisol levels collected from saliva. Cortisol is a biological marker for stress. Participants will use the See Me Serene app for 4 weeks. People interested in participating can contact the research team from within the app.

“Our hope is that See Me Serene will be easy to use and that it will help people cope with the stress and anxiety they’re feeling as a result of being stuck indoors,” Dr. Gordon said. “If our pilot results are promising, we will seek funding to conduct a large-scale efficacy trial. In the meantime, the app will be free for anyone to use.” See Me Serene is available on the App Store and the Google Play Store.

The BIO5 grant was made possible with resources from the BIO5 Institute and the Technology and Research Initiative Fund (TRIF) to help researchers quickly pivot their work to address the pandemic in areas related to improving the health of Arizonans. 

The Technology and Research Initiative Fund that helped launch BIO5 in 2001 continues to be a catalyst in enabling effective, cross-disciplinary bioscience research and innovation at the University of Arizona, where initiatives and projects are carefully chosen to align with areas of state and national need.

Over the past 19 years of TRIF, over $50 million has been invested in building critical facilities and research services that UArizona is leveraging today to quickly and robustly respond to the current COVID-19 crisis. TRIF allows the flexibility to pivot and repurpose campus resources to engage in the complex fight against COVID-19, drawing on faculty expertise, campus facilities, logistical assets, research labs, and campus staff and leadership to provide immediate assistance in the battle against the pandemic.

The See Me Serene App is available from the App Store and Google Play. Find more information here.