key: cord-0848572-17yki391
authors: Ross, Lisa; Meier, Niessa
title: Improving adult coping with social isolation during COVID‐19 in the community through nurse‐led patient‐centered telehealth teaching and listening interventions
date: 2021-02-03
journal: Nurs Forum
DOI: 10.1111/nuf.12552
sha: 99106030350a2cc02e5f586b734324034dac48cd
doc_id: 848572
cord_uid: 17yki391

BACKGROUND: The coronavirus disease 2019 (COVID‐19) pandemic led to social isolation which both threatens mental health and has been shown to increase the risk for early death by 50%, and to contribute to increased rates of heart disease, hypertension, stroke, and inflammation. LOCAL PROBLEM: No identified special programs to address loneliness related to social isolation were in place. This project aimed to improve adult coping with COVID‐19 in the community to 80% over 8 weeks. METHODS: Three interventions were implemented concurrently and studied through Plan–Do–Study–Act cycles. Each cycle started with a test of change, followed by data collection and analysis using run charts, aggregate data tables, and field notes. This analysis guided the design of new tests of change for each intervention in the following cycle. Iterative changes were introduced through four cycles over 8th weeks. INTERVENTIONS: These included a data‐gathering survey, a telehealth teach‐back tool and a telehealth listening tool. All interventions were implemented remotely through telehealth contacts. RESULTS: The project engaged 44 participants and successfully addressed loneliness by creating a social connection with 100% of participants and 82% of participants learned something new. CONCLUSION: Telehealth interventions hardwired to be patient‐centered can provide isolated populations with meaningful social contact.

The newness of the COVID-19 pandemic and a concern for the wellbeing of community members were the impetus for this 8- week rapid cycle quality improvement project. It consisted of three core interventions. These were implemented concurrently through four Plan-Do-Study-Act (PDSA) cycles. Each cycle started with a test of change (TOC) for each intervention followed by 2 weeks of data collection. Then, data analysis and review of the literature led to the design of a new tests of change for the next 2-week cycle. Four PDSA cycles were completed.

The core interventions began with a survey administered using Google Forms. The survey questions were continually modified throughout the 8 weeks of implementation according to the iterative quality improvement process. A complete list of survey questions is displayed in Table 3 . Of note, every iteration of the dynamic survey included the question "What worries you the most about COVID-19?" This question is the cornerstone of patient-centered care and responses to this question steered the subsequent interventions.

The survey was followed by a telehealth encounter via either phone or video call for the implementation of both of the other interventions. First, education was provided and then reinforced using a telehealth teach-back tool. All teaching was followed by use of a telehealth teach-back tool. The tool used was a single question asked by the project implementer during the call: "I want to be sure that I explained that clearly, please teach it back to me." A variety of teaching topics were explored over the 8 weeks, these were planned to address learning needs identified through the survey. Initially teaching was provided around the prevention of COVID-19. By the end of the first 2-week cycle, a good understanding of prevention measures had been established in the community, so a survey question was added to ask "What question do you have/what would you like to learn more about relating to COVID-19?" Teaching on the topic identified by each participant was then addressed during that participant's telehealth contact, following the principals of patientcentered care. However, by the completion of the second cycle, it was apparent that project participants were struggling to identify teaching needs. It was also noted that many participants reported on the survey that what worried them the most was the death or critical illness of themselves or someone they loved. Consequently, the teaching topic for Cycle 3 addressed end of life care decision making using guidance from The Conversation Project, an initiative of the Institute for Healthcare Improvement. 13 This iterative change was made to maintain patient-centeredness. Questions were added to the survey to prepare the participants for this discussion. These survey questions revealed that, in contrast to the general population, 80% of project participants already had health care proxy documents in place. By this time, survey data revealed that almost all participants were struggling with loneliness during social isolation. Iterative techniques ultimately led to standardized teaching of strategies to mitigate loneliness as discussed in a current publication in the popular press. 14 Telehealth listening was the second intervention implemented during the call. Implementation was standardized by using the single question tool: "On your survey you reported that [insert survey response] is the thing that worries you the most about  please say more about that." The project implementer used active listening techniques as the participant spoke. The link between the survey and the telehealth listening intervention compelled the project to remain patient-centered. At the completion of each PDSA cycle success on each of the three interventions, as well as information gathered, were used to inform the new TOC (Table 1 ).

Objective information on the processes and outcomes of the interventions was collected using surveys and tallies taken during participant contacts and then displayed in run charts and aggregate data workbooks. Reflections on encounters with participants recorded in the field notes were also studied by the implementer every 3 to 4 days. Additionally, awareness of current events and topics in the news were key to planning small tests of change. Ogrinc et al. 16 describe iterative change as a strategy to overcome natural resistance to change and ensure buy-in. It is a powerful method to achieve lasting change in complex systems.

A portfolio of six measures was assembled to monitor the impact of the three core interventions in identifying and meeting community members needs during social isolation. Measures planned for studying the interventions are displayed in Table 2 . The pre-survey was studied to measure the reliability of administration and success in obtaining the desired information. The telehealth provision of both active listening and of new information, and a check for clarity in the participant's understanding were tracked. Finally, the participants' level of concern following telehealth listening was measured. Reliability of the process data was achieved using Google technology and the rigor of the project implementer. Contextual changes were documented in the field notes and in the aggregate data tables. The data was assessed for completeness and accuracy by crosschecking the workbooks with the results data collected by Google Forms for the pre-and post-surveys. Tallies taken during contacts with participants depended on the diligence of the project implementer.

Quantitative data were displayed on run charts and analyzed by identifying runs, shifts, and trends that would indicate special cause variation, meaning that variation in the data could be attributed to the T A B L E 1 Plan-Do-Study-Act (PDSA) cycles and interventions 

Forty-four adults from 14 states participated in the standardized screening, telehealth teaching and telehealth listening interventions which successfully identified the community need to address social isolation and addressed that need. Patient-centeredness was sustained through the project through continual modifications to the survey and by using survey responses to guide the telehealth teaching and telehealth listening interventions. The project met the aim of identifying a community need during COVID-19, which was found to be a need for social connection-and addressing that need through telehealth teaching and telehealth listening. The interventions resulted in participants reporting both that they felt a connection with the project implementer and that "it was nice to talk with someone for a while today" in 100% of the cases.

Over the 8-week implementation period, 100% (44) of participants were surveyed using the project survey tool that was continually modified using the quality improvement methodology. The open-ended question asking "What worries you the most about COVID-19?" appeared on every iteration of the survey. This is a variation on the question "What matters to you?" that is promoted by the Institute for Healthcare Improvement as a tool to increase healthcare care quality and safety and to minimize barriers to care. 15 It was also used by the Institute of Medicine in developing the quality domain of patientcentered care. 17 Responses to this question ranged from concerns about illness and death, a vaccine, the behavior of others, and economic issues. In Cycle 1 (N = 14), the survey was introduced, and success in its administration process was established. It was discovered that the survey could also be used to direct the teaching provided. So, in Cycle 2 (N = 10), a survey question was added to identify a topic of interest for teaching. This did not change the outcome being measured. Just 5 (50%) of participants identified a topic for teaching, so this question was removed from the survey at the end of Cycle 2. In Cycles 3 and 4, the proportion of respondents who identified a concern remained unchanged despite the survey being revamped in Cycle 3 (N = 11) to eliminate the questions assessing risk for COVID-19 infection that were not addressed in the project interventions and to include questions about end-of-life decision-making. Participants were more eager and conscientious in completing the surveys than expected. Table 3 displays questions included on the survey.

All of the participants (N = 44) were taught new information based on the needs indicated on the intake survey and the telehealth teach-back tool was used in 33 (75%) of the cases. In Cycle 1 (N = 14) , the telehealth teach-back method was introduced on the topic of COVID-19 prevention, and 6 (43%) of participants were found to need a clarification. It was discovered that teaching via fact sheets was ineffective because participants referred back to the fact sheets during the telehealth teach-back method, undermining the tool. In AIM: Improve adult comprehension of and coping with COVID-1% to 80% over 60 days.

Mean score on COVID knowledge and concern survey (1-5) 3.3

Outcome: Mean % patients identified with at least one concern 100

Teach back Process: # participants reporting they looked at the fact sheets or who had oral teaching/# participants who returned surveys Outcome: Mean % participants reporting decrease in level of concern 27

Abbreviations: COVID-19, coronavirus disease 2019; TOC, test of change.

relating to COVID-19?" and teaching was provided to address that topic. The result was that 2 (20%) needed clarification. For Cycle 3 (N = 11), the teaching topic evolved further as many participants struggled to identify a learning need and the implementer predicted that end-of-life decision making would be of interest to all participants due to rising death rates from COVID-19. In this cycle the survey revealed that only 2 (18%) of participants had not already talked to their designated health care proxy about their wishes for end of life care. This led to telehealth teach-back being used inconsistently and just 1 (9%) participant needed clarification. So, in Cycle 4 the teaching topic was changed to strategies to address loneliness because 10 (90%) participants in Cycle 3 reported that they wished they had more social contact. In Cycle 4 (N = 9), telehealth teach-back was used more consistently, and 3 (33%) of participants needed clarification. The smallest number of participants who required clarifications occurred during Cycle 3 because the implementer decided against using telehealth teach-back in this cycle. Patient-centeredness was prioritized in the context of teaching that was not meaningful to the participants. This prioritization is understood as a bias of the project implementer.

The telehealth listening tool was used in all 44 cases, but this intervention did not consistently lead to a decrease in participants' level of concern. What was found instead is that 100% of participants asked reported that they felt a connection with the project implementer and 100% reported that "it was nice to talk with someone for a while today." Patient-centeredness was assured in every contact as the tool asked the participant to discuss the concern that they had previously identified on the survey. In Cycle 1, the telehealth listening tool was introduced (N = 14), and 5 (36%) reported a decrease in their level of concern. It was discovered that the efficacy of the telehealth listening tool used via phone calls was limited, so in Cycle 2 (N = 10), video calls were used instead of phone calls, which resulted in 3 (33%) of participants reporting a decrease in their level of concern. At this point, it was discovered that social interaction was more meaningful for participants than counseling. So, in Cycle 3 (N = 11) a question was added to the follow-up survey to measure how much the participant valued the social contact made through project participation. In this Cycle, 2 (18%)

The project was systematically patient-centered as the survey was used to collect information about each participant's needs and values which was then incorporated into the subsequent telehealth interventions. Use of the telehealth teach-back tool resulted in 36 (82%) of participants learning something new through the project. The telehealth listening tool led to 100% of participants feeling a connection with the project implementer and 100% reporting that "it was nice to talk with someone." Social contact made a difference.

The quality improvement initiative pilot project demonstrated that social contact via patient-centered telehealth tools was an effective structure for mitigating loneliness and isolation in a convenience sample of adults living in the United States. Patient-centeredness is an approach found to decrease anxiety. 18 Respect for patients' preferences, education, and emotional support are core concepts of patient-centered care. 19 The project was designed to be patientcentered by using patient-reported needs and concerns to direct the use of the telehealth listening and telehealth teach-back tools.

Telehealth teach-back was in fact a strong tool for reinforcing teaching, but its use was found to be influenced by the implementer′s biases. This finding aligns with Talevski et al.'s 20 call for support for clinicians in implementing the teach-back method. Listening has been found to be impactful in promoting emotional improvement, 6 

Almost all participants in this study had a personal relationship with the implementer and so do not represent the general population. A convenience sample was used to meet the time constraints of the project, and no effort was made to control for this bias. Further, the survey tools used were not validated, and there were no controls on the implementation of the telehealth teach-back tool or telehealth listening tool, though conscientiousness was encouraged.

This project successfully provided meaningful social contact for community members impacted by COVID-19 through the use of telehealth teaching and listening tools implemented by an advanced practice nurse. Patient-centeredness was foundational to the project design and contributed to the success of the interventions. This telehealth project mirrors befriending projects. Further study should work to illuminate all the benefits of befriending programs and best practices for their implementation, especially in a telehealth environment.

Typologies of loneliness, living alone and social isolation, and their associations with physical and mental health

Loneliness and social isolation as risk factors for mortality: a metaanalytic review

The Implications of COVID-19 for mental health and substance use. KFF Web site

Centers for Disease Control and Prevention. Coping with stress: Pandemics can be stressful

Interventions to reduce social isolation and loneliness among older people: an integrative review

The role of 'active listening' in informal helping conversations: impact on perceptions of listener helpfulness, sensitivity, and supportiveness and discloser emotional improvement

Building trust in home healthcare

Telehealth: no longer an idea for the future

Committee on Quality of Health Care in America -Institute of MedicineCrossing the Quality Chasm: A New Health System for the 21st Century

A framework for public health action: the health impact pyramid

Agency for Healthcare Research and Quality Web site

Effectiveness of befriending interventions: a systematic review and meta-analysis

Institute for Healthcare Improvement. The Conversation Project

Together: The Healing Power of Human Connection in a Sometimes Lonely World

Institute for Healthcare Improvement. The power of four words

Fundamentals of healthcare improvement: a guide to improving your patients' care. 2nd. ed. Oak Brook, IL: The Joint Commission and the Institute for Healthcare Improvement

Shared decision making -The pinnacle of patient-centered care

Effects of patient-centered communication on anxiety, negative affect, and trust in the physician in delivering a cancer diagnosis: A randomized, experimental study

Partnering with patients, residents, and families: A resource for leaderson of hosptials, ambulatory care settings, and long term care communities. Institute for Patient-and Family-Centered Care

Teach-back: A systematic review of implementation and impacts

Improving adult coping with social isolation during COVID-19 in the community through nurse-led patient-centered telehealth teaching and listening interventions

The authors acknowledge Gail Spake for editorial revisions.

http://orcid.org/0000-0003-3256-8947Niessa Meier https://orcid.org/0000-0003-0908-0871

T A B L E 3 Responses to survey questions Have you been connecting with social groups? 35 (80) 9 (20) Are you considered higher risk due to a vulnerable condition? Vulnerable means > 60 years old, immunocompromised (weakened immune system due to certain conditions or medications), has lung disease (asthma or COPD), or has chronic health conditions (diabetes, heart disease, and hypertension).

Included in cycles 1-2 (N = 24)Are you self-quarantining or isolating yourself? 23 (96) 1 (4)Have you traveled internationally (outside of the United States) within the past 14 days? 0 (0) 24 (100) Have you traveled to one of the endemic areas in the United States in the past 14 days? (Endemic areas are those in which there is a higher incidence of COVID-19).2 (8) 22 (92) Have you had close contact with a laboratory-confirmed or probable case of COVID-19 within the past 14 days? 1 (4) 23 (96) Have you had close contact with a person with acute respiratory illness who has been outside the United States in the past 14 days? Do you know who you would want to make decisions on your behalf if you're not able to (be your health care proxy)? 20 (100) 0 (0)Have you talked to that person or anyone else about your wishes and preferences for end-of-life care? 16 (80) 4 (20)