Telemonitoring interventions for the management of heart failure have seen limited adoption in Canadian health systems, but isolated examples of telemonitoring programs do exist. An example of such a program was launched in a specialty heart failure clinic in Toronto, Canada, and a recent implementation evaluation concluded that reducing the cost of delivering the program is necessary to ensure its sustainability and scalability.The objectives of this study were to (1) understand which components of the telemonitoring program could be modified to reduce costs and adapted to other contexts while maintaining program fidelity and (2) describe the changes made to the telemonitoring program to enable its sustainability within the initial implementation site and scalability to other health organizations.Semistructured interviews probed the experiences of patients (n=23) and clinicians (n=8) involved in the telemonitoring program to identify opportunities for cost reduction and resource optimization. Ideas for adapting the program were informed by the interview results and prioritized based on (1) potential impact for sustainability and scalability, (2) feasibility, and (3) perceived risks to negatively impacting the program’s ability to yield desired health outcomes.A total of 5 themes representing opportunities for cost reduction were discussed, including (1) Bring Your Own Device (BYOD), (2) technical support, (3) clinician role, (4) duration of enrollment, and (5) intensity of monitoring. The hardware used for the telemonitoring system and the modalities of providing technical support were found to be highly adaptable, which supported the decision to implement a BYOD model, whereby patients used their own smartphone, weight scale, and blood pressure cuff. Changes also included the development of a website aimed at reducing the burden on a technical support telehealth analyst. In addition, the interviews suggested that although it is important to have a clinician who is part of a patient’s circle of care monitoring telemonitoring alerts, the skill level and experience were moderately adaptable. Thus, a registered nurse was determined to be more cost-effective and was hired to replace the existing nurse practitioners in the frontline management of telemonitoring alerts and take over the technical support role from a telehealth analyst.This study provides a user-centered example of how necessary cost-reduction actions can be taken to ensure the sustainability and scalability of telemonitoring programs. In addition, the findings offer insights into what components of a telemonitoring program can be safely adapted to ensure its integration in various clinical settings. Meta-analyses have shown that telemonitoring for patients with heart failure (HF) can improve patients’ health outcomes and reduce health care utilization -4. Howevone-size-fits-all approach does not work  phone because the[n]...I could pull out all those reports from Medly myself and give it to a doctor, a walk-in, anywhere...I was given a phone that I was not familiar with...so it took me awhile to learn it and to get familiarized with it.HFpro064Medly app was available on a tablet:One patient who did not own a smartphone said they would prefer if the The only reason why I haven’t bothered getting an iPhone is I have an iPad...I like my iPad because the screen is nice and big...It was never important to me to have a phone that has all the bells and whistles.HFpro159Medly phone because they like to keep all the equipment together. Although a separate phone was their preference, all patients said they would use their own device if that was the only option. Many patients understood the economic implications and felt it was reasonable:A minority of patients interviewed said they preferred having the separate I think that it makes it so much easier to have  all together...I know it might be more cost-effective but it is so much easier on your mental being that you go in, you do what you have to do..[But] you do what you have to do.HFpro052A clear majority of patients preferred the convenience of Bluetooth data transfer but also said they would manually enter biometric data if their existing peripheral devices were not Bluetooth-enabled:The bonus of this whole system is the Bluetooth...Typing in numbers, you [would] get tired of it...For me if I’m looking at my own health, it wouldn’t bother me a bit but I'm different from someone else.HFpro089I like the fact that [the data transfer] is done for you. If I had no other choice, then you have no other choice.HFpro154Approximately half of the patient participants said they would purchase Bluetooth devices out-of-pocket, but some participants perceived this option as being unfair, echoing clinician concerns of accessibility:I might [purchase the equipment]...[but] I’m not sure it’s really fair to ask people to do that because you’d automatically filter out a lot people who either couldn’t claim it on insurance or weren’t going to do that...(the) system would all go wrong; it would just be upper middle-class people.HFpro061Clinicians, not having had direct experience with training and giving technical assistance to patients, did not have strong feelings regarding the format of technical support. However, 1 clinician stated there is an opportunity to minimize resources required for onboarding a patient:It would be nice as much as possible to automate aspects of the onboarding...because I think actually paying somebody to be there to onboard people will be difficult to scale.Clinician 1Another clinician said that although the format of training needs to be appropriate, it is also important that the patient can start with the program immediately after the decision is made as opposed to scheduling training on a future date:When you go in as a clinician and you have a conversation with the patient about a plan of care and the role of [telemonitoring], what it can offer and why it’s important. You [need] an immediate...“Okay here’s your system, you’ve been immediately trained, you’ve been setup,” versus them going home, 2-3 weeks going by [with the patient thinking] “Oh maybe it’s not that important.”Clinician 2All patients described a positive experience with the face-to-face onboarding, but when asked if it was essential, many reflected that it might not be because the system was intuitive to use. Even those who were not tech savvy said they could figure it out at home by themselves or with the help of a family member, especially if they could follow along with a video:I think the face-to-face was good because I watched [the THA] as she was putting the stuff in and I’m a visual learner...If I see it, it makes perfect sense...I tell people all the time, if you’re stuck on something there’s a video on YouTube of everything...I mean, it was nice having the face-to-face but that’s not always an option.HFpro159Although most patients had positive things to say about calling the technical support services, others hesitated before seeking help for fear of being a burden and confusion about who to call:Well [I didn’t contact technical support because] I just don’t want to bother anybody.HFpro064_6mIt wasn’t Bluetoothed properly [and] I didn’t really know who to call. I probably had [the] number, but that was kind of a little bit bothersome.HFpro106_6mClinicians believed that the scope of practice of a registered nurse (RN) or NP is well suited for triaging and addressing many telemonitoring alerts. All clinicians agreed that an MRP with HF experience needs to be involved, particularly to deal with the more serious alerts:I think that the first line of defense is totally appropriate to be nursing with some training in HF because Medly] is a rules-based system and therefore critical alerts should escalate to the physician. The non-critical alerts I absolutely believe that the first line of defense could be a nurse, nurse practitioner, physician assistant, all would be appropriate.Clinician 1It’s ultimately a great role for nurse practitioners to champion because you need to have that person that can assess and make a clinical decision about changing a med[ication] or bringing someone in urgently to be seen in the clinic.Clinician 2Regardless of the type of professional involved, most respondents believed that telemonitoring programs would be most effective if the clinician receiving and responding to alerts was part of the patient’s care team as opposed to the alerts being sent to a third-party telehealth clinician:I think one of the issues with Medly...is you still need to have the most responsible person for the Medly involved in the actual patient's clinical care in some way.Clinician 2Medly program with their previous experience with another telemonitoring program:Patients generally agreed with this sentiment, expressing that they prefer the person receiving telemonitoring alerts to have the ability to act immediately. One patient made this point by contrasting the I accepted [to be enrolled because they] said [my health information] would go straight to [UHN]...I think [with my previous telemonitoring system] they sent it to [various people] and eventually [my doctor] would see it. But he might be 4th or 5th down the line.HFpro159Clinicians felt that patients could eventually be removed from a telemonitoring program if they were no longer actively benefitting . However, a generalizable duration of enrollment could not be established:Some [patients] just might like the comfort of knowing that [they]’re tied into a clinical team that’s still there if you need help. But I think you have to look at it from your larger team because you can’t just have endless people enrolled in the program, you probably will have to have a maximum at some [point]...I think if someone’s been really stable for 6 months, they haven’t had a lot of alerts, they are very confident as to what their target weight is, what they need to do in terms of lifestyle modifications and symptoms to watch for, then they’ve learned what they needed to learn in that 6 months and they don’t require [the program].Clinician 2I think there may be an optimal time to improve self-care...there may be a curve and the curve plateaus and there may not be any further incremental benefit to self-care other than knowing that there is this rules-based system keeping an eye on them right. So it may be that you optimize self-care within 3 months...but patients [might] want to stay on it. And again, if you can really demonstrate value I don’t have a problem with that.Clinician 1Many patients spoke of HF as being a lifelong condition and that they would like to stay in the program for as long as possible or until something came up that made the program unnecessary, such as undergoing a heart transplant:I think for me [HF is] a lifestyle thing now. I think I’d be a fool not to use [Medly], I guess that sums it up. I was so sick and dead that I take my recovery very seriously...I think I’d be a fool not to take advantage of it.HFpro107I’ve got a lifelong condition so I don’t really see an end time, unless I end up going for a heart transplant, which I’m not going to hopefully have to do anytime soon. So yeah, I think [my participation] will be ongoing.HFpro019Clinicians recognized that asking clinicians to be available at all times to receive and respond to telemonitoring alerts is not scalable. However, they also strongly felt that these interventions are most effective if there is someone monitoring alerts 7 days per week:It’s not really fair for a single person to be on-call 24/7. You have to take that into consideration in terms of physician burnout and all those things. There should be a mechanism to deal with that, whether it goes to the physician on-call or something like that. But I do think that in order for this to be effective, a 24/7 tool would be more appropriate than a business hours tool because it’s not like people get sick only during business hours.Clinician 6Medly system provides patients with clinically validated messages, allowing for a form of 24/7 feedback even if a clinician is not always available:Although participating clinicians said they would strive to have alerts monitored 7 days per week, their responses also highlighted that the requirements for intensity of monitoring are dependent on the telemonitoring system itself. For example, many clinicians highlighted that the rules-based algorithm in the I may be camping somewhere where I am not accessible. But I think the whole thing of the Medly system is it doesn’t rely on me [seeing] the alerts, the patients are instructed to do things [by the algorithm]. We have set up a plan and they have to act accordingly. They don't have to wait for me to respond to [follow the instructions].Clinician 8Medly program felt that someone should be available to respond to alerts 7 days per week but that this may also be contingent on the disease severity of the patients enrolled in the program:Patients both with and without experience in the If somebody weren’t that sick and they just had a bit of a heart issue, I don’t know if they would like this big brother, big sisterly thing where the [clinicians] call first thing in the morning on Sunday...I love that part. I think that’s the essence of the system...I mean [my doctor] is a world-renowned cardiologist and she calls me on Sunday morning at 7, because my reading is a little high. I can’t believe it, it’s the ultimate professionalism. If she didn’t, I wouldn’t be heartbroken, but I just think that she uses the system as it should be used.HFpro107Medly program were interpreted and classified according to the degree to which they could be adapted while maintaining program fidelity. As shown in Medly program’s soft periphery. The participation of a clinician (role and intensity of monitoring) and the monitoring of patients over time are central components of any telemonitoring program theory of change, indicating some overlap with the intervention’s hard core. However, the interviews suggest some degree of adaptability depending on contextual factors, which explains why intensity of monitoring, clinician role, and duration of enrollment were classified as moderately adaptable and part of a fuzzy boundary between the hard core and soft periphery. These findings informed the decisions to adapt the Medly program as described in Qualitative results related to opportunities to modify components of the This qualitative study is the first to describe adaptations to an existing HF telemonitoring program aimed at enabling its sustainability and scalability. The redesign was informed by interviews with clinicians and patients to identify which program components could be adapted while maintaining program fidelity. User perceptions helped identify that the type of peripheral devices used and the format of technical support were highly adaptable, making them ideal targets for cost reduction measures. This led to the decision to move forward with a hybrid BYOD model and lower-touch technical support services, which would substantially reduce the cost burden to the clinic for delivering the program. In addition, findings related to the clinician role confirmed that frontline alert management should be done by someone within the patient’s immediate circle of care rather than being outsourced to an offsite telehealth clinician. This informed a more cost-effective model in using an RN to replace the existing NPs as the frontline manager of telemonitoring alerts and to absorb the technical support functions previously performed by the THA. The notion of an RN playing both the central clinical and operational roles within telemonitoring services is supported in the literature ,23. In tBecause no generalizable dose with respect to duration of enrollment and intensity of monitoring could be established, no changes were made at the existing program site. However, the moderately adaptable nature of these components may reveal opportunities for scaling as they might be tailored to allow for program integration within sites with different patient populations, resources, and objectives. For example, although rapid feedback from a clinician is often described as the most important component of a telemonitoring service , a cliniSeveral studies have explored the barriers to and facilitators of implementing telehealth systems ,26 but fMany authors cite the ubiquity of smartphones as an opportunity for delivering telemonitoring services at a lower cost ,29. HoweThe finding that clinicians believe patients could exit a telemonitoring program after they have stabilized or gained self-care skills is supported by other studies . We founMedly program. In stating this limitation, we emphasize that our intent was to describe adaptations to a specific telemonitoring program rather than to provide a detailed blueprint for implementing all HF telemonitoring interventions in any given clinical context. We argue that the context-dependent nature of implementing complex interventions makes the creation of such a blueprint impossible. Rather, we have sought to provide foundational considerations for developers of telemonitoring programs and for implementation scientists who wish to sustain and scale existing telemonitoring programs to other clinical sites and health care organizations. Second, the pragmatic nature of this study meant that patients can be enrolled in the Medly program without consenting to participate in the evaluation activities, making them ineligible to participate in the interviews. Our inability to purposely sample these patients may have led to selection bias. Third, the interview guides were developed to probe the opinions of users on specific program components. We recognize that our approach for compartmentalizing and defining the various components of this complex intervention was subjective and context specific; this should be considered when determining the transferability of results to alternative settings. Finally, although the resulting user-guided adaptations are expected to maintain the fidelity of the intervention, the true impact of these changes was not empirically tested in this study. This important question will be evaluated as part of a subsequent publication on the overall impacts of the Medly program as well as patient adoption and adherence to the intervention.First, although participants were asked to consider their responses with respect to telemonitoring in general, it is likely that their responses were influenced by their experiences with the Theories of diffusion of innovation suggest that one of the keys to scaling health interventions lies in adapting elements of its delivery to better fit the implementation context. However, this is only true if fidelity of the intervention can be maintained and its potential effectiveness is not compromised. This concept has informed the implementation of cost reduction measures of an existing HF telemonitoring program to ensure its sustainability. Our findings suggest that the peripheral devices used in telemonitoring programs and the format of technical support are highly adaptable, making them ideal targets for cost reduction measures. Duration of enrollment and intensity of monitoring are inextricable components of a telemonitoring intervention, but the dose of these components required to yield expected outcomes is highly context dependent. Our efforts provide a user-centered example of how necessary actions can be taken to improve the sustainability and scalability of telemonitoring programs.


On average, PCTs met twice (range 2–4 times) between workshop sessions. Learners valued the PCTs, and 1 commented on the value of working with peers in PCTs, having no one in a similar position within his immediate work environment. Participants’ written comments strongly endorsed the value of the workshops for their work, with the coaching skills session seen as the most valuable. Some participants worry that skills will decrease over time without continued reinforcement. All but 1 participant reported that they planned to continue with the PCT. DISCUSSION/SIGNIFICANCE OF IMPACT: The number of applicants to our program suggests a need and motivation for staff to participate in the STEP-MDP. Participants’ reported improved skills and sense of community. To maintain the COP and address worry about degradation of skills we are planning to remind PCTs to meet once a month and will follow-up with them 3 and 6 months post intervention to evaluate their continued development. This spring a second cohort will receive the training. We believe developing these core teamwork skills will lead to more collaborative, efficient, and innovative research. We have implemented a successful program targeting critical members of research teams with potential to facilitate expansion of institutional capacity for translational research. It will be important to understand the long-term impact of the program on individuals, on team science, on research, and ultimately on the health of the public.OBJECTIVES/SPECIFIC AIMS: Skillful research staff members are critical to productive translational research teams and yet their ongoing professional development is rarely formally addressed. Through the Strategic Teamwork for Effective Practice-Mentor Development Program (STEP-MDP), we aimed to both create a community of practice (COP) for research staff and build the skills needed to enhance research team performance. METHODS/STUDY POPULATION: We selected 16 participants of 32 staff-level applicants from among the NYU Schools of Medicine, Social Work and Nursing for the first STEP-MDP cohort. Participants included research assistants, coordinators, managers, and directors. We delivered 3, two-hour workshops, scheduled 3 weeks apart, focused on team communication, identifying team areas for improvement, and mentorship/coaching skills. Peer-Coaching Teams (PCTs) were created by pairing participants at the same position level, and PCTs worked together at each session to explore and practice learned skills. Sessions featured brief didactics, group-based learning and exercises based on participants’ real issues. A variety of active learning techniques such as brainstorming, role-playing, problem solving, and peer coaching were used. Practical core readings, worksheets, and summary cards were provided. PCTs met between sessions to practice coaching skills, and troubleshoot problems. RESULTS/ANTICIPATED RESULTS: Participants (n=16) completed a 37-item retrospective pre/post self-assessment of team behaviors and skills, and a STEP-MDP evaluation survey at the end. We saw pre-post improvements in each of 5 self-assessment domains: Communication (4 items, pre-mean 2.66, post mean 3.36,


Few data are available on the long-term effect of pulmonary rehabilitation (PR) and on long PR programs in interstitial lung diseases (ILD).max), quality of life , quadriceps force (QF) and objectively measured physical activity in ILD after the 6-month PR-program and after 1 year.We aimed to evaluate the effects of PR on exercise capacity  were randomly assigned to receive a 6 month-PR program or usual medical care.max 19, [8 to 29]%pred; SGRQ − 12,[− 19 to − 6] points; QF 10, [1 to 18] %pred). The gain was sustained after 1 year . Physical activity did not change.Exercise capacity, quality of life and muscle force increased significantly after the program as compared to control  contains supplementary material, which is available to authorized users. Interstitial lung diseases (ILD) are a group of disorders characterized by progressive dyspnoea, exercise limitation and poor quality of life , 2. TreaIt has been shown that quadriceps weakness  and physRare randomised controlled trials exist about the effectiveness of PR in ILD –13. A CoThe aim of this study was to evaluate the feasibility and effectiveness of a longer (6-month) multidisciplinary PR program on exercise tolerance, muscle strength, quality of life and physical activity in a randomized controlled trial. In addition, long-term benefits of the program were investigated.Patients with chronic ILD referred to the ILD clinic in the University Hospital of Leuven were considered for enrolment. According to eligibility criteria, potential candidates were informed about the protocol and written informed consent was obtained, between March 2009 and September 2011. The study was approved by the local ethics committee (B32220095560) of this hospital.Inclusion criteria were a diagnosis of ILD according to internationally established criteria with a formal workup and multidisciplinary discussion , 2, dyspExclusion criteria were comorbidities  or systemic manifestations  that do not allow training and a life expectancy below 3 months.Patients were randomly assigned to the rehabilitation or control group using sealed envelopes prepared and shuffled before the start of the study by an independent person unrelated to the study protocol. The envelope was opened by the allocator sequentially, only after the participant’s name was written on it.Patients assigned to the rehabilitation group were invited to attend a 6-month outpatient rehabilitation program with a total of 60 sessions, 3 times per week for the first 3 months and thereafter twice weekly. The program was performed in accordance with the guidelines  and is dAll measurements were made at enrolment and at 3, 6 and 12 months after the start of the study.The primary outcome of the study, functional exercise capacity, was measured as the distance walked during the best of two 6-minute walking tests (6MWD)  and alsoCO); arterial partial pressure of oxygen (PaO2); maximal work rate (Wmax); 6MWD; quadriceps (QF) and hand grip (HF) muscle force; quality of life evaluated by the the St George’s respiratory (SGRQ) and the chronic respiratory disease questionnaires (CRQ) and dyspnoea (MRC 1 to 5). More details on the assessments are provided in the Additional file The secondary outcomes were forced vital capacity (FVC); slow vital capacity (SVC); diffusing capacity for carbon monoxide , in order to assess objectively their physical activity. They were instructed to wear the monitor for at least 7 consecutive days, from waking up until going to bed. Days with less than 8 h of wearing time during waking (defined as 7 AM-8 PM) were excluded. Only week days were used to minimize the variability. A valid measurement was defined as having at least 2 valid weekdays. The influence of the duration of the daylight time was included as a covariate .Mean step count and mean time in at least moderate intense physical activity (MPA) were chosen as the physical activity outcomes. MPA was defined as any activity with an energy expenditure above 3 METs . The SenPhysical activity at 1 year was not included in the analysis due to the large number of missing data at this time point, caused by incompliance of patients and technical problems. For this reason the data were not judged as being representative of the entire sample and therefore not included in the analyses.All adverse events during the rehabilitation program were registered.P values below 0.05 were considered as significant in all analyses (R version 3.2.1) [All variables were expressed as means ± standard deviation (SD) or 95% confidence interval (95% CI). A minimal 6MWD benefit of 38 ± 43 m might be expected after 3 months . To antin 3.2.1) . Group, n 3.2.1) . The numFigure Sixty-seven percent of patients completed the rehabilitation program and 60% of the randomized patients were followed up at 1 year.p = 0.045) and hypersensitivity pneumonitis was more represented in the rehabilitation group. The groups were matched for other parameters , health status  and quadriceps force at the end of PR  after a 6-month outpatient PR program in ILD and the first study investigating the PR-effect on objectively measured physical activity (PA). As hypothesized, exercise capacity, health status and muscle force improved significantly after PR; these benefits were maintained after 1 year in those patients that completed the program. PR did not change the physical activity level.The improvements in exercise capacity (6MWD) and quality of life  are relevant, as they exceeded the minimal clinically important difference (MCID) after PR and at 1-year follow-up  over the course of the 6-month PR program. This number was slightly higher than observed in ILD following some shorter programs , 33, 39,% over thSecond, assessors were not blinded for 6MWD (main outcome) which may have led to an overestimation of the benefit, however this probably will not have affected the results of quality of life.Third, only 20% from the eligible candidates were randomized in the present study Fig. . This maWe conclude that a 6-month outpatient pulmonary rehabilitation program resulted in improvements in functional and maximal exercise capacity, health status and muscle force but not in physical activity in patients with ILD. The benefits were maintained at 1-year follow-up.Additional file 1:Table S1. Baseline characteristics. Table S2. Baseline values of dropouts compared to non-dropouts patients at 1-year. Table S3. Effects of PR and at 1-year on maximal exercise capacity and muscle force. Table S4. Effects of PR and at 1-year on quality of life. Table S5. Effects of PR and at 1-year on lung function. Table S6. Effects of PR and at 1-year with penalizing treatment of missing data. (DOCX 57 kb)Online data supplement contains


The purpose of this study was to examine changes in psychological and occupational well-being in education professionals who attended a yoga-based program.t tests were used to compare scores between time points.Education professionals who attended a 3-day yoga-based RISE  program were recruited to participate. RISE was administered at the Kripalu Center for Yoga & Health. Measures of psychological and occupational well-being, and health-related behaviors were completed before (baseline), after (post), and 2 months after RISE (follow-up). Forty-four participants completed baseline and post and were included in the analysis. Of those, 33 participants also completed the follow-up. Paired samples P values < .001), resilience, satisfaction with life, as well as exhaustion and professional efficacy which are dimensions of burnout . At the follow-up, significant improvements were maintained for mindfulness, empowerment, self-compassion, sleep quality , resilience, vigor, and exhaustion  and positive affect, satisfaction with life, and work engagement .Compared to baseline, at post, participants showed improvements in perceived stress, mindfulness, empowerment, positive affect, negative affect, self-compassion, total work engagement, vigor, sleep quality (all These findings suggest that the yoga-based RISE program improves psychological and occupational well-being in education professionals. In addition, participants reported that attending RISE was feasible, they could continue using RISE practices long-term, shared them with work colleagues, and reported that RISE positively impacted both their daily lives and workplace environment. With these promising results, additional controlled research is warranted. In the United States, more than half of educators experience excessive stress several days per week,7 Furthermore, there is growing evidence of yoga’s effectiveness for improving psychological, occupational, and physical health in professionals, including stress, mood, fatigue, and tension in police officer trainees8; perceived stress and depression in teachers9; improved self-care, mindfulness, and burnout in nurses10; reduced work-related stress in mental health professionals11; improved anger, anxiety, and sleep quality in armed forces members12; depression, stress, mindfulness, and self-compassion in mental health-care professionals13; and stress, resilience, mindfulness, affect, empowerment, and self-compassion in frontline professionals from multiple sectors including education.14Yoga is a mind–body practice comprised of many components, including physical postures and exercises, breathing exercises, relaxation techniques, meditation, and mindfulness practices. Systematic research reviews support the use of yoga for promoting psychological, occupational, and physical health.1517 A recent study of a 15-day residential yoga program for primary school teachers resulted in improvements in mental well-being and state anxiety compared to a no treatment control.17 However, there was no assessment of occupational health or constructs hypothesized to mediate improvements in educator stress or anxiety, such as resilience or mindfulness. Furthermore, a 15-day residential yoga program would likely not be feasible for many education organizations. To date, the effect of a brief residential yoga program for education professionals has yet to be investigated. Yoga programs developed by the Kripalu Center for Yoga & Health  have resulted in improved psychological and physical health in professionals including police officers,8 military personnel,18 health-care workers,13 and a heterogeneous group of frontline professionals from education, corrections, and social services sectors.14Despite these promising findings, there have only been a few studies on yoga programs specifically for education professionals.Sixty-four professional educators  from nearby schools in the Pittsfield MA District School Board that attended a 3-day RISE program in 2017 and 2018 were recruited to participate in the study. Attendees were sent an e-mail containing information about the study 2 weeks before the start of the program and were sent a link to the survey 10 days before the start of the program. Of those recruited, 57 program attendees agreed to be in the research study and completed the baseline survey (89.1% of attendees). The final sample consisted of 44 participants (77.2% of participants enrolled) who completed the assessments at baseline and post. Of the 44 participants, 33 participants also completed the follow-up assessment  were available to participants when RISE was not in session.The RISE program was delivered as a 3-day residential immersion program at Kripalu. Highly experienced, certified yoga teachers with at least 200-hour Yoga Alliance certification in addition to RISE facilitator training administered the RISE program. RISE attendees had the option of being housed at the retreat center in multiguest rooms or commuting from home. RISE included 5 hours of daily structured sessions of yoga postures, meditation, mindfulness practices, breathing techniques, and education about mindful communication, mindful sleep preparation, and mindful eating. The RISE program has also been described in detail elsewhere.19 Questionnaires were administered to participants at 3 time points: baseline (1–10 days preprogram), post (1–10 days following RISE), and follow-up (2-month post-RISE). The attendees were sent 3 reminder e-mails and 1 text message or phone call reminder if they did not respond to the survey invitation by e-mail.Surveys were administered online using the Partners HealthCare version of the software platform REDCap.Participants completed a demographic questionnaire, which included age, gender, race, ethnicity, and education.20 was used to measure participants’ subjective level of stress. The PSS displays adequate levels of reliability and validity.20 For this study, we measured a Cronbach’s alpha of .87 for the PSS.The 10-item version of the Perceived Stress Scale (PSS)21 and we measured a Cronbach’s alpha of .89 for the RS.The Resilience Scale (RS) was used to measure participants’ level of resilience, an ability that enhances individual adaptation to stress and challenging situations. The RS displays high levels of reliability and validity,22 with a Cronbach’s alpha of .86 for this study.Positive and Negative Affect Schedule (PANAS) was used to measure positive and negative mood. The PANAS displays good internal consistency reliability and construct validity,23 The FFMQ assesses 5 distinct facets of mindfulness: observing, describing, awareness, nonjudgment of experience, and nonreactivity to inner experience.23 The FFMQ shows good internal consistency reliability, with a Cronbach’s alpha of .92 for this study.The Five Facet Mindfulness Questionnaire (FFMQ) is a well-validated, reliable 39-item scale for the assessment of mindfulness.25 We measured the internal consistency as Cronbach’s alpha of .84 for the PES.The Psychological Empowerment Scale (PES) is a 12-item scale that measures participants’ psychological empowerment, a sense of efficacy, competence, and self-determination. The PES displays acceptable levels of reliability and validity.26 is a brief, well-validated version of the SCS. The SCS-SF includes 12 items that measure self-compassion. The internal consistency reliability of the SCS-SF is high, with a Cronbach’s alpha of .87.26 We measured a Cronbach’s alpha of .86 for the SCS in this study.The Self-Compassion Scale–Short Form (SCS-SF)27 A total satisfaction with life score is obtained by summing the item scores. We measured a Cronbach’s alpha of .89 for the SWLS.The Satisfaction with Life Scale (SWLS) is a well-validated, short, 5-item scale that measures overall life satisfaction.4 The MBI-GS measures burnout across 3 factors: exhaustion (EX), cynicism (CYN), and professional efficacy (PE). Items are rated on a scale from 0 (never) to 6 (every day). The MBI had a Cronbach’s alpha of .74 for this study.The Maslach Burnout Inventory—General Survey (MBI-GS) is a well-validated and reliable 16-item measure of professional burnout.27 The UWES-9 displays good validity and reliability.28 We measured a Cronbach’s alpha of .89 for the UWES-9.The Utrecht Work Engagement Scale (UWES-9) is used to measure engagement in one’s occupation across 3 subscales: vigor (VI), dedication (DE), and absorption (AB).2931 measures job satisfaction with a single item, “At this moment, I am fairly satisfied with my job,” with the response rated from 1 (strongly agree) to 5 (strongly disagree). Lower scores indicate higher job satisfaction.The single-item Job Satisfaction ScaleThe Lifestyle Questionnaire is a self-report questionnaire of health-related behaviors including physical activity, diet, and sleep disturbance that was developed by some of the authors of this study. The 4-item questionnaire assessed participants’ average minutes per day of physical activity, average daily vegetable and fruit intake, and sleep quality, rated from 1 (very good) to 4 (very bad), with lower numbers indicating better sleep quality.An Impact Questionnaire assessed participants’ continued use of RISE skills and practices, sharing aspects of the program with others, and program feasibility. At post, on a visual analog scale from 0  to 100 (very much so), participants indicated the degree to which they planned on practicing RISE skills and concepts , how likely they were to share what they learned in the program with others, and how feasible it was to accommodate the program into their schedule. At the 2-month follow-up, participants were asked to indicate the degree to which they had been practicing the RISE skills and concepts since the program, the degree to which they observed a positive shift in their workplace experience from being introduced to mind–body/mindfulness practices in the program, and the degree to which they shared what they learned in the program with others.t tests were performed to compare participants’ scores between baseline and post and baseline and follow-up. Pearson correlations were performed between change scores  for constructs of interest. The alpha level was set to .05 for statistical significance for all analyses. No adjustments were made for multiple outcome measures (to reduce type I error) based on the relatively small sample size and preliminary nature of this study.One-way analyses of variances (ANOVAs) were conducted to compare baseline scores between participants who completed measures at all 3 time points (full completers) and participants who only completed measures at the first 2 time points . ANOVAs were conducted to compare baseline scores and change between participants who stayed at the retreat center and participants who commuted. Paired samples F = 6.64, P = .014  and participants who completed all surveys . Partial completers showed higher levels of the absorption dimension of work engagement compared to full completers, .014 see . There wF = 4.35, P = .043  reported higher levels of baseline work engagement than those who commuted to the Kripalu retreat center  for the program, .043 see . There wP values > .20.An ANOVA revealed no significant baseline differences between occupation type ; all t tests revealed statistically significant improvements in perceived stress t(42) = −6.20, P < .001; resilience, t(43) = 2.85, P = .007; positive affect, t(42) = 5.53, P < .001; negative affect, t(42) = −5.36, P < .001; mindfulness, t(43) = 5.45, P < .001; empowerment, t(43) = 4.12, P < .001; self-compassion, t(41) = 4.77, P < .001; and satisfaction with life, t(41) = 2.98, P = .005, from baseline to post. With respect to the occupational well-being measures  = 3.40, P < .001, and its subscale vigor, t(41) = 3.77, P < .001; and the EX, t(40) = 2.95, P = .005, and PE dimensions of burnout, t(40) = 3.10, P = .004. There was no significant change in job satisfaction from baseline to post, t(39) = 1.57, P = .124.Means and standard deviations for the psychological and occupational health measures are displayed in measures , paired t(27) = 2.92, P = .007; positive affect, t(32) = 2.41, P = .022; mindfulness, t(27) = 6.09, P < .001; empowerment, t(28) = 3.63, P < .001; self-compassion, t(31) = 3.96, P < .001; and satisfaction with life, t(31) = 2.15, P = .039. Levels of perceived stress, t(31) = −1.87, P = .07; and negative affect t(32) = −1.91, P = .06; were marginally significant  at the follow-up compared to baseline. With respect to the occupational health measures  = 2.46, P = .020, and its subscale vigor, t(31) = 3.02, P = .005; and the EX dimension of burnout, t(30) = 3.15, P = .004. There was no significant change in job satisfaction from baseline to follow-up, t(30) = 1.12, P = .271. The correlations between change scores  for questionnaires are displayed in At the 2-month follow-up, with respect to the psychological health measures , signifimeasures , paired There were no significant differences in change scores between participants who stayed at the retreat center (guests) and those who commuted to the retreat center for the RISE program  = 1.84, P = .073; fruit intake, t(41) = 1.65, P = .107; or vegetable intake, t(41) = 1.77, P = .083. At follow-up, there were also no significant differences in average daily duration of exercise, t(30) = .59, P = .560; fruit intake, t(30) = .39, P = .702; or vegetable intake, t(29) = 1.15, P = .258, compared to baseline.Paired sample t tests revealed a significant increase in sleep quality from baseline to post, t(41) = −4.37, P < .001. At the follow-up, participants’ increase in sleep quality remained significantly higher than baseline, t(30) = 3.72, P < .001 .48 In addition to reduction of stress, positive changes in lifestyle habits, including increased exercise, nutrition, and proper sleep can prevent negative health outcomes.49 We observed improvements in sleep quality immediately following and up to 2 months following RISE. A systematic review of the effect of MBIs on sleep quality reported improvements in sleep quality following yoga interventions.50 Unexpectedly, there were no changes in exercise or vegetable and fruit intake. Results from other yoga interventions have indicated that yoga increases physical activity and improves diet.51 It is unclear why we did not observe improvements in exercise and diet. However, the current intervention was delivered over 3 days with the option to commute, compared to the previously published study, which was delivered as a residential program over 5 days with all participants staying as guests.14 Therefore, participants may not have had as much time at the retreat center to shift their exercise and diet. Participants who commuted may not have stayed for meals at the retreat center, in which fresh fruits and vegetables were available, or may not have engaged in as much physical activity as the guests, such as hiking or using the exercise facility.Chronic workplace stress can lead to poor physical health, including the development of noncommunicable lifestyle diseases such as diabetes and cancer.Given the preliminary nature of this study, there are several limitations that require discussion. First, the use of a single-arm design with a modest sample size is a significant limitation in not controlling for possible nonspecific effects of the intervention and limiting statistical power, although still useful for conducting a more informed future randomized controlled trial. This study provided necessary early stage feasibility data for future work, which will compare educators attending RISE to passive and active control groups, such as educators attending a retreat without RISE. Second, participants were a heterogeneous group of education professionals, categorized as teachers, special education teachers, counselors, and administrators. We observed no baseline differences across each category; however, a future study with a larger population with an equal number of participants from each category could enable a proper statistical analysis to detect differences. Another limitation is that participants did not complete practice logs of their use of the practices outside of the program, preventing an assessment of home practice on changes in outcome measures. However, the overall assessment of use across practices provides some indication at this early stage of research. Finally, the reliance on self-report measures to assess changes in psychological and occupational health is limiting, and future studies will aim to include objective measures such as physiological correlates of health, workplace absenteeism, productivity, student behavior, and academic performance. Future work may also implement a multitiered RISE program delivered to administrators, teachers, and students of the same school and will include an assessment of changes at the individual and institutional level.Taken together, the results of this study indicate that the yoga-based RISE program improved psychological and occupational health and well-being, and sleep quality in education professionals immediately following and 2 months following the program. Furthermore, participants reported that the program was very feasible and that they continued to use the practices and techniques in their professional and personal lives. Workplace stress remains a growing concern for many organizations, often leading to a loss of productivity and absenteeism. Effective and feasible programs that build resilience in education professionals to reduce stress are needed to prevent burnout and detrimental outcomes to health and well-being. The results of this study support the use of Kripalu’s yoga-based RISE program for improving psychological health and well-being in education professionals.


There is limited evidence about the most appropriate way to improve physical and oral function in older people. The aim of this study was to clarify the effectiveness of a long‐term care prevention program combining physical exercise, oral health instruction, and nutritional guidance among community‐dwelling older people.We included 43 older people aged at least 65 years  in Bungotakada City, Japan. The 3‐month program involved a weekly intervention. Physical and oral function was investigated on the first day of the program  and at the end of the program . Physical function was examined using measures such as handgrip strength, timed up‐and‐go test, and one‐leg standing time with eyes open. An oral diadochokinesis test was used to assess oral function.pa and ka and the repetitive saliva swallowing test was significantly improved in both groups. The dysphagia risk assessment for the community‐dwelling elderly score was significantly lower in younger participants after 3 months.Mean maximum handgrip strength increased significantly in older people aged ≤74 years (younger participants) and those aged ≥75 years (older participants) after 3 months compared with the baseline. The timed up‐and‐go test duration was significantly lower in older participants after the program. Repetition of the monosyllables Participation in a 3‐month program combining physical exercise, oral health instruction, and nutritional guidance may contribute to improvement or maintenance of oral and physical function in older people. In 2017, 27.7% of Japan's population was aged ≥65 years, and this proportion is expected to increase to approximately 30% in 2025 . To guarantee the comprehensive provision of preventive and healthcare services, nursing care, and life support for older people, the Japanese Ministry of Health, Labor and Welfare has introduced a community‐based integrated care system model  or long‐term support (n = 2), and those with stroke‐related motor paralysis (n = 0) were excluded. A further 13 participants dropped out for personal reasons unrelated to the program. The study therefore included 43 older people  for analysis. All participants signed an informed consent agreement, and almost all 43 participants attended this 3‐month program regularly. The sample size required for the Wilcoxon signed‐rank tests using G*Power  with a statistical power of 80%, a significance level of 5%, and an effect size of 0.5 was calculated to be 28 subjects. Therefore, the sample size was large enough in this study.Since 2015, the local government of Bungotakada City, Oita Prefecture, Japan, has been providing a health program that includes physical exercise, oral health instruction, and nutritional guidance for older people aged ≥65 years living in several local communities. The local government sent invitation letters to older people aged ≥65 years living in three local communities calling for participation in this health program. Fifty‐eight older people participated in this program from May to November 2018. The study design was approved by the Ethical Committee of Hiroshima University (No. E‐2545). To exclude older people with a decline in activities of daily living, older people certified as requiring help , tooth brushing instruction, and oral health instruction . A dental hygienist provided individual tooth brushing instruction as well as detailed instructions on how to correctly perform the oral exercises.Nutritional guidance included education on several topics  and cooking practice to prevent malnutrition among older people. This part of the program was provided by a nutritionist. At the end of the 3‐month program, physical and oral function was tested again and the questionnaire was repeated Table .2.3Physical function was examined using the measures of a handgrip strength test, a timed up‐and‐go test, and a one‐leg standing time with eyes open test. Handgrip strength and one‐leg standing time with eyes open were performed according to the New Physical Fitness Test of the Japanese Ministry of Education, Culture, Sports, Science and Technology . The mea2.4pa, ta, and ka, as quickly as possible for 5 s. The number of repetitions was automatically measured by a counting device . A repetitive saliva swallowing test (RSST) was used to assess swallowing function. The participants were instructed to swallow saliva as many times as possible over a 30‐s period. Elevation of the thyroid cartilage during swallowing was evaluated by touch. Fewer than three swallows over 30 s was considered a swallowing disorder.To evaluate oral health status, a dental hygienist checked participants' teeth, oral hygiene status, oral mucosal condition, and denture use and performed oral wetness measurement, oral bacterial counts, and oral function tests. An oral diadochokinesis test was used to assess oral motor function Duffy, . Partici2.5Oral frailty was evaluated using the Kihon Checklist (KCL) developed by the Japanese Ministry of Health, Labor and Welfare. This checklist includes several categories  was used to count the number of oral bacteria. Samples were obtained from the tongue surface using a cotton swab, in line with the manufacturer's instructions. This detection device employs the dielectrophoretic impedance measurement method and ensures that oral bacteria are counted rapidly  through 1 (only a few times) and 2 (many times) to 3 . The score is calculated by summing the five answers. A higher total score indicates better mental health.The World Health Organization five well‐being index (WHO‐5) is widely used to evaluate subjective quality of life and psychological well‐being . The Mann–Whitney U test was used to evaluate significant differences in clinical factors and physical and oral parameters between the groups. Fisher's exact test was used to evaluate significant differences in clinical factors. The Wilcoxon signed‐rank test or McNemar's test was used to assess the differences in physical and oral parameters before and after intervention. Spearman's rank correlation coefficient was used for statistical analysis. 44.1The participants' clinical characteristics are summarized in Table 4.2p = .03). However, there was no significant difference in other physical function measures between the groups at baseline. Mean maximum handgrip strength was significantly higher in both groups at 3 months compared with baseline  was significantly lower in both groups at 3 months Table . The repThe oral bacterial count was also lower in both groups at 3 months, with this decrease being significant in older participants.4.4The S‐WHO‐5‐J score was significantly higher in all participants at 3 months (10.5 ± 2.7) compared with baseline (9.4 ± 2.7). The S‐WHO‐5‐J score was also significantly higher in younger participants at 3 months  in community‐dwelling older adults aged ≥65 years  and tongue pressure  worsens the nutritional status of older people (Morisaki, Miura, & Hara, Our results suggest that a 3‐month combination program, including physical exercise, oral health instruction, and nutritional guidance, may contribute to healthy aging in older people. However, one limitation of this study was that the overall size of the population was small. Additionally, most participants were healthy and independent older people, who positively participated in this program. There is therefore also a need to investigate the program's efficacy among people who are not actively involved in community health programs.6Participation in a long‐term care prevention program may suppress the deterioration of physical and oral function in independent older people. Further studies are needed to clarify the correlation between physical and oral function and the duration of participation in community‐based health programs.The authors declare that they have no competing interests.


We describe an on-site clinical mentoring program aimed at improving emergency obstetrical and new-born care (EmONC) in Nepal and assess its effectiveness on nurses’ knowledge and skills. In Nepal, both the maternal mortality ratio  and the neonatal mortality rate  were among the highest in the world in 2016, despite impressive progress over recent decades considering the challenging environment.From September 2016 to April 2018, three experienced nurses conducted repeated mentoring visits in 61 comprehensive or basic EmONC centers and birthing centers located in 4 provinces of Nepal. Using updated national training manuals and teaching aids, these clinical mentors assessed and taught 12 core EmONC clinical skills to their nurse-mentees. Clinical mentors worked with management mentors whose goal was to improve the nurses’ working environment. We assessed whether the cohort of nurse-mentees performed better as a group and individually performed better at the end of the program than at baseline using relevant tests .p <  0.001). Clinical assessment scores increased significantly for each participant, and therefore for the group. SBA-trained mentees had better knowledge of maternal and new-born care and were better able to perform the 12 core clinical skills throughout the program.In total, 308 nurses were assessed, including 96 (31.2%), 77 (25.0%) and 135 (43.8%) who participated in all three, two or only one mentoring session, respectively. In total, 225 (73.0%) worked as auxiliary nurse-midwives (ANMs), while 69 (22.4%) worked as nurses. One hundred and ninety five (63.3%) were trained as skilled birth attendants, of which 45 (23.1%) were nurses, 141 (72.3%) were auxiliaries and 9 (4.6%) had other positions. The proportion of ANMs and nurse-mentees who obtained a knowledge assessment score ≥ 85% increased from 57.8 to 86.1% (Our study suggests that on-site clinical mentoring of nurses coupled with health facility management mentoring can improve nurses’ clinical competences in and performance of maternity and new-born care. Assessing evidence of impact on patient safety would be the next stage in evaluating this promising intervention. Nepal is a landlocked, low-income country with geographical conditions that make it one of the most disaster-prone countries worldwide  . Nepal aThe observed progress can be attributed to government efforts, which, after the civil war in the 1990s, demonstrated a consistent policy focus on maternal and child health, with sustained financial commitment and funding for maternal health through the national program ‘Aama Surkshya’. This program was implemented by the Family Health Division (FHD) of the Ministry of Health and Population (MoHP) in 2005 and offers cash to women who deliver at a health facility and to health care providers who attend the deliveries , which cMentorship of health workers was introduced in Nepal by the FHD/MoHP in 2014 with the support of the Deutsche Gesellschaft fur International Zusammernarbeit (GIZ), which channels the German technical cooperation, and its bilateral Nepal-Germany program aimed at improving maternal and new-born care (MNC). The decision to implement this program was based on the need to follow-up on a MNC provider training program run by the Nick Simons Institute and the FHD of the MoHP, as well as on preceding experience in mentoring to expand abortion care . The iniA second phase of this mentoring program was implemented in 2016 at the request of the MoHP. This phase included some districts affected by the earthquake, expanded the mentorship to the staff working in birthing centers and promoted the use of tools developed by the National Health Training Center for skilled birth attendants (SBAs). The objectives of this second phase were to i) improve the clinical capacity of MNC service providers, ii) improve the quality of management in health facilities, and iii) support referral networks. Mentoring was considered a comprehensive teaching and learning process in which senior health workers, who served as the mentors, provided personalized support to juniors, who were the mentees, based on the mentees’ needs, to strengthen their ability to provide quality health care .Different mentoring models have been used in diverse country contexts for supporting clinical staff, ranging from field-based teams of mainly non-physician health workers to highly skilled mentors  and nurse mentors in India and Rwanda –13. HoweThe objective of this paper is to describe a mentoring program aimed at improving emergency MNC in Nepal and to assess its effectiveness on nurses’ knowledge and skills.We prospectively performed repeated cross-sectional assessments of the knowledge and clinical skills of a cohort of nurses working in comprehensive or basic EmONC centers (CEONCs and BEONCs) and birthing centers in Nepal. These nurses work either as ‘staff nurses’ (they should have received at least a 3-year pre-service nursing training) or as auxiliary nurse-midwives (ANMs) (their pre-service training lasts only 18 months). Some ANMs and staff nurses were certified as SBAs after completion of a 2-month SBA training. Both types of nurses, SBA certified or not, should be able to attend to women in labour, managing both normal and complicated deliveries (before transfer to a higher facility for appropriate care whenever it is possible). In remote birthing centers, ANMs often work alone.The mentoring program lasted from September 2016 to April 2018 in seven CEONCs, 19 BEONCs and 35 birthing centers in seven/72 districts of Province no. 7, 5, 6 and 3 in Nepal. These health facilities represent, respectively, 6.7, 11.9 and 2.0% of all CEONCs, BEONCs and birthing centers existing in 2015 [The clinical mentors organized three mentoring sessions (each lasting three to four days) in each targeted health facility between December 2016 and March 2018. A total of 12 MNC topics were covered (some of them introduced during the second mentoring session only): completing a normal delivery and resuscitating a new-born, plotting and interpreting a partograph, managing shock due to a post-partum haemorrhage, safely referring a woman or a new-born to a higher-level health facility, performing a vacuum delivery, performing manual aspiration, promoting kangaroo mother care, managing an eclampsia case, decontaminating used medical equipment and using sterile gloves.In accordance with the standards-based management and recognition approach developed by Jhpiego, which has been used since 1997 and has been implemented in more than 30 countries , the menThe 14 clinical mentors were nursing graduates with extensive maternity and public health and training experience, selected with the help of the Ministry of Health based on technical criteria and their communications skills and experience; four of them were SBA trainers. They were trained on the mentoring approach and QI tools in October 2016 and were supervised by the program team.Clinical mentors worked in pairs with management mentors who supported health facility management teams. In a given health facility, clinical and management mentors jointly conducted mentoring sessions. The management mentors worked with the health facility heads and management committees and covered eight quality care domains: health facility management, infrastructure, patient dignity, staffing, supplies and equipment, drugs, and infection prevention  were removed from the analyses. The National Health Training Center and the program team defined good knowledge and performance scores as scores equal to or above 85%.We then assessed whether the mentees performed better as a group at the end of the program than at baseline. We therefore compared the proportion of ANMs and nurses with scores ≥85% between the first and last mentoring sessions using the chi-square test.We completed the analysis by assessing the change in mentees’ assessment scores from baseline to the end of the program according to their SBA status using the Kruskal-Wallis equality-of-population rank test. The mentees who became SBAs during the program were removed from the analysis comparing SBAs with non-SBAs.Finally, since not all mentees attended all mentoring sessions, we also assessed whether they individually performed better at the end of the program using the Wilcoxon matched-pairs signed-rank test. In this test, each mentee was matched with herself at baseline and at the end of the program, and her first assessment was used as the point of reference for comparisons.p <  0.05).All analyses were performed using Stata 13  software. Statistical significance was defined at a 5% threshold . It is a review of an educational program jointly implemented with the MoHP of Nepal. Delivery and evaluation of this educational program were approved by and implemented with the MoHP. All nurses involved in this education program provided their oral consent to participate in the program, and were allowed to drop out anytime. Their consent was recorded in the anonymized program follow-up database. Knowledge and skills assessments were considered part of the learning experience. Databases that recorded assessment results were anonymized, with access restricted to data analysts and program managers.The clinical mentoring program reached a total of 308 nursing staff. Of them, 196 benefitted from the first mentoring session, 197 from the second session and 184 from the last one. A total of 96 mentees (31.2%) participated in all three mentoring sessions, 77 (25.0%) received two mentoring sessions, and 135 (43.8%) were reached only once  had undergone an 18-month pre-service ANM training course. Seventy-three mentees (23.3%) had a nursing certificate obtained after a 3-year nursing course, and 45 (14.6%) had a bachelor’s degree in nursing. A total of 195 mentees (63.3%) were trained as SBAs, including 45 nurses (23.1%), 141 ANMs (3.1%), and 9 with other or unknown positions (4.6%). Of all the mentees, 225 (73.0%) worked as ANMs and 69 (22.4%) worked as nurses.All 308 mentees were female Table . Their mp = 0.001). Staff working in CEONCs also had better knowledge than staff in BEONCs and birthing centers . We did not find evidence that staff with higher nursing education performed better in the knowledge assessment than less educated staff or that nurses had better knowledge than ANMs.During the first mentoring session, 185 ANMs and nurses completed the initial knowledge assessment, with 107 (57.8%) of them correctly answering 85% or more of the 26 questions (Table p = 0.01); SBAs performed better than non-SBAs , as well as staff working in CEONCs . We did not find evidence of any association between the level of nursing education and clinical performance at baseline.Of the 186 ANMs and nurses assessed for at least one clinical skill at baseline, 27 (14.5%) obtained a good overall clinical score  . The greatest improvement was observed in the birthing centers (+ 80.7%) among SBAs (+ 72.3%), ANMs (+ 67.6%) and staff with the lowest level of nursing education (+ 67.3%).p = 0.005; + 21.0% among ANMs vs +  18% among nurses, p = 0.03, respectively)  had better knowledge and skills than those of other staff. Nevertheless, this result raised questions about the quality of their pre-service training. These findings corroborate a recent study that concluded the presence of “limited capacities of maternity staff in Nepal, despite important investments from the Government” . HoweverNotable improvement was observed after this structured mentoring program was provided by senior nurse peers. The mentees significantly improved their knowledge in MNC, with 86.1% of them reaching a ‘good level of knowledge’, as defined by the MoHP of Nepal. The mentees also improved their ability to perform the 12 core MNC clinical skills of this program, with marked improvements in the following three procedures that save mothers’ and new-borns’ lives: managing eclampsia, managing post-partum haemorrhage shock, and resuscitating a new-born.This mentoring program appeared to have greatest impact among the staff with the lowest level of nursing education and in the lowest level of health facilities providing maternity care, namely, the birthing centers, where most of the staff are ANMs who work in isolated and remote areas despite their limited education. Interestingly, the mentoring program had a strong positive effect on non-SBAs, although the QI tools used were primarily designed for SBAs. We strongly believe that this is due to the individual-to-individual approach used in the programme, which allowed mentors to tailor their input according to the needs of each mentee.The lack of a control group means that we are unable to determine to what degree the changes in outcome are solely the result of the intervention. Moreover, we assessed the nurses’ clinical skills mostly using case scenarios and simulation models due to the limited caseload in some health facilities, which do not replace clinical observations during the provision of care to actual patients. This difficulty is inherent to QI programs in EmONC. Emergencies in maternity settings are often unpredictable and rare in places with low caseloads . MoreoveThe institutionalization of this mentoring program within the MoHP in a sustainable form was initiated as early as the beginning of the program by the FHD/MoHP and the National Training Health Center. More than 90 government mentors were already trained and certified by the FHD/MoHP and the National Health Training Center at the end of the program. Funds have been secured by the MoHP to cover their travel and accommodation costs, as well as to fund extra staff to fill the gaps created while mentors are away from their post to perform their mentoring activities.However, the overall sustainability of the program remains unclear, mainly due to the local political context, as the health system is undergoing a complete restructuring to fit into a newly implemented federal system. The program team suggested that the MoHP explore the feasibility of developing ‘cascade-mentoring’, with local mentors further trained and mentored by provincial mentors, as successfully implemented in Uganda in the area of MNC . Nepal hGiven the geo-economical context of Nepal and its current transition from a central government to a regional system, it will take time before all birthing centers have a trained midwife or SBA-registered nurse. Meanwhile, and because SBAs are better equipped to address normal deliveries and obstetrical complications than their non-trained peers, SBA training is still provided and should be scaled-up and accelerated for all employed maternity staff and combined with regular refresher courses and supervision/mentoring by experienced nurses. Plans are currently being made by the MoHP to reshape the existing SBA course into a ‘bridging course’ to become a certified 1-year midwifery course for all staff who have previously completed the 3-year PCL nursing course. Trained staff will be registered as midwives in the Nepal Nursing Council.Among the lessons learned from this program, we found that on-site clinical mentoring in remote locations requires motivated mentors, engaged mentees and support from hospitals and health facility management committees. During qualitative focus group discussions held during the closing project meeting, the program team, including the mentors, also observed that mentoring builds teamwork, staff confidence, motivation, and a sense of ownership and pride. This finding may be due to one innovative feature of this mentoring program: the bundle approach linking clinical and management mentoring. Given that high-quality clinical services strongly depend on management support for the provision of basic infrastructure, water, power, equipment and supplies, as well as regular cleaning and maintenance, all clinical mentoring activities were organized jointly with the management mentors, promoting synergy, interaction and collaboration between the clinical and management teams, as seen elsewhere . At the Among the factors that adversely affected the implementation of the program, in addition to the low caseload mentioned in the limitations section, we note the difficulty of maintaining the cohort of nurse-mentees due to frequent staff transfers and vacancies (mainly training opportunities or pregnancy leaves). An additional challenge was the changing political context, as Nepal’s constitution was revised during the program, and the MoHP moved from a centralized ministry to a federal context.Quality of care has recently gained much attention, as it is now clear that universal health coverage will not be reached without improvement in the quality of health services . DespiteAdditional file 1. Quality domains targeted by health facility management mentoring.Additional file 2. Content of the knowledge assessment questionnaire.Additional file 3: Table S1. Changes in assessment scores from baseline to end line by SBA status, Nepal, 2016-2018.Additional file 4: Table S2. Changes in assessment scores from baseline to end line by mentees' function status, Nepal, 2016-2018.


This earthquake seems to be spatially located between two major historical earthquakes, the 1868 Mw 8.8 earthquake in southern Peru and the 1877 Mw 8.5 earthquake in northern Chile. Continuous GPS data were used to model the coseismic slip of the mainshock and the largest aftershock (Mw 7.6). The afterslip was modeled for 273 days (end of year 2014) after the largest aftershock, revealing two patches of afterslip: a southern patch between the mainshock and the largest aftershock and a patch to the north of the mainshock. Observations from the seismic network indicate that aftershocks were concentrated near the southern patch. Conversely, the northern patch contained hardly any aftershocks, indicating a dominant aseismic slip. The Pisagua earthquake occurred within a prominent, curved section of the Andean subduction zone. This section may have acted as a barrier for the largest historical earthquakes and as an isolated segment during the Pisagua earthquake.We performed an integrated analysis of the coseismic slip, afterslip and aftershock activity of the 2014 M Geodetic and seismic observations of recent large-magnitude earthquakes in subduction zones show that barriers are usually characterized by fault segments with low degrees of locking4, where the accumulated stress is low5. Barriers may also be regions that preferentially exhibit aseismic afterslip due to the presumed prevalence of velocity-strengthening friction at the fault surface6. With the improvement of earthquake observations, the quasi-stationary behavior of fault segmentation models has become obsolete. Earthquake segments rupturing together during large earthquakes (Mw > 8.5) have confirmed this concept and revealed the role of stress transfer from one fault segment to another7. In this manner, barriers can be considered as transient fault elements that can be partially or completely crossed by larger (Mw > 8.5) earthquakes. Although there are indications about the physical processes controlling the occurrence of barriers, it is still unclear under what circumstances the gaps between ruptures act as barriers to rupture propagation or alternatively act as nucleation points or even as a bridge to rupture neighboring asperities. It has been proposed that the occurrence of barriers may be controlled by several factors, including large-scale lithological heterogeneities8, the nonplanarity of fault surfaces9, or fluid localization10.Theoretical models and earthquake observations reveal that subduction earthquake ruptures often stop their lateral propagation at specific places, which are called barriersst, 2014, by the Mw 8.1 Pisagua earthquake11. This area had remained unruptured since the two major historical earthquakes that occurred in southern Peru and northern Chile, the 1868 Mw 8.8 and the 1877 Mw > 8.5  of the plate margin is characterized by a significant curved plan view extending through southern Peru and northern Chile Fig. . In this19. These stations are operated by different research groups including IPOC, Caltech, CSN Chile and ISTerre21. The details, names, distribution and processing of cGPS data are presented in Tables 22. The GPS site positions were estimated daily and independently using a weighted least square technique. In the second step, loosely constrained daily solutions from global tracking IGS sites were combined with everyday solutions obtained from GAMIT, resulting in loosely constrained locations for the entire survey. These combined solutions were passed through a Kalman filter with GLOBK using a local stabilization method16 to estimate network-adjusted site coordinates. The horizontal (East and North) and vertical (Up) components, relative to the position vectors, are precise within 2–3 and 4–5 mm, respectively. We utilized the GPS sites KOUR in French Guyana, BRAZ, BRFT and CHPI in Brazil, and RIO2 in Patagonia and GLPS on the Nazca plate, which were not displaced from the Maule earthquake in 201023. The genuine GPS sites GLPS, KOUR, BRAZ and RIO2 were utilized for constraining our solutions. The International Terrestrial Reference Frame (ITRF) 2008 was executed through GLORG using locally produced h-files. This stabilization strategy defines a reference frame by reducing, using a least squares rationality, the departure from the a priori data determined in the ITRF200824. The GPS time series are shown in Fig. For coseismic displacements, we computed the daily positions of 19 cGPS stations in two steps using GAMIT/GLOBK software 25. The cGPS sites recorded large horizontal displacement towards the trench associated with both the mainshock on April 1st, 2014, and the largest aftershock on April 3rd, 2014  position components of the time series by using the principal component analysis method (PCAIM)014 Fig. .Figure 2rd, 2014 (after the largest Mw 7.6 aftershock), for 273 days  to simulate the Earth’s media. The estimation of Coulomb stress is based on the faulting parameters of the mainshock (strike/dip/rake), the fault slip and the apparent coefficient of friction in the crust32:s is the change in shear stress, Δσn is the change in normal stress and ΔP is the pore pressure change . The Coulomb stress change is computed using the modeled distribution of coseismic slip of the mainshock and largest aftershock at the plate interface, shown in Fig. The Coulomb stress changes (CSC) introduced by the mainshock were computed using Coulomb 3.333. This catalogue contains 4706 aftershocks with local magnitude of at least (Ml) < 1.4 and complete magnitudes above ~2.8  < 2.7. The relocated aftershocks are shown in the Supplementary Data , joint inversion models16 using high-rate GPS (HrGPS) and strong motion places the maximal slip downward to 25 km depth  define a better resolution of the coseismic slip. In these models, the slip is more concentrated, and therefore, peak slip appears higher, reaching up to 10 m. It is consisting with a rupture dominated by one main asperity. Those models also suggest a secondary asperity located southeast of the mainshock epicenter. The moment release function38 indicates that one large asperity was the energetic one during the mainshock. All the models coincide in to define the position of this energetic asperity.The coseismic slip was concentrated in a single patch extending approximately 95 km along-strike and 130 km downdip, located to the south of the mainshock epicenter. The slip of the largest aftershock was distributed south of the mainshock rupture. The 6.24 m peak coseismic slip of the mainshock occurred at 19.7°S, −70.8°W at a depth of approximately 23 km Fig. . The chepth Fig. . One imp38. See Tables The rupture of the largest aftershock was placed southward of the main rupture and propagated beneath the coastal line. According to the checkerboard test see Fig. , the coso = 1.98 × 1021 N m, corresponding to a magnitude of Mw = 8.13, and the largest aftershock yielded 3.22 × 1020 N m, equivalent to a Mw 7.6 earthquake. The cumulative postseismic moment released as afterslip (during the 273-days following the largest aftershock) was 3.27 × 1020 Nm, which is approximately 16.5% of the mainshock and corresponds to a magnitude of Mw 7.61.The afterslip from the inverted cGPS time series for the 273 days of postseismic relaxation exhibits temporal continuity decay, and the cumulative magnitude of afterslip increases with time. The afterslip model indicates that following the largest aftershock, afterslip mainly occurred in two separated patches, one located at the northern main rupture boundary and another at the southern rupture ends Fig. . The nor33. To better understand the relationship between seismic and aseismic slip in the postseismic period, we calculated the seismic moment released from published seismic catalog33 . By comparing this amount with the cumulative seismic moment released as afterslip, we conclude that only ~41.8% of the postseismic afterslip occurred due to seismic processes and that the remaining 58.10% was released aseismically.Omori’s law indicates that aftershock activity decays after 9 months to the background seismicityg33 Fig. . In the The CSC induced along the megathrust by the coseismic slip of the mainshock and the largest aftershock ranged from +0.46 to −2.76 bars, as shown in Fig. 39. This law provides the evolution of an afterslip U(t), as shown in Eq.  ruptures. The most-curved part could exhibit a mixed behavior, as barrier for these giant earthquakes and as a single segment for smaller earthquakes (Mw < 8.1). Following this idea, the historical 1868 Mw 8.8 earthquake and the 1877 Mw 8.5 earthquake broke the straight portion of the margin. In Fig. 49. Although the exact distribution of the rupture of these earthquakes is still in debate, existing models49 agree that these earthquakes stopped their lateral propagation in the most-curved part of the margin, where the Pisagua earthquake was located. A previous contribution11 has described this region, where the Pisagua Earthquake struck as an earthquake segment, referred as the Camarones Segment. This segment is separated at 21°S from a southern segment, called the Loa Segment, by an area of reduced locking. According to this previous contribution, this segment hosted the 1877 earthquake. Therefore, we propose that the junction zone of these two historical earthquakes represents a seismic barrier for the two great historical earthquakes. In this context, these two large historical earthquakes may have ruptured fully locked and straight segments localized in southern Peru and northern Chile . These observations strongly suggest that the curved section of the megathrust hosts significant temporal and spatial variations in terms of rate-state friction laws, behaving dually as a barrier during the two large historical ruptures and as a single segment during the Pisagua earthquake.We propose a general model in which the margin curvature of southern Peru and northern Chile and the Iquique ridge control earthquake segmentation at regional scale. Straight segments allow for hosting giant (Ms Mw < 8.. Followi51. The shear strength over this type of flat subduction segments is more homogeneous and therefore more likely to be exceeded over large areas. We suggest that along-strike straight subduction segments behave in a similar manner. Also, kinematic models of the main shock and the largest aftershock of Pisagua earthquake sequence suggest that an along-dip segmentation occurred during the propagation of both ruptures45. This segmentation has been interpreted as a result of a change of dip angle of the subducting slab. Figure w 8.8 Maule 2010 earthquake and the Mw 8.3 2015 Illapel earthquake. These two earthquakes stop their propagation at major changes in strike of the interplate contact; this observation indicates that along-strike changes in curvature of the interplate contact could control rupture propagation due to variation in shear strength and/or variation in locking.Our segmentation model claims an important role of the curvature variation of the interplate contact geometry along-strike. Another model suggests that giant earthquakes are propagated along dip flat segments of subduction zonesWhy the seismic gap did not rupture totally during the Pisagua earthquake can be explained by the heterogeneous locking, margin curvature and subducting ridges, which determine heterogeneous prestress levels at the interplate and fault segmentation. The area of the Pisagua earthquake most likely represents a region where the level of prestress was higher since the time of the two largest historical earthquakes. This area probably did not completely slip during the events of 1868 and 1877, and a slip deficit has accumulated since those times. The adjacent segments, given by the areas of the historical earthquake in the south of Peru and in the north of Chile, have increased the potential for earthquake nucleation because the slip deficit still remains high. The better earthquake scenario in terms of impact for the coastal cities of Peru and Chile is that these two adjacent segments rupture separately. However, both segments can rupture together if the slip deficit remains high near the trench in the rupture area of the Pisagua earthquake. The seismic moments released by all the processes involved in the Pisagua earthquake were not able to reduce the accumulated seismic moment deficit of the entire seismic gap. Therefore, we agree that this region still has the potential to generate a great earthquake, as has occurred in the past.Earthquake segmentation in northern Chile correlates with curved plate geometry


This session will address the evolving work of Geriatric Workforce Enhancement Programs (GWEP) to educate and train the primary care workforce and partner with community based organizations to address gaps in healthcare. The inaugural GWEP awardees were announced at the 2015 White House Conference on Aging. In November 2018 the Health Resources and Services Administration (HRSA), released the second GWEP Notice of Funding Opportunity (NoFO). The new funding opportunity reflects current policy priorities. In addition, for the first time in 9 years a Notice of Funding Opportunity was released for the Geriatric Academic Career Award (GACA) program. The return of the GACA program indicates the success of advocacy efforts to increase programs to support geriatric training and the development of geriatric academic professionals. Individual symposiums will explore the policy priorities reflected in the GWEP NoFO including the use of technology for training and care delivery, the age-friendly healthcare and dementia-friendly community initiatives, and value-based care including improving partnership with community based organizations. Additionally, an individual symposium will present the GACA program and discuss the advocacy process leading to the reintroduction of this program. During the last congress advocates of the GWEP and GACA programs supported authorization and funding of geriatric programs. Geriatrics programs describing the work of the GWEPs and GACAs were reinserted into the legislative process, although this reauthorization was not completed. This advocacy process garnered strong bipartisan and agency support. The session will describe these efforts and will conclude with an update on current authorization and appropriation status.


Being a well-rounded physician requires competencies that extend beyond traditional medical training. This study explores one residency program’s attempt to address the need to foster career management and leadership skills. A year-long didactic program was initiated to tackle both career management and leadership development. At the conclusion of the program, a survey revealed an increase in perceived competency in the domains taught. There was also a measurable increase in the amount of scholarly and quality improvement projects done in the department where the program was implemented. To support and develop physician competencies, healthcare organizations may derive immense benefit from a program that fosters both career management and leadership skills. Traditional postgraduate physician education focuses on learning the clinical aspects of a physician’s career. There is a lack of published literature on how training programs address needs such as leadership education and career development -5. A 201Without a career development curriculum, physicians are left to learn necessary skills through a non-standardized process of ad hoc mentorship, which leads to less-than-optimal career progress for physicians. This lack of career development also leads to a collectively diminished input from physicians in the nation’s health care conversations. There has been a renewed push for incorporating these topics into residency training. In 2017, the Accreditation Council for Graduate Medical Education added requirements specific to these topics [Riverside County Regional Medical Center  is a 439-bed safety net medical center. It trains resident physicians in several primary and specialty residency training programs. In the2009-2010 academic year, the department of anesthesia implemented an education program to train its residents in the business of medicine and healthcare leadership.The course was structured around a once-a-month, one-hour didactic program and an assignment to be completed at a medical conference. Each session has an assignment due the day of the session in preparation. The first part of the course focused on the individual’s career management. The latter portion focused on topics important to developing leadership skills.The career skills covered in the course began with personal branding, curriculum vitae, and resume development. These skills were bundled together and became the building blocks for the rest of the course. An example of an exercise in this course was having residents develop a unique personal brand that would be of interest to a future employer. These courses typically focused on technical expertise in a sought-after area or desirable personality traits, such as being a hard-working team player. Participants were then encouraged to find and complete resume-worthy projects that would highlight their specific areas of strength and provide the additional, collective benefit of increasing the program’s number of quality improvement and academic projects.The second component was dedicated to marketing residents. More specifically, the course was geared toward helping residents convey their unique values to potential employers. The exercise required that residents write short speeches about their strengths. The students then practiced delivering these speeches to peers who provided feedback to help refine the messaging. The next step in their evolution was a networking assignment where they applied what they had learned. Each year, the residency program sends residents to a local medical conference, and each resident is given a networking assignment to complete at the conference. Students are told to engage with a new contact in the form of a casual conversation and practice the script they had refined during the sessions. These skills form a core set of personal skills that are fostered and reinforced throughout the rest of the year’s course.The next block taught the practical aspects of evaluating and valuating different types of medical practice. It included contracting, insurance, organizational structure, reimbursement, benefit analysis, negotiation and retirement benefits. The final portion of the program covered medical staff structure, governance, health care reform, and future trends in medicine. Several measurements were taken to help assess the efficacy of the program. Pre-program and post-program surveys on perceived competency were completed by participants at the first and last sessions, respectively, to get a subjective measure of the program. The survey used a Likert scale. The quantity of scholarly activity generated by the resident physicians was also assessed and compared to the prior two-year average for the program.In addition to resident-perceived competency, the number of quality improvement and scholarly activity projects was measured before and after implementation of the program. Finally, the number of individuals the resident had contacted because of the networking assignment was measured as an indicator of the application of their networking curriculum.The pre-program and post-program survey results on the residents’ perceived competency is presented in Table The number of quality improvement projects and scholarly activity per resident increased as well. Before the implementation of this program, there was an average of 0.5 projects per resident. Upon the conclusion of the year, this number increased to an average of 15 projects per resident for that year of training. Finally, the number of residents who had met someone they had not previously known in the field went from none (for the prior three-year average) to 0.75 people/resident.The implementation of a year-long monthly training program increased the average perceived competencies in the career, business, and leadership domains. While this measure is only in the perceived competency, it likely reflects an improvement in these knowledge domains. One advantage of a written curriculum is that it institutionalizes training and skill-building instead of relying on the disorganized, ad hoc mentorship that previously existed.In terms of networking, the resulting 75-fold increase in residents who had communicated their value proposition to a stranger in the field cannot be assumed to mean they had achieved a quality network. It did, however, give them an opportunity to practice and reinforce a newly acquired skill with the possible future benefit of building their networks.From both the trainee’s and the program’s point of view, an additional advantage to a program such as the one described is an increase in the volume of scholarly activity. The quality of the activity was not assessed due to the subjectivity of an analysis like this. This does likely represent an advantage to both the resident and the program as a whole.One area that was not assessed was the residents’ overall satisfaction with this type of program. Anecdotally, residents in the earlier years of their education expressed subjective frustration that the program was taking them away from their clinical studies. The more senior residents did not express this same frustration. Further, upon follow-up with graduates of the program, they all expressed an appreciation for learning these types of skills. Additional studies and program development efforts based on alumni experience would be of value in the future.The implementation of a curriculum focused on developing the resident career, and leadership skills may improve a resident’s perceived knowledge, increase his or her professional network, and increase the volume of scholarly activity by the resident. It is plausible that healthcare organizations may derive immense benefit from a program that fosters both career management and leadership skills, and physicians with this additional training have an improved chance for optimizing their careers, which, collectively, is to the benefit of the healthcare system.