Programs supporting adolescent parents have been shown to increase socio-economic opportunities and promote healthy child development for young families, but retaining young parents is challenging. The Massachusetts Pregnant and Parenting Teen Initiative (MPPTI) offers case management and linkages to community and clinical services to young families. We examine engagement strategies identified by MPPTI participants and staff members in relation to participant retention by program site to identify potential strategies for increasing program engagement.We employed a mixed-methods approach incorporating quantitative data on program participant characteristics and program retention by site with qualitative data from staff and participant interviews and focus groups.Key program engagement strategies identified by both MPPTI staff and youth participants were social-emotional supports, staffing model, and concrete supports. We found significant differences in program retention by site; the two sites with the highest levels of program retention offered all engagement strategies identified.Quantitative data on program retention coupled with qualitative data from staff and youth interviews suggests that in our program, there may be an association between the engagement strategies identified and levels of program retention. The majority of research on youth program engagement focuses on youth as a broad group and not specifically on adolescent parents. This paper builds upon previous research by identifying specific strategies for engaging high-risk young families in case management programming. The effect of these strategies on program retention and subsequent program outcomes should be further explored.Unplanned adolescent births are associated with decreased socioeconomic opportunities and poor health outcomes for both the adolescent parents and their children. Adolescent parents more frequently report postpartum depression  offers case management and linkages to community and clinical services to expectant and parenting adolescents aged 14–24 years. The goal of MPPTI is to provide a comprehensive support model for expectant and parenting adolescents so that they (1) increase academic achievement and employment, (2) improve reproductive health outcomes, and (3) enhance family stability. MPPTI uses a two-generation model consisting of the following core services: helping participants set and work toward achieving education/employment goals; assessing reproductive, primary, and pediatric care needs and providing supported referrals; providing behavioral health supports as necessary either directly or via referral; assisting with securing housing; conducting screenings for child development and providing referrals to early intervention services; offering concrete supports such as child care and transportation; and providing health education. MPPTI targets adolescents who are disengaged from or ineligible for other young parent programming. Many programs serving young families have eligibility requirements such as serving only first-time parents or employing age cutoffs (i.e. serving only adolescents under age 21). Some programs may also restrict eligibility to participants who can commit to proscribed attendance requirements up front. To achieve program outcomes, MPPTI aims to engage participants in the program for a minimum of six months and ensure that participants have at least monthly check-ins with program staff.During 2014–2017, services were provided by community-based agencies in five Massachusetts communities with high teen birth rates. The funded communities—Chelsea, Holyoke, Lawrence, New Bedford, and Springfield—have teen birth rates that are 3 to 4 times the state rate and up to 1.7 times the national rate  test was performed to determine if the mean number of months of program participation differed significantly by agency. Post hoc analyses comparing pairwise differences in agencies’ mean number of months of engagement were made using Scheffe’s test. Spearman correlation was used to test if there was any correlation between: (1) program engagement and participant characteristics, including demographics, being homeless, and education/employment status at the time of program entry, and (2) program engagement and number of engagement strategies employed by agency. Engagement strategies were coded as yes/no for the presence of the following strategies identified during qualitative interviews: support groups, social activities, and concrete supports.Key informant interviews were conducted with staff at each of the five community agencies implementing MPPTI. Five semi-structured group interviews lasting approximately one hour each were conducted with 16 staff members. Staff members were recruited for participation based on their roles in the program: at least one youth worker and one program coordinator or supervisor were invited to participate via email. Staff members were interviewed on the following topics using a 10-question guide: services provided, barriers to service delivery, approaches for recruiting and retaining participants, partnerships, resources/funding, successes, and lessons learned. We report only on services provided and participant recruitment and retention approaches. Staff interview results are reported by agency and not by individual staff member.Six youth focus groups were conducted in English and Spanish with a convenience sample of 19 MPPTI participants across the five program sites. Current participants ages 18 and older were recruited by youth workers at their respective program sites to participate in the focus groups and were offered a meal and child care as incentives. Youth self-selected to participate after being provided with the information by youth workers. One focus group was conducted per community in four of the program sites; two focus groups were conducted in the community of Springfield. All focus group participants were between 18 and 24 years old. Sixteen of the participants identified as female and three identified as male. While the gender make-up of focus group participants was reflective of all program participants, youth under the age of 18 were not represented and information on participants’ race/ethnicity and specific needs, such as housing and academic supports, was not examined. Focus group length ranged from 30 to 60 minutes. A 12-question focus group guide was used; these questions covered motivation for participating in the program, services received, interaction with program staff, program satisfaction, and suggestions for improvement.Focus groups and key informant interviews were conducted from July to August 2016. All participants consented to being interviewed and were able to opt out of answering questions they did not feel comfortable with. The Massachusetts Department of Public Health (MDPH) and Harvard University institutional review boards approved the project in July 2016. A Harvard University doctoral student with a master’s degree in public health and more than five years’ experience in qualitative data collection and analysis developed the question guides for the staff interviews and youth focus groups, conducted the interviews and focus groups, coded data, and led the qualitative data analysis. The question guides were not piloted before use. An MDPH staff member sat in on the interviews and focus groups, which were audio recorded and transcribed. Interviews and focus groups were held at the program sites. An inductive analysis approach  and ranged from 9.6 to 18.8 months , being Hispanic , requiring an interpreter , and being female . There were significant negative associations between number of months of program engagement and being homeless at the time of program entry  and not being in school and not being employed at the time of program entry . There were no significant associations between number of months of program engagement and age, having graduated high school, or pregnancy status.Working with young people…can be difficult. They move a lot, their phones aren’t working anymore, they’re homeless, they’ve got stuff going on and they can’t be in one place long enough with you emotionally to connect with something. A lot of our folks have experienced multiple traumas in life and find trust very difficult. And the work is challenging.All staff from agencies interviewed stated they received a high number of referrals and had significant need for services for adolescent parents in their communities. Staff from all five agencies also reported that getting participants in the door and keeping them engaged were significant challenges. A staff member at one agency said,Program components identified as being helpful by both the key informant interviews and the youth focus groups were (1) social-emotional supports, (2) staffing model, and 3) concrete supports. A summary of these key themes is presented in Table  concreteSocial-emotional supports such as supportive relationships with staff members, social activities (family activities or “field trips”), and support groups (wellness or parenting groups) were most frequently mentioned by youth as their reasons for remaining in the program. Program participants varied in their preferences for which types of social-emotional supports were most helpful. Some participants emphasized close relationships with program staff. Several participants preferred field trips or gatherings where the purpose was to have fun rather than formal support groups. Although many participants reported support groups to be engaging, some participants said they did not like groups.Supportive Staff Relationships. The most common theme across both the key informant interviews and youth focus groups was creating trusting relationships between staff members and program participants. Program staff emphasized that building relationships with participants was key to engaging them in the program and getting them enrolled in direct services such as educational programs and reproductive health care. A program director stated, “I think the backbone of the model is to establish a transformational relationship between the youth worker and the mom.”Youth spoke positively of program staff that were nonjudgmental and relatable because they had similar lived circumstances or prior experience working with youth: “With [staff X], I’m able to trust cause he used to do this work before he came here. He was very experienced and knew what to do.” Several participants stated they worked toward going back to school or seeking employment because their youth workers pushed them or believed in them more than they felt other adults in their lives had. One youth stated, “When you’re in a bad position or feeling down, you don’t have that motivation…they are always right there and it’s like you have this opportunity and we can do this.”Building supportive relationships with program staff countered the most common barrier reported by youth to engaging in services, which was hesitation around trusting staff. One participant said, “I thought…I didn’t really vibe with professional people because I feel like they are not down to earth. I felt like I had to put on a mask with these people with all smiles…that’s why I wasn’t open to help at all from anyone.”Social Activities. Staff at two funded agencies mentioned social activities as engagement strategies. Staff at one agency said the “selling point” for engaging youth in programming was “summer trips.” Participants were eager to be involved in the program so that they could build community with the other participants and participate in these trips and other social activities.Participants also frequently mentioned social activities as key to program engagement. Youth from two agencies stated that field trips kept them interested in attending the program, and participants from another agency suggested increasing the number of social activities the program provides. When asked how to make the program better, one participant stated, “More playdates cause I don’t really know that many people around here…It would be nice to have more parent get-togethers cause sometimes when you’re a young parent you don’t go out as much.”Support Groups. The opportunity to interact with other adolescent parents was an important aspect of support groups. When discussing a parenting group offered, one participant said,The other thing about the groups, too, is that sometimes there is support within the groups, like she can teach me something that I didn’t know. It’s like we’re all the same age, we can relate to each other, we come from the same background, same city, same everything.Some participants enjoyed the groups primarily for the social aspects of connecting with other adolescent parents. When asked about their favorite part of the program, one participant said, “Groups. Cause it was like fun…we used to come every week. We were having so much fun.”Two participants stated not liking groups: one preferred one-on-one interaction with program staff and another preferred smaller groups, stating that the groups offered had too many people in them. Several other participants described not being open to groups when beginning the program because they did not feel comfortable, but that after some time they opened up and enjoyed the groups.When you are trying to create a fluid system and everyone has their own system…[it] is a challenge to making sure that young people are being taken care of. Everyone is in their silo doing their own thing but you’re trying to cross refer.... Good vision, but I think there were too many cooks in the kitchen.Another theme among both the staff and participants was staffing. Building time into staff schedules to coordinate case management with other program staff appeared to be critical to clearly communicating with participants. Four agencies used a centralized staffing model in which services were offered directly by the agency and participants were assigned a youth worker who acted as their point person. One agency used a network model in which multiple organizations provided direct services and participants typically did not have one point person. Program staff at two of the agencies with a centralized approach emphasized the importance of staff communication to coordinate care and suggested discussing every case at least once per month in a group setting. Program staff at the agency using the network model discussed staff communication as a significant challenge:Youth participants in the network model also noted that communication and coordination of services were barriers: “Nobody communicated with me. Like…you got referred cause of this, this, and that. They didn’t tell me that…. Who referred me? So it was weird to meet all these people all at once and all saying that they were my [youth] worker.”All agencies reported that they offered incentives to increase program engagement. When probed, agencies defined incentives as supports such as child care, transportation, food, and clothing. No MPPTI agencies offered cash incentives for program participation. Youth reported that these supports allowed them to more easily access the program: “That was like the best thing when I first came here, when they said that they had the child care so it makes it easy.”We identified three key strategies—social-emotional supports, staffing model, and concrete supports—perceived to be important in program engagement by MPPTI program staff and participants. Quantitative data on program retention coupled with qualitative data from staff and youth interviews suggest that in MPPTI, there may be an association between some of the strategies identified and levels of program retention. Much of the previous research on youth program engagement has not focused exclusively on adolescent parents and therefore may miss some of the unique needs of this population. Participants most frequently reported social-emotional supports as key to program engagement. To our knowledge, few studies examine social activities as engagement strategies for young parents. The link between providing social-emotional supports and in particular purely social activities such as field trips or play dates in relation to program retention and achieving program outcomes should continue to be explored.Young parents in programs with more centralized staffing models described better communication and trusting relationships with program staff. This theme corresponds to previous research identifying quality staff-participant relationships as key to program engagement (Greene et al. While the two agencies with the highest levels of program retention used a “centralized” model and offered all engagement strategies we identified, a third agency employing all engagement strategies identified and using a centralized staffing model did not have a similar level of program retention. Our analysis does not capture all of the program components or other factors related to program engagement. For example, social activities were identified as a program component by three agencies, but we did not examine the types of social activities offered by agency, the frequency with which activities were offered, or how many youth participated in each type of activity. Other program components such as the quality of programming related to employment or educational supports were not included in our study and may also play an important role in program engagement.Spearman correlation results indicated significant associations between homelessness and not being in school/not being employed at program entry and program retention. The two agencies with the highest percentages of homeless participants at program entry also had the lowest levels of program retention. Our study did not explore the interaction between participant characteristics and engagement strategies in relation to program retention. Some engagement strategies may be more effective for certain populations. Further research could examine which engagement strategies are most effective, especially within the realm of social-emotional supports.There are limitations to this study. Youth focus groups were conducted among a convenience sample of current program participants over the age of 18. Therefore, the views expressed may not represent all youth in programming and may differ from the views of participants under age 18 and participants who were no longer engaged in the program at the time of the focus groups. We examined only five sites which differed on participant characteristics, location, and other factors beyond the engagement strategies and staffing model we examined in this paper. We cannot rule out that differences in these factors may be predictors of program engagement because we did not conduct robust analyses on these factors. Finally, we did not measure the quality of the engagement strategies identified or of the staff relationships with participants.This paper builds upon previous research identifying specific strategies for youth program engagement (Asheer et al.


As telemedicine adoption increases, so does the importance of building cohesion among physicians in telemedicine teams. For example, in acute telestroke services, stroke specialists provide rapid remote stroke assessment and treatment to patients at hospitals without stroke specialty care. In the National Telestroke Program (NTSP) of the U.S. Department of Veterans Affairs, a virtual (distributed) hub of stroke specialists throughout the country provides 24/7 consultations nationwide. We examined how these specialists adapted to distributed teamwork, and we identified cohesion-related factors in program development and support.We studied the virtual hub of stroke specialists employed by the NTSP. Semi-structured, confidential interviews with stroke specialists in the virtual hub were recorded and transcribed. We explored the extent to which these specialists had developed a sense of shared identity and team cohesion, and we identified factors in this development. Using a qualitative approach with constant comparison methods, two researchers coded each interview transcript independently using a shared codebook. We used matrix displays to identify themes, with special attention to team cohesion, communication, trust, and satisfaction.Of 13 specialists with at least 8 months of NTSP practice, 12 completed interviews; 7 had previously practiced in telestroke programs in other healthcare systems. Interviewees reported high levels of trust and team cohesion, sometimes even more with their virtual colleagues than with co-located colleagues. Factors facilitating perceived team cohesion included a weekly case conference call, a sense of transparency in discussing challenges, engagement in NTSP development tasks, and support from the NTSP leadership. Although lack of in-person contact was associated with lower cohesion, annual in-person NTSP meetings helped mitigate this issue. Despite technical challenges in establishing a new telehealth system within existing national infrastructure, providers reported high levels of satisfaction with the NTSP.A virtual telestroke hub can provide a sense of team cohesion among stroke specialists at a level comparable with a standard co-located practice. Engaging in transparent discussion of challenging cases, reviewing new clinical evidence, and contributing to program improvements may promote cohesion in distributed telemedicine teams. Team cohesion is a key factor in team performance and effectiveness, representing the degree of “belongingness” felt by individual team members, the strength of the shared bond and investment in the overall group, and overall team integration , 2. As hTelestroke (telemedicine for stroke) connects patients with offsite physicians for stroke evaluation and treatment . TelestrAn alternative network model, the virtual hub , requires no central facility –15. SuchVirtual hubs also present distinct challenges to building cohesive teams. For specialists, some challenges appear similar to those in physical hubs, including adapting to changes in workload and payment structure , 17. OthThrough its Veterans Health Administration (VHA), the Department of Veterans Affairs (VA) operates the largest integrated healthcare system in the United States. In 2017, the Neurology Program Office in the VA Office of Specialty Care and the Office of Rural Health started a virtual-hub telestroke network, the National Telestroke Program (NTSP) . AlthougWe conducted a qualitative, interview-based study of stroke specialists employed by the VA NTSP. We recruited stroke specialists with at least eight months of NTSP employment for semi-structured, confidential interviews. The interviews were collected as part of the ongoing NTSP program evaluation, which was approved as an operational (not research) project. Interviews were audiotaped, transcribed, and analyzed. Analysis of these interviews was approved as expedited research (protocol #1602800879) by the Institutional Review Board at Indiana University and the Research and Development Committee at Richard L. Roudebush VA Medical Center.To limit socially desirable responding, we chose interviewers and notetakers  who had no previous relationship with any of the participants . By workThis work was part of a formal evaluation of NTSP, which was deployed and began treating patients in September 2017. By the end of the interviews in May 2018, NTSP included 10 spoke sites and had logged over 150 consultations with local emergency medicine staff. To ensure sufficient experience with the system, we sought specialists with eight months or greater experience in NTSP, excluding program administrators.NTSP is linked to VHA’s leadership through its Executive Champion, who is also the Deputy Director of Neurology in VHA Specialty Care Services. The program pays specialists per shift worked, not per encounter. For specialists already affiliated with VA, shifts are separate work rather than additional responsibility in their current (non-telestroke) positions. NTSP specialists, regardless of state residence, are credentialed through one facility in VHA and approved to consult on Veterans receiving care at VA facilities in any US state or territory. NTSP is not centrally mandated; medical facility participation is voluntary. Facilities choosing to receive telestroke services from NTSP are both urban and rural and are typically filling a gap in acute stroke care.Per the study aims, the interview team (including the lead interviewers) prepared a question-based interview guide  on theseTo identify interview topics, we reviewed literature on healthcare teamwork  and virtInterviews were either face-to-face or telephoned, and participation was uncompensated. During interviews, interviewers referred to a printed copy of the guide . Using dFive people coded transcripts: the three lead interviewers , one notetaker (EM), and the leader of the NTSP evaluation team . We met semimonthly. First, we drafted a codebook using the domains from the interview guide. Then, together, we read two transcripts and revised the codebook until codes were mutually distinct and collectively comprehensive. Between meetings, using qualitative data analysis software (NVivo 12 ), two coM = 33, SD = 11). Initial recruitment and the first four interviews were completed at VA’s SimLearn Center (simulation training facility) in Florida, where attendees were learning how to plan and run acute telestroke simulation training sessions. Subsequent recruitment and interviews were done by telephone. Given the program’s small size, we attempted to interview the entire cohort. All 13 eligible specialists who were approached agreed to be interviewed; 12 (92%) were scheduled and interviewed in the second quarter of 2018. The thirteenth was unable to commit to an interview during the study period. All interviewees had completed at least 10 shifts on call, and all interviewees reported completing telestroke consultations (self-estimates ranged between 4 and 20).Interviews were led by HM , HP 4],,4], and Key characteristics of NTSP’s virtual service included its organizational context and membership. NTSP had a flat organization within a larger vertical organization (VA); rather than using intermediaries, NTSP administrators and specialists typically communicated directly with each other and with spoke sites. Eight participants (67%) reported previous practice in telemedicine. Only three participants (25%) knew at least one other NTSP specialist before joining. Four specialists were full-time VA clinical providers, one specialist practiced full time outside VA, and the rest (58%) split their full-time clinical positions between VA and a university affiliate outside of NTSP. Reasons participants gave for joining NTSP included personal interest, professional growth, the flexibility of distributed work, and the ability to help more patients than one could through conventional practice.We identified facilitators and barriers to team building and classified each as more internal or more external Table . FacilitFrom five related concepts, we identified four themes as phrases  and summ[My] communications with [NTSP’s medical director] are oftentimes by telephone and it’s, it’s a real plus. I know that if anything significant comes up, I can call her and get a hold of her right away. [P12]Conversely, a participant with scheduling conflicts during the weekly calls expressed decreased feeling of team presence.Unfortunately, I have my clinic on Monday morning …. That would probably be one of the things that may diminish what I feel in terms of being part of the team. [P11]Participants also noticed situations when the communication tool or timing seemed inappropriate for the message . thoroughly discuss those in the weekly conference calls and then set a time in the future will, where they will be implemented, you know, rather than … sending out an e-mail during the week and indicating the changes expected, you know, right away. [P12]Specialists used scheduled and unscheduled communication for complementary goals. Scheduled communication clarified roles. It centered on a weekly case review conference call hosted by NTSP’s clinical leaders. Highlights from this call, attended only by NTSP specialists and administrators, were discussions of challenges, sharing of new research, and reflection on recent notable cases. Between these conference calls, communication consisted of mobile calls, mobile messaging, and electronic mail. Mobile calls were routed to the on-call consultant. Mobile messages used SMS and the mobile chat application WhatsApp . Email services included those provided by VA and other official affiliations. Through these tools, specialists clarified processes and addressed logistics and emergent needs. These tools also connected specialists directly with administrators.When I am able to participate with meetings and everything, I just get that feeling that everyone has like fully bought in. [P11]Program administrators led by example, and specialists noticed.It’s a really ambitious initiative, and obviously, it’s had its kind of challenges as they’ve rolled it out just from a technological and coordination perspective and teaching perspective, but you know. The group that they’ve put together, especially the leadership with [Medical Director] and [Chief], these guys are phenomenal in terms of what their dedication level is to the program. You know. They just really set the tone of just people that are really hard working and are motivated to make this thing as functional and as usable as possible. [P11]Administrators fostered an inclusive team culture.[NTSP’s medical director], she’s really really good at making sure that everybody is participating and their voice is being heard. I think she really enables the providers to speak up when there’s something that they’re concerned about. I really like that environment. I think that she was very instrumental in building that kind of comfortable cohesive environment, and it really does start with that weekly meeting. That’s probably the best example of it. [P5]Engagement in program development included setting up technology for newcomers and aligning schedules. The culture resembled that of a startup company.I like it when I see the other providers taking on their own leadership niches because I get to see them at something that they’re good at and can learn something from them. [P1]… the team is very excited about changing the system, improving the system, constantly making it, trying to make it better, and so it’s really exciting working with people that think like that and have that energy, because it gives you energy, gives me energy. [P5]Specialists took on multiple roles to address the program’s growing needs. Team engagement in program development was a facilitating factor in cohesion. Administrators cultivated team salience by further engaging the specialists in implementation problem solving.There are just some times when it’s really difficult to do the right thing for the patient because the technology’s interfering with that. … Like I literally have to pull up a list of my passwords every shift and like make sure they all work because if one of them’s broken then I can’t even complete that shift. [P1]Although most technology challenges were perceived as external to the program, some challenges came from software changes within the program. Moving among competing software applications elicited uncertainty.That it’s been a little bit challenging in the beginning to get the technology streamlined, especially because we’re juggling a lot of different programs. Initially, we were using one video thing, and then we moved to FaceTime, and then just for me as a non-VA provider, getting on-boarded into the kind of VA construct and getting access to CPRS and VistA [electronic health records] and all of that, that was immensely challenging when patient testing. [P11]However, some of the technical challenges resulted in solutions that providers were interested in spreading outside their NTSP practice.Yeah, and actually [Apple FaceTime] that’s something that we are looking to maybe fold into our [academic hospital] system as well based on my experience as a possible backup.” [P11].“Most of the specialists discussed their competences with telemedicine delivery. They often compared their previous programs with this one. P4 had set up a different neurology telemedicine program, deeming it “frustrating,” and conceded “this [NTSP approach] is the way to do it.”Almost all of the people that are doing this [NTSP] are fairly technology savvy, you know what I mean, so like emailing and texting is pretty easy. [P8]Experience with other systems increased specialists’ tolerance of technology barriers. Despite technical challenges, specialists reported high levels of satisfaction with the NTSP. Some of this tolerance was shaped by previous telemedicine practice. But previous practice in telemedicine also served as contrast to NTSP’s problems.I think our support system is much better. I think that it’s great that we have our weekly meeting, everybody gets together, we discuss. It’s definitely more a collaborative team. Everybody knows each other. We all talk to each other in our weekly meeting. I think that’s what the VA system is doing better. [P5]At times, the level of team cohesion rivaled that of co-located colleagues. For example, one specialist reported a greater frequency of talking with remote colleagues than with co-located ones at the same medical facility and even within a local service.We are four neurologists there, you know, in the VA in [City]. One person is hospital coverage … which I was doing before … so I see him, but the other two neurologists I haven’t seen for long. Like one person – [Name] – his wife was texting me. I said I had seen [him] like almost like four months back, you know? So this [NTSP] is more interaction. … So at like certain times you don’t see people in your own facility. [P2]To find a sense of belonging within the virtual team, common goals may have helped. Recurring reasons to join across participants were personal growth and professional service.I think in general the group feels like the hardest challenges and the most frustrating hurdles have come from outside the group as opposed to within …. You know, technical requirements, security requirements, organizational limitations, or even for example regional culture, like site culture. Like all of those things have been external to our group and so when they come up it feels much more like we’re on the same team trying to find solutions as opposed to anything from within the group causing challenges. [P1]Participants reported positive effects of membership on their professional identities.I think it [being a telestroke provider at VA] gave me back my identity as a stroke specialist … So, for nine months when I first joined the VA, I did not do a lot of acute stroke. So, finding out about this program was a great bonus ... because I really, I wasn’t sure, I was looking for that chance to do patient interaction and not just treating patients on the camera. So, I think I have a good balance now, so, a lot happier. [P9]Participants found cohesion through the shared experience and unique value proposition of a professional niche. Contributors to cohesion included the weekly case conference call, a sense of transparency in discussing challenges, engagement in program development tasks, and support from program administration. Participants helped each other find solutions to technology problems, which increased the feeling of others’ investment in their own success.Specialists unanimously praised NTSP and expressed high degrees of satisfaction with the program. They actively identified with the program (“we” appeared often in the transcripts). Several of the specialists pointed out that they enjoyed being part of a virtual team and that they were often the only stroke neurologist on staff at their local VA facility. They developed a collective self-efficacy for problem-solving within the VA environment. They felt like part of a special team with talented members, and being part of this team was meaningful to them. They spoke about practicing at VA in a more positive light because of their work in the NTSP and identifying themselves with the VA organization.Well, I enjoy the work, and I also enjoy the people, and I have to say that this [NTSP] program runs well, and being a part of this kind of VA program for me was really sort of a breath of fresh air. [P4]Helping each other with technology, a contributor to cohesion, may have also moderated the negative effect of technology issues on satisfaction. For example, to access the electronic health records system from their tablet computers, participants found answers together.… we were emailed links but there was no interest on the part of the helpdesk, and I'm not talking about the mobile helpdesk and [IT specialist] who is here with us today, but just sort of the general VA helpdesk, so in the end we sort of kind of figured it out ourselves or found someone in our local IT to sort of figure these things out. [P4]Both communication and engagement worked through cohesion to influence satisfaction. Especially between on-call shifts, communication among participants and with program administrators led to sharing of problems and solutions, promoting unity.In this qualitative study of stroke neurologists employed by the VA NTSP in a virtual service, we identified factors related to team cohesion and satisfaction with distributed work. Strategies for community maintenance included national program leadership support, communication channels, both scheduled and open, and the ability to adopt, change, and clarify internal roles. Having a shared purpose facilitated team cohesion and satisfaction by framing challenges as external to the group and overcome together, rather than internal and alone. These reports, plus favorable comparisons between specialists’ virtual colleagues and their physical counterparts, all indicated that high team cohesion is achievable without regular in-person contact among a virtual clinical team.NTSP’s early development may be explained by some administrative choices, starting with personnel hiring. Specialists were sought both within and outside VA, ensuring different perspectives on potential best practices. Second, functional communication structures were set up: a virtual meeting with weekly contact, at least one in-person meeting throughout the year, and an open mobile telephone line for urgent needs. Finally, specialists were involved in program development and engaged in ongoing problem-solving. These choices, implemented early, fostered a collective ownership of the program and ensured practice barriers were addressed.NTSP’s specialists built a virtual community of practice together. First, they participated in the weekly calls and other communication structures. Regular interaction and the weekly calls provided psychological safety for sharing complex cases where best practices were not entirely clear, while flexible scheduling promoted individual participation. In response to the invitation to help develop the program, they took initiative in solving problems and appeared to take collective ownership of NTSP. They reported interacting positively with one another in a responsive manner. This active participation by specialists appeared to be associated with reported satisfaction.Among reports of virtual-hub networks providing specialty care services e.g. , 39), to, to39]),Our study integrates well with prior work linking team cohesion in virtual settings with quality of work, job satisfaction and workforce retention. For example, our results align with those from a study of 14 virtual teams that discovered the relationship between individual trust and team cohesion was reciprocal and created a positive feedback loop . Our quaRegarding the implementation of virtual telemedicine hubs, our study builds on a recent qualitative study  by identRegarding virtual communities of medical practice, our study extends a recent finding  that knoLast, our study adds to research on physicians’ increasing use of secure, consumer-oriented mobile messaging software like WhatsApp , 50. In Strengths of this study include its nearly exhaustive sample recruitment, its focus on an important and unique virtual subspecialist population serving across a national healthcare system, and its infrequently studied context of virtual medical practice. Although limitations center on recruiting from only one healthcare system, telemedicine programs in other healthcare systems may share VHA’s facilitators and barriers . This study was an early snapshot of the NTSP. Later surveys will assess specialists’ satisfaction with program outcomes over time. Nonetheless, NTSP is a large, national virtual telemedicine program in the US, and this evaluation of team cohesion and satisfaction may inform strategies that future virtual telehealth programs can use to promote professional and organizational identities to minimize staff turnover, a costly implementation barrier.Our findings support three recommended actions for developing team cohesion in similar programs: supporting secure, direct communication among specialists and administrators, giving specialists meaningful roles in program development, and examining current practices regularly while implementing changes at predictable times. These actions may help virtual teams successfully address the somewhat universal and persistent challenges of personnel onboarding and changing technology. Establishing best practices for acute telestroke hubs may also help other forms of teleneurology  and, moFuture research about virtual teams could include natural experiments  and planned ones . Exploratory work of interest includes examining the associations between team cohesion and patient and program outcomes. Opportunities for between-group comparison could include studies of virtual team development and salience among other medical subspecialties, comparing a virtual with a traditional health service delivery program, or comparing an acute care team (like telestroke) with a scheduled care team (like outpatient teleneurology consultation). In addition to future research, our study can inform the development of telemedicine program infrastructure or hubs including leadership support and team dynamics to foster organizational identity and provider satisfaction.We examined how a national telemedicine program successfully developed team cohesion among a virtual team of stroke specialists. These findings may help administrators build team cohesion in virtual teams in other contexts and disciplines.


Background: EBUS-TBNA is an integral tool in the diagnosis and staging of lung cancer and other diseases involving mediastinal lymphadenopathy. Most studies attesting to the performance of EBUS-TBNA are prospective analyses performed under strict protocols. The objective of our study was to compare the accuracy of EBUS-TBNA to surgery in diagnosing hilar and mediastinal pathologies in a tertiary hospital, staffed by pulmonologists with and without formal interventional pulmonary training.Methods: We retrospectively analyzed subjects who underwent EBUS-TBNA followed by a confirmatory surgical procedure from January 2012 to December 2018. The primary outcome was to evaluate the accuracy of EBUS-TBNA in the diagnosis of all mediastinal disease. Secondary analyses determined the accuracy of EBUS-TBNA in cancer, NSCLC, and non-malignant lesions individually.Results: One hundred and forty-three subjects had an EBUS-TBNA procedure followed by surgery. EBUS-TBNA for all pathologies had an accuracy of 81.2% (CI 95% 73.8–87.4) and sensitivity of 55.1% (CI 95% 41.5–68.3). The accuracy and sensitivity of individual groups were: cancer , NSCLC , and non-malignancy . The NSCLC group had 15 false negatives and 5 (33.3%) of them were due to non-sampling of EBUS accessible nodes. Missed sampling led to a change in the final staging in 8.6% of NSCLC subjects.Conclusion: The accuracy of EBUS-TBNA across all groups was comparable to those reported previously. However, the sensitivity was comparatively lower. This was primarily due to the large number of EBUS-TBNA accessible lymph nodes that were not sampled. This data highlights the need for guidelines outlining the best sampling approach and lymph node selection. Lung cancer is the leading cause of cancer death in both men and women in the United States. More than 225,000 new diagnoses and 160,000 deaths due to lung cancer occur annually in the United States , 4. CompAs with any medical advancement, EBUS-TBNA has its own limitations. EBUS-TBNA cannot sample all the lymph nodes stations and the success of the technique depends on the provider's skills . HoweverA drawback of these studies is that most of them report accuracy based on clinic-radiological follow-up without comparison to the gold standard of surgical biopsy, which might result in overestimation of accuracy. Studies on the real-life evaluation of the accuracy of the procedure by comparison with the surgical lymph node biopsy are limited. We aimed to evaluate the performance of EBUS-TBNA in diagnosing both malignant and benign lesions, at a tertiary hospital with bronchoscopists with and without formal interventional bronchoscopy training. We compared the results of EBUS-TBNA with those of mediastinoscopy or intrapleural surgery that evaluated mediastinal LNs.We conducted a retrospective, observational study analyzing all the subjects who underwent EBUS-TBNA of mediastinal and hilar lymph nodes followed by surgical intervention (mediastinoscopy and/or lymph node dissection) at the University of Miami Hospital (UMH) and the Miami Veterans Affairs (VA) medical center from first of January 2012 through end of December 2018. Pulmonologists at both hospitals are employed by the University of Miami.In the VA setting, EBUS-TBNA is performed under general endotracheal anesthesia and in the University Hospital setting, the procedure is performed only under moderate sedation. All the EBUS-TBNA procedures were performed by pulmonologists.EBUS-TBNA was performed using Olympus (BF-UC180F both at Miami VA and UMH) equipment. Selective sampling of lymph nodes by EBUS-TBNA was performed based on discussions between the pulmonologists and thoracic surgeons. If EBUS-TBNA was positive for mediastinal LN involvement, those cases were discussed at tumor board for consideration of induction therapy if single station and non-bulky (<3 cm) lymph nodes and considered for definitive chemotherapy-radiotherapy if multi-station or bulky lymph nodes. If EBUS-TBNA was negative, the same criteria as described above was used for selective mediastinal staging through mediastinoscopy before anatomic resection. Lymph node dissection of N1 and N2 was routinely performed in all surgeries for lung cancer.EBUS-TBNA cytology was performed as previously reported . SurgicaAll subjects who underwent EBUS-TBNA in both the centers were maintained in a separate directory. Medical records of each subject was reviewed to identify individuals who underwent surgical procedures following EBUS-TBNA. Only those who were subjected to subsequent surgical procedures were included in this study. Subjects who did not have a surgical procedure following EBUS-TBNA and subjects who did not have lymph nodes sampled during surgery or EBUS-TBNA were excluded from the study.Descriptive variables, including demographics, EBUS-TBNA, and surgical procedures, were reported in numbers and percentages. We described the EBUS-TBNA test characteristics in comparison to surgery by calculating sensitivity and specificity and test relevance by calculating the positive predictive value (PPV) and negative predictive value (NPV). True positives (TP) were defined as LNs with the same pathological diagnosis in EBUS-TBNA and surgery and true negatives (TN) were defined as LNs without pathological findings in both EBUS-TBNA and surgery. False negatives (FN) were defined as either EBUS-TBNA finding an absence of disease in an LN but the presence of disease on surgical evaluation or EBUS failing to sample accessible pathological lymph node. False positives (FP) were defined as EBUS-TBNA finding disease that was not seen in the pathology from surgical specimens. Accuracy of EBUS-TBNA was defined as the ability to correctly diagnose the presence or absence of pathology in lymph nodes and calculated by an equation TP+TN/TP+TN+FP+FN. Our primary outcome was to define the accuracy of EBUS-TBNA in detecting any type of pathology in mediastinal and hilar lymph nodes. Secondary outcomes evaluated the accuracy of EBUS separately in the diagnosis of cancer, NSCLC and non-malignant lesions individually.A total of 948 subjects underwent EBUS-TBNA during the study period, of which 143 had a subsequent surgical procedure. From the remaining 805, 218(27%) had negative EBUS-TBNA sampling of lymph nodes, 304 (37.7%) had NSCLC, 50 (6.2%) SCLC, and 117 (14.5%) had other malignancies . One hundred and sixteen (14.4%) patients had non-cancer diagnosis. In the 143 subjects, 117(81.8%) had PET/CT, and 26(18.2%) had only CT before EBUS-TBNA procedure. Four subjects were not included in the final analysis as the lymph nodes identified with pathology on surgery were not accessible by EBUS-TBNA . The mean interval between EBUS-TBNA and the surgical procedure was 39 days (ranging from 2 to 142 days). The demographics of the study group are shown in the table below .Of the 139 subjects appropriate for analysis, 124 subjects (86.7%) had a primary diagnosis of cancer and 19 subjects (13.3%) had non-malignant lesions .For all 139 subjects, our data found 32 true positives (23%), 26 false negatives (18.7%), and 81 (58.3%) true negatives. There were no false positives. Data analysis found the sensitivity was 55.1% (CI 95% 41.5–68.3), specificity was 100%, was PPV 100%, NPV was 75.7% (CI 95% 70–80.5) and accuracy was 81.2% (CI 95% 73.8–87.4).Of the 120 (86.3%) subjects with a diagnosis of cancer, the number of true positives was 21 (17.5%), false negative was 22 (18.3%) and true negative was 77 (64.2%). The sensitivity, specificity, PPV, NPV, and accuracy of EBUS-TBNA for cancer was 48.8% (CI 95% 33.3–64.5), 100%, 100%, 77.8% (CI 95% 72.3–82.4) and 81.7% (CI 95% 73.6–88.1), respectively . On furtOut of 139 subjects, 94 (67.6%) had NSCLC as the primary diagnosis. Of the primary tumors, 33.3% originated in the right upper lobe (RUL), 21.9% in the left upper lobe (LUL), 10.4% in the right middle lobe (RML), 15.6% in the right lower lobe (RLL) and 18.7% in the left lower lobe (LLL). Data revealed 14 true positives (14.9%), 15 false negatives (15.9%), and 65 true negatives 65 (69.1%). Among the false negatives, 5/15 (33.3%) were due to non-sampling of EBUS accessible lymph nodes. Statistically, EBUS-TBNA for NSCLC had a sensitivity of 48.3% (CI 95% 29.5–67.5), specificity of 100%, PPV of 100%, NPV of 81.2% (CI 95% 75.3–86), and accuracy of 84% (CI 95% 75–90.8). The locations of the primary tumor were fairly evenly distributed in the false positives; 22% in RML, 11% in RLL, 16.7% in RML, 27.8% in LUL and 22% in LLL.Among true positive subjects, we further analyzed to identify the proportion of cases where EBUS-TBNA showed the highest station of lymph node involved in NSCLC. Out of 14 True positives, 10 showed the highest stage of NSCLC on EBUS. In 4 subjects, EBUS-TBNA showed involvement of only N1 station, but surgery showed involvement of N2 nodes (LN 7 in three subjects and LN 4R in one subject). Only 1 had the concerned N2 node punctured on EBUS. The other 3 did not have the involved N2 lymph node sampled .With the number of lymph nodes not sampled in EBUS-TBNA in consideration, we further analyzed the effect of missed EBUS biopsy in both true positive and false negative subjects and compared the EBUS-TBNA and final surgery staging for NSCLC. In total, 11 NSCLC subjects had a surgical procedure diagnose disease in lymph nodes not sampled by EBUS-TBNA. In 3 subjects (27.3%), the involved stations in surgery was the same N staging compared to EBUS-TBNA and were excluded. In the remaining 8 subjects (72.7%), surgery showed newly diagnosed N1 or N2 disease compared to EBUS-TBNA. This resulted in a change of final staging in 7/8 (87.5%) of these subjects .Nineteen (13.7%) out of 139 subjects had non-malignant lesions on final diagnosis. 12 subjects (63.1%) had granulomas and the remaining had infection and nonspecific inflammation. There were 6 true positives (31.6%), 4 false negatives (21%), and 9 true negatives (47.4%). The performance of EBUS in non-malignant disease found a sensitivity of 60% (CI 95% 26.2–87.8), specificity of 100%, PPV of 100%, NPV of 69.2% (CI 95% 51.3–82.8), and an accuracy of 78.9% (CI 95% 54.4–93.9). The 4 false-negative LNs on EBUS-TBNA here were found to have granulomas on surgical pathology.Among the 143 subjects, only 11 had core biopsies done in the EBUS procedure. Only 2 subjects had a pathological diagnosis in core biopsy which was negative in TBNA cytology, with one patient having mini-forceps biopsy of station 8 diagnostic of carcinoid and one patient having mini-forceps biopsy of station 12R diagnostic of metastatic renal cell carcinoma.The results of our study show that EBUS-TBNA had an accuracy of 81.2% in the diagnosis of mediastinal and hilar lymph node pathology. Disease-specific accuracy was 81.7%, 84% and 78.9% in the diagnosis of cancer, NSCLC and non-cancer lesions, respectively. The accuracy achieved was largely comparable with those reported in literature –17. The The paramount utility of EBUS-TBNA is for the identification of lymph nodal metastasis in NSCLC, and the sensitivity of EBUS-TBNA in regards to this varies widely, with various studies reporting sensitivity ranging from 46 to 96% , 19. TheOne reason for such a result is the relatively high number of lymph nodes that were involved in pathology but were not sampled by EBUS-TBNA, leading to a false-negative result. In 8 subjects with NSCLC, EBUS-TBNA did not sample the lymph node that was positive on surgery. Apart from a high false-negative rate, the effect of missed lymph node sampling also resulted in surgical upstaging of cancer in 7 subjects with NSCLC. All of them had PET/CT before EBUS-TBNA but uptake in the metastatic lymph node was seen in only 3 of the subjects and CT showed enlarged lymph node larger than 1cm in 3 of them. In 3 subjects who had PET-positive lymph nodes, EBUS-TBNA sampled LN 11R, 8, 13R, and 2R, whereas surgery showed involvement of LN 10R, 7,12R and 4R, respectively. In one subject where CT alone identified enlarged infra-hilar lymph node of size 1.9 cm, EBUS-TBNA sampled 11L (negative) but surgery identified cancer in 10L.The smallest lymph node metastasis identified on surgery was 8 mm in size on imaging. A systemic approach by the sampling of all mediastinal and hilar lymph nodes larger than 5 mm rather than a “targeted approach” whereby only abnormal lymph nodes seen on imaging are sampled, may result in fewer missed lymph nodes and thereby improved sensitivity. This approach has shown to reduce the number of subjects requiring upstaging after surgical procedure . SamplinAnother reason for the low sensitivity of EBUS-TBNA in our study could be our rigorous study methodology. An analysis of six review articles/meta-analysis of EBUS showed that only 16.3% (7/43) were retrospective studies. All the others were prospective studies with strict protocols. Most of these studies report EBUS-TBNA performance based on clinico-radiological comparison and follow-up, rather than comparing it with pathology results from surgical sampling. Moreover, several studies attesting the accuracy of EBUS comes from a small group of authors, all interventional pulmonologists , 23–27. In the 4 subjects where lymph nodes were not accessible by EBUS-TBNA, one was intraparenchymal. The other nodes that were inaccessible were 5,6,8 and 9 the latter two of which can be reached using EUS-FNA . StudiesThe use of EBUS-TBNA in the diagnosis of mediastinal and hilar lymph node pathology has become more and more prevalent due to its lower cost, less invasiveness and fewer adverse events compared to surgical lymph node sampling. Combined with high accuracy, it makes for the ideal first step in the diagnosis of pathology in mediastinal and hilar lymph nodes. The main aim of our study was to identify the performance of EBUS-TBNA by comparing it with surgical pathology outcomes in a tertiary hospital setting where no protocols and guidelines of prospective studies are involved. This study highlights the fact that in centers where guidelines are not followed thoroughly, the outcomes are clearly inferior. We strongly encourage that hospitals and providers must follow the latest guidelines defined for selection and sampling of lymph nodes for EBUS-TBNA , 29, 30.Our study has the limitations pertinent to retrospective studies. Some of the patients had an interval of more than 3 months between EBUS-TBNA and surgical confirmation due to unavoidable circumstances and this might have affected the results. Also, as with any endoscopic procedure, the probability of missing small foci of metastasis on EBUS-TBNA also needs to be considered.As EBUS-TBNA sampling of Mediastinal and hilar lymph node for pathological diagnosis and cancer staging becomes commonplace, more evaluation of its performance in conventional hospital settings is needed. Even though the performance of EBUS-TBNA in our center had a satisfactory accuracy of 81.2% for all pathologies, the low sensitivity was a cause for concern. This is especially imperative in lung cancer, where critical treatment decisions are made based on EBUS-TBNA results. Guidelines describing the best sampling approach and lymph node size threshold for needle puncture should be followed to achieve better outcomes.All datasets generated for this study are included in the article/supplementary material.The studies involving human participants were reviewed and approved by University of Miami Institutional review board. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.MM and MSM were involved in data collection, study design, analysis, preparation and review of manuscript. ED and SA were involved in data collection and review of manuscript. NV, DN, and GH were involved in review of manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Employee burnout and its associated consequences is a significant problem in the healthcare workforce. Workplace animal therapy programs offer a potential strategy for improving employee well-being; however, research on animal therapy programs for healthcare workers is lacking. This study aimed to evaluate the feasibility, acceptability and preliminary impact of an animal-assisted support program to improve healthcare employee well-being.In this mixed-methods pilot intervention study, we implemented an animal-assisted support program in a multidisciplinary healthcare clinic at a large VA hospital. The program included 20 sessions over 3 months, each approximately 1-h long. Real-time mood data were collected from participants immediately before and after each session. Participation rates were tracked in real time and self-reported at follow-up. Data on burnout and employee perceptions of the program were collected upon completion via a survey and semi-structured interviews. Differences in mood and burnout pre/post program participation were assessed with t-tests.n = 39) participated in any given session, averaging participation in 9/20 sessions. Mood  significantly improved from immediately before employees interacted with therapy dogs (M = 2.9) to immediately after (M = 4.5) (p = 0.000). Employees reported significantly lower levels of patient-related burnout  after  participating (p = 0.002). Qualitative findings suggested that employees were highly satisfied with the program, noticed an improved clinic atmosphere, and experienced a reduction in stress and boost in mood.Participation was high; about 51% of clinic employees (Establishing an animal-assisted support program for employees in a busy healthcare clinic is feasible and acceptable. Our pilot data suggest that animal-assisted programs could be a means to boost mood and decrease facets of burnout among healthcare employees. Burnout in the workplace is characterized by depletion of employees’ emotional resources and reduction of their feelings of success and achievement . Within Evidence suggests that burnout is highly prevalent among healthcare employees, impacting more than half of healthcare providers and staff , 16–21. One strategy for improving morale in the workplace and protecting against the potential for burnout is offering animal-assisted support programs for employees. Evidence suggests that such programs can have significant positive impacts on employee well-being, and have been associated with reductions in workplace stress and absenteeism, and improvements in employees’ mood, health, productivity, job satisfaction, and work quality –28. AnimWe completed a mixed-methods intervention pilot study using an explanatory sequential approach . The study ran from Spring 2018 to Spring 2019; animal-assisted program sessions were held in late Summer/early Fall of 2018.n = 39) to participate.We implemented an animal-assisted support program in a multidisciplinary healthcare clinic housed within a large midwestern VA hospital. We invited all providers and staff working in that clinic . Employees participated in the sessions as their schedule allowed; we did not standardize how long employees were able to interact with the dogs nor what activities they engaged in with the dogs (both of which were at the employee’s discretion).We used several strategies to support program implementation. Prior to program implementation, we distributed a ‘key facts sheet’ highlighting important information about the program and an informational letter with program details and dates to all clinic employees. We placed a calendar on the door of the conference room indicating visit dates, and coordinated with the hospital’s cleaning staff to ensure they knew the room would need attention after each visit. When the program was initiated, we sent reminder emails to clinic employees and the dog handlers reminding them of sessions. During each visit, we placed additional signage outside of the conference room and at the front desk to remind employees that we were holding a visit at that time.We collected data pre-, during, and post-program implementation: We fielded a baseline survey with clinic employees to gather information needed to refine and finalize program logistics and collect baseline data on employee outcomes . The survey along with an informational letter was distributed during a clinic meeting to all staff in attendance and copies were also distributed to all clinic employees after the meeting to ensure those not in attendance at the meeting had the opportunity to participate. A reminder survey was distributed 2 weeks later to optimize participation. The survey took approximately 5–10 min to complete.Participation rates were tracked in real-time by the study staff. We worked with clinic leadership to ascertain the total number of employees per shift. Participation was also self-reported on the post-implementation survey. In addition, each employee was asked to fill out a visual-analogue scale  indicatiFollow-up data on employee outcomes , program participation , and employee perceptions of the program were collected upon program completion using the follow-up survey and semi-structured interviews (see below). Post-implementation survey distribution processes mirrored those used during the pre-implementation survey.Semi-structured interviews were conducted with key stakeholders  to examine perceptions of program feasibility and acceptability, and overall experiences. All clinic employees and dog handlers were invited to participate in an interview. Interviews were typically 30 min in duration, were audio recorded, and subsequently transcribed verbatim.The following key outcomes were assessed:Observed participation rates comprised the proportion of employees who participated in each session out of the number of employees typically on that shift during the day of the week we held that session. The overall proportion of clinic employees who participated in the program and the average number of sessions employees participated in were calculated based on data provided by respondents on the post-implementation survey.Real-time mood was measured using a visual-analogue scale created specifically for use in this study. The scale ranged from 1 = worst mood to 5 = best mood.Burnout was measured using the Copenhagen Burnout Inventory (CBI), a valid and reliable measure of employee perceptions of burnout . The CBIOn the post-implementation survey, we asked participants to rate the extent to which they liked the program , and to tell us about their general experiences with the program using an open-ended, short-answer question.We asked employees to comment on program feasibility , acceptability , and general experiences with the program . We asked the dog handlers about feasibility issues, including perceptions of frequency and length of sessions and space, acceptability, including issues related to program implementation and setting, and general perceptions of the program, including how they thought the program was received by clinic employees.Adoption rates, real-time mood, burnout, and employee perceptions of the program were examined using descriptive statistics. Differences in mood and burnout before and after interacting with the therapy dogs were assessed using t-tests. An alpha level of 0.05 was used to determine statistical significance.Qualitative data from the semi-structured key informant interviews was analyzed by two qualitative experts using an inductive and deductive data-driven coding approach , 33 to iStatistical analyses were conducted using SPSS Version 23 . Qualitative analyses were conducted using NVivo Version 12 . This study was approved by the appropriate VA Institutional Review Boards.We received completed pre-participation mood scales following approximately 91% of employee encounters with the animal-assisted support program and post-participation mood scales from approximately 86% of encounters. Twenty-two completed pre-implementation surveys (56.4% response rate) and 16 completed post-implementation surveys (41.0% response rate) were returned. We completed 10 key informant interviews (five with clinic employees and five with dog handlers). A total of 12 different dog handlers conducted visits for the study.Survey participants were predominantly female, of white race and non-Hispanic ethnicity, and included physicians, nurses, individuals with other clinical responsibilities, and non-clinical support staff Table . Intervin = 39) participated  participated in 9 of the 20 visits on average (range: 1–18).Participation in the program was high; on any given day we held a session, about 51% (range: 33–82%) of the employees working in the clinic , with average reported mood scores improving significantly from immediately before the employees interacted with the therapy dog (M = 2.9) to immediately after (M = 4.5). Anecdotally, interviews revealed that employees experienced a positive mood boost from spending time with the dogs, which in turn, affected how they approached their subsequent clinical responsibilities, as one employee expressed:“. . .[the PUPPY program sessions] did definitely improve my overall mood. So if I was seeing a Veteran shortly thereafter, they would, of course, be the beneficiary of that mood.”Participating in the program significantly improved employee’s mood in real-time (t(316) = − 17.97, M = 18.0) vs. before (M = 40.0) participating in the program (t (36)=3.33, p = 0.002). Differences in average reported personal  and work-related  burnout were not significant, but trended in the hypothesized direction. During the interviews, employees were asked to describe how the PUPPY program affected their overall work experience in the clinic. Employees felt that the program offered a therapeutic break during their workday, which reduced mid-day burnout. As described by one employee:“. . .you might have a real busy day administratively or with patients, and obviously doing mental health as I do sometimes can be somewhat draining, and it gave you just that great recharge that you would need to kind of disconnect from your workday for a short period of time, and then that recharge that you need to go back in and start fresh and finish your day.”Another employee described how participating in the program reduced their levels of stress over time, highlighting the importance of offering the program for multiple sessions:“. . . I didn’t feel any effects in the beginning. But, when I was a little more intentional about going to the pet therapy, and kind of settling myself down and participating a little bit with the animal and the trainer, I really did see some benefits. . . It just took me two or three, or four sessions to really kind of get into it and feel like, let’s see if it really does make a difference. And then when I really did make a connection then I really looked forward to going. And I was like, yeah, this really does help me feel a little better. And this is for me.”Employees reported significantly lower levels of patient-related burnout  after (n = 14) reporting that they liked the program to a very large extent and another 14% to a moderate extent. Employees gave the program resounding endorsements, reporting that the benefits were far-reaching, both for the individual and the clinic as a whole. Interviewees similarly highlighted the positive interactions they had with the dogs and dog handlers, expressing enjoyment from observing and petting the dogs and chatting with the dog handlers.Post-implementation survey data indicated that employee satisfaction with the program and implementation was high, with 71% of respondents  among healthcare employees. This is an important finding, because research indicates that experiencing patient-related burnout is associated with decreased job performance  and turnWe did not, however, find that program participation significantly impacted work-related or personal burnout among the employees in our sample. These findings may signify that participating in an animal-assisted support program impacts facets of burnout differently. It may also, however, reflect the limited scope of our feasibility pilot, including that our work was contained to one hospital clinic and the resulting small sample size limited the power of our study. Accordingly, we cannot be sure that the lack of significant differences in two of our burnout sub-scales was attributable to the intervention not meaningfully impacting those aspects of burnout or a lack of power to detect differences.Historically, interventions designed to improve workplace burnout have focused on the individual  , 37. HowGiven the success of the program in this study, the implementation process we used provides a solid foundation for future efforts to implement employee-targeted animal-assisted support programs in healthcare settings. We found several strategies particularly helpful to our implementation efforts, including pre-implementation engagement of end-users, providing ample information about the program to employees before and during implementation, and exercising flexibility with logistics. However, it is important to note that implementation of this type of program is not one-size-fits-all. The scheduling and space protocols we describe were specifically developed to reflect the clinic context in which we were working. Each healthcare facility that embarks upon such a program should coordinate with each of its clinics to determine their preferences for scheduling and space, and to ensure that their employees can participate in program sessions. One possibility for clinics that do not have space available to dedicate for the program is to make rounds with the dog to people’s offices or hold the visits in more public spaces in the hospital, such as lobbies.Our results also highlight that employee perceptions of such programs may evolve favorably over time and with exposure, highlighting the importance of offering multiple program sessions over time. In addition, it is likely that, were a program like this to be discontinued after some time, its positive impacts would wear off, further substantiating the need to offer program sessions on an ongoing basis so its desired impacts have the opportunity to be realized. One key question, which was beyond the scope of the current study, is how many times (and how regularly) individuals would need to participate in the program to reap benefit from it, as well as how long individuals need to interact with the dogs during any given session and whether there are certain activities that participants can do during these interactions that would be more impactful. Future research should examine these important questions, including what the right “dose” of such a program is for it to have optimal effects and how long the benefits of participation last.In order to optimize future program implementation and facilitate larger scale roll-out, additional research is needed to assess factors that influence program implementation in various healthcare clinics across facilities of varying size and complexity. Future work might also explore the feasibility of implementing employee-facing animal therapy programs in facilities where these programs do not currently exist for patients, as well as the factors that are associated with why the program may positively impact facets of employee wellness and (as mentioned above) what the right dose of the program is to optimize its impact.The generalizability of our results may be limited as a result of recall/social desirability bias of self-report visual-analogue scale and survey data, as well as some factors related to the composition of the employees working in the clinic , and that clinics may differ in baseline satisfaction and cohesiveness. In addition, we did not validate the visual analogue scale used, including its appropriateness for a healthcare worker population, and the utility of a 5-point scale to capture mood . Moreover, the way that workflow and staffing is structured in this clinic may impact generalizability of the implementation-related information to other similar settings wherein staffing is handled differently. Because not everyone likes dogs, this program may not be appropriate for all employees; alternative strategies to enhance employee wellness should be considered for individuals who do not wish to interact with a dog. Of note, because of the quasi-experimental design used and the nature of our pre/post data, the analyses presented were descriptive and as such, we cannot draw causal inferences from them.Our data suggest that animal-assisted programs could be a means to boost mood and decrease facets of burnout among healthcare employees. The study further suggests that establishing such a program for employees in a busy healthcare clinic is feasible and acceptable to employees. Based on these results, we believe that additional research to establish the effectiveness of animal-assisted support in improving healthcare employee wellness is warranted. In particular, randomized controlled trials are needed to systematically assess the impacts of this type of program on healthcare employee outcomes and identify factors that can influence their implementation.


The real-time quaking-induced conversion (RT-QuIC) assay is a highly reproducible and robust methodology exhibiting an excellent pre-mortem diagnostic accuracy for prion diseases. However, the protocols might be time-consuming and improvement of the detection technology is needed. In the present study, we investigated the influence of a pre-analytical cerebrospinal fluid (CSF) treatment with proteinase K (PK) on the kinetic of the RT-QuIC signal response. For this purpose, we added PK at different concentrations in RT-QuIC reactions seeded with Creutzfeldt–Jakob disease (sCJD) CSF. We observed that a mild pre-analytical PK treatment of CSF samples resulted in an increased seeding efficiency of the RT-QuIC reaction. Quantitative seeding parameters, such as a higher area under the curve (AUC) value or a shorter lag phase indicated a higher conversion efficiency after treatment. The diagnostic accuracy resulting from 2 μg/ml PK treatment was analyzed in a retrospective study, where we obtained a sensitivity of 89%. Additionally, we analyzed the agreement with the previously established standard RT-QuIC protocol without PK treatment in a prospective study. Here, we found an overall agreement of 94% to 96%. A Cohen’s kappa of 0.9036 (95% CI: 0.8114–0.9958) indicates an almost perfect agreement between both protocols. In conclusion, the outcome of our study can be used for a further optimization of the RT-QuIC assay in particular for a reduction of the testing time. These include the PMCA  include clinical examinations combined with magnetic resonance imaging (MRI) of the brain, electroencephalography (EEG), and laboratory analysis of cerebrospinal fluid CSF; . Surrogathe PMCA , the amythe PMCA , the quathe PMCA , and thethe PMCA ,b. Ataral groups , 2016. Tl groups ; for sCJSc detection by RT-QuIC  treatment of CSF samples (sCJD and controls) on the PrP conversion efficiency in the RT-QuIC as defined by quantitative seeding parameters, such as the lag phase or the area under the curve (AUC). After selection of a PK concentration, we performed a retrospective study to define the sensitivity and a prospective study to compare the accordance of the RT-QuIC with and without pre-analytical PK treatment.The studies involving human CSF samples were reviewed and approved by the local Ethics Committee of the University Medicine Göttingen, Von Siebold-Str. 37075 Göttingen, No. 24/8/12. All samples were analyzed blinded for at least personal data.We performed a retrospective study including 65 sCJD patients  as well as 20 control subjects without prion disease. All sCJD cases were diagnosed as probable cases according to diagnostic consensus criteria; 20 were confirmed by autopsy . From thThe control group included patients either healthy or with clinically defined alternative diagnosis such as Alzheimer’s disease, alpha synucleinopathies, or psychiatric disorders . Additionally, we included a prospective cohort that consisted of 35 RT-QuIC positive cases (suspected sCJD cases) and 51 cases exhibiting a negative RT-QuIC seeding response (suspected controls). These samples were collected during diagnostic routine without any further characterization.We conducted the RT-QuIC analysis according to an established protocol , 2018. ECerebrospinal fluid samples were subjected to a mild pre-analytical treatment with PK in a range of 0–6 μg/ml. After adding PK, samples were incubated for 30 min at 37°C. Subsequently, PK was deactivated by heating at 65°C for 30 min.Acrylamide gels (12%) were fixed in a solution containing 50% methanol and 10% glacial acetic acid for 1 h. After 1 h, solution was exchanged. Staining with 1% Coomassie brilliant blue R-250, 50% methanol, and 10% glacial acetic occurred for 20 min with gentle agitation. Destaining in 40% methanol and 10% glacial acetic acid solution was carried out until the gel background was fully transparent destained. Finally, gels were stored at RT in 5% glacial acetic acid solution.Post hoc test. Two groups  were compared using the Student’s t test, while for non-normally distributed values, we considered the Mann–Whitney U test as appropriate. All analyses were conducted by using GraphPad Prism 8.Agreement between the standard and the modified protocol was measured with the Cohen’s kappa statistics, available in the vcd R package . Then, mWe performed a mild pre-analytical treatment of CSF samples with PK (2 μg/ml). After adding PK, samples were incubated for 30 min at 37°C. Subsequently, PK was deactivated by heating at 65°C for 30 min.The incubation step for 30 min at RT or at 37°C alone or in combination with the incubation of 30 min at 65°C (without PK) exhibited a non-significant effect on signal response compared to untreated reactions .In PK-treated reactions, the deactivation step is required; otherwise, all sCJD (MM) seeded reactions showed a negative seeding response comparable to controls . In contSubsequently, 20 well-characterized CSF samples from sCJD (MM) patients and 20 controls without prion disease were treated with different PK concentrations (0–6 μg/ml). After PK treatment, samples were subjected to RT-QuIC analysis using the standard protocol , 2018, wThe impact of a pre-analytical CSF treatment with 2 μg/ml PK on the total protein amount and the quantitative seeding parameters (such as lag phase and AUC) was now analyzed more in detail.Coomassie Brilliant Blue staining. Quantification of band intensities occurred by Image Lab software. Interestingly, we observed total protein amounts up to 50% decreased after PK treatment  by gel electrophoresis followed by reatment .Next, we calculated quantitative seeding parameters of untreated in comparison to PK (2 μg/ml)-treated RT-QuIC reactions seeded with sCJD MM CSF. The obtained data indicated that RT-QuIC reactions pre-analytically exposed to PK revealed a significantly shorter lag phase, which decreased from more than 30 h (untreated) to 6–9 h on average as well as an increased AUC value after PK treatment , while cThe sensitivity of RT-QuIC after pre-analytical treatment with PK was analyzed in a retrospective study. The cohort consisted of 65 sCJD patients . After pre-analytical exposure to 2 μg/ml PK, samples were analyzed via RT-QuIC for 40 h. The sensitivities varied between different sCJD codon 129 MV genotypes between 87% and 91%, while the average sensitivity for all sCJD genotype was 89% .To determine the analytical agreement of the optimized RT-QuIC (with PK 2 μg/ml) and the standard RT-QuIC, a prospective study on a patient cohort consisting of 35 samples with a positive RT-QuIC response as well as 51 samples exhibiting a negative standard RT-QuIC response was performed. PK-treated and untreated samples were analyzed in parallel on the same plate. Interestingly, we obtained an agreement of 94% for the RT-QuIC positively classified cases and 96% for all CSF samples exhibiting a negative RT-QuIC signal response . In addiin vitro protein misfolding amplification systems, such as the RT-QuIC, have been established providing relevant improvements in prion disease diagnostics and prion research (C as a substrate) exhibited a total assay duration for testing of 80 h  to the previous standard protocol in a prospective study. The accordance between both protocols varied between 94 and 96% with a Cohen’s kappa of 0.9036 (95% CI: 0.8114–0.9958), which indicates an almost perfect agreement between both protocols. For four CSF samples, where we do not have any follow-up information, both protocols disagreed. One explanation may be an increase of sensitivity of the RT-QuIC after PK treatment. However, to finally elucidate this issue, a retrospective study on a higher number of well-characterized samples  is recommended.Besides the standard or first generations of the RT-QuIC, a few studies successfully applied a so termed second generation of the RT-QuIC assay. In the second generation of the RT-QuIC, a truncated Syrian hamster recombinant PrP substrate (amino acids 90–231) and some modifications  of the standard RT-QuIC protocol have been used . In contIn summary, our study provides an alternative to the originally as second generation described RT-QuIC for a further optimization of this test. The pre-analytical treatment of CSF with PK helps to reduce the testing time by increasing the conversion efficiency indicated by a shorter lag phase, higher AUC values, and an increase of the sensitivity.All datasets presented in this study are included in the article/The studies involving human participants were reviewed and approved by local ethics committee in Göttingen (No. 24/8/12). The patients/participants provided their written informed consent to participate in this study.IZ and MS conceived the study. MC and SC performed experiments. IZ, MC, FL, and MS analyzed and interpreted data. IZ and MS drafted the manuscript. SZ, AV-P, and FL critically revised the manuscript. All authors read and approved the final manuscript version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.