DNP Student Project: Yvonne Bossert

Summary

Yvonne Bossert, a veteran registered nurse, transitioned from her extensive career in cancer patient care to explore a broader perspective on healthcare after personal challenges in 2020. She focused on the mental health of the elderly, inspired by the increasing loneliness epidemic in the U.S. and globally. Her project at Samuel Merritt University explored the efficacy of a group walking program by the American Heart Association to alleviate loneliness and depression. Despite a small sample size, findings highlighted the potential for such community programs to foster social connection and mental well-being, suggesting a paradigm shift in addressing loneliness as a public health issue.

Highlights

• Yvonne Bossert shifted her career to address mental health and loneliness after feeling disconnected from direct patient care. 💡
• The project's pilot utilized the American Heart Association's walking program to investigate its effects on loneliness and depression. 🏃‍♀️
• Surveys showed a high prevalence of loneliness, with participants experiencing notable improvement in social engagement. 🌟
• Participant feedback emphasized newfound companionship and motivation, despite limited statistical significance. 👭
• Challenges included a small, homogeneous participant group and environmental factors like weather. 🌦️

Key Takeaways

• Loneliness is a significant public health issue, affecting increasing numbers of people worldwide, and it is closely tied to mental health outcomes like depression. 🌍
• Yvonne Bossert transitioned her career towards educating healthcare providers and focused her DNP project on mental health and loneliness in the elderly. 🚶‍♀️
• A community-based walking program showed promise in reducing loneliness, evidenced by positive participant feedback. 👫
• Despite statistical insignificance, the project's qualitative feedback indicated a notable improvement in participants' feelings of connectedness and well-being. 📈
• The project underscores the importance of addressing loneliness as a social determinant of health and suggests implementing walking programs in various community settings. 🏛️

Overview

Meet Yvonne Bossert, a dedicated nurse who's taken a new route in her career path to tackle a growing epidemic—loneliness. With a wealth of experience in oncology and research, she felt the pull to venture into the mental health domain, particularly focusing on the elderly. Her journey led her to create a community-based walking program aimed at alleviating loneliness and depression.

Through meticulous planning and the support of the American Heart Association's established walking agenda, Yvonne embarked on a mission. She gathered a small group from her local church to participate in this project, which combined the benefits of exercise with social interaction. Despite a limited number of participants, the qualitative feedback was not just encouraging; it was heartwarming. Participants found joy, new friendships, and a sense of community, which for some, became a reason to get out of bed each day.

While statistically the results of the walking program didn’t show significant change, the real stories from participants painted a rich picture of community and connection. These narratives highlighted the need for such interventions and sparked a conversation about expanding these programs to more diverse and extensive populations, showing true promise in reshaping health care approaches to loneliness and mental health.

Chapters

• 00:00 - 03:00: Introduction and Background The Introduction and Background chapter provides an overview of a walking program aimed at reducing loneliness and depression. The presenter, Yvonne Bossert, a registered nurse with 35 years of experience, primarily in oncology, introduces herself. She shares her career journey and highlights her previous role as the Director of a research program in a clinic.
• 03:00 - 06:00: Project Proposal and Objectives The chapter titled 'Project Proposal and Objectives' discusses the speaker's transition from working in clinical trials to becoming a nurse educator. After feeling exhausted and burned out from managing various phases of clinical trials, the speaker decided to change career paths. They took up a new role at a pharmaceutical company where they currently work as a nurse educator. In this role, they focus on educating healthcare providers and support staff.
• 06:00 - 09:00: Importance of Loneliness as a Health Issue The chapter delves into the theme of loneliness and its impact on health, framed within the context of the narrator's personal and professional life. The narrator reflects on their feelings of guilt for stepping away from clinical settings during 2020, amidst the global challenges faced during the pandemic. The turning point comes with the personal loss of a brother, leading to a profound realization about the role of nursing from a broader perspective. This underlines the need to address loneliness as a significant health issue that extends beyond conventional healthcare environments.
• 09:00 - 12:00: Screening Tools for Loneliness and Depression The chapter discusses the broader perspective of nursing, emphasizing its impact on individual and population health. The narrator, who is pursuing a Doctor of Nursing Practice (DNP), shares personal insights, including details about their large family consisting of five children, some of whom are married, and the joy of having six grandchildren. These family commitments occupy a significant portion of their free time.
• 12:00 - 15:00: Intervention and Methodology The chapter titled 'Intervention and Methodology' delves into the theme of mental health, focusing on the elderly population as a vulnerable group. The author explains their long-standing interest in mental health and shares that this interest has influenced many of their project proposals. These proposals specifically target the mental well-being of senior citizens, highlighting the need for attention in this demographic. The chapter also mentions a significant discussion with a figure named Dr. Love, which likely influences the direction or focus of the interventions or methodologies discussed.
• 15:00 - 18:00: Results and Participant Feedback The chapter discusses a personal experience where a project proposal was rejected, leading to a shift in focus towards the themes of walking and loneliness. It highlights a significant statistic from a 2018 survey by Cigna indicating that over 43% of adults in the United States experience loneliness.
• 18:00 - 21:00: Project Limitations This chapter discusses the prevalence and increase of loneliness, highlighted by survey data showing that over 60% of respondents in 2021 experienced loneliness. The issue is characterized as an epidemic, impacting not only the United States but countries worldwide, including Japan.
• 21:00 - 25:00: Sustainability and Future Research The chapter discusses the issue of loneliness, highlighting its significance due to its impact on health. In the UK, there are Ministers appointed specifically to address loneliness and seek interventions. Dr. Hollis emphasizes the importance of recognizing and addressing loneliness because it leads to serious health consequences such as increased heart disease, functional decline, hypertension, hyperlipidemia, and elevated BMI.
• 25:00 - 33:00: Panel Feedback and Discussion The chapter discusses the impact of inflammatory cytokine increase, which is linked to autoimmune disorders, cancers, and overall deterioration of global health. It highlights how such increases can also lead to early-onset dementia, personality disorders, suicidal thoughts, and depression. The content emphasizes that depression and loneliness are intertwined closely enough to be nearly indistinguishable.

DNP Student Project: Yvonne Bossert Transcription

• 00:00 - 00:30 this presentation is on a walking program to decrease loneliness and depression my name is Yvonne bossert I have been a registered nurse for 35 years now it's hard to believe I've spent the majority of my career working with cancer patients which I always felt was a privilege and an honor to be a part of their Journey for the last 10 years I was in the clinic I was working as the Director of a research program where we were doing
• 00:30 - 01:00 phase one phase two and phase three clinical trials and toward the end of that I was feeling completely exhausted and burned out and I made a very drastic decision to go in a completely different Direction with my career and took a position as a nurse educator with pharmaceutical company so I currently work for this company and I educate providers and support staff on
• 01:00 - 01:30 hematologic malignancies and I also provide support for our product portfolio that being said when 2020 hit I struggled with guilt about being away from the clinic and away from the hospital setting and wondered how he could continue to make an impact and I realized that after the death of my brother that what I wanted to do was look at Nursing From A broader perspective you know given that ten
• 01:30 - 02:00 thousand foot view of what nursing is and how it can impact not just the health of one individual but of whole populations and I made the decision to return and get my dnp I have a very large family I have five children three of them are married now they're all grown and out of the house and I've also been blessed with six grandchildren and they take up the majority of my spare time when I'm not
• 02:00 - 02:30 in school and not working um one of the things that's interested me for a long time has been mental health specifically and many of the first project proposals that I had were centered on mental health and particularly the mental health of the elderly because I felt like that was an extremely vulnerable population and out of that and a discussion that I had with Dr Love
• 02:30 - 03:00 when one of my project proposals was deemed not suitable by my company I had to rethink what I was going to do and I hit upon walking and the problems of loneliness and more than a third of the adults in the United States suffer from loneliness now Cigna the Healthcare Company sent out a survey to their subscribers in 2018 and found that more than 43 percent
• 03:00 - 03:30 of the respondents experienced some degree of loneliness when that survey was repeated in 2021 that number affected more than 60 percent of the people responding to that survey this is of epidemic proportions here in the United States and we know it's a problem but it isn't isolated just to the United States this is a worldwide program in fact both Japan and the
• 03:30 - 04:00 United Kingdom have Ministers of loneliness to look the problem and search for interventions but as Dr Hollis likes to say so what why does this matter we all feel lonely once in a while but it does matter because there are very real consequences of loneliness including an increase in heart disease functional decline hypertension hyperlipidemia an increase in BMI
• 04:00 - 04:30 inflammatory cytokine increase which we know can thereby lead to autoimmune disorders and Cancers and Global Health deterioration it can also lead to early onset dementia personality disorders suicidal ideation and depression in fact what I found in the literature is that depression and loneliness are so closely intertwined as to be almost indistinguishable from one another
• 04:30 - 05:00 it can also lead to early mortality one longitudinal study showed that loneliness was associated with a decrease in total life expectancy of 3.6 years and this was all cause mortality the study also found that it was associated with an unhealthy lifestyle a decrease in overall quality of life and multiple comorbidities because it has such serious consequences
• 05:00 - 05:30 it's something that needs to be screened for and we need to identify appropriate interventions in fact some have proposed that loneliness should become one of the social determinants of Health there are a number of screening tools available one is the dejung gear fold screening tool and I probably butchered that name but it's an 11 item questionnaire but the one that's used most commonly particularly here in the
• 05:30 - 06:00 United States is the UCF UCLA loneliness scale now this original scale was a 20 item questionnaire but it's gone through a number of tests over the years for psychometric testing for validity and reliability of shorter versions of the form including an eight item questionnaire a six and a three item pre-screened questionnaire I chose the six item questionnaire for this project because it was shorter it
• 06:00 - 06:30 was more appropriate for a community-based project and was less of a burden on the participants now leech in her dnp project used the three item questionnaire to assess elderly patients in the Home Health Care setting and then if they had a high score they were offered a menu of items to hopefully decrease loneliness and these included loneliness support line uh humor music scripture reading and
• 06:30 - 07:00 reminiscence and she did indeed find a decrease in the scores of the UL S3 for that particular project now screening for depression is something that's done routinely in doctors offices and Clinics and this is a nine item questionnaire however there is a two item questionnaire that's been psychometrically tested and is valid and reliable as a first look at whether or not patients are at risk for depression
• 07:00 - 07:30 I also Incorporated this because the close tie between depression and loneliness and these were measured the pre and post intervention now within the literature I found a number of different interventions including the use of social media crafting support groups mindfulness journaling mentoring programs and exercise and what I found was the more successful programs involved socialization and group interaction
• 07:30 - 08:00 I chose the American Heart Association walking program because this is an established evidence-based program designed for cardiac patients however it was easily implemented for the purposes of this project due to its structure it's clearly outlined events and the suitability suitability for group walking and the time frame in which to complete the walking program so the purpose of this project really
• 08:00 - 08:30 was to determine if walking as a group could positively impact loneliness the Pico question therefore is will the use of the American Heart Association six-week beginner walking program decreased the incidence of loneliness and depression in adults at Trinity Episcopal Church in Folsom California as measured by the UCLA loneliness scale six and the patient Health questionnaire 2 pre and post intervention
• 08:30 - 09:00 the methods I used included identifying and appropriate framework in fact I found the implementation framework logic model which is specifically designed for community-based programs I then have my screening tools uls-6 and the phq2 my site selection was Trinity Episcopal Church I'm a member there they were agreeable to using the site not only as a meeting place for the walking program
• 09:00 - 09:30 but also to recruit participants from I chose the American Heart Association walking program as I stated previously it's amenable to this particular project for Community because it sets expectations on what they were going to do each day that they walk now the AHA has two different walking programs one was a four-week walking program that is for intermediate Walkers I chose the
• 09:30 - 10:00 six-week program because it was a beginner walking program and was accessible to almost everyone who wanted to participate I recruited volunteers to lead the walking program because I'm employed full-time and wasn't available Monday through Thursday to walk with the participants once I did all that I set my dates and began recruitment of participants in the month of August and I used Flyers newsletters
• 10:00 - 10:30 um and informational sessions pre-intervention anyone who was interested in participating was asked to sign a general release of liability and this released both the university and the Church of any liability in the event of an injury that would take place during the walking program once they sign that release of liability then everyone was given an anonymized demographic form as well as the uls-6
• 10:30 - 11:00 and phq2 now those forms were numbered and those numbers carried through to the end of the study for pre and post-intervention comparison purposes the demographic form included information on sex General age range their work status their living situation their marital status I wanted to find out were they with people and interacting with people on a daily basis that was the whole idea behind the
• 11:00 - 11:30 demographics that I collected then the intervention as mentioned previously was for six weeks and post-intervention they were given the same numbered form to complete once again it was anonymized the uls-6 and phq2 but what I didn't anticipate were the unsolicited comments that were written on the bottom of the forums and I will share those with you now there was no change in the phq2 scores essentially except for participant
• 11:30 - 12:00 number two she had a modest change to hers but the rest of them were low except for patient participant number four and her phq2 scores were actually quite high this would be someone that if you saw her in a clinic you would refer her to the phq-9 to further evaluate for levels of depression the new there was a numerical Improvement in the uls six scores now
• 12:00 - 12:30 participants number one and two have the lowest loneliness scores but they also corresponded with low depression scores and also it's interesting to note that both of these participants were married and lived with their respective spouses now participant number three and four had higher loneliness scores and both of them were divorced and lived alone and I don't know if there was correlation
• 12:30 - 13:00 there but I thought that was interesting to note now there was an issue with question number two the answers or the responses weren't always consistent with what the other responses were in the survey and I think it's because on the uls-6 that's the only positive question on that survey all of the rest of them are negative and as a result that question is reverse scored and I'm wondering if they didn't read
• 13:00 - 13:30 the item carefully or they responded to uh quickly now when I did the statistical analysis you can see that it was not significant the p-value in fact was 0.0989 and although you didn't see a statistically significant difference in Pre and post-intervention scores what was really telling were the comments that were written on the bottom of this final surveys one participant said I
• 13:30 - 14:00 rarely walk with friends but this experience has taught me the benefit and joy of interacting while walking while another said I would do this again if it were available here I enjoyed getting to know new people but the one that really touched me and really spoke to the value of a group walking program was the final respondent and that was this gave me a reason to get out of bed every day and this was from
• 14:00 - 14:30 participant number four who had the highest loneliness scores and also had the highest depression scores now there were some limitations with this as there are with all projects and all research it was a very small sample size there were just four people who participated and because it was from a single site there was a lack of diversity all of them were upper middle class they all lived in their own homes it was a very homogeneous group of people they were
• 14:30 - 15:00 all white but it is reflective of the parish and all of them were over the age of 65 which isn't surprising because it's difficult to commit to a daily walk at 10 A.M in the morning uh the weather was a bit of an issue the heat was pretty um hard to manage on some of the days even though it was in September and part of October and there was an issue with smoke one day where the air quality
• 15:00 - 15:30 index was quite high and so we actually had to cancel the walk that day there was some volunteer Dropout but I had already identified backups just in case and it was a good thing I had done that because somebody else was able to step in and cover that when someone dropped out the American Heart Association walking program really provided the structure that I needed for this project it very
• 15:30 - 16:00 clearly outlines what the participants are to do how long they would walk and the the intensity of the walk so it not only set expectations for the participants but also for the volunteers everyone knew exactly how long it would take each day they met also having that consistent time days of the week and an exact meeting place the church property is quite large and so they identified
• 16:00 - 16:30 quickly that there was one particular tree where they would meet that was easy for them to locate and there was also significant camaraderie among the participants and throughout it they were able to share stories about themselves and about travels family prayer work experience and they even exchanged telephone numbers so thinking about sustainability this really is a low-cost or no cost intervention that's accessible to most
• 16:30 - 17:00 people it could be implemented almost anywhere at schools churches Civic organizations and Parks and Recreation departments this is something though that the community would need to be made aware of and so what do you do you create Flyers that are posted where people go regularly places like pharmacies clinics doctor's offices grocery stores places
• 17:00 - 17:30 like that where people gather on a regular basis the information also needs to be shared with providers particularly Family Practice providers and internal medicine and gerontologists and although this protocol was open or the project was open to anyone over the age of 18 the participants were all over the age of 65 so it's also important to share the information with gerontologists and I do intend to publish and I have the
• 17:30 - 18:00 submission package ready to go um and for that and it is uh the American gerontological society Journal I can get that out loneliness is significant and it's a huge problem and we talked about the consequences of that and as a result we need to begin screening and that's something particularly advanced practice providers need to look at this as an
• 18:00 - 18:30 issue now Humana I do not endorse them but they do have a loneliness toolkit that I found online and it's for providers and this includes the uls-3 that very shortened version of the UCLA loneliness scale and they recommend that it be used as part of the annual physical exam or during a routine office visit if patients score high they recommend that they be referred to Mental Health Services but they offer no other
• 18:30 - 19:00 specific recommendations for intervention future research really should be focused on adults with high loneliness or depression screening scores applying the walking intervention and then measuring those scores post intervention to see if there is a true verifiable benefit of walking programs to decrease loneliness and depression there are larger implications of walking programs really are of benefit and
• 19:00 - 19:30 thinking about this how can we encourage walking if safety is an issue so we need to think about sidewalks lighting crime rates and offer Alternatives and getting people to places where they can meet and walk together as a group and what about inclement weather can you find places that are indoors such as school gymnasiums or indoor shopping malls the positive comments were very encouraging to me and gave me at least
• 19:30 - 20:00 an initial Peak into the benefit of a walking program in a community setting it there was an increase in socialization the participants and I think there's value in and accessibility of community-based walking programs on a personal note I will say this has stopped me perseverance and the challenges in overcoming obstacles along the way to complete my DMP program but ultimately it's taught me the value of
• 20:00 - 20:30 community Dorothy Day who started Catholic Charities her autobiography was titled the long loneliness and she says in there we have all known the long loneliness and we have learned that the only solution is love and that love comes with community loneliness is a near Universal phenomenon it is no different than pain thirst and hunger in telling us we have a need and we need to address that and look at
• 20:30 - 21:00 that as one of those social determinants of health and I hope that by publishing this and relaying this information to others that they will see the significance of loneliness and begin screening for it and hopefully find interventions that might include a community-based walking program I do want to acknowledge Dr Hollis for her guidance her wisdom and for keeping me in the program when I swore I was
• 21:00 - 21:30 going to quit I also want to thank you Dr Wyckoff for your encouragement your help in overcoming some of the obstacles and your insistence on scholarly intent and I want to thank my family most of all their love and support I could not have gotten through this without them and I want to thank Dr Marie Christine Seitz one of my co-workers for listening to this presentation over and over and over again and making recommendations and also I want to thank my mother she
• 21:30 - 22:00 is also a nurse and a role model and a sounding board for me and my biggest cheerleader and my greatest fan so thank you foreign thank you Yvonne a great presentation thank you um and really uh to use the
• 22:00 - 22:30 words in the Trap absolutely groundbreaking um I would like to open the first question to Dr Rush please yeah that was that was um first of all just an incredible um project and presentation and that was actually my comment that this is groundbreaking and I'm not I'm gonna have to sit and kind of stew on this a little bit for a while because I'm not exactly sure why this is um just really speaking to me and I and I think it's because like you said it's
• 22:30 - 23:00 just a universal part of life right loneliness happiness hunger thirst all of that and I have not I'm sitting here racking my brain I have never ever ever been asked by a healthcare provider are you lonely they certainly say do you feel safe in your own home dude you know those questions that I don't think they even really are asking for any real reason except to check a box right yeah and this is such a huge huge thing that is on one hand seems so simple right so why aren't we
• 23:00 - 23:30 doing it so I think this is just an incredible project and raising this awareness is just fantastic so congratulations really good job thank you very much as you can tell I was very passionate about this topic you should be you should be it's great thank you Dr Stacy I saw your hand out yeah it was these sort of stole something by Thunder because it's the very same thing I love
• 23:30 - 24:00 this project I'm passionate about walking within social groups um uh I joined a group last year and I cannot express how much they've elevated my mood and my I sleep better I think better I was able to finish my dnp project because of the support that I got from this walking group it was um I like I really really loved this project and again I've never been asked about my loneliness I mean you know and we can work around a lot of people and
• 24:00 - 24:30 still be lonely and I so that's often I do hope that you publish um this is I I never would have thought about it this is just phenomenal phenomenal work I hope that your church is able to continue with their walkthrough yes they are actually they're going to set this up you know I shared this with Rector and father Todd said oh well we need to continue this he said I think we just need to put it on the calendar and make
• 24:30 - 25:00 this a routine thing he said maybe not four days a week but at least three days a week where people could all meet and know that this is something that's happening and they do have um because like a lot of churches it's mostly retired people so they do have people who can lead the group and have volunteered to spearhead this but it's something I also want to share with other churches in the area because it's something that's not just limited to Trinity Episcopal it could be done at any of the churches in the area
• 25:00 - 25:30 yeah yeah thank you uh Dr fermento uh thank you um Yvonne outstanding work um you know I Echo their faculty uh members and I and I think you know um as I mentioned earlier I was uh commenting on Christa's uh presentation I work with the geriatric population and I've never even thought to ask about loneliness I think
• 25:30 - 26:00 I talk about you know increasing uh you know social support and engagement um and social interaction when only when addressing depression um and you know I think that uh one of the reasons perhaps that loneliness is not um asked about or addressed is because we're not really sure as providers how to
• 26:00 - 26:30 um what to recommend or what what is an evidence-based intervention that will be meaningful and so if you know you don't want to open the box if you don't have a response or there's no um you know you don't know what to say you know we'll go and hang out with your family or go to the community center or call a friend you know so it's really this is wonderful and uh I was just talking to our Clinic director last week about
• 26:30 - 27:00 having a walking and talking Group which is you know but I didn't even I don't know that the the American Heart Association has an actual um evidence-based walking program set forth so I truly hope that you publish and I hope that this is sustainable within your church and that we can start to develop this type of social support um you know for uh all populations but particularly the geriatrics and I think
• 27:00 - 27:30 that loneliness and isolation has really come to light um after the pandemic and you know for across all social um and age age groups and social demographics uh so excellent work excellent excellent thank you so much um one thing that um I approve you say can you close the loop on what we would do with
• 27:30 - 28:00 um abnormal PhD screens for the phq2 screen you know it's always been recommended that if they have a high screening score they should go on to complete the phq nine and if the person scores high on the phq nine then there are referrals to mental health because this is someone who has significant depression and I you know it was interesting because the volunteer who started out walking with
• 28:00 - 28:30 participants expressed concerns about this one participant who had the very high phq2 score and also had the highest loneliness scores and indeed one of the days when I did walk with participants I really had a sense of that from this person and you know the nurse in me wanted to make recommendations but of course I didn't because that wasn't my role in this setting but um you know I think
• 28:30 - 29:00 for because those two are closely associated that even though she had a high loneliness score it did go down some post interventions so that's encouraging her depression scores didn't change better loneliness score did
• 29:00 - 29:30 do we have other questions for Yvonne if not I would like to congratulate you Yvonne on your project and um I would like to close this session with Yvonne's presentation thank you so much thank you