A Pilot Randomised Control Trial Exploring the Feasibility and Acceptability of Delivering a Personalised Modular Psychological Intervention for Anxiety Experienced by Autistic Adults: Personalised Anxiety Treatment-Autism (PAT-A).

Anxiety is commonly experienced by autistic people and impacts on quality of life and social participation. New anxiety interventions are required to effectively meet the needs of autistic people. Personalised Anxiety Treatment-Autism (PAT-A©) is a bespoke, modular approach to treating anxiety in up to 12 sessions. This study explored the feasibility and acceptability of delivering PAT-A© in the UK National Health Service (NHS). A single-blind randomised controlled trial design. Thirty-four autistic adults were recruited via clinical services and randomised to receive either PAT-A© or enhanced treatment as usual (CCSP). Outcome assessments relating to anxiety, quality of life and related constructs were completed at baseline, immediately post intervention; and at 3 and 12 months. Seventy-one percent of the PAT-A© group and 65% of the CCSP met diagnostic threshold for at least three anxiety disorders. Retention was good across both groups, with 82% (N = 14/17) completing the full course of PAT-A© and 71% (N = 12/17) attending both psychoeducational sessions in CCSP. 94% in PAT-A© and 82% in CCSP completed some follow up assessment 3 months post-intervention. Thematic analysis of interview data revealed that many participants valued the personalised approach, developed transferable skills and experienced positive changes to their anxiety. Participants were willing to be recruited and randomised, PAT-A© was feasible to deliver in the NHS and the trial methods and materials were acceptable. Our findings indicate that a fully powered clinical and cost-effectiveness trial of PAT-A© is warranted.

Evaluating process and effectiveness of a low-intensity CBT intervention for women with gynaecological cancer (the EPELIT Trial).

Background: Improving survival from gynaecological cancers is creating an increasing clinical challenge for long-term distress management. Psychologist-led interventions for cancer survivors can be beneficial, but are often costly. The rise of the Psychological Wellbeing Practitioner (PWP) workforce in the UK might offer a cheaper, but equally effective, intervention delivery method that is more sustainable and accessible. We aimed to test the effectiveness of a PWP co-facilitated intervention for reducing depression and anxiety, quality of life and unmet needs. Methods: We planned this trial using a pragmatic, non-randomised controlled design, recruiting a comparator sample from a second clinical site. The intervention was delivered over six-weekly sessions; data were collected from participants at baseline, weekly during the intervention, and at one-week and three-month follow-up. Logistical challenges meant that we only recruited 8 participants to the intervention group, and 26 participants to the control group. Results: We did not find significant, between-group differences for depression, quality of life or unmet needs, though some differences at follow-up were found for anxiety ( p<.001). Analysis of potential intervention mediator processes indicated the potential importance of self-management self-efficacy. Low uptake into the psychological intervention raises questions about (a) patient-driven needs for group-based support, and (b) the sustainability of this intervention programme. Conclusions: This study failed to recruit to target; the under-powered analysis likely explains the lack of significant effects reported, though some trends in the data are of interest. Retention in the intervention group, and low attrition in the control group indicate acceptability of the intervention content and trial design; however a small baseline population rendered this trial infeasible in its current design. Further work is required to answer our research questions, but also, importantly, to address low uptake for psychological interventions in this group of cancer survivors. Trial registration: ClinicalTrials.gov, NCT03553784 (registered 14 June 2018).

An increasing number of people are surviving for longer time periods following treatment for gynaecological cancer and this means we need to change how we care for and support a growing cancer survivor population. Psychological distress and poor quality of life are common in people affected by cancer, and these do not always improve once treatment ends. Providing psychological support can be expensive, which means that not everyone who wants it can access it. Psychological Wellbeing Practitioners (PWPs) have been introduced in UK health care. This workforce might offer an alternative for providing psychological support to a greater number of cancer survivors. We aimed to test how good a PWP co-delivered intervention is at improving depression, anxiety and quality of life in people who had been treated for gynaecological cancer. The intervention was delivered to small groups of patients over six weekly sessions. We compared those who received the intervention with a similar patient group who did not have access to the same psychological support from a different hospital. Participants reported their psychological wellbeing and quality of life at the point of recruitment, weekly for six weeks, and then at follow-up time-points one week and three months later. Because of low interest in the group intervention we did not recruit to target. Only 8 participants took part in the intervention, and we recruited only 26 participants in the control group. This means we can't have full confidence in our results. Nonetheless, the findings indicate that this intervention was helpful for improving participants' anxiety levels. Further trials, which recruit a larger number of cancer survivors, are needed to answer our research questions. However, this trial indicates acceptability and potential benefit. We also need to undertake research to understand why so few cancer survivors wanted to take part in this group-based intervention.

Treating anxiety in autistic adults: study protocol for the Personalised Anxiety Treatment-Autism (PAT-A©) pilot randomised controlled feasibility trial.

BACKGROUND: Anxiety is common in autistic adults and significantly limits everyday opportunities and quality of life. Evidence-based psychological therapies offered by mental health services often fail to meet the needs of autistic adults. The development of appropriate treatments for mental health conditions and, in particular, anxiety has been identified as a key priority by the autism community. The Personalised Anxiety Treatment-Autism (PAT-A©) trial aims to address this need by investigating the feasibility and acceptability of delivering an individualised psychological treatment for anxiety experienced by autistic adults. METHODS/DESIGN: This is a pilot randomised controlled feasibility trial. Up to 40 autistic adults with clinically diagnosed anxiety will be randomised into one of two groups (either the PAT-A© intervention or Current Clinical Services Plus two emotional literacy skills sessions). Before randomisation, participants will receive a detailed clinical assessment to inform formulation and guide anxiety treatment. As part of the baseline assessment participants will also identify two personally important 'target situations' that cause significant anxiety and impact upon their daily life. Based upon the formulation and identified target situations, participants randomised to the PAT-A© intervention will receive up to 12 individualised, one-to-one therapy sessions. Initial emotional literacy training sessions will be followed by a bespoke, modular, needs-based treatment approach utilising one or more of the following approaches: Mindfulness, Coping with Uncertainty in Everyday Situations (CUES), social anxiety and graded exposure within Virtual Reality Environments. Participants in the control arm will receive two psycho-educational sessions focussing on understanding and describing emotions and be signposted to healthcare provision as required. Data will be collected through quantitative and qualitative methods. DISCUSSION: This feasibility pilot trial serves as the first stage in the development and evaluation of a manualised personalised, evidence-based psychological therapy treatment for anxiety in autistic adults. Study outcomes will be used to inform an application for a fully powered multi-site intervention trial of adults and young people. TRIAL REGISTRATION: ISRCTN, ID: 15881562. Retrospectively registered on 9 August 2019.

Using Virtual Reality Environments to Augment Cognitive Behavioral Therapy for Fears and Phobias in Autistic Adults.

Fears and phobias are common in people on the autism spectrum and can impact on their ability to undertake usual daily activities. Graded exposure to the anxiety-provoking stimulus is a recognized method of treatment for fears/phobias in the nonautistic population but may pose specific difficulties for autistic people. For example, real-life exposure can be too anxiety-provoking to allow treatment to take place, and imaginal exposure can be problematic. To address this, we developed an intervention that combines cognitive behavioral therapy (CBT) with immersive virtual reality (VR) exposure to reduce anxiety. Following successful trials of this intervention with young people on the autism spectrum, we report a pilot study using the same intervention with autistic adults. Eight adults (aged 18-57 years) received one psychoeducation session and then four 20-minute sessions of graded exposure with a therapist in an immersive VR room (known as the Blue Room). Each participant completed all sessions showing that the intervention is feasible and acceptable. Outcomes were monitored at 6 weeks and 6 months postintervention. Five of the eight participants were classified as intervention responders and at 6 months after the end of intervention were experiencing real-life functional improvements. These preliminary findings show that VR-graded exposure alongside CBT may be an effective treatment for autistic people with phobias. LAY SUMMARY: Why was this study done?Anxiety is common in autistic adults. For some people, fears and phobias regarding everyday objects and situations occur frequently affecting everyday life. The main method to treat fears and phobias for people without autism is gradual exposure to the situation that causes anxiety. However, this method may be challenging for people on the autism spectrum. We wanted to test a new method of treatment that uses cognitive behavioral therapy (CBT) delivered with gradual exposure in a fully immersive virtual reality (VR) environment.What was the purpose of this study?We have already delivered this treatment successfully with autistic children. We wanted to test if this treatment would work for autistic adults. Changing traditional psychological treatments, such as CBT, to make it more suitable for autistic people is recommended by the National Institute for Health and Care Excellence.What did the researchers do?We recruited eight autistic adults (aged 18-57 years) with a fear/phobia and their supporter (parent/friend/support worker). Each adult had one session with a therapist to learn anxiety management techniques. They then had four 20-minute sessions of graded exposure with a therapist in an immersive VR room (known as the Blue Room). Each participant had a computer-generated scene designed for their specific anxiety-provoking situation. After four sessions, the participant tried real-life exposure with their supporter. We measured progress at 6 weeks and 6 months after the last VR session.What were the results of this study?Each participant completed all four sessions. This shows that the intervention was possible to deliver and acceptable to autistic people and therapists. Participants completed assessments at 6 weeks and 6 months after the VR sessions. Five of the eight participants were "responders" to the intervention. This means that 6 months after the last VR session, they still had real-life day-to-day improvements in relation to their phobia.What do these findings add to what was already known?We had not delivered this intervention to autistic adults previously. The findings show that this VR intervention has the potential to be an effective treatment for anxiety in autistic adults.What are the potential weaknesses in the study?This is a small study and future work will be a larger trial of this treatment-comparing results from people who get the intervention with people who do not. We would also want to have an outcome assessor who did not know whether people had received the intervention or not.How will these findings help autistic adults now or in the future?This new intervention has the potential to help autistic adults manage their anxiety in stressful situations and therefore may improve their quality of life.

Seeing the Meaning: Top-Down Effects on Letter Identification.

Most models of reading agree that visual word recognition is underpinned by a highly interactive network in which both bottom-up and top-down processes contribute. What remains unknown is whether evidence of top-down effects upon letter processing are restricted to word-form level information, or whether meaning-level information also plays a role. Here we sought to investigate top-down semantic influences upon letter detection using semantic manipulations of real word imageability and semantic priming, as well as a manipulation of nonword orthographic and phonological composition which varied degree of similarity to real words. A continuous adaptive staircase procedure was used, allowing us to assess the exposure duration needed for accurate letter perception in different stimulus types. Results revealed that in terms of both exposure duration and decision reaction times, words showed an advantage over pseudohomophones and pseudowords, which in turn showed advantages over consonant strings. High imageability words were processed more efficiently than low imageability words, both in terms of the exposure duration required for accurate letter identification and also decision reaction times. The presence of a related as opposed to unrelated semantic prime significantly shortened exposure duration, but also lengthened decision reaction times. This inhibitory semantic priming effect in reaction time was attributed to the interference at the decision stage by stronger activation of the prime letters in the case of related relative to unrelated trials. Taken together, the present results establish for the first time that the semantic dimensions of imageability and semantic priming exert significant effects on letter identification, indicating meaning-level influences on the very earliest stages of written word recognition.

Parenting Interventions for Children with Tic Disorders: Professionals' Perspectives.

Tic disorders can have an emotional and social impact on children and families, which can in turn have a reciprocal impact on tics. Research into parenting interventions within this population is limited. Twenty-five professionals' views on the acceptability, effectiveness, feasibility and utility of parenting interventions were explored using Q-methodology. Three highly correlated factors emerged, indicating three viewpoints with discrete elements that were underpinned by similar general perspectives. All factors endorsed a psychological approach, the importance of parenting practices, and theoretical and clinical justifications for parenting interventions. Discrete elements of the viewpoints debated the advocated focus, barriers and audience of interventions. Multidisciplinary professionals endorsed parenting interventions as a therapeutic tool within tic disorders. Results provide suggestions to further develop and implement interventions.

Is there an economic case for investing in nursing care--what does the literature tell us?

AIM: To determine the cost effectiveness of increasing nurse staffing or changing the nursing skill mix in adult medical and/or surgical patients? BACKGROUND: Research has demonstrated that nurse staffing levels and skill mix are associated with patient outcomes in acute care settings. If increased nurse staffing levels or richer skill mix can be shown to be cost-effective hospitals may be more likely to consider these aspects when making staffing decisions. DESIGN: A systematic review of the literature on economic evaluations of nurse staffing and patient outcomes was conducted to see whether there is consensus that increasing nursing hours/skill mix is a cost-effective way of improving patient outcomes. We used the Cochrane Collaboration systematic review method incorporating economic evidence. DATA SOURCES: The MEDLINE, CINAHL, SPORTDiscus and PsychINFO databases were searched in 2013 for published and unpublished studies in English with no date limits. REVIEW METHODS: The review focused on full economic evaluations where costs of increasing nursing hours or changing the skill mix were included and where consequences included nursing sensitive outcomes. RESULTS: Four-cost benefit and five-cost effectiveness analyses were identified. There were no cost-minimization or cost-utility studies identified in the review. A variety of methods to conceptualize and measure costs and consequences were used across the studies making it difficult to compare results. CONCLUSION: This review was unable to determine conclusively whether or not changes in nurse staffing levels and/or skill mix is a cost-effective intervention for improving patient outcomes due to the small number of studies, the mixed results and the inability to compare results across studies.

Mental time travel in dysphoria: Differences in the content and subjective experience of past and future episodes.

Previous research has shown that depressed individuals demonstrate a number of biases in their ability to retrieve past events and simulate future events. The current study investigated the content and phenomenological experience of past and future events in dysphoric and non-dysphoric individuals. Results indicated that dysphoric, compared with non-dysphoric, individuals reported fewer positive events across both temporal directions. Furthermore, phenomenological characteristics ratings suggested that dysphoric individuals saw future, but not past, events as less vivid, coherent, sensorially detailed, bodily experienced, emotionally intense and important with respect to their life story and identity. These findings are discussed with reference to theories regarding the functions of 'mental time travel', in particular how the muted subjective experience of future episodes in depression may impair future planning, problem-solving and self regulation.

The Use of Unregulated Staff: Time for Regulation?

Internationally, shortages in the nursing workforce, escalating patient demands, and financial constraints within the health system have led to the growth of unlicensed nursing support workers. Recently, in relation to the largest publicly funded health system (National Health Service), it was reported that extensive substitution of registered nurses with unskilled nursing support workers resulted in inadequate patient care, increased morbidity and mortality rates, and negative nurse outcomes. We argue that it is timely to consider regulation of nursing support workers with their role and scope of practice clearly defined. Further, the addition of these workers in a complementary model of care (rather than substitutive model) should also be explored in future research, in terms of impact on patient and nurse outcomes.

An exploration of nursing research perceptions of registered nurses engaging in research activities at a metropolitan hospital in Western Australia.

AIM: To explore perceptions about nursing research of registered nurses (RNs) who were engaged in research activities at a metropolitan hospital in Western Australia. BACKGROUND: In order to improve RNs' research engagement and promote evidence-based practice, Nurse Research Consultants (NRCs) were appointed jointly by the study hospital and a local university. This joint appointment commenced in 2004 in the hospital's emergency department. Early findings indicated that the NRC role was effective in assisting registered nurses with research activities and hence the NRC role was expanded to all areas of the hospital. However, no formal investigation had been carried out to explore the effect of the NRC role on RNs' engagement with nursing research across the hospital. DESIGN: A qualitative interview process. METHODS: Ten RN participants from the adult and paediatric wards were interviewed. Audio-recorded data were transcribed verbatim and thematic analysis was undertaken. RESULTS: Four main themes were identified, namely: perceptions of nursing research, perceived enablers, perceived barriers and improving research engagement. There was some overlap with some sub-themes being linked with more than one theme. This appeared to be due to differing levels of research education and research engagement. CONCLUSION: 6pc some of the RNs that participated in this study were experienced in the conduct of research, finding adequate support from NRCs in the workplace, whilst others experienced barriers limiting their involvement in nursing research activities. These barriers could be reduced with additional education, support, improved communication, time and opportunities to undertake research activities.

The anterior temporal lobes are critically involved in acquiring new conceptual knowledge: evidence for impaired feature integration in semantic dementia.

Recent evidence from multiple neuroscience techniques indicates that regions within the anterior temporal lobes (ATLs) are a critical node in the neural network for representing conceptual knowledge, yet their function remains elusive. The hub-and-spoke model holds that ATL regions act as a transmodal conceptual hub, distilling the various sensory-motor features of objects and words into integrated, coherent conceptual representations. Single-cell recordings in monkeys suggest that the ATLs are critically involved in visual associative learning; however, investigations of this region in humans have focused on existing knowledge rather than learning. We studied acquisition of new concepts in semantic dementia patients, who have cortical damage centred on the ventrolateral aspects of the ATLs. Patients learned to assign abstract visual stimuli to two categories. The categories conformed to a family resemblance structure in which no individual stimulus features were fully diagnostic; thus the task required participants to form representations that integrate multiple features into a single concept. Patients were unable to do this, instead responding only on the basis of individual features. The study reveals that integrating disparate sources of information into novel coherent concepts is a critical computational function of the ATLs. This explains the central role of this region in conceptual representation and the catastrophic breakdown of concepts in semantic dementia.

The critical role of nurses to the successful implementation of the National Safety and Quality Health Service Standards.

The National Safety and Quality Health Service Standards requires health service compliance by 2013 and covers several areas including governance arrangements, partnerships with consumers and eight key clinical processes. Nurses in Australia comprise 62% of the hospital workforce, are the largest component and hence play a critical role in meeting these standards and improving the quality of patient care. Several of the standards are influenced by nursing interventions, which incorporate any direct-care treatment that the nurse performs for a patient that may be nurse or physician initiated. The ability for nurses to undertake these interventions is influenced by the hours of care available, the skill mix of the nursing workforce and the environment in which they practice. Taking into consideration the predicted nursing shortages, the challenge to successfully implement the National Safety and Quality Health Service Standards will be great. This paper examines the role of nursing in the delivery of the National Standards, analyses the evidence with regard to nursing-sensitive outcomes and discusses the implications for health service decision makers and policy.

An initial evaluation of direct care staff resilience workshops in intellectual disabilities services.

The emotional responses to challenging behaviour of direct care staff who support people with intellectual disabilities is thought to be an important mediating factor within the stress experienced by staff and a potential maintaining factor in challenging behaviour. A brief workshop to improve direct care staff resilience was developed and initially evaluated using a measure of emotional reaction to challenging behaviour and a measure of burnout. It was found that negative emotional reactions to challenging behaviour significantly reduced following the workshop, but a measure of burnout did not. This may indicate the usefulness of this intervention with direct care staff in managing their emotional reactions to challenging behaviour. However, further development and evaluation of such interventions with direct care staff is required to explore ways of impacting upon burnout and managing the display of challenging behaviour.

What's in a word? A parametric study of semantic influences on visual word recognition.

To what extent does semantic information play a functional role in visual word recognition? Theories of word recognition vary in the importance assigned to semantic information in visual lexical decision, with past research suggesting that the nature of the foils is a crucial determinant of semantic reliance. Here, we explored the conditions under which semantic variables influence lexical decision. Normal readers performed visual lexical decision tasks in which imageability and semantic priming were manipulated, with nonword foils varying systematically in their orthographic and phonological similarity to the real words. The effects of imageability and semantic priming increased in magnitude as nonword foils became progressively more wordlike. These findings provide a clear illustration of the flexible use of semantic information to support normal visual word recognition.