The Association of Nursing Homes' Organizational Context with Care Aide Empowerment: A cross-sectional study.

BACKGROUND AND OBJECTIVES: Organizational context is thought to influence whether care aides feel empowered, but we lack empirical evidence in the nursing home sector. Our objective was to examine the association of features of nursing homes' unit organizational context with care aides' psychological empowerment. RESEARCH DESIGN AND METHODS: This cross-sectional study analyzed survey data from 3765 care aides in 91 Western Canadian nursing homes. Random-intercept mixed-effects regressions were used to examine the associations between nursing home unit organizational context and care aides' psychological empowerment, controlling for care aide, care unit and nursing home covariates. RESULTS: Organizational (IVs) culture, social capital, and care aides' perceptions of sufficient time to do their work were positively associated with all four components of psychological empowerment (DVs): competence (0.17 [0.13, 0.21] for culture, 0.18 [0.14, 0.21] for social capital, 0.03 [0.01, 0.05] for time ), meaning (0.21 [0.18, 0.25] for culture, 0.19 [0.16, 0.23] for social capital, 0.03 [0.01, 0.05 for time), self-determination (0.38 [0.33, 0.44] for culture, 0.17 [0.12, 0.21] for social capital, 0.08 [0.05, 0.11] for time), and impact (0.26 [0.21, 0.31] for culture, 0.23 [0.19, 0.28] for social capital, 0.04 [0.01, 0.07] for time). DISCUSSION AND IMPLICATIONS: In this study, modifiable elements of organizational context (i.e., culture, social capital, and time) were positively associated with care aides' psychological empowerment. Future interventions might usefully target these modifiable elements of unit level context in the interest of assessing their effects on staff work attitudes and outcomes, including the quality of resident care.

Organizational Context and Facilitation Interactions on Delirium Risk in Long-Term Care: A Cross-Sectional Study.

OBJECTIVES: Organizational context (eg, leadership) and facilitation (eg, coaching behaviors) are thought to interact and influence staff best practices in long-term care (LTC), including the management of delirium. Our objective was to assess if organizational context and facilitation-individually, and their interactions-were associated with delirium in LTC. DESIGN: Retrospective cross-sectional analysis of secondary data. SETTING AND PARTICIPANTS: We included 8755 residents from 281 care units in 86 LTC facilities in 3 Canadian provinces. METHODS: Delirium (present/absent) was assessed using the Resident Assessment Instrument-Minimum Data Set 2.0 (RAI-MDS 2.0). The Alberta Context Tool (ACT) measured 10 modifiable features of care unit organizational context. We measured the care unit's total care hours per resident day and the proportion of care hours that care aides contributed (staffing mix). Facilitation included the facility manager's perception of RAI-MDS reports' adequacy and pharmacist availability. We included unit managers' change-oriented organizational citizenship behavior (OCB) and an item reflecting how often care aides recommended policy changes. Associations of organizational context, facilitation, and their interactions with delirium were analyzed using mixed-effects logistic regressions, controlling for covariates. RESULTS: Delirium symptoms were prevalent in 17.4% of residents (n = 1527). Manager-perceived adequacy of RAI-MDS reports was linked to reduced delirium symptoms (odds ratio [OR] = 0.63). Higher care hours per resident day (OR = 1.2) and an available pharmacist in the facility (OR = 1.5) were associated with increased delirium symptoms. ACT elements showed no direct association with delirium. However, on care units with low social capital scores (context), increased unit managers' OCB decreased delirium symptoms. On care units with high vs low evaluation scores (context), increased staffing mix reduces delirium symptoms more substantially. CONCLUSIONS AND IMPLICATIONS: Unit-level interactions between organizational context and facilitation call for targeted quality improvement interventions based on specific contextual factors, as effectiveness may vary across contexts.

The effectiveness of transdiagnostic cognitive behavioural therapy for anxiety disorders: the role of and impact of comorbid depression.

Transdiagnostic Cognitive Behaviour Therapy (tCBT), an intervention designed to be applicable across multiple diagnoses, was introduced to improve limitations in traditional therapy such as cost and access to trained therapists. It has been established as an effective and efficacious treatment for anxiety disorders, though there has been little research focussed on the role of depression. The current study investigated the role of comorbid depression during tCBT for anxiety disorders in primary care settings as an outcome and a moderator of anxiety outcomes. Results of multi-level ANOVAs indicated no significant difference in anxiety outcomes regardless of whether there was a comorbid depression diagnosis in the tCBT condition, and that individuals with a comorbid depression diagnosis experienced significantly greater reduction in anxiety severity than those without. Depression symptom severity decreased to a significantly greater extent in the tCBT condition than in TAU when the outcome measure of Patient Health Questionnaire was utilised as the outcome measure, but this was not mirrored when the Clinician Severity Rating was utilised as the outcome measure. This study provides preliminary support for the effectiveness of Transdiagnostic Cognitive Behaviour therapy for those with both a principal anxiety disorder and comorbid depression in symptom reduction.

Building a Program Theory of Implementation Using Process Evaluation of a Complex Quality Improvement Trial in Nursing Homes.

BACKGROUND AND OBJECTIVES: Significant quality problems exist in long-term care (LTC). Interventions to improve care are complex and often have limited success. Implementation remains a black box. We developed a program theory explaining how implementation of a complex intervention occurs in LTC settings-examining mechanisms of impact, effects of context on implementation, and implementation outcomes such as fidelity. RESEARCH DESIGN AND METHODS: Concurrent process evaluation of Safer Care for Older Persons in residential Environments (SCOPE)-a frontline worker (care aide) led improvement trial in 31 Canadian LTC homes. Using a mixed-methods exploratory sequential design, qualitative data were analyzed using grounded theory to develop a conceptual model illustrating how teams implemented the intervention and how it produced change. Quantitative analyses (mixed-effects regression) tested aspects of the program theory. RESULTS: Implementation fidelity was moderate. Implementation is facilitated by (a) care aide engagement with core intervention components; (b) supportive leadership (internal facilitation) to create positive team dynamics and help negotiate competing workplace priorities; (c) shifts in care aide role perceptions and power differentials. Mixed-effects model results suggest intervention acceptability, perceived intervention benefits, and leadership support predict implementation fidelity. When leadership support is high, fidelity is high regardless of intervention acceptability or perceived benefits. DISCUSSION AND IMPLICATIONS: Our program theory addresses important knowledge gaps regarding implementation of complex interventions in nursing homes. Results can guide scaling of complex interventions and future research.

Development and validation of the Overall Fidelity Enactment Scale for Complex Interventions (OFES-CI).

BACKGROUND: In many quality improvement (QI) and other complex interventions, assessing the fidelity with which participants 'enact' intervention activities (ie, implement them as intended) is underexplored. Adapting the evaluative approach used in objective structured clinical examinations, we aimed to develop and validate a practical approach to assessing fidelity enactment-the Overall Fidelity Enactment Scale for Complex Interventions (OFES-CI). METHODS: We developed the OFES-CI to evaluate enactment of the SCOPE QI intervention, which teaches nursing home teams to use plan-do-study-act (PDSA) cycles. The OFES-CI was piloted and revised early in SCOPE with good inter-rater reliability, so we proceeded with a single rater. An intraclass correlation coefficient (ICC) was used to assess inter-rater reliability. For 27 SCOPE teams, we used ICC to compare two methods for assessing fidelity enactment: (1) OFES-CI ratings provided by one of five trained experts who observed structured 6 min PDSA progress presentations made at the end of SCOPE, (2) average rating of two coders' deductive content analysis of qualitative process evaluation data collected during the final 3 months of SCOPE (our gold standard). RESULTS: Using Cicchetti's classification, inter-rater reliability between two coders who derived the gold standard enactment score was 'excellent' (ICC=0.93, 95% CI=0.85 to 0.97). Inter-rater reliability between the OFES-CI and the gold standard was good (ICC=0.71, 95% CI=0.46 to 0.86), after removing one team where open-text comments were discrepant with the rating. Rater feedback suggests the OFES-CI has strong face validity and positive implementation qualities (acceptability, easy to use, low training requirements). CONCLUSIONS: The OFES-CI provides a promising novel approach for assessing fidelity enactment in QI and other complex interventions. It demonstrates good reliability against our gold standard assessment approach and addresses the practicality problem in fidelity assessment by virtue of its suitable implementation qualities. Steps for adapting the OFES-CI to other complex interventions are offered.

Cost-Effectiveness of Group Transdiagnostic Cognitive Behavioural Therapy for Anxiety Disorders in Primary Care Settings: Economic Evaluation From the Healthcare System Perspective Over a 1-Year Time Horizon.

AIM: To assess the incremental cost-effectiveness ratio (ICER) of group transdiagnostic cognitive-behavioural therapy (tCBT) added to treatment as usual (TAU) for anxiety disorders compared to TAU only from the healthcare system perspective over a 1-year time horizon. METHODS: Data from a pragmatic multisite randomized controlled trial where adults (18-65 years) with an anxiety disorder were randomized to tCBT + TAU (n = 117) or TAU (n = 114). Group tCBT is a 12-week (2h weekly sessions) community-based intervention. Health service utilization and related costs were captured from medico-administrative data and included those for the intervention, ambulatory visits, hospitalizations and medications. Effectiveness was based on quality-adjusted life years (QALYs). The study included measures at baseline, 4, 8, and 12 months. Intention-to-treat and complete case analyses were carried out. Missing data were imputed using multiple imputation analyses. Seemingly unrelated regression analyses were used to assess the effect of the intervention on total costs and QALYs while also adjusting for baseline confounders. The probability of cost-effectiveness of the intervention was assessed according to different willingness-to-pay (WTP) thresholds using the net benefit regression method. RESULTS: The ICER of tCBT + TAU as compared to TAU in the intention-to-treat analysis was $6,581/QALY. Complete case analyses showed a similar ICER of $6,642/QALY. The probability at a WTP threshold of $20,000 and $40,000 that tCBT + TAU as compared to TAU is cost-effective is 93.0% and 99.9%. CONCLUSION: tCBT added to TAU appears to be cost-effective from the healthcare system perspective for treating adult patients with anxiety disorders. Larger trials including young and older adults as well as a range of anxiety disorders are needed to further investigate the cost-effectiveness of tCBT in different patient populations.

Nursing assistants' use of best practices and pain in older adults living in nursing homes.

BACKGROUND: Inadequate pain management persists in nursing homes. Nursing assistants provide the most direct care in nursing homes, and significantly improving the quality of care requires their adoption of best care practices informed by the best available evidence. We assessed the association between nursing assistants' use of best practices and residents' pain levels. METHODS: We performed a cross-sectional analysis of data collected between September 2019 and February 2020 from a stratified random sample of 87 urban nursing homes in western Canada. We linked administrative data (the Resident Assessment Instrument-Minimum Data Set [RAI-MDS], 2.0) for 10,093 residents and survey data for 3547 nursing assistants (response rate: 74.2%) at the care unit level. Outcome of interest was residents' pain level, measured by the pain scale derived from RAI-MDS, 2.0. The exposure variable was nursing assistants' use of best practices, measured with validated self-report scales and aggregated to the unit level. Two-level random-intercept multinomial logistic regression accounted for the clustering effect of residents within care units. Covariates included resident demographics and clinical characteristics and characteristics of nursing assistants, unit, and nursing home. RESULTS: Of the residents, 3305 (30.3%) were identified as having pain. On resident care units with higher levels of best practice use among nursing assistants, residents had 32% higher odds of having mild pain (odds ratio, 1.32; 95% confidence interval, 1.01-1.71; p = 0.040), compared with residents on care units with lower levels of best practice use among nursing assistants. The care units did not differ in reported moderate or severe pain among residents. CONCLUSIONS: We observed that higher unit-level best practice use among nursing assistants was associated with mild resident pain. This association warrants further research to identify key individual and organizational factors that promote effective pain assessment and management.

Moderators of the cost-effectiveness of transdiagnostic CBT for anxiety disorders over an 8-month time horizon using a net-benefit regression framework.

BACKGROUND: Access to evidence-based psychological treatment is a concern in many parts of the globe due to government-level financial constraints and patient-level barriers. Transdiagnostic cognitive behavioural therapy (tCBT) is an effective treatment approach that uses a single protocol for anxiety disorders which could enhance the dissemination of evidence-based psychotherapy. In a context of limited resources, the study of treatment moderators can allow to identify subgroups for which the cost-effectiveness of an intervention differs, information that could impact decision-making. So far, there has been no economic evaluation of tCBT for different subpopulations. The objectives of this study, using the net-benefit regression framework, were to explore clinical and sociodemographic factors as potential moderators of the cost-effectiveness of tCBT compared to treatment-as-usual (TAU). METHODS: This is a secondary data analysis of a pragmatic randomized controlled trial opposing tCBT added to TAU (n = 117) to TAU only (n = 114). Data on costs from the health system and the limited societal perspectives, as well as anxiety-free days, an effectiveness measure based on the Beck Anxiety Inventory, were collected over an 8-month time horizon and used to derive individual net-benefits. The net-benefit regression framework was used to assess moderators of the cost-effectiveness of tCBT + TAU as opposed to TAU alone. Variables of sociodemographic and clinical nature were assessed. RESULTS: Results showed that the number of comorbid anxiety disorders significantly moderated the cost-effectiveness of tCBT + TAU compared to TAU from the limited societal perspective. CONCLUSIONS: The number of comorbid anxiety disorders was identified as a moderator affecting the cost-effectiveness of tCBT + TAU compared to TAU from the limited societal perspective. More research is needed to strengthen the case of tCBT from an economic standpoint for large-scale dissemination. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02811458, 23/06/2016.

The Complexity of Burnout Experiences among Care Aides: A Person-Oriented Approach to Burnout Patterns.

Care aides working in nursing homes experience burnout attributed to various workplace stressors. Burnout dimensions (exhaustion, cynicism, and reduced professional efficacy) interact to form distinct burnout patterns. Using a person-oriented approach, we aimed to identify burnout patterns among care aides and to examine their association with individual and job-related factors. This was a cross-sectional, secondary analysis of the Translating Research in Elder Care 2019-2020 survey data collected from 3765 care aides working in Canadian nursing homes. We used Maslach Burnout Inventory to assess burnout and performed latent profile analysis to identify burnout patterns, then examined their associations with other factors. We identified an engaged pattern (43.2% of the care aide sample) with low exhaustion and cynicism and high professional efficacy; an overwhelmed but accomplished pattern (38.5%) with high levels of the three dimensions; two intermediate patterns-a tired and ineffective pattern (2.4%) and a tired but effective pattern (15.8%). The engaged group reported the most favorable scores on work environment, work-life experiences, and health, whereas the tired and ineffective group reported the least favorable scores. The findings suggest complex experiences of burnout among care aides and call for tailored interventions to distinct burnout patterns.

Safer Care for Older Persons in (residential) Environments (SCOPE): a pragmatic controlled trial of a care aide-led quality improvement intervention.

BACKGROUND: The increased complexity of residents and increased needs for care in long-term care (LTC) have not been met with increased staffing. There remains a need to improve the quality of care for residents. Care aides, providers of the bulk of direct care, are well placed to contribute to quality improvement efforts but are often excluded from so doing. This study examined the effect of a facilitation intervention enabling care aides to lead quality improvement efforts and improve the use of evidence-informed best practices. The eventual goal was to improve both the quality of care for older residents in LTC homes and the engagement and empowerment of care aides in leading quality improvement efforts. METHODS: Intervention teams participated in a year-long facilitative intervention which supported care aide-led teams to test changes in care provision to residents using a combination of networking and QI education meetings, and quality advisor and senior leader support. This was a controlled trial with random selection of intervention clinical care units matched 1:1 post hoc with control units. The primary outcome, between group change in conceptual research use (CRU), was supplemented by secondary staff- and resident-level outcome measures. A power calculation based upon pilot data effect sizes resulted in a sample size of 25 intervention sites. RESULTS: The final sample included 32 intervention care units matched to 32 units in the control group. In an adjusted model, there was no statistically significant difference between intervention and control units for CRU or in secondary staff outcomes. Compared to baseline, resident-adjusted pain scores were statistically significantly reduced (less pain) in the intervention group (p=0.02). The level of resident dependency significantly decreased statistically for residents whose teams addressed mobility (p<0.0001) compared to baseline. CONCLUSIONS: The Safer Care for Older Persons in (residential) Environments (SCOPE) intervention resulted in a smaller change in its primary outcome than initially expected resulting in a study underpowered to detect a difference. These findings should inform sample size calculations of future studies of this nature if using similar outcome measures. This study highlights the problem with measures drawn from current LTC databases to capture change in this population. Importantly, findings from the trial's concurrent process evaluation provide important insights into interpretation of main trial data, highlight the need for such evaluations of complex trials, and suggest the need to consider more broadly what constitutes "success" in complex interventions. TRIAL REGISTRATION: ClinicalTrials.gov , NCT03426072, registered August 02, 2018, first participant site April, 05, 2018.

An examination of sudden gain prevalence across cognitive-behavioural therapy for anxiety and depressive disorders: A quantitative analysis and meta-analytic review.

Sudden gains, incidences of unexpectedly large and stable session to session symptom reductions during psychotherapy, have been shown in samples of individuals receiving treatment for both anxiety and depressive disorders, although seemingly more frequently in sample receiving treatment for depressive disorders. This may suggest that sudden gains are a function of depression, but the high comorbidity between anxiety and depressive disorders makes this difficult to assess. Study One utilised a sample of 117 adults undergoing CBT for a principal anxiety disorder to explore the effect of comorbid depression on sudden gain prevalence. Results indicated that sudden gains were not more prevalent in the comorbid depression group; however, the frequency of sudden gains was significantly related to comorbid depressive disorder severity. Study Two involved a meta-analysis of 48 studies to compare sudden gain prevalence between trials of CBT for depressive disorders versus anxiety-related disorders. The results of the meta-analysis indicated significantly higher rates of sudden gains in samples with a principal depressive disorder diagnosis, compared to a principal anxiety disorder diagnosis. Sudden gains may therefore be driven by depression, but only at the more severe level.

An analysis of differential improvement by diagnosis in group transdiagnostic cognitive behaviour therapy for anxiety disorders.

INTRODUCTION: Anxiety disorders are the most prevalent among the mental health disorders and have a negative impact on an individual's life. Cognitive behaviour therapy (CBT) is documented as the most effective treatment for anxiety disorders. However, challenges associated with implementing diagnosis-specific CBT have led to transdiagnostic approaches of CBT (tCBT). tCBT uses a single protocol with core elements of CBT for treatment of anxiety disorders broadly. The aim of the current study is to examine whether participants with different principal anxiety diagnoses demonstrate similar anxiety reduction. METHODS: The current study involved a secondary analysis of 117 participants randomly allocated to receive tCBT for anxiety disorders in a pragmatic randomised effectiveness trial. Beck Anxiety Inventory (BAI) and Clinician Severity Ratings (CSR) scales were administered at pre- and post-treatment and one-year follow-up, while the Anxiety Disorder Diagnostic Questionnaire - Weekly (ADDQ-W) was administered each session. RESULTS: Mixed-factorial analyses of variance (ANOVAs) indicated that participants with GAD, SAD and PD/A improved to post-treatment and maintained to follow-up, with no differential improvement across principal diagnoses. Mixed effect regression modelling of session by session measures indicated non-differential negative slopes across principal diagnoses of GAD, SAD and PD/A. CONCLUSION: Overall, results indicate that group tCBT for anxiety disorders shows equal effectiveness for GAD, PD/A, and SAD in real-world conditions.

Cost-effectiveness of transdiagnostic group cognitive behavioural therapy for anxiety disorders v. treatment as usual: economic evaluation of a pragmatic randomized controlled trial over an 8-month time horizon using self-reported data.

BACKGROUND: This economic evaluation supplements a pragmatic randomized controlled trial conducted in community care settings, which showed superior improvement in the symptoms of adults with anxiety disorders who received 12 sessions of transdiagnostic cognitive-behavioural group therapy in addition to treatment as usual (tCBT + TAU) compared to TAU alone. METHODS: This study evaluates the cost-utility and cost-effectiveness of tCBT + TAU over an 8-month time horizon. For the reference case, quality-adjusted life years (QALYs) obtained using the EQ-5D-5L, and the health system perspective were chosen. Alternatively, anxiety-free days (AFDs), derived from the Beck Anxiety Inventory, and the limited societal perspective were considered. Unadjusted incremental cost-effectiveness/utility ratios were calculated. Net-benefit regressions were done for a willingness-to-pay (WTP) thresholds range to build cost-effectiveness acceptability curves (CEAC). Sensitivity analyses were included. RESULTS: Compared to TAU (n = 114), tCBT + TAU (n = 117) generated additional QALYs, AFDs, and higher mental health care costs from the health system perspective. From the health system and the limited societal perspectives, at a WTP of Can$ 50 000/QALY, the CEACs showed that the probability of tCBT + TAU v. TAU being cost-effective was 97 and 89%. Promising cost-effectiveness results using AFDs are also presented. The participation of therapists from the public health sector could increase cost-effectiveness. CONCLUSIONS: From the limited societal and health system perspectives, this first economic evaluation of tCBT shows favourable cost-effectiveness results at a WTP threshold of Can$ 50 000/QALY. Future research is needed to replicate findings in longer follow-up studies and different health system contexts to better inform decision-makers for a full-scale implementation.

Changes in Health and Well-Being of Nursing Home Managers from a Prepandemic Baseline in February 2020 to December 2021.

OBJECTIVE: To evaluate changes in mental health and well-being (eg, quality of work life, health, intention to leave) among nursing home managers from a February 2020 prepandemic baseline to December 2021 in Alberta, Canada. DESIGN: Repeated cross-sectional survey. SETTING AND PARTICIPANTS: A random sample of nursing homes (n = 35) in urban areas of Alberta was selected on 3 strata (region, size, ownership). Care managers were invited to participate if they (1) managed a unit, (2) worked there for at least 3 months, and (3) worked at least 6 shifts per month. METHODS: We measured various mental health and well-being outcomes, including job satisfaction (Michigan Organizational Assessment Questionnaire Job Satisfaction Subscale), burnout (Maslach Burnout Inventory-exhaustion, cynicism, efficacy), organizational citizenship behaviors (constructive efforts by individuals to implement changes to improve performance), mental and physical health (Short Form-8 Health Survey), burden of worry, and intention to leave. We use mixed effects regression to examine changes at the survey time points, controlling for staffing and resident acuity. RESULTS: The final sample included 181 care managers (87 in the pre-COVID survey; 94 in the COVID survey). Response rates were 66.9% and 82.5% for the pre-COVID and COVID surveys, respectively. In the regression analysis, we found statistically significant negative changes in job satisfaction (mean difference -0.26, 95% CI -0.47 to -0.06; P = .011), cynicism (mean difference 0.43, 95% CI 0.02-0.84; P = .041), exhaustion (mean difference 0.84, 95% CI 0.41-1.27; P < .001), and SF-8 mental health (mean difference -6.49, 95% CI -9.60 to -3.39; P < .001). CONCLUSIONS AND IMPLICATIONS: Mental health and well-being of nursing home managers worsened during the pandemic, potentially placing them at risk for leaving their jobs and in need of improved support. These findings should be a major concern for policy makers, particularly given serious prepandemic workforce shortages. Ongoing assessment and support of this understudied group are needed.

A Self-Help Manual for Psychological Distress and Quality of Life During a Haemopoietic Stem-Cell Transplant: An Effectiveness and Acceptability Pilot.

Haemopoietic stem-cell transplantation (HSCT) can be a highly distressing procedure that negatively impacts quality of life (QoL). Self-help interventions can help improve psychopathology and wellbeing in patients with physical illness, but have rarely been trialled with HSCT recipients. This study aimed to pilot the utility of a self-help manual intervention during the acute phase of HSCT. Forty autologous and allogeneic HSCT candidates were randomly assigned to a self-help manual intervention or treatment as usual (TAU). Psychological distress (BSI-18) and QoL (FACT-BMT-Vs4) were measured pre-, 2-3 weeks and 3 months post-HSCT. Linear mixed-effects analyses showed no significant group-time interaction for global QoL (p = .199) or global distress (p = .624). However, highlighting a protective role during admission, manual participants showed minimal QoL or somatic distress change at 2-3 weeks post-transplant compared with moderate-large effects for reduced QoL (d = 0.62) and increased somatic distress (d = - 0.81) for TAU patients. Thematic analysis suggests the manual helped prepare patients for transplant and provided strategies to improve distress and QoL. This pilot provides preliminary evidence for the benefit of a self-help manual during hospitalisation for a HSCT. More intensive, recovery-focussed care, however, may be needed to improve psychological health in the post-hospital period. Retrospectively registered trial (ANZCTR No. 12620001165976, 6th November 2020).

The Influence of Transdiagnostic Vulnerability Factors on PTSD Symptom Clusters in a Veteran Sample.

BACKGROUND: There is continuing debate as to the latent structure underpinning posttraumatic stress disorder symptomatology. The transdiagnostic vulnerability factors of negative affect, anxiety sensitivity (and subcomponents) and intolerance of uncertainty have previously demonstrated the ability to explain symptom clusters in a range of anxiety and depressive disorders, and may give further understanding of PTSD symptomatology. METHOD: Within an Australian Defence Force veteran population, structural equation modeling is utilized to assess whether a hierarchical Original Model containing negative affect as the general cognitive factor, anxiety sensitivity and intolerance of uncertainty as mid-level factors, can explain variability among posttraumatic stress disorder symptom clusters as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. A further hierarchical Anxiety Sensitivity Extended model consisting of the general cognitive factor of negative affect and the three sub-factors of anxiety sensitivity as mid-level factors was also tested upon PTSD symptom clusters. RESULTS: Both the hierarchical Original and Anxiety Sensitivity Extended models fit the data well. Within both models, negative affect consistently showed significant direct effects upon the posttraumatic stress disorder symptom clusters. In the Original Model, anxiety sensitivity served as a significant mediator of negative affect for several symptom clusters, while intolerance of uncertainty was non-significant both as a direct effect and as a mediator of negative affect. In the Anxiety Sensitivity Extended Model, the cognitive concerns sub-factor of anxiety sensitivity served as a significant mediator of negative affect for several symptom clusters, while the social and physical concerns sub-factors did not have significant direct or mediating effects. CONCLUSIONS: This study demonstrates a transdiagnostic hierarchical model significantly explains the severity of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition posttraumatic stress disorder symptom constructs within a subclinical population. Negative affect and anxiety sensitivity can each be targeted with specific interventions, suggesting new avenues to augment current gold standard psychotherapeutic interventions.

A scoping review of psychosocial interventions to reduce internalised shame.

Internalised shame has been linked to psychopathology and consistently identified as a predictor of poor treatment outcomes and premature therapy termination. We conducted a scoping review of therapist-delivered psychosocial interventions to reduce internalised shame to learn how to improve outcomes for individuals experiencing shame.Six bibliographical databases were searched for studies measuring internalised shame pre- and post-treatment. We screened 6846 abstracts; 42 full-text manuscripts were retrieved, with 16 studies meeting the inclusion criteria. Of these, 10 studies examined between- and within-subject effects, and 6 studies exclusively examined within-subject effects.Twelve of the sixteen included studies reported small to moderate within-group reductions in internalised shame. Between group analyses showed that shame interventions may be more effective than no treatment or treatment as usual, but not more effective than an active comparator.Successful treatments often involved psychoeducation, experiential exercises, and techniques to increase social support and emotional expression; however, study quality was weak to moderate and the importance of each of these techniques for reducing internalised shame was not determined.

Conceptual and relational advances of the PARIHS and i-PARIHS frameworks over the last decade: a critical interpretive synthesis.

BACKGROUND: The number of research publications reporting the use of the Promoting Action on Research Implementation in Health Services (PARIHS) framework and the integrated PARIHS (i-PARIHS) framework has grown steadily. We asked how the last decade of implementation research, predicated on the (i-)PARIHS framework (referring to the PARIHS or i-PARIHS framework), has contributed to our understanding of the conceptualizations of, relationships between, and dynamics among the core framework elements/sub-elements. Building on the Helfrich et al. (2010) review of research on the PARIHS framework, we undertook a critical interpretive synthesis to: (1) identify conceptual and relational advances in the (i-)PARIHS framework and (2) identify conceptual and relational aspects of the (i-)PARIHS framework that warrant further work. METHODS: We performed a systematic search in PubMed/PubMed Central, Ovid MEDLINE, CINAHL, JSTOR, SCOPUS, Web of Science, and PsycInfo. Articles were eligible for synthesis if they (a) were peer-reviewed articles, written in English, and published between January 2009 and December 2021, (b) applied the (i-)PARIHS framework explicitly to guide implementation research, and (c) made conceptual (expanding the conceptualization of core elements) and/or relational contributions (elaborating relationships among elements/sub-elements, or theorizing the relationships using empirical data). We used a critical interpretive synthesis approach to synthesize conceptual-relational advances of the (i-)PARIHS framework. RESULTS: Thirty-seven articles were eligible for synthesis. Twenty-four offered conceptual contributions, and 18 offered relational contributions (5 articles contributed in both ways). We found conceptual expansion of all core (i-)PARIHS elements, with most emphasis on context (particularly outer context and leadership), facilitation, and implementation success. Articles also gave insights into the complex relationships and relational dynamism among these elements, characterized as contingent, interactive, multilevel, and temporal effects. CONCLUSIONS: We observed developmental advances of the (i-)PARIHS framework and proposed several directions to further advance the framework. Conceptualization of (i-)PARIHS elements (particularly evidence/innovation and recipients) need to be further developed by specifying conceptual and operational definitions of underlying sub-elements. Relationships among (i-)PARIHS elements/sub-elements need to be further elaborated through empirical studies that consider situational contingencies and causal complexities. This will require examining necessity and sufficiency of (i-)PARIHS elements/sub-elements in relation to implementation outcomes, interactions among elements, and mechanism-based explanations.