Cluster-randomised controlled trial of an occupational therapy intervention for children aged 11-13 years, designed to increase participation to prevent symptoms of mental illness.

BACKGROUND: The impact of occupational therapy on mental health outcomes for children is largely unexplored. The aim of this study was to investigate an evidence-based occupational therapy intervention designed to increase participation in daily occupations to prevent symptoms of mental illness for children and run in schools. METHODS: The study used a pragmatic, cluster-randomised controlled trial design with two arms. Fourteen clusters (schools), equating to 151 child participants, were stratified by school decile-rank category and block randomised. Blinding of participants post-randomisation was not feasible; however, outcomes assessors were blinded. Outcomes were measured at baseline, after the parallel and crossover phases, and at follow-up; and were anxiety symptoms (primary), depression symptoms, self-esteem, participation and wellbeing. Intention-to-treat analysis was applied and mixed linear modelling was used to account for clusters and repeated measures, and to adjust for covariates identified. RESULTS: This trial found significant positive effects of the intervention on child-rated satisfaction with their occupational performance and teacher-rated child anxiety. No evidence was found to support the effect of the intervention on anxiety and depression symptoms, self-esteem and wellbeing. CONCLUSIONS: This was the first known cluster-randomised controlled trial to investigate an occupational therapy intervention promoting emotional wellbeing in a non-clinical sample of children. No compelling evidence was found to support the use of the intervention in schools in its current format, however, results were promising that the focus on occupations influenced participation. Recommendations are made to redesign the intervention as an embedded intervention in the classroom, cotaught by teachers and including parental involvement.

Cross-cultural acceptability and utility of the strengths and difficulties questionnaire: views of families.

BACKGROUND: Screening children for behavioural difficulties requires the use of a tool that is culturally valid. We explored the cross-cultural acceptability and utility of the Strengths and Difficulties Questionnaire for pre-school children (aged 3-5) as perceived by families in New Zealand. METHODS: A qualitative interpretive descriptive study (focus groups and interviews) in which 65 participants from five key ethnic groups (New Zealand European, Maori, Pacific, Asian and other immigrant parents) took part. Thematic analysis using an inductive approach, in which the themes identified are strongly linked to the data, was employed. RESULTS: Many parents reported they were unclear about the purpose of the tool, affecting its perceived value. Participants reported not understanding the context in which they should consider the questions and had difficulty understanding some questions and response options. Maori parents generally did not support the questionnaire based approach, preferring face to face interaction. Parents from Maori, Pacific Island, Asian, and new immigrant groups reported the tool lacked explicit consideration of children in their cultural context. Parents discussed the importance of timing and multiple perspectives when interpreting scores from the tool. CONCLUSIONS: In summary, this study posed a number of challenges to the use of the Strengths and Difficulties Questionnaire in New Zealand. Further work is required to develop a tool that is culturally appropriate with good content validity.

Measuring Neurobehavioral Functioning in People With Traumatic Brain Injury: Rasch Analysis of Neurobehavioral Functioning Inventory.

OBJECTIVE: To examine internal construct validity of the Neurobehavioral Functioning Inventory (NFI) by applying Rasch analysis. SETTING: An outpatient rehabilitation program trial in New Zealand employing a goal-setting intervention in people with traumatic brain injury (TBI). PARTICIPANTS: One hundred eight people (mean age = 46 years; 73% male) between 6 months and 5 years post-TBI. DESIGN: Rasch analysis of the NFI (Partial Credit Model). RESULTS: Three NFI subscales were not unidimensional and at least 4 items in each subscale had disordered response categories. Two items showed differential item functioning by age, 1 item by educational attainment, and 2 items were found to misfit the overall construct. These items were excluded from the total score calculation. The revised scale fit the Rasch model and supported the internal construct validity of the NFI. CONCLUSIONS: Current scoring of the NFI subscales for people with TBI in New Zealand does not meet the requirements of the Rasch model. The revised version of NFI can improve the interpretation of scores but should be further tested with people with TBI in other settings.

The Multiple Sclerosis-Fatigue Self- Efficacy (MS-FSE) scale: initial validation.

OBJECTIVE: To examine the validity and sensitivity to change of the Multiple Sclerosis-Fatigue Self-Efficacy scale. DESIGN: A validation study nested within a randomized controlled trial. SETTING: Community setting. PARTICIPANTS: Adults with a clinically definite diagnosis of multiple sclerosis and significant fatigue taking part in a randomized controlled trial evaluating a group-based fatigue management programme (FACETS) for people with multiple sclerosis (N=164). MAIN MEASURES: The 9-item Multiple Sclerosis-Fatigue Self-Efficacy scale was completed at baseline, 1-, 4- and 12 months post intervention. Validity, internal consistency and sensitivity to change were examined using classical test theory and Rasch analysis. RESULTS: Item 3 was unanswered by 6% of respondents as they did not know any other people with multiple sclerosis; remaining analyses were carried out with this item deleted. All response choices were utilised, no floor or ceiling effects were evident and there were few missing responses. Cronbach's alphas were high (baseline, 0.89; follow-up 1, 0.93; follow-up 2, 0.94; follow-up 3, 0.90). The Multiple Sclerosis-Fatigue Self-Efficacy scale (8-item) demonstrated good sensitivity to change following attendance of the FACETS programme (within participant effect sizes 0.66 and 0.69 and 0.54 at 1, 4, and 12 months follow-up). Principal Components Analysis yielded one component. In the Rasch analysis two items with disordered thresholds were rescored. Item 8 displayed differential item functioning by disability and was combined into a testlet with item 4, resulting in a unidimensional scale. The sample was well targeted to the scale. CONCLUSION: At a scale level the Multiple Sclerosis-Fatigue Self-Efficacy scale is internally valid and has good sensitivity to change.

Exploring researchers' experiences of working with people with acquired brain injury.

PURPOSE: This study aimed to investigate the challenges and positive experiences of researchers who work with people who have experienced an acquired brain injury and their families. METHODS: People who were currently or had previously worked as a researcher in the field of acquired brain injury (using either quantitative or qualitative methods) were invited to participate in a focus group or individual interview about their experiences. An expert reference group meeting was held to discuss strategies that could be implemented to enhance the researcher experience based on the interview data. RESULTS: A total of 19 researchers who worked across four different research teams took part in the study. Six inter-connected themes were identified: researcher motivation, meaning and fulfillment; human connection; knowing and understanding the role; complexity of brain injury in the research context; the research process; and state of the researcher. A number of recommendations for supporting researchers more effectively were identified. DISCUSSION: Researchers described a number of positive aspects as well as tensions they encountered in their role. The findings highlight the need to ensure researchers are supported effectively to ensure the quality of research studies in the field of brain injury.

One year follow-up of a pragmatic multi-centre randomised controlled trial of a group-based fatigue management programme (FACETS) for people with multiple sclerosis.

BACKGROUND: Fatigue is one of the most common and debilitating symptoms of multiple sclerosis (MS). The aim was to evaluate the effectiveness at 1-year follow-up of a manualised group-based programme ('FACETS') for managing MS-fatigue. METHODS: One-year follow-up of a pragmatic multi-centre randomised controlled trial. People with MS and significant fatigue were randomised to FACETS plus current local practice (FACETS) or current local practice alone (CLP), using concealed computer-generated randomisation. Participant blinding was not possible. Primary outcome measures were fatigue severity (Global Fatigue Severity subscale of the Fatigue Assessment Instrument), self-efficacy (MS-Fatigue Self-Efficacy) and disease-specific quality of life (MS Impact Scale). RESULTS: Between May 2008 and November 2009, 164 participants were randomised. Primary outcome data were available at 1 year for 131 (80%). The benefits demonstrated at 4-months in the FACETS arm for fatigue severity and self-efficacy largely persisted, with a slight reduction in standardised effect sizes (SES) (-0.29, p = 0.06 and 0.34, p = 0.09, respectively). There was a significant difference on the MS Impact Scale favouring FACETS that had not been present at 4-months (SES -0.24, p = 0.046). No adverse events were reported. CONCLUSIONS: Improvements in fatigue severity and self-efficacy at 4-months follow-up following attendance of FACETS were mostly sustained at 1 year with additional improvements in MS impact. The FACETS programme provides modest long-term benefits to people with MS-fatigue. TRIAL REGISTRATION: ISRCTN76517470.

Systematic review of guidelines for the physical management of osteoarthritis.

OBJECTIVE: To undertake a systematic critical appraisal of guidelines to provide a summary of recommendations for the physical management of osteoarthritis (OA). DATA SOURCES: The Cochrane Library, MEDLINE, CINAHL, SPORTDiscus with Full Text, Scopus, ScienceDirect, PEDro, and Google Scholar databases were searched (2000-2013) to identify all guidelines, protocols, and recommendations for the management or treatment of OA. In addition, Internet searches of all relevant arthritis organizations were undertaken. All searches were performed between July 2012 and end of April 2013. Guidelines that included only pharmacological, injection therapy, or surgical interventions were excluded. Guidelines published only in English were retrieved. STUDY SELECTION: OA guidelines developed from evidence-based research, consensus, and/or expert opinion were retrieved. There were no restrictions on severity or site of OA, sex, or age. Nineteen guidelines were identified for evaluation. DATA EXTRACTION: The quality of all guidelines was critically appraised using the Appraisal of Guidelines for REsearch and Evaluation II instrument. Each guideline was independently reviewed. All relevant recommendations for the physical management of OA were synthesized, graded, and ranked according to available evidence. DATA SYNTHESIS: Seventeen guidelines with recommendations on the physical management of OA met the inclusion criteria and underwent a full critical appraisal. There were variations in the interventions, levels of evidence, and strength of recommendations across the guidelines. Forty different interventions were identified. Recommendations were graded from "strongly recommended" to "unsupported." Exercise and education were found to be strongly recommended by most guidelines. CONCLUSIONS: Exercise and education were key recommendations supporting the importance of rehabilitation in the physical management of OA. This critical appraisal can assist health care providers who are involved in the management of people with OA.

The cardiac model of rehabilitation for reducing cardiovascular risk factors post transient ischaemic attack and stroke: a randomized controlled trial.

OBJECTIVE: To evaluate the feasibility and effectiveness of a standard National Health Service cardiac rehabilitation programme on risk factor reduction for patients after a minor stroke and transient ischaemic attack. DESIGN: Single-blind randomized controlled trial. SETTING: Cardiac rehabilitation classes. SUBJECTS: Twenty-four patients. INTERVENTION: All participants received standard care. In addition, the intervention group undertook an eight-week cardiac rehabilitation programme consisting of weekly exercise and education classes. OUTCOME MEASURES: Cardiovascular disease risk score; lipid profiles; resting blood pressure; C-reactive protein (measured with a high sensitive assay) and fibrinogen levels; blood glucose; obesity; physical activity levels; subjective health status (SF-36); Hospital Anxiety and Depression Scale. RESULTS: Group comparison with independent t-tests showed a significantly greater improvement in the cardiovascular disease risk score for participants in the intervention group compared to standard care (intervention 25.7 ± 22.8 to 23.15 ± 18.3, control 25.03 ± 15.4 to 27.12 ± 16.1, t = -1.81, P < 0.05). There were also significant improvements for the intervention group in activity levels (intervention 9.41 ± 7.7 to 8.08 ± 5.7, control 14.50 ± 5.5 to 9.83 ± 6.6, t = -2.00, P < 0.05) and the SF-36 domains of physical functioning (intervention 70 ± 24.6 to 75.4 ± 11.1, control 90.00 ± 12.4 to 83.16 ± 17.3, t = -2.72, P < 0.05) and mental health (intervention 84 ± 40 to 92 ± 40, control 88.00 ± 60 to 84 ± 44, z = -2.06, P < 0.05). CONCLUSION: The results suggest that standard cardiac rehabilitation programmes are a feasible and effective means of reducing the risk of future cardiovascular events for patients after minor stroke and transient ischaemic attack.

First Contact Physiotherapy: An evaluation of clinical effectiveness and costs.

BACKGROUND: First Contact Physiotherapy Practitioners (FCPPs) are embedded within general practice, providing expert assessment, diagnosis and management plans for patients with musculoskeletal disorders (MSKDs), without the prior need for GP consultation. AIM: To determine the clinical effectiveness and costs of FCPP-led compared to GP-led models of care. DESIGN AND SETTING: Multiple site case study design. UK GP practices. METHOD: General Practice sites were recruited representing three models: 1. GP-led care; 2. FCPPs who could not prescribe/inject (Standard (St)); 3. FCPPs who could prescribe/inject (Additional Qualifications (AQ)). Patient participants from each site completed clinical outcome data at baseline, 3 and 6 months. The primary outcome was the SF-36v.2 Physical Component Score (PCS). Healthcare usage was collected for 6 months. RESULTS: N=426 adults were recruited from 46 practices across the UK. Non-inferiority analysis showed no significant difference in physical function (SF36-PCS) across all three arms at 6 months (p=0.999). At 3 months a significant difference in numbers improving was seen between arms: 54.7% GP consultees; 72.4% FCPP-St, 66.4% FCPP-AQ; (p=0.037). No safety issues were identified. Following initial consultation, a greater proportion of patients received medication (including opioids) in the GP-led arm (44.7%) compared with FCPP-St (17.5%) and FCPP-AQ (22.8%); (p<0.001). NHS costs (initial consultation and over 6 months follow up) were significantly higher in the GP-led model (median £105.50) vs FCPP-St (£41) and FCPP-AQ (£44); (p<0.001). CONCLUSION: FCPP led models provide safe, clinically effective and cost-beneficial management for patients with MSKDs in general practice and reduced opioid use in this cohort.

A pragmatic parallel arm multi-centre randomised controlled trial to assess the effectiveness and cost-effectiveness of a group-based fatigue management programme (FACETS) for people with multiple sclerosis.

BACKGROUND: Fatigue is a common and troubling symptom for people with multiple sclerosis (MS). AIM: To evaluate the effectiveness and cost-effectiveness of a six-session group-based programme for managing MS-fatigue (Fatigue: Applying Cognitive behavioural and Energy effectiveness Techniques to lifeStyle (FACETS)). METHODS: Three-centre parallel arm randomised controlled trial with economic evaluation. Patients with MS and significant fatigue were randomised to FACETS plus current local practice (FACETS) or current local practice alone (CLP), using concealed computer-generated randomisation. Participant blinding was not possible. Primary outcomes were fatigue severity (Fatigue Assessment Instrument), self-efficacy (Multiple Sclerosis-Fatigue Self-Efficacy) and disease-specific quality of life (Multiple Sclerosis Impact Scale (MSIS-29)) at 1 and 4 months postintervention (follow-up 1 and 2). Quality adjusted life years (QALYs) were calculated (EuroQoL 5-Dimensions questionnaire and the Short-form 6-Dimensions questionnaire). RESULTS: Between May 2008 and November 2009, 164 patients were randomised; primary outcome data were available for 146 (89%). Statistically significant differences favour the intervention group on fatigue self-efficacy at follow-up 1 (mean difference (MD) 9, 95% CI (4 to 14), standardised effect size (SES) 0.54, p=0.001) and follow-up 2 (MD 6, 95% CI (0 to 12), SES 0.36, p=0.05) and fatigue severity at follow-up 2 (MD -0.36, 95% CI (-0.63 to -0.08), SES -0.35, p=0.01) but no differences for MSIS-29 or QALYs. No adverse events reported. Estimated cost per person for FACETS is £453; findings suggest an incremental cost-effectiveness ratio of £2157 per additional person with a clinically significant improvement in fatigue. CONCLUSIONS: FACETS is effective in reducing fatigue severity and increasing fatigue self-efficacy. However, it is difficult to assess the additional cost in terms of cost-effectiveness (ie, cost per QALY) as improvements in fatigue are not reflected in the QALY outcomes, with no significant differences between FACETS and CLP. The strengths of this trial are its pragmatic nature and high external validity. TRIAL REGISTRATION: Current Controlled Trials ISRCTN76517470.

Living well with disability: needs, values and competing factors.

BACKGROUND: Obesity is more prevalent for disabled people (estimated as being between 27-62%) compared to the general population (17-22%). Disabled people are more likely to report poorer general health and acquire a range of obesity-related secondary conditions. Although there are many physical activity and nutrition initiatives aimed at obesity prevention, little is known about whether these options are relevant and accessible for disabled people. The Living Well Study aimed to better understand the issues faced by disabled people when engaging in physical activity and healthy eating. METHODS: The study drew on a participatory action research design involving key stakeholders. There were two core cyclical phases (A and B), in which data collection was followed by a period of analysis, reflection and refinement. Focus groups and interviews were held with individuals who experience a range of disabilities, family members, service providers and representatives from disability advocacy groups. We sought to explore the importance and meaning of physical activity and healthy eating and factors that influenced engagement in these. Data in phase A were analysed using conventional content analysis drawing on constant comparative methods to identify themes of importance. In phase B, data analysis occurred alongside data collection, using a structured template to summarise participants' agreement or disagreement with the draft themes and recommendations, until the themes and recommendations were refined based on participants' corroboration. RESULTS: 146 participants aged between 10-69 years, from both rural and urban areas and of different cultural backgrounds participated. Seven interconnecting themes that related to engagement in living well behaviours emerged with a wide range of external factors (such as people, knowledge, time, cost, identity and the environment) impacting on living well options. The central theme - It depends: needs, values and competing factors - emphasised the complexity faced by a disabled person when balancing the external factors with their own personal values and needs in order to arrive at a decision to engage in healthy living behaviours. CONCLUSIONS: Although disabled people experience similar issues when participating in healthy living behaviours as those living without disability, additional factors need to be addressed in order to improve opportunities for 'living well' in these populations. This information has implications for health professionals to target the relevance and content of interventions.

Validation of the WHOQOL-BREF quality of life questionnaire for general use in New Zealand: confirmatory factor analysis and Rasch analysis.

PURPOSE: The present study validated the abbreviated version of the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire for general use in New Zealand. METHODS: A random postal sample from the national electoral roll was used, and 808 questionnaires were returned. Psychometric properties of the instrument were assessed, including tests of the four-domain factor structure using confirmatory factor analysis and Rasch analysis. RESULTS: Goodness-of-fit from the confirmatory factor analysis were good, and the overall conclusion of the Rasch analysis supported the confirmatory factor analysis (CFA) findings after dealing with problems of threshold ordering, local dependency, and differential item functioning (DIF). CONCLUSIONS: The WHOQOL-BREF is valid for general use in New Zealand. In the future work, the WHOQOL-BREF domain scores should either be analyzed using non-parametric statistics or data should be fitted to the Rasch model to derive interval person estimates.

A qualitative study exploring patients' experiences of standard care or cardiac rehabilitation post minor stroke and transient ischaemic attack.

OBJECTIVE: To explore individuals' experiences of receiving either standard care or comprehensive cardiac rehabilitation post minor stroke or transient ischaemic attack. DESIGN: A qualitative study using semi-structured interviews, alongside a randomized controlled trial, exploring the effectiveness of comprehensive cardiac rehabilitation compared with standard care. Interviews were transcribed verbatim and subjected to thematic analysis. SETTING: Individuals' homes. SUBJECTS: People who have experienced a minor stroke or transient ischaemic attack and who were partaking in a secondary prevention randomized controlled trial (6-7 months post the event, 17 males, five females; mean age 67 years). INTERVENTIONS: Not relevant. MAIN MEASURES: Not relevant. RESULTS: Four themes were identified: information delivery, comparing oneself with others, psychological impact, attitudes and actions regarding risk factor reduction. Participants indicated a need for improved information delivery, specific to their own risk factors and lifestyle changes. Many experienced psychological impact as a result of their minor stroke. Participants were found to make two types of social comparison; the comparison of self to another affected by stroke, and the comparison of self to cardiac patients. CONCLUSION: Comprehensive cardiac rehabilitation was reported to have positive effects on people's motivation to exercise. Following a minor stroke, many individuals do not recall information given or risk factors specific to them. Downward comparison with individuals who have had a cardiovascular event led to some underplaying the significance of their minor stroke.

Randomised pragmatic waitlist trial with process evaluation investigating the effectiveness of peer support after brain injury: protocol.

INTRODUCTION: Traumatic brain injury (TBI) is an important global health problem. Formal service provision fails to address the ongoing needs of people with TBI and their family in the context of a social and relational process of learning to live with and adapt to life after TBI. Our feasibility study reported peer support after TBI is acceptable to both mentors and mentees with reported benefits indicating a high potential for effectiveness and likelihood of improving outcomes for both mentees and their mentors. OBJECTIVES: To (a) test the effectiveness of a peer support intervention for improving participation, health and well-being outcomes after TBI and (b) determine key process variables relating to intervention, context and implementation to underpin an evidence-based framework for ongoing service provision. METHODS AND ANALYSIS: A randomised pragmatic waitlist trial with process evaluation. Mentee participants (n=46) will be included if they have moderate or severe TBI and are no more than 18 months post-injury. Mentor participants (n=18) will be people with TBI up to 6 years after injury, who were discharged from inpatient rehabilitation at least 1 year prior. The primary outcome will be mentee participation, measured using the Impact on Participation and Autonomy questionnaire after 22 weeks. Primary analysis of the continuous variables will be analysis of covariance with baseline measurement as a covariate and randomised treatment as the main explanatory predictor variable at 22 weeks. Process evaluation will include analysis of intervention-related data and qualitative data collected from mentors and service coordinators. Data synthesis will inform the development of a service framework for future implementation. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the New Zealand Health and Disability Ethics Committee (19/NTB/82) and Auckland University of Technology Ethics Committee (19/345). Dissemination of findings will be via traditional academic routes including publication in internationally recognised peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12619001002178.

Benefits of realist evaluation for rapidly changing health service delivery.

Realist evaluation is a methodology that addresses the questions: 'what works, for whom, in which circumstances, and how?'. In this approach, programme theories are developed and tested against available evidence. However, when complex interventions are implemented in rapidly changing environments, there are many unpredictable forces that determine the programme's scope and architecture, as well as resultant outcome. These forces can be theorised, in real time, and included in realist evaluation outputs for current and future optimisation of programmes. Reflecting on a realist evaluation of first-contact physiotherapy in primary care (the FRONTIER Study), five important considerations are described for improving the quality of realist evaluation outputs when studying rapidly changing health service delivery. These are: (1) ensuring that initial programme theories are developed through creative thinking sessions, empirical and non-empirical literature, and stakeholder consultation; (2) testing the causal impact of formal and informal (eg, emergent) components of service delivery models; (3) contrasting initial programme theories with rival theory statements; (4) envisioning broad system impacts beyond the immediate implementation setting; and (5) incorporating rapidly evolving service developments and context changes into the theory testing process in real-time (eg, Additional Role Reimbursement Scheme, COVID-19). Through the reflections presented, the aim is to clarify the benefit of realist evaluation to assess emerging models of care and rapidly changing health service delivery.

Construct Validity of the Holistic Complementary and Alternative Medicines Questionnaire (HCAMQ)-An Investigation Using Modern Psychometric Approaches.

The scientific basis of efficacy studies of complementary medicine requires the availability of validated measures. The Holistic Complementary and Alternative Medicine Questionnaire (HCAMQ) is one such measure. This article aimed to examine its construct validity, using a modern psychometric approach. The HCAMQ was completed by 221 patients (mean age 66.8, SD 8.29, 58% females) with chronic stable pain predominantly from a single joint (hip or knee) of mechanical origin, waiting for a hip (40%) or knee (60%) joint replacement, on enrolment in a study investigating the effects of acupuncture and placebo controls. The HCAMQ contains a Holistic Health (HH) Subscale (five items) and a CAM subscale (six items). Validity of the subscales was tested using Cronbach alpha's, factor analysis, Mokken scaling and Rasch analysis, which did not support the original two-factor structure of the scale. A five-item HH subscale and a four-item CAM subscale (worded in a negative direction) fitted the Rasch model and were unidimensional (χ2 = 8.44, P = 0.39, PSI = 0.69 versus χ2 = 17.33, P = 0.03, PSI = 0.77). Two CAM items (worded in the positive direction) had significant misfit. In conclusion, we have shown that the original two-factor structure of the HCAMQ could not be supported but that two valid shortened subscales can be used, one for HH Beliefs (four-item HH), and the other for CAM Beliefs (four-item CAM). It is recommended that consideration is given to rewording the two discarded positively worded CAM questions to enhance construct validity.

Collegial surface acting emotional labour, burnout and intention to leave in novice and pre-retirement nurses in the United Kingdom: A cross-sectional study.

Aim: To investigate the relationship between surface and deep acting in nurses' patient-focused and collegial emotional labour, with emotional exhaustion, depersonalization and personal accomplishment and intention to leave. Design: A cross-sectional descriptive study using the Emotional Labour Scale, the Maslach Burnout Inventory and intention to leave Yes/No questions with 118 Registered Nurses to measure patient-focused and collegial emotional labour, burnout and intention to leave. Results: Surface acting in patient-focused and collegial emotional labour was found to have positive associations with burnout and intention to leave their current job. Only surface acting in patient-focused emotional labour was positively associated with intention to leave the organization and/or the profession. The novice nurses carried out more deep acting collegial emotional labour than the pre-retirement nurses. Conclusions: Collegial emotional labour is significant to nurses' intention to leave their current job but not their intention to leave the organization and/or the profession.

Design considerations for a multiple sclerosis fatigue mobile app MS Energize: A pragmatic iterative approach using usability testing and resonance checks.

Multiple sclerosis (MS) is a chronic neurological condition affecting around 2.2 million people worldwide. The illness includes a range of symptoms, with fatigue considered to be one of the most disabling. This paper describes how a pragmatic and iterative approach, supported by usability and resonance testing, was used to build a minimum viable product of MS Energize-or MS Energise in UK English regions. MS Energise is a mobile application focused on self-management of fatigue for people with MS. The iterative approach included various stages of testing, during which user feedback including comments about interface, navigation and content, was sought to inform incremental app development and continual improvement. Usability testing was conducted with 11 people with longstanding multiple sclerosis in New Zealand and the United Kingdom, and focused on particular sections of the app as well as the accessibility of the app to users with MS. Two participants contributed to further resonance testing post-release to ensure the app was perceived as relevant and useful to the user. The usability testing and resonance testing phases suggested that user experience of MS Energise was mostly positive. Participants provided a number of suggestions for improvements to aspects of content and design; some of which we implemented during our app development process. Findings will also contribute to future planning and design iteration to enhance the user experience. The next step is further improvement of MS Energise prior to a trial of its clinical and cost effectiveness.

The subjective index for physical and social outcome (SIPSO) in stroke: investigation of its subscale structure.

BACKGROUND: Short and valid measures of the impact of a stroke on integration are required in health and social settings. The Subjective Index of Physical and Social Outcome (SIPSO) is one such measure. However, there are questions whether scores can be summed into a total score or whether subscale scores should be calculated. This paper aims to provide clarity on the internal construct validity of the subscales and the total scale. METHODS: SIPSO data were collected as part of two parallel surveys of the met and unmet needs of 445 younger people (aged 18-65) with non-recent stroke (at least one year) and living at home. Factor, Mokken and Rasch analysis were used. RESULTS: Factor analysis supported a two factor structure (explaining 68% of the variance) as did the Mokken analysis (overall Loevinger coefficient 0.77 for the Physical Integration subscale; 0.51 for the Social Integration subscale). Both subscales fitted the Rasch model (P > 0.01) after adjusting for some observed differential item functioning. The 10-items together did not fit the Rasch model. CONCLUSIONS: The SIPSO subscales are valid for use with stroke patients of working age but the total SIPSO is not. The conversion table can be used by clinicians and researchers to convert ordinal data to interval level prior to mathematical operations and other parametric procedures. Further work is required to explore the occurrence of bias by gender for some of the items.

Multi-centre parallel arm randomised controlled trial to assess the effectiveness and cost-effectiveness of a group-based cognitive behavioural approach to managing fatigue in people with multiple sclerosis.

BACKGROUND: Fatigue is one of the most commonly reported and debilitating symptoms of multiple sclerosis (MS); approximately two-thirds of people with MS consider it to be one of their three most troubling symptoms. It may limit or prevent participation in everyday activities, work, leisure, and social pursuits, reduce psychological well-being and is one of the key precipitants of early retirement. Energy effectiveness approaches have been shown to be effective in reducing MS-fatigue, increasing self-efficacy and improving quality of life. Cognitive behavioural approaches have been found to be effective for managing fatigue in other conditions, such as chronic fatigue syndrome, and more recently, in MS. The aim of this pragmatic trial is to evaluate the clinical and cost-effectiveness of a recently developed group-based fatigue management intervention (that blends cognitive behavioural and energy effectiveness approaches) compared with current local practice. METHODS/DESIGN: This is a multi-centre parallel arm block-randomised controlled trial (RCT) of a six session group-based fatigue management intervention, delivered by health professionals, compared with current local practice. 180 consenting adults with a confirmed diagnosis of MS and significant fatigue levels, recruited via secondary/primary care or newsletters/websites, will be randomised to receive the fatigue management intervention or current local practice. An economic evaluation will be undertaken alongside the trial. Primary outcomes are fatigue severity, self-efficacy and disease-specific quality of life. Secondary outcomes include fatigue impact, general quality of life, mood, activity patterns, and cost-effectiveness. Outcomes in those receiving the fatigue management intervention will be measured 1 week prior to, and 1, 4, and 12 months after the intervention (and at equivalent times in those receiving current local practice). A qualitative component will examine what aspects of the fatigue management intervention participants found helpful/unhelpful and barriers to change. DISCUSSION: This trial is the fourth stage of a research programme that has followed the Medical Research Council guidance for developing and evaluating complex interventions. What makes the intervention unique is that it blends cognitive behavioural and energy effectiveness approaches. A potential strength of the intervention is that it could be integrated into existing service delivery models as it has been designed to be delivered by staff already working with people with MS. Service users will be involved throughout this research. TRIAL REGISTRATION: Current Controlled Trials ISRCTN76517470.