Using the ICF and psychological models of behavior to predict mobility limitations

Aims to test the ability of a model that integrates the theory of planned behavior (TPB) into the International Classification of Functioning Disability and Health (ICF) to predict walking limitations in adults awaiting hip or knee replacement surgery. Study Design and Participants: Cross-sectional structural equation modeling study of activity limitations in 190 adults. Method: A postal questionnaire measuring the TPB, ICF and walking limitations. Results: The integrated model accounted for more variance in activity limitations (57%) than either the TPB or ICF alone. Control beliefs (TPB) significantly mediated the relationship between impairment (ICF) and activity limitations. Conclusions: The integrated model provides an interdisciplinary theoretical framework that identifies intervention targets to effect reductions in disability without the need for concomitant reductions in impairment

Recovery from disability after stroke as a target for a behavioural intervention: Results of a randomised controlled trial

Purpose: Disability following stroke is highly prevalent and is predicted by psychological variables such as control cognitions and emotions, in addition to clinical variables. This study evaluated the effectiveness of a workbook-based intervention, designed to change cognitions about control, in improving outcomes for patients and their carers. Method: At discharge, stroke patients were randomly allocated (with their carers) to a 5-week intervention (n = 103) or control (normal care: n = 100). The main outcome (at 6 months) was recovery from disability using a performance measure, with distress and satisfaction as additional outcomes. Results: The intervention group showed significantly better disability recovery, allowing for initial levels of disability, than those in the control group, F(1,201) = 5.61, p = 0.019. Groups did not differ in distress or satisfaction with care for patients or carers. The only psychological process variable improved by the intervention was Confidence in Recovery but this did not mediate the effects on recovery. Conclusions: A large proportion of intervention participants did not complete the workbook tasks. This was perhaps associated with the fairly low level of personal contact with workbook providers. The modest success of this intervention suggests that it may be possible to develop effective behavioural interventions to enhance recovery from disability in stroke patients

MOBILE and the provision of total joint replacement

Modern joint replacements have been available for 45 years, but we still do not have clear indications for these interventions, and we do not know how to optimize the outcome for patients who agree to have them done. The MOBILE programme has been investigating these issues in relation to primary total hip and knee joint replacements, using mixed methods research

What does the chronic pain grade questionnaire measure?

This study explored the ability of the Chronic Pain Grade Questionnaire (CPG) to operationalise the WHO's model of health outcomes, namely the International Classification of Functioning, Disability and Health (ICF). Twelve expert judges used the method of discriminant content validation to allocate the seven items of the CPG to one or more ICF outcome, namely, impairment, activity limitations and participation restrictions. One-sample t-tests classified each item as measuring impairment, activity limitations or participation restrictions, or a combination thereof. The results indicated that the CPG contains items able to measure each of the three ICF outcomes. However, the pain grade classification system used in the CPG conflates the ICF outcomes. The implication of this conflation of outcome for the assessment of interventions is discussed

Exploring differential item functioning in the SF-36 by demographic, clinical, psychological and social factors in an osteoarthritis population

The SF-36 is a very commonly used generic measure of health outcome in osteoarthritis (OA). An important, but frequently overlooked, aspect of validating health outcome measures is to establish if items work in the same way across subgroup of a population. That is, if respondents have the same 'true' level of outcome, does the item give the same score in different subgroups or is it biased towards one subgroup or another. Differential item functioning (DIF) can identify items that may be biased for one group or another and has been applied to measuring patient reported outcomes. Items may show DIF for different conditions and between cultures, however the SF-36 has not been specifically examined in an osteoarthritis population nor in a UK population. Hence, the aim of the study was to apply the DIF method to the SF-36 for a UK OA population. The sample comprised a community sample of 763 people with OA who participated in the Somerset and Avon Survey of Health. The SF-36 was explored for DIF with respect to demographic, social, clinical and psychological factors. Well developed ordinal regression models were used to identify DIF items. Results: DIF items were found by age (6 items), employment status (6 items), social class (2 items), mood (2 items), hip v knee (2 items), social deprivation (1 item) and body mass index (1 item). Although the impact of the DIF items rarely had a significant effect on the conclusions of group comparisons, in most cases there was a significant change in effect size. Overall, the SF-36 performed well with only a small number of DIF items identified, a reassuring finding in view of the frequent use of the SF-36 in OA. Nevertheless, where DIF items were identified it would be advisable to analyse data taking account of DIF items, especially when age effects are the focus of interest

Does the impact of osteoarthritis vary by age, gender and social deprivation? A community study using the International Classification of Functioning, Disability and Health

The aim of the study was to explore if the impact of osteoarthritis varies with respect to age, gender and social deprivation. Impact was defined as impairment, activity limitations and participation restriction (International Classification of Functioning, Disability and Health (ICF)). Investigating the functioning of the ICF model for subgroups is important both practically and theoretically.  The sample comprised a community sample of 763 people diagnosed with osteoarthritis. Uncontaminated measures of the ICF constructs were developed using discriminant content validity from a pool of 134 items, including the WOMAC and SF-36. Multigroup Structural Equation Modelling was used to explore if the same pathways exist for subgroups of gender, age and social deprivation. Results: Different significant paths were found for gender and social deprivation: impairment did not predict participation restriction for women and those most deprived, whereas these paths were significant for men and those less deprived. No difference in the paths was found for age. The impact of osteoarthritis appears to vary with respect to gender and social deprivation but not age. This suggests both that osteoarthritis per se does not adequately explain the health outcomes observed and that different clinical approaches may be appropriate for people of different gender and levels of deprivation. Implications of Rehabilitation • The ICF model appears to vary with respect to gender and social deprivation for people with osteoarthritis. • The ICF model did not appear to vary with respect to age for people with osteoarthritis. • Different treatments and interventions for osteoarthritis may need to be targeted for specific gender and social deprivation groups

Moritz Schlick on the Value of Play

The focus of this essay is Moritz Schlick’s On the Meaning of Life. Schlick wrote On the Meaning of Life in 1927 and hoped to push back against pessimist currents of thought that were popular at the time by using the concepts of play and youth. Schlick defines plays as any “activities which carry their own purpose and value within them, independently of any extraneous goals…” (Schlick, M. 2008, p.64). For Schlick, these intrinsically valuable activities are the key to creating meaningful lives. However, I argue that there are certain tensions in Schlick’s essay that need addressing. In the first half of this essay, I make some vital changes to Schlick’s theory of play in order to address these tensions. In particular, through a discussion of Aristotle’s concepts of leisure and play, along with Mihaly Csikszentmihalyi’s concept of flow, I argue that play should be understood as a state rather than as certain activities. I also explore aspects of Schlick’s writing such as his distinction between joy and pleasure and the potential criticisms that could be levelled at this distinction. By addressing the tensions in Schlick’s work and by clarifying his theory of play, I hope to show that play is a serious candidate for giving us more meaningful and fulfilling experiences. Having addressed the issues in On The Meaning of Life, the second half of this essay is dedicated to showing how we can maximise play in our lives. To do this, I begin with an exploration of the relationship between our values and play via a discussion of Friedrich Nietzsche’s writing and argue that in order to maximise playfulness in our lives, there is a subsidiary task, which is to uncover and analyse our own values. Lastly, I argue that playfulness is a skill that we can, and ought, to develop, and explore Csikszentmihalyi’s suggestions for how we might develop this skill

Exploring differential item functioning in the Western Ontario and McMaster Universities osteoarthritis index (WOMAC)

Background: The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) is a widely used patient reported outcome in osteoarthritis. An important, but frequently overlooked, aspect of validating health outcome measures is to establish if items exhibit differential item functioning (DIF). That is, if respondents have the same underlying level of an attribute, does the item give the same score in different subgroups or is it biased towards one subgroup or another. The aim of the study was to explore DIF in the Likert format WOMAC for the first time in a UK osteoarthritis population with respect to demographic, social, clinical and psychological factors. Methods: The sample comprised a community sample of 763 people with osteoarthritis who participated in the Somerset and Avon Survey of Health. The WOMAC was explored for DIF by gender, age, social deprivation, social class, employment status, distress, body mass index and clinical factors. Ordinal regression models were used to identify DIF items. Results: After adjusting for age, two items were identified for the physical functioning subscale as having DIF with age identified as the DIF factor for 2 items, gender for 1 item and body mass index for 1 item. For the WOMAC pain subscale, for people with hip osteoarthritis one item was identified with age-related DIF. The impact of the DIF items rarely had a significant effect on the conclusions of group comparisons. Conclusions: Overall, the WOMAC performed well with only a small number of DIF items identified. However, as DIF items were identified in for the WOMAC physical functioning subscale it would be advisable to analyse data taking into account the possible impact of the DIF items when weight, gender or especially age effects, are the focus of interest in UK-based osteoarthritis studies. Similarly for the WOMAC pain subscale in people with hip osteoarthritis it would be worthwhile to analyse data taking into account the possible impact of the DIF item when age comparisons are of primary interest

Work-related stress:the Impact of COVID-19 on Critical Care and Redeployed Nurses

Objective: To use the job demands−resources model of occupational stress to quantify and explain the impact of working in critical care during the COVID-19 pandemic on nurses and their employing organisation. Design: Two-phase mixed methods: a cross-sectional survey (January 2021–March 2022), with comparator baseline data from April to October 2018 (critical care nurses only), and semistructured interviews. Participants: Critical care nurses (n = 461) and nurses redeployed to critical care (n = 200) who worked in the United Kingdom National Health Service (primarily Scotland) between January 2021 and March 2022. The 2018 survey was completed by 557 critical care nurses (Scotland only). Survey response rate in Scotland was 32% but could not be determined outside Scotland. Forty-four nurses were interviewed (critical care = 28, redeployed = 16). Methods: A survey measured job demands, job resources, health impairment, work engagement and organisational outcomes. Data were compared to 2018 data. Regression analyses identified predictors of health impairment, work engagement and organisational outcomes. Semistructured interviews were conducted remotely, audio-recorded and transcribed. Data were analysed deductively using framework analysis. Findings: Three-quarters of nurses reached threshold for psychological distress, approximately 50% reached threshold for burnout emotional exhaustion and a third clinically concerning post-traumatic stress symptoms. Compared to 2018, critical care nurses were at elevated risk of probable psychological distress, odds ratio 6.03 (95% CI 4.75 to 7.95); burnout emotional exhaustion, odds ratio 4.02 (3.07 to 5.26); burnout depersonalisation, odds ratio 3.18 (1.99 to 5.07); burnout accomplishment, odds ratio 1.53 (1.18 to 1.97). There were no differences between critical care and redeployed nurses on health impairment outcomes, suggesting elevated risk would apply to redeployed nurses. Job demands increased and resources decreased during the pandemic. Higher job demands predicted greater psychological distress. Job resources reduced the negative impact of job demands on psychological distress, but this moderating effect was not observed at higher levels of demand. All organisational outcomes worsened. Lack of resources predicted worse organisational outcomes. In interviews, staff described the pace and amount, complexity, physical and emotional effort of their work as the most difficult job demands. The sustained high-demand environment impacted physical and psychological well-being, with most interviewees experiencing emotional and physical exhaustion, burnout, and symptoms of post-traumatic stress disorder. Camaraderie and support from colleagues and supervisors were core job resources. The combination of sustained demands and their impact on staff well-being incurred negative organisational consequences, with increasing numbers considering leaving their specialty or nursing altogether. Dissemination events with a range of stakeholders, including study participants, identified staffing issues and lack of learning and development opportunities as problematic. Critical care nurses are concerned about the future delivery of high-quality critical care services. Positive aspects were identified, for example, reduced bureaucratic systems, increased local autonomy and decision-making, recognition of the critical care nurse skill set. Conclusions: The National Health Service needs to recognise the impact of COVID-19 on this staff group, prioritise the welfare of critical care nurses, implement workplace change/planning, and support them to recover from the pandemic. The National Health Service is struggling to retain critical care nurses and, unless staff welfare is improved, quality of care and patient safety will likely decline. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR132068.</p