The Importance of Autonomy and Performance Goals in Perceived Workload Among Behavioral Health Providers

OBJECTIVE

The authors sought to assess workplace characteristics associated with perceived reasonable workload among behavioral health care providers in the Veterans Health Administration.

METHODS

The authors evaluated perceived reasonable workload and workplace characteristics from the 2019 All Employee Survey (AES; N=14,824) and 2019 Mental Health Provider Survey (MHPS; N=10,490) and facility-level staffing ratios from Mental Health Onboard Clinical Dashboard data. Nine AES and 15 MHPS workplace predictors of perceived reasonable workload, 11 AES and six MHPS demographic predictors, and facility-level staffing ratios were included in mixed-effects logistic regression models.

RESULTS

In total, 8,874 (59.9%) AES respondents and 5,915 (56.4%) MHPS respondents reported having a reasonable workload. The characteristics most strongly associated with perceived reasonable workload were having attainable performance goals (average marginal effect [AME]=0.10) in the AES and ability to schedule patients as frequently as indicated (AME=0.09) in the MHPS. Other AES characteristics significantly associated with reasonable workload included having appropriate resources, support for personal life, skill building, performance recognition, concerns being addressed, and no supervisor favoritism. MHPS characteristics included not having collateral duties that reduce care time, staffing levels not affecting care, support staff taking over some responsibilities, having spirit of teamwork, primary care-mental health integration, participation in performance discussions, well-coordinated mental health care, effective veteran programs, working at the top of licensure, and feeling involved in improving access. Facility-level staffing ratios were not significantly associated with perceived reasonable workload.

CONCLUSIONS

Leadership may consider focusing resources on initiatives that support behavioral health providers' autonomy to schedule patients as clinically indicated and develop attainable performance goals.

Behavioral Health Provider Burnout and Mental Health Care in the Veterans Health Administration

BACKGROUND

Although many studies assess predictors of provider burnout, few analyses provide high-quality, consistent evidence on the impact of provider burnout on patient outcomes exist, particularly among behavioral health providers (BHPs).

OBJECTIVE

To assess the impact of burnout among psychiatrists, psychologists, and social workers on access-related quality measures in the Veterans Health Administration (VHA).

DESIGN

This study used burnout in VA All Employee Survey (AES) and Mental Health Provider Survey (MHPS) data to predict metrics assessed by the Strategic Analytics for Improvement and Learning Value, Mental Health Domain (MH-SAIL), VHA's quality monitoring system. The study used prior year (2014-2018) facility-level burnout proportion among BHPs to predict subsequent year (2015-2019) facility-level MH-SAIL domain scores. Analyses used multiple regression models, adjusting for facility characteristics, including BHP staffing and productivity.

PARTICIPANTS

Psychologists, psychiatrists, and social workers who responded to the AES and MHPS at 127 VHA facilities.

MAIN MEASURES

Four compositive outcomes included two objective measures (population coverage, continuity of care), one subjective measure (experience of care), and one composite measure of the former three measures (mental health domain quality).

KEY RESULTS

Adjusted analyses showed prior year burnout generally had no impact on population coverage, continuity of care, and patient experiences of care but had a negative impact on provider experiences of care consistently across 5 years (p < 0.001). Pooled across years, a 5% higher facility-level burnout in AES and MHPS had a 0.05 and 0.09 standard deviation worse facility experiences of care from the prior year, respectively.

CONCLUSIONS

Burnout had a significant negative impact on provider-reported experiential outcome measures. This analysis showed that burnout had a negative effect on subjective but not on objective quality measures of Veteran access to care, which could inform future policies and interventions regarding provider burnout.

Assessing workplace civility: Validity and 1‐year test‐retest reliability of a Japanese version of the CREW Civility Scale

Objectives

This study aimed to examine the reliability and validity of the Japanese version of the eight‐item CREW Civility Scale which measures workplace civility norms and compare the civility scores among various occupations.

Methods

A longitudinal study included all employees in a social care organization (N = 658) and a cross‐sectional study included all civil servants in one city (N = 3242) in Japan. Structural validity was tested through confirmatory factor analyses (CFA). Construct validity was assessed through Pearson's correlations of civility with other variables. Internal consistency was assessed by Cronbach's alpha and 1‐year test‐retest reliability was assessed by the Intraclass Correlation Coefficient (ICC).

Results

The results of CFA showed an acceptable level of model fit (TLI =0.929; CFI =0.949; and SRMR =0.034). CREW Civility Scale scores were significantly positively correlated with supervisor support, co‐worker support, and work engagement, while significantly negatively correlated with incivility, workplace bullying, intention to leave, and psychological distress, which were consistent with our hypotheses. Cronbach's alpha coefficient was 0.93 and ICC was 0.52. Younger, high‐educated, and managerial employees and, childminder/nursery staff reported higher civility. High school graduates and respondents who did not graduate from high school, part‐time employees, nurses, paramedical staff, and care workers reported lower civility.

Conclusions

The Japanese version of the CREW Civility scale is a reliable, valid measure of civility, appropriate for Japanese workplaces as well as for use in multi‐national studies alongside other existing versions of this scale in English, Portuguese and Farsi.

Relationships between work-environment characteristics and behavioral health provider burnout in the Veterans Health Administration

Objective

To identify work–environment characteristics associated with Veterans Health Administration (VHA) behavioral health provider (BHP) burnout among psychiatrists, psychologists, and social workers.

Data Sources

The 2015–2018 data from Annual All Employee Survey (AES); Mental Health Provider Survey (MHPS); N = 57,397 respondents; facility‐level Mental Health Onboard Clinical (MHOC) staffing and productivity data, N = 140 facilities.

Study Design

For AES and MHPS separately, we used mixed‐effects logistic regression to predict BHP burnout using surveys from year pairs (2015–2016, 2016–2017, 2017–2018; six models). Within each year‐pair, we used the earlier year of data to train models and tested the model in the later year, with burnout (emotional exhaustion and/or depersonalization) as the outcome for each survey. We used potentially modifiable work–environment characteristics as predictors, controlling for employee demographic characteristics as covariates, and employment facility as random intercepts.

Data Collection/Extraction Methods

We included work–environment predictors that appeared in all 4 years (11 in AES; 17 in MHPS).

Principal Findings

In 2015–2018, 31.0%–38.0% of BHPs reported burnout in AES or MHPS. Work characteristics consistently associated with significantly lower burnout were included for AES: reasonable workload; having appropriate resources to perform a job well; supervisors address concerns; given an opportunity to improve skills. For MHPS, characteristics included: reasonable workload; work improves veterans' lives; mental health care provided is well‐coordinated; and three reverse‐coded items: staffing vacancies; daily work that clerical/support staff could complete; and collateral duties reduce availability for patient care. Facility‐level staffing ratios and productivity did not significantly predict individual‐level burnout. Workload represented the strongest predictor of burnout in both surveys.

Conclusions

This study demonstrated substantial, ongoing impacts that having appropriate resources including staff, workload, and supervisor support had on VHA BHP burnout. VHA may consider investing in approaches to mitigate the impact of BHP burnout on employees and their patients through providing staff supports, managing workload, and goal setting.

Studying the relationships between authentic leadership, structural empowerment, and civility in the palliative care sector in Portugal

PURPOSE

This paper aims to propose a model studying the relationship of authentic leadership (AL), structural empowerment (SE) and civility in the palliative care sector. This model proposes SE as a mediator between AL and civility.

DESIGN/METHODOLOGY/APPROACH

Data was collected from 213 employees working in five major public palliative care hospitals in central Portugal. The study sample was predominantly female (80.3%) and the response rate was 42.6%. Variables were measured using the Authentic Leadership Inventory, Workplace Civility Scale and Conditions of Work Effectiveness Questionnaire II scales. Hayes' PROCESS macro for mediation analysis in SPSS was used to test the hypothesized model.

FINDINGS

Results suggest that AL has a significant positive direct relationship with both SE and civility. Furthermore, SE demonstrated to play a partial mediation effect between AL and civility.

PRACTICAL IMPLICATIONS

This study may be of use for healthcare administration encouraging the development of AL, suggesting that the more leaders are seen as authentic, the more employees will perceive they have access to workplace empowerment structures and a civil environment.

ORIGINALITY/VALUE

Considering the mainstream literature in healthcare management, to the best of the authors' knowledge, this is the first study to date to integrate the relation of AL, SE and civility in the palliative care sector. Further, the research model has not previously been introduced when considering the mediating role structural empowerment can play between AL and civility.

Workplace bullying among mental health providers with lived experience of a mental health challenge

Mental health care providers who have a personal lived experience of mental health challenges are valuable employees who may be vulnerable to workplace bullying, which causes harm both to these individuals and to their organizations. We used snowball sampling to survey 40 mental health professionals with lived experience about their history of workplace bullying and whether or not their lived experience was known ("out") or concealed ("closeted"). We found that our sample experienced workplace bullying at much higher rates than published samples from the general population. More than three-quarters of our sample reported having ever experienced bullying and almost half had been bullied in the past year. Furthermore, most of those who had ever experienced bullying reported having been closeted at the time. Further exploratory analyses identified some specific aspects of bullying that might be fruitful areas for future research. We conclude with implications for employee recruitment and retention, vocational rehabilitation, and organizational development. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Examining burnout profiles in relation to health and well-being in the Veterans Health Administration employee population

The goals of this paper were twofold: (a) To provide a population overview of burnout profiles by occupation in a large, health care sector employee population and (b) to investigate how burnout profiles relate to self-reported health behaviours, chronic conditions, and absenteeism. Burnout profiles were considered by 5 main occupational groups (physicians, nurses, other clinical, administrative, and wage grade [trade, craft, and labor workers]) in survey respondents (n = 86,257 employees). Logistic regression analyses were conducted to examine how burnout profiles were associated with health controlling for gender, age, race, ethnicity, and occupational group. Employees in the "Frustrated/Burning Up" and "Withdrawing/Burned Out" profiles, respectively, had significantly increased odds of anxiety (OR = 2.17; 99% CI [2.04, 2.31]; OR = 2.21; 99% CI [2.05, 2.38]), depression (OR = 2.06; 99% CI [1.93, 2.20]; OR = 2.20; 99% CI [2.04, 2.38]), sleep disorders (OR = 1.98; 99% CI [1.85, 2.12]; OR = 1.97; 99% CI [1.81, 2.13]), low back disease (OR = 1.60; 99% CI [1.50, 1.71]; OR = 1.58; 99% CI [1.47, 1.70]), physical inactivity (OR = 1.49; 99% CI [1.38, 1.60]; OR = 1.68; 99% CI [1.54, 1.83]), and 5 or more days away from work (OR = 1.74; 99% CI [1.65, 1.85]; OR = 2.15; 99% CI [2.01, 2.30]). Burnout is related to the health of employees. Burnout profiles offer a way to assess patterns of burnout by occupational group and may help customize future interventions.

Does nurse job satisfaction influence adherence to the central line insertion checklist and central line-associated bloodstream infections in the Veterans Health Administration?

Nurses satisfied with their jobs report less job stress, more effective nurse-physician collaboration, and higher patient satisfaction scores. It is unknown if job satisfaction influences adherence to best practices or patient outcomes. This secondary data analysis investigated the relationship between job satisfaction, adherence to the central line insertion checklist, and central line-associated bloodstream infections (CLABSIs). Results showed a decreased risk of CLABSI with higher job satisfaction, on average. No relationship was observed with checklist adherence.

‘You just can’t do it all’: a secondary analysis of nurses' perceptions of teamwork, staffing and workload

The purpose of this study was to re-examine data to explore connections between nurses’ perceptions of teamwork, staffing and workload, focusing on salient aspects and connections, from the nurses’ perspective. Insufficient staffing levels and imbalanced workload distributions are prominent challenges in contemporary healthcare which can cause increased incident reports, medical errors and lower patient satisfaction. Using a novel form of secondary analysis – an original qualitative analysis followed by a quantification of the qualitative data, we found themes of teamwork, staffing and workload were interrelated in the data. When facing workload challenges created by understaffing, participants directly attributed their units’ ability to meet the needs of patient care to levels of teamwork on the unit. We suggest that teamwork in healthcare needs targeted organisational support. In other words, healthcare organisations must systematically approach and monitor the status of nursing teamwork, e.g. implement programmes to develop it as needed, particularly when faced with staffing and workload challenges. Healthcare leaders can learn from and the healthcare delivery workplace can be shaped by listening to teamwork perceptions of nurses.

Further examination of predictors of turnover intention among mental health professionals

WHAT IS KNOWN ON THE SUBJECT?: When mental health professionals leave organizations, detrimental effects on quality of patient care occur. Reasons for leaving include incivility, lack of autonomy, perceptions of unfair treatment and feeling psychologically unsafe at work. This paper sought to investigate additional reasons why mental health professionals intend to quit or to cognitively withdraw from their jobs. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: Past research on this topic is limited in its scope and data. Mainly fragmented evidence is available about predictors of job satisfaction and turnover intention (i.e. different mental health occupations examined in separate studies). Only two existing studies that examined broader mental health provider groups were limited by including few workforce settings, small sample sizes and insufficiently rigorous statistical analyses. We examined four occupations (mental health nurses, social workers, psychologists and psychiatrists), each represented through a large sample in multiple settings, all within one large healthcare network with complex patients. Our contribution is finding additional predictors (supervisory support, emotional exhaustion) of job satisfaction/turnover intention. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Organizations can consider using culture change initiatives to increase civility at work; this includes leadership support and role modelling of workplace behaviours. Leaders should monitor staffing levels and high workloads to pre-empt emotional exhaustion, which predicts turnover. Hiring and training supervisors should involve not only technical expertise, but also 'soft skills' necessary for creating civil and supportive work environments. Leaders and managers should use employee feedback data (e.g. organizational surveys) to learn about the workplace environments, and address areas of employees' concern.

ABSTRACT

Introduction Given the global shortage of mental health professionals, high turnover rates within this workforce are concerning. We used United States of America Veterans Health Administration data to add to the limited knowledge about this topic. Aim We examined predictors of turnover intention, or an employee's cognitive withdrawal from their job, in a large sample of direct care mental health professionals, separating among occupations to increase the pragmatic relevance of our findings. Method Survey data from 10 997 mental health employees working in direct patient contact (2432 registered nurses, 3769 social workers, 2520 psychologists and 1276 psychiatrists) were used in a cross-sectional design with structural equation modelling techniques for model testing. Results Job satisfaction was predicted by civility (courteous and respectful workplace behaviours) and supervisory support. Job satisfaction predicted emotional exhaustion which predicted turnover intention. Job satisfaction also directly predicted turnover intention and turnover plans. Discussion Predictors of job satisfaction included civility and supervisory support. Emotional exhaustion predicted turnover intention. Results inform organizational actions to address these work environment characteristics. Implications for practice Organizations can initiate culture changes to improve civility and develop supervisors' 'soft skills' in conjunction with technical expertise.

Association between psychosocial, organizational and personal factors and prevalence of musculoskeletal disorders in office workers

The purpose of this study was to investigate the relationship between organizational and personal (individual) factors with the prevalence of musculoskeletal disorders (MSDs) in office workers of the Iranian Gas Transmission Company. The participants rated two questionnaires - the standardized Nordic Musculoskeletal Questionnaire to measure the prevalence of MSDs, and the Veterans Healthcare Administration All Employee Survey questionnaire (2004 version) - to measure psychosocial, organizational and individual aspects of job satisfaction and workplace climate. The highest prevalence of MSDs was found in the lower back (49.7%) and neck (49.0%) regions. Results of the logistic regression models showed that some psychosocial and organizational factors and also some individual factors were associated with prevalence of MSDs (p < 0.05).These findings illustrate the need to consider all elements of the work system as a whole in future studies and in organizational planning.

Job satisfaction of Department of Veterans Affairs peer mental health providers

OBJECTIVES

Department of Veterans Affairs (VA) peer specialists and vocational rehabilitation specialists are Veterans employed in mental health services to help other Veterans with similar histories and experiences. Study objectives were to (a) examine job satisfaction among these employees, (b) compare them to other VA mental health workers, and (c) identify factors associated with job satisfaction across the 3 cohorts.

METHODS

The study sample included 152 VA-employed peer specialists and 222 vocational rehabilitation specialists. A comparison group included 460 VA employees from the same job categories. All participants completed the Job Satisfaction Index (11 aspects and overall satisfaction ratings). Linear regression was used to compare job satisfaction and identify its predictors among the 3 cohorts.

RESULTS

Job satisfaction was fairly high, averaging "somewhat satisfied" to "very satisfied" in 6 (peer specialists) and 9 (vocational rehabilitation specialists) of the 11 aspects and overall job ratings. Adjusting for length of employment, age and gender resulted in no significant group differences with 2 exceptions: White peer specialists were less satisfied with pay and promotion opportunities than vocational rehabilitation specialists and comparison-group employees. Across all cohorts, shorter length of time employed in the job was associated with higher job satisfaction.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The high job satisfaction levels among the 2 peer cohorts suggest support for the policy of hiring peer specialists in the VA. Furthermore, the results are consistent with those of the nonveteran samples, indicating that integrating peer providers into mental health care is possible in VA and non-VA settings.

Team Process Variation Across Diabetes Quality of Care Trajectories

Conceptual frameworks in health care do not address mechanisms whereby teamwork processes affect quality of care. We seek to fill this gap by applying a framework of teamwork processes to compare different patterns of primary care performance over time. We thematically analyzed 114 primary care staff interviews across 17 primary care clinics. We purposefully selected clinics using diabetes quality of care over 3 years using four categories: consistently high, improving, worsening, and consistently low. Analyses compared participant responses within and between performance categories. Differences were observed among performance categories for action processes (monitoring progress and coordination), transition processes (goal specification and strategy formulation), and interpersonal processes (conflict management and affect management). Analyses also revealed emergent concepts related to psychological and organizational context that were reported to affect team processes. This study is a first step toward a comprehensive model of how teamwork processes might affect quality of care.

Nurse perceptions of workplace environment: differences across shifts

AIM

To evaluate whether nurse work shift affected workplace perceptions.

BACKGROUND

Although the importance of work schedule in shaping work attitudes, generally (and specifically for nurses) is well accepted, much work remains in characterising how and why nurses' perceptions might differ across shifts.

METHODS

Using an exploratory study of observational data, we examined whether shift influenced non-supervisory nurses' job perceptions in the Veterans Health Administration All Employee Survey (n = 14057; years 2008, 2010, 2012). The size of differences in item means (95% C.I.) across shifts was evaluated graphically. Using ordinal logistic regression, we accounted for the ordinal outcome variables and controlled for the demographic and survey year effects.

RESULTS

Nurses' perceptions of workplace climate differed across shifts. Items with the greatest differences, consistent across years and analytic methods, involved supervisors and fairness. Night and weekend shift nurse ratings were more negative than for weekday shift nurses.

CONCLUSIONS

Off-shift nurses are less satisfied with work/life balance, their supervisors and especially fairness. Overall satisfaction and turnover intention are not affected to the same extent.

IMPLICATIONS FOR NURSING MANAGEMENT

These results indicate several specific areas that nurse managers can address through workforce support and communication.

Assimilation approach to measuring organizational change from pre- to post-intervention

AIM: To present a conceptual and measurement strategy that allows to objectively, sensitively evaluate intervention progress based on data of participants’ perceptions of presenting problems.

METHODS: We used as an example an organization development intervention at a United States Veterans Affairs medical center. Within a year, the intervention addressed the hospital’s initially serious problems and multiple stakeholders (employees, management, union representatives) reported satisfaction with progress made. Traditional quantitative outcome measures, however, failed to capture the strong positive impact consistently reported by several types of stakeholders in qualitative interviews. To address the paradox, full interview data describing the medical center pre- and post- intervention were examined applying a validated theoretical framework from another discipline: Psychotherapy research. The Assimilation model is a clinical-developmental theory that describes empirically grounded change levels in problematic experiences, e.g., problems reported by participants. The model, measure Assimilation of Problematic Experiences Scale (APES), and rating procedure have been previously applied across various populations and problem types, mainly in clinical but also in non-clinical settings. We applied the APES to the transcribed qualitative data of intervention participants’ interviews, using the method closely replicating prior assimilation research (the process whereby trained clinicians familiar with the Assimilation model work with full, transcribed interview data to assign the APES ratings). The APES ratings summarized levels of progress which was defined as participants’ assimilation level of problematic experiences, and compared from pre- to post-intervention.

RESULTS: The results were consistent with participants’ own reported perceptions of the intervention impact. Increase in APES levels from pre- to post-intervention suggested improvement, missed in the previous quantitative measures (the Maslach Burnout Inventory and the Work Environment Scale). The progress specifically consisted of participants’ moving from the APES stages where the problematic experience was avoided, to the APES stages where awareness and attention to the problems were steadily sustained, although the problems were not yet fully processed or resolved. These results explain why the conventional outcome measures failed to reflect the intervention progress; they narrowly defined progress as resolution of the presenting problems and alleviation of symptomatic distress. In the Assimilation model, this definition only applies to a sub-segment of the change continuum, specifically the latest APES stages. The model defines progress as change in psychological processes used in response to the problem, i.e., a growing ability to deal with problematic issues non-defensively, manifested differently depending on APES stages. At early stages, progress is an increased ability to face the problem rather than turning away. At later APES stages, progress involves naming, understanding and successfully addressing the problem. The assimilation approach provides a broader developmental context compared to exclusively symptom, problem-, or behavior- focused approaches that typically inform outcome measurement in interpersonally based interventions. In our data, this made the difference between reflecting (APES) vs missing (Maslach Burnout Inventory, Work Environment Scale) the pre-post change that was strongly perceived by the intervention recipients.

CONCLUSION: The results illustrated a working solution to the challenge of objectively evaluating progress in subjectively experienced problems. This approach informs measuring change in psychologically based interventions.

Relationship between mental states in depression: the assimilation model perspective

Metacognitive theories describe relationships between mental-affective self-states, including the capacity of one self-state to reflect upon another self-state. The assimilation model is a metacognitive approach that understands self-states as made of traces of experiences at different levels of integration. Psychological problems are understood as impaired accessibility of certain self-states to the person's normal awareness. These states are distressing or otherwise subjectively problematic when they emerge. This exploratory study used the assimilation framework to describe mental states in 17 clients who participated in a clinical trial of cognitive-behavioral therapy for depression. Three clinically sophisticated raters examined transcripts of 1h-long psychotherapy session per client to construct qualitative descriptions of self-states and their relationship patterns in these depressed individuals. We then systematically compared and integrated these raters' descriptions of the clients' self-states. In each case, we found a conflict between two internally incompatible states: an interpersonally submissive state and an interpersonally dominant one, a pattern consistent with the model's theoretical description of depression.

Numbers in assimilation research

We describe the assimilation model, a developmental theory of psychological change that focuses on interpretive study of people’s experience in therapy. Assimilation research relies on methods that are simultaneously interpretive and quantitative, and uses them in mutually complementary ways. We explain how quantitative techniques have been useful in research on the model. We give examples of numeric techniques and their uses in specific studies that included helping establish reliability of interpretive accounts of clients’ change, investigating substantive issues of theoretical interest, testing hypotheses about the model, and formulating clinical implications of assimilation concepts. These procedures quantify our understanding of people’s subjective experience of change in therapy and rely on contextual interpretation of meanings. These examples illustrate and advocate the use of numeric properties for the purposes of contextual interpretive inquiry.

The relationship between organizational climate and quality of chronic disease management

OBJECTIVE

To test the utility of a two-dimensional model of organizational climate for explaining variation in diabetes care between primary care clinics.

DATA SOURCES/STUDY SETTING

Secondary data were obtained from 223 primary care clinics in the Department of Veterans Affairs health care system.

STUDY DESIGN

Organizational climate was defined using the dimensions of task and relational climate. The association between primary care organizational climate and diabetes processes and intermediate outcomes were estimated for 4,539 patients in a cross-sectional study.

DATA COLLECTION/EXTRACTION METHODS

All data were collected from administrative datasets. The climate data were drawn from the 2007 VA All Employee Survey, and the outcomes data were collected as part of the VA External Peer Review Program. Climate data were aggregated to the facility level of analysis and merged with patient-level data.

PRINCIPAL FINDINGS

Relational climate was related to an increased likelihood of diabetes care process adherence, with significant but small effects for adherence to intermediate outcomes. Task climate was generally not shown to be related to adherence.

CONCLUSIONS

The role of relational climate in predicting the quality of chronic care was supported. Future research should examine the mediators and moderators of relational climate and further investigate task climate.

Civility, Respect, Engagement in the Workforce (CREW)

This article presents a description and preliminary evaluation of a nationwide initiative by the Veterans Health Administration (VHA) called Civility, Respect, and Engagement in the Workforce (CREW). The goal of CREW is to increase workplace civility as assessed by employee ratings of interpersonal climate in workgroups. Once endorsed by the VHA leadership and adopted by the leaders of particular VHA hospitals, CREW was conducted by local facility coordinators who were trained and supported by the VHA National Center for Organization Development. This article explains the conceptual and operational background of CREW and the approach used to implement the initiative, presents results from two CREW administrations with a total of 23 sites, and reports significant preintervention to postintervention changes in civility at intervention sites as compared to no significant changes at comparison sites within each administration. It discusses these findings in the conceptual (theoretical) and operational (intervention evaluation) context of interventions targeting civility.

Insight, quality of life, and functional capacity in middle-aged and older adults with schizophrenia

OBJECTIVE

The quality of life (QOL) for individuals with schizophrenia is determined by a number of factors, not limited to symptomatology. The current study examined lack of insight as one such factor that may influence subjective QOL or functional capacity. It was hypothesized that insight would significantly interact with symptom severity to influence subjective QOL. Insight was not expected to influence the relation between symptom severity and functional capacity.

METHODS

Participants were middle-aged and older outpatients who met diagnostic criteria for schizophrenia or schizoaffective disorder, and subsyndromal depression. Insight, psychopathology, and subjective QOL were assessed via semi-structured interviews and functional capacity was assessed via performance-based measures.

RESULTS

Insight interacts with negative symptom severity to predict subjective QOL. Severity of negative symptoms and insight contribute directly to functional capacity.

CONCLUSIONS

Individuals with intact insight may be better able to manage their symptoms, resulting in improved QOL. Treatment implications for improving the QOL of middle age and older adults with schizophrenia are discussed.

Submissive voices dominate in depression: assimilation analysis of a helpful session

Using the assimilation model, we describe a theoretical paradox in which interpersonally assertive parts of the depressed person's personality are dominated and suppressed by parts that are interpersonally submissive and passive. We examine the relevance of this paradox to therapeutic work, focusing on a particularly helpful session (according to the therapist) from the case of Joan, a woman seen for depression in cognitive-behavioral therapy. We consider how the therapist intervened to enhance communication between the interpersonally submissive and dominant parts of Joan and discuss the implications of this process for therapy with such clients.

Escitalopram for comorbid depression and anxiety in elderly patients: A 12-week, open-label, flexible-dose, pilot trial

BACKGROUND

Comorbid depression and anxiety may result in greater symptom severity and poorer treatment response than either condition alone. Selective serotonin reuptake inhibitors have been found to be effective in treating both depression and anxiety; however, pharmacodynamic and pharmacokinetic changes associated with aging warrant special attention in medication trials in older patients.

OBJECTIVE

The objective of this study was to assess the efficacy and tolerability of short-term (12-week) administration of escitalopram oxalate 10 to 20 mg/d for moderate to marked comorbid depression and anxiety in elderly patients.

METHODS

This open-label, flexible-dose (10-20 mg/d), pilot trial was conducted at the Psychiatry Service, Veterans Affairs Medical Center, Cincinnati, Ohio. Outpatients aged > or =65 years were included if they met the criteria for comorbid major depressive disorder (MDD) and generalized anxiety disorder (GAD), as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, for > or =4 weeks and had a baseline Montgomery-Asberg Depression Rating Scale (MADRS) score of >22 and a Hamilton Rating Scale for Anxiety (HAM-A) score of > or =18. All patients received escitalopram 10 to 20 mg/d. The primary efficacy variables were the mean changes from baseline in total MADRS and HAM-A scores at 12 weeks (last observation carried forward). The secondary efficacy end point was the change from baseline in Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) 8 subscale scores. Adverse events were assessed at each visit (treatment weeks 1, 2, 3, 4, 6, 8, 10, and 12) with the use of open-ended questioning.

RESULTS

Twenty patients were enrolled (mean [SD] age, 73.0 [4.8] years; 6 [30%] women; race: 17 [85%] white, 2 [10%] black, and 1 [5%] "other"). Seventeen (85%) of 20 patients completed the study; 3 (15%) withdrew: 1 (5%) due to lack of efficacy and 2 (10%) due to adverse events (dizziness and somnolence [1 (5%) patient each]). Statistically significant improvements from baseline to end point were found with escitalopram treatment (MADRS: t19 = 7.38, P < 0.001, effect size = 2.93; HAM-A: t19 = 4.19, P < 0.001, effect size = 1.83). Significant changes from baseline in scores on 4 (Social Functioning, Role Functioning-Emotional, Mental Health, and Energy/Fatigue) of the 8 subscales of the SF-36 were also found (all, P < 0.01).

CONCLUSION

In this small study in elderly patients with comorbid MDD and GAD, treatment with escitalopram 10 to 20 mg/d for 12 weeks was associated with significant improvements in symptoms of depression and anxiety.

Acknowledging problematic voices: processes occurring at early stages of conflict assimilation in patients with functional somatic disorder

OBJECTIVES

This study elaborates the assimilation model's account of client processes at an early stage (Level I). This model describes therapeutic change as a gradual assimilation of problematic experiences, or voices, into the client's personality. The Assimilation of Problematic Experiences Scale (APES; Stiles et al., 1991) measures client's increasing ability to recognize, accept and utilize these previously avoided voices.

DESIGN AND METHODOLOGY

Two researchers rated session excerpts from two psychotherapy cases, where the 'problematic voice' (PV) was initially unassimilated. Passages rated at APES Level I, along with their verbal assimilation descriptions, were later scrutinized for change processes. Voice dynamics within each passage were detailed and reviewed, to hypothesize substage processes representing movement. Both procedures involved a convergence process: raters first independently analysed, then shared their findings over successive rounds.

CONCLUSIONS

Across cases, shifts in the quality of negative affect were evident. Anxiety increased throughout this stage, as clients began to sustain exposure to intrusive problematic experiences. Later, Level I substages also showed an increase in conscious apperception of dominant voice characteristics including its resistance to experiencing PVs. Together, these relatively subtle changes indicated clients' increasing ability to familiarize themselves with PV qualities and recognize their historic defences against them, prior to identifying and accepting them as part of their personalities.

Vocal manifestations of internal multiplicity: Mary's voices

According to the assimilation model, personality may be considered as a community of internal voices representing traces of previous experiences. This study addressed the hypothesis that a person's internal voices sound different from each other. First, following an intensive qualitative procedure, four clinically sophisticated raters identified six internal voices in a 45-minute interview with Mary, a graduate student in psychology. They characterized the voices by (a) distinctive names, (b) descriptions of vocal and personality characteristics, and (c) sets of excerpted passages. Next, using the voice names and descriptions, additional raters independently sorted the passages into groups. Sortings based on transcript plus audio agreed with the sophisticated raters on 68.9% of the passages, as compared with 37.2% for sortings based on transcript only, while chance agreement expected for both was 16.7%. These findings support a literal view of internal multiplicity, consistent with a modular organization of experiential information within personality.