Educational & Child Psychology; Vol. 36 No. 3 33Evaluating.docx

Educational & Child Psychology; Vol. 36 No. 3 33
Evaluating the impact of an autogenic
training relaxation intervention on levels
of anxiety amongst adolescents in school
Tracey Atkins & Ben Hayes
Aim: This study aimed to investigate the impact of a group-
based autogenic training (AT) relaxation
intervention on levels of anxiety in adolescents in mainstream
school settings.
Method: A mixed-methods design was used to measure
differences in levels of anxiety and explore a range
of perceived changes between groups over time. Sixty-six young
people aged between 14 and 15 years old
from four mainstream schools in the UK were randomly
assigned within each school to an intervention
or wait-list control group. Quantitative data were analysed using
a mixed between-within subjects ANOVA.
Qualitative information from 12 volunteer participants was
analysed using thematic analysis.
Findings: Results showed a main effect of time for both the
intervention group and the wait-list group
however, no significant main interaction was found. Qualitative
results showed perceived improvements
in social relationships and connectivity; reflectiveness; self-
awareness; physiological symptoms; and a sense
of control.
Limitations: Measures were reliant on self-reported data.
Schools were recruited through self-referral and
expression of interest, excluding participants who may not have

the opportunity to take part. There were
no opportunities to collect follow-up data.
Conclusions: Results suggest that a structured AT relaxation
intervention delivered in a familiar
school environment may significantly reduce levels of anxiety
amongst adolescents. However, significant
improvements for the wait-list group also raises questions
around the potential of other supportive
variables, such as acknowledgement and validation of feelings,
the promise and availability of
forthcoming support and the potential impact of raised
awareness and interest in pupil wellbeing
amongst school staff.
Keywords: autogenic training; relaxation; adolescence; mind-
body interventions; anxiety.
M
ENTAL HEALTH difficulties in
young people are a serious cause for
concern across the world. The World
Health Organization (WHO) reports that in
half of all cases of mental health conditions,
onset has occurred by the age of 14 years
old; suicide is the third leading cause of
death in 15–19 year olds; and the second
leading cause of death in girls (WHO, 2018).
It is estimated that one in ten children and
young people aged 5–16 years old have
a diagnosable mental health disorder in the
UK alone; and at least one in 12 children
and young people deliberately self-harm
(Young Minds, 2018).
In 2009, the UK government identi-
fied mental health as everyone’s business

(Department of Health; DoH, 2009) and
was specific about prevention and the tran-
sition time between adolescence and early
adulthood. Suggestions for schools include
promoting students’ mental health as part
of their curriculum (Department for Educa-
tion; DfE, 2016), highlighting the desire of
young people themselves to be more involved
with the development, delivery and evalu-
ation of interventions (National Institute
of Health and Clinical Excellence; NICE,
2014); making use of group work to teach
specific skills and empower young people;
34 Educational & Child Psychology; Vol. 36 No. 3
and identifying the expertise and role of
educational psychologists (EPs) (Weare &
Gray, 2003). The mental health of the nation
was viewed by the Prime Minister as one of
the ‘greatest social challenges of our time’
(Gov.uk, 2017). A government green paper
now aims to transform services by training
new mental health workers including educa-
tional mental health practitioners to work
in schools and in collaboration with NHS
professionals (DoH & DfE, 2017)
Adolescence and brain development
Adolescence is recognised as a period of
social and psychological change and neuro-
biological development that can either

enhance vulnerability or provide a window of
opportunity for growth and learning (Dahl
et al., 2018). Research into cognitive and
affective development in adolescence shows
that on the one hand cognitive development
appears to progress regardless of pubertal
changes (Dahl, 2004), but on the other,
although development during this period
takes place in regions of the brain associated
with regulation of behaviour and emotion
and the evaluation of risk and reward, these
are impeded by increases in arousal, moti-
vation and sensation seeking behaviour.
Consequently, while there are advances
in reasoning and decision-making skills, and
the ability to comprehend the consequences
of impulsivity, these can be easily over-ridden
not only by a natural propensity to experi-
ence intense feelings but also a keen desire
to seek these intense feelings out, occasion-
ally at a serious or fatal cost (Dahl, 2004).
Adolescence and Mental Health
Adolescents are particularly at risk of expe-
riencing emotional distress as their brains
mature (Blakemore & Frith, 2011). It is
a period of life where many experience their
first episode of mental health difficulties
(Kessler et al., 2005). Literature suggests
an increase in stress hormones compared
to adults (Romeo, 2009) and a clear asso-
ciation between exposure to chronic stress
and significant changes in emotion and
cognition, such as anxiety and depression
(Romeo, 2017). Sensitivity to the effects of

stress also inhibits typical brain development
and maturation (Sinclair et al., 2014). The
impact of exposure to stress is associated
with risk-taking and aggression (Byrne &
Mazanov, 2002) but despite the cognitive
capabilities to do so (Dahl, 2004) adoles-
cents are less able to apply effective problem
solving strategies to cope (Llorca et al., 2017).
Changes in social acceptance, negative rela-
tionships, experience of bullying, and fear
of peer rejection are all strong predictors of
anxiety disorders (Carr, 2002; Horwitz et al.,
2011; Morris & Kratochwill, 1991; Roza et al.,
2003), and yet adolescents are far less likely
than other young people with psychiatric
disorders to be in contact with supportive
services or receive any treatment (Chavira et
al., 2004; Neil & Christensen, 2009).
Relaxation interventions in schools
Relaxation training in its many forms can
be used exclusively as an intervention or
in conjunction with other cognitive or
psychotherapeutic programmes (Ashton,
2015). Purposeful muscle-relaxation and
controlled breathing techniques have been
used to treat a range of psychological prob-
lems (Kobayashi-Suzuki et al., 2014) and
educational stress (Manjushyambika et al.,
2017). Progressive muscle relaxation (PMR)
has been found to raise self-esteem, particu-
larly amongst females with moderate levels
of depression (Larson et al., 2014; Reyn-
olds & Coats, 1986); reduce aggression, and
improve levels of aspiration, vitality, mental
health and social functioning (Nickel et

al., 2005). Interventions such as mindful-
ness and autogenic training (AT) have had
a positive impact on quality of sleep (Bootzin
& Stevens, 2005), attention skills (Jha et al.,
2007), emotional regulation (Metz et al.,
2013), and self-reported wellbeing (Sanger
et al., 2018). More recently, findings for
meditation in schools have been linked to
improvements in coping skills, social rela-
tionships and eating disorders (Wisner et
al., 2010).
Evaluating the impact of an autogenic training relaxation
intervention
Autogenic training (AT)
Based on research into sleep and hypnosis,
AT was developed as a relaxation technique
by Schultz and Luthe in 1959. AT focuses
on an observant and passive attitude towards
one’s own cognitive, emotional and phys-
ical state, and through a series of taught
exercises over a period of five to ten weeks,
a deep state of relaxation can be achieved.
Once learned, AT can be used regularly
without the need for any external human
or material support. It is considered to be
one of a range of mind–body interventions
recognised by the American Psychological
Association (APA; Kotecki et al., 2014), and
consistent with interventions recommended
to treat anxiety disorders (Carr, 2002),

such as ‘self-instructional training focusing
on control and competence’ and ‘relaxation
skills’ (pp.199).
Research into the effects of AT shows
reductions in anxiety amongst adults
(Ernst & Kanji, 2000; Garvin et al., 2001;
Manzoni et al., 2008) and improvements
in externalising emotional and behavioural
presentation (Goldbeck & Schmidt, 2003)
amongst young people. However, there
is a distinct gap in the literature for AT
from an educational perspective. Previous
research has mainly focused on adults in
health settings with small sample sizes and
what research there is for young people
lacks transparency. Given the similarities
between AT and other relaxation-based
interventions, it is surprising that there is
no empirical evidence for the use of AT
to address anxiety and wellbeing amongst
young people in the UK.
The role of the educational psychologist
in delivering relaxation interventions
There are professional and ethical reasons
why EPs should be involved in the devel-
opment and delivery of innovative inter-
ventions to promote mental health in
schools. Although still in its infancy, the
evidence base for mind–body relaxation
interventions is growing and the concept
is now widely recommended to address the
psychological wellbeing of young people
and their educators (Kotecki et al., 2014;

Weare, 2015). Interventions vary dramat-
ically in content and it is not clear which
particular elements of programme design
distinctively contribute to its overall effec-
tiveness (Khoury et al., 2013). However,
EPs are uniquely placed to apply psycho-
logical research and theory and deliver
evidence-based programmes to support
young people experiencing emotional
problems in school (Macleod et al., 2015;
Perfect & Morris, 2011). In the light of
government concerns (DfE, 2016; Weare,
2015) this includes personal health and
wellbeing as well as academic achievement
(Cameron, 2006; Rydzkowski et al., 2015).
Many EPs want to engage in more high
quality casework (Boyle & Lauchlan, 2009)
and are open to expanding their reper-
toire of skills to include more therapeutic
approaches (Jimerson & Oakland, 2007).
EPs are also increasingly supporting others
to provide direct support with supervision,
guidance and advice at a whole school level.
These skills can help to fill the gaps in
outreach services and contribute to work
typically offered by other agencies (Truong
& Ellam, 2014).
It is recommended that EPs work along-
side resident pastoral support staff providing
direct interventions or supervision, espe-
cially where a more targeted and individual
approach is necessary (Weare, 2015). In such
cases, EPs provide a service that follows strict
ethical guidelines and draws on the principles
of competence, responsibility and integrity.

They continuously further their professional
development and expertise, apply knowledge
of the advantages and limitations of different
types of interventions, especially in terms of
universal availability and potential harm, and
recognise the proper protocols for consent,
privacy and information sharing. In addi-
tion, their awareness of group dynamics and
therapeutic alliance can greatly enhance the
outcomes of an intervention whether they
train others or take part directly with young
people (MacKay, 2007).
The present study
Given the potential for improving well-
being through the delivery of a range of
relaxation-based interventions in schools,
this study aimed to investigate the impact
of a group-based AT relaxation intervention
on levels of anxiety amongst adolescents
in schools, and to gather the perceptions
about the intervention from the young
people taking part.
Method
The study employed a partially mixed,
concurrent, equal status mixed methods
design (Leech & Onwuegbuzie, 2009). Quan-
titative and qualitative data were collected
independently of each other using nested

samples for the qualitative components of
the study. Data were then analysed separately
before drawing the two strands together for
integration at the overall interpretation
stage at the end of the study (Creswell &
Plano Clark, 2011).
Sample sizes
Using ‘G*Power’, an average effect size of
d = 0.68 (Cohen, 1998) chosen from research
reflecting the use of AT with as close a sample
population as possible to the present study
(Stetter & Kupper, 2002) and a proposed
alpha level of 0.05 was used to calculate
a sample size of between 56 (one-tailed) and
70 (two-tailed) participants in order for the
study to provide a statistical power in excess
of 80 per cent.
Quantitative and qualitative measures
Pre and post quantitative information was
gathered using the Spence Children’s Anxiety
Scale (SCAS; Spence, 1997). This self-report
measure is widely used around the world
for both clinical and community purposes.
Forty-four items are rated on a four-point
Likert scale ranging from 0 = Never to
3 = Always. Example questions include
‘I worry about things’ and ‘I can’t seem to
get bad or silly thoughts out of my head’.
Table 1: Phases of thematic analysis (Braun & Clarke, 2006)
Phase Description of the process
1. Familiarising yourself with your data The data was

transcribed by the researcher and
re-read three times. Initial notes were made at
this time.
2. Generating initial codes Interesting features of the data were
coded in
a systematic fashion across the entire data set
again by summarising quotes and extracts for
meaning.
3. Searching for themes Codes were then collated and linked
together
into potential themes.
4. Reviewing themes Themes were then checked for congruence
with
phases 1 and 2 to generate a ‘thematic map’.
5. Defining and naming themes Data was then revisited again to
refine themes
and generate clear definitions and titles. At this
point, coded transcripts and definitions were
viewed and analysed by a peer before being
discussed for inter-rater reliability.
6. Producing the report The researcher then selected the most
vivid,
compelling extract examples to illustrate
an overall picture of the results.
intervention

Table 2: Semi-structured interview schedule
Questions Rationale
1. What has the AT group meant to you? (Don’t
be afraid to say negatives as well as positives…)
Open question to prompt initial thoughts about
their experience of AT.
2. Have you noticed any changes in yourself
– or not?
Open question for recipient to explore what
they perceive to be ‘changes’.
3. What was it like for you? Open question for recipient to think
about
emotional responses to the intervention.
4. Was it what you expected it to be? Direct question to prompt
for differences in
initial perceptions of the intervention and for
participants to compare what they actually
experienced.
5. Is it something you are likely to keep
practising or not?
Direct question with prompt for responding
either way: ‘or not?’
Designed to assess the extent to which the
intervention has been incorporated into
lifestyles.

6. What will you remember the most about
learning AT?
Open question to prompt further understanding
of experiences relating to AT.
7. Is there anything else you would like to say
about your experience of AT?
Open question to give further opportunity to
express thoughts in case previous questions
have not included information.
Sub-scales include obsessive compulsive
disorder, separation anxiety, social phobia,
panic agoraphobia, physical injury fears and
generalised anxiety. Cronbach’s alpha for
the total SCAS score was reported consist-
ently between 0.90 and 0.92; and between
0.54 to 0.83 for the six subscales (Muris et
al., 2000, 2002; Spence, 1997; Spence et al.,
2003). Post-intervention qualitative informa-
tion was gathered by three participants from
each school (total n = 12). Each participant
was interviewed on an individual basis for
up to 15 minutes a session. Responses were
then analysed using the thematic analysis
procedure (Braun & Clarke, 2006) outlined
in Table 1.
Sampling methods and procedure
For the quantitative phase of the study and for
practical and geographical reasons, conven-
ience sampling (Onwuegbuzie & Collins,
2007) was initially used, whereby schools

in an area of the South East of England were
approached to express interest. Identifying
a specific geographical area counteracted
some of the issues around matching groups
from different schools within a large local
authority – although it was recognised that
generalisability across a wider population
would be limited. Once schools were iden-
tified, volunteer sampling was employed to
recruit individuals from each school who
were then provided with written information
about AT from the British Autogenic Society
(BAS) and consent forms to complete. After
completing the SCAS pre-measure question-
naire individuals were randomised to either
the intervention or wait-list group. At the post
intervention stage, individual semi-structured
interviews with three participants from each
mainstream setting were held approximately
one week after post-intervention quantita-
tive data collection. The interview schedule
is outlined in Table 2.
Table 3: Summary of participant and school characteristics
School 1 School 2 School 3 School 4
I W I W I W I W

N = 11 10 7 6 7 5 10 10
Gender
Male 1 5 3 10 10
Female 10 10 7 6 2 2
Mean age 15.0 15.8 15.0 14.8 15.0 15.0 15.3 14.7
Ethnicity
White British 11 9 7 6 6 5 10 9
Irish 1
White other 1
Kurdish 1
SEN
C&L 2 2 1 1 2 1
SEMH 3
C&I 1 1
Sensory impairment 1
Physical disability 1
Socio-economic status
Type of school Community Grammar Grammar Grammar

Gender Mixed Girls Mixed Boys
Ethnic minorities > national
average
< national
average
< national
average
< national
average
SEN < national
average
< national
average
< national
average
< national
average
FSM > national
average
< national
average
< national
average
< national

average
I = Intervention group; W = Waitlist group; C&L = Cognition
and learning;
SEMH = Social emotional and mental health; C&I =
Communication and interaction;
SEN = Special educational needs; FSM = Free school meals.
intervention
Participants
Sixty-six adolescents aged 14 and 15 years
old took part in the study. An independent
samples t-test was used to assess possible
differences in anxiety scores (SCAS) between
intervention and wait-list groups at the
pre-intervention assessment stage. No signif-
icant between-group differences were found
however, initial scores for the SCAS prior
to the intervention showed that the mean
score for males fell within the average range
of anxiety level (M = 29.4, SD = 14.94);
and the mean score for females within the
elevated range of anxiety level (M = 43.41,
SD = 17.77). Further details on participant
characteristics are outlined in Table 3.
Intervention details
The AT intervention consisted of six weekly
sessions lasting approximately 30 minutes

each. Each session followed the same struc-
ture as outlined in Table 4. Examples of the
AT exercises included encouraging a seated
position with eyes closed, followed by
auto-suggestions of heaviness and warmth to
isolated parts of the body. The participants
repeated formulas in their minds such as:
‘My arms and legs are heavy and warm’, ‘My
neck and shoulders are heavy’, ‘My forehead
is cool and clear’. A new exercise formula
was taught each week which built on the
previous one, to eventually achieve physio-
logical and psychological feelings of relax-
ation through classical conditioning. This
technique is intended to be self-sufficient
and transferable across contexts so that no
props or additional resources are needed.
Each session was delivered by the same qual-
ified autogenic therapist (the first author)
and a manualised programme of training was
delivered to all groups meaning that direct
replication was possible (Wolery, 2011).
Results
Quantitative analysis
Scores for the SCAS were analysed using
a mixed between-within subjects analysis of
variance (ANOVA). Output showed no signif-
icant interaction between group and time,
Wilk’s l = 0.96, F(1, 64) = 2.87, p = 0.095,
partial h2 = 0.04. There was a significant main
effect for time, Wilk’s l = 0.64, F(1, 64) = 36,
p < 0.0005, partial h2 = 0.36, suggesting that
anxiety scores for both groups did change
between pre and post-intervention time points

(see Table 5). The main effect comparing
groups was not significant, F(1, 64) = 0.41, p
= 0.52, partial h2 = 0.006, suggesting no differ-
Table 4: Structure of AT sessions
Activity
1 Participants were asked for feedback on how the exercise
practice from the previous session
had gone, along with the opportunity for further questions and
clarification. Keeping a
diary was encouraged but was for the participants’ own
reflection and reference.
2 The old exercise was practiced once again, feedback was
sought, and questions answered.
3 The new exercise for the week was introduced. The researcher
provided the rationale along
with modelling and psychoeducational information.
4 The new exercise was practiced together.
5 Participants were asked for feedback on their experience.
6 Additional short exercises were introduced and explained but
not practiced.
7 The researcher talked through the home practice and
information was provided in the form
of a hand-out.
8 Home practice was recommended 3 times a day, every day.

ence in the effectiveness of the intervention
compared to the wait-list control group (see
Table 6). Given the differences between male
and female anxiety levels before the interven-
tion, an additional ANOVA was run with sex
as an additional between subjects factor with
no interaction found for sex.
Qualitative analysis
Transcripts of qualitative information were
checked for accuracy by the researcher
and a peer before thematic analysis and
interpretation began. Inter-rater reliability
percentage agreement scores were estab-
lished at 93 per cent and were calculated
by dividing the number of times a code was
identified and agreed by both coders by the
number of times it was possible for a code
to occur (Boyatzis, 1998). The thematic
map (Figure 1) highlights five over-arching
themes and contributing sub-themes that
indicate the perceived changes that took
place as a result of the AT intervention.
Relationships
A number of participants made reference
to changes in the way they thought about
and related to others. Sub-themes included
better friendships, increased feeling of
connectivity to others, a desire to share their
new knowledge, and the benefits of group

participation. One participant said she had
‘definitely’ noticed changes in her friend-
ships. She felt that her feelings about herself
had prompted her to think differently about
her friends’ intentions and that her mood
had impacted positively on the reciprocity
and quality of her friendships.
Others commented on the sessions being
a bonding experience where everyone had
been on a journey learning together; and
for someone who had ‘suffered from anxiety
for a while’, he noticed an increase in his
ability to join in with activities he previously
found difficult.
Many participants revealed an ability to
think of others besides themselves, demon-
strating a desire to help them, and not be
‘bothered by the tiny things any more’.
One young man with an autism spectrum
condition commented that it was easier to
learn in a group as it took the focus away from
him and gave him more freedom to engage.
Emotional awareness and control
Participants also reported changes in
emotional reactivity and emotional aware-
ness. Three participants talked about how
they usually reacted aggressively towards
pressure. They were more able to take a step
back in the face of antagonism in class and
social situations, or simply to ignore it.

Table 5: SCAS anxiety scores for intervention and wait-list
groups across pre and post time points
Intervention group Wait-list group
Time period N M SD N M SD
Time 1 35.00 39.22 17.10 31.00 34.58 18.65
Time 2 35.00 30.45 16.91 31.00 29.70 18.64
Table 6: SCAS anxiety scores for intervention compared to
wait-list group
using mixed between-within ANOVA
F value Sig. Effect size
Main effect of time F (1,64) = 36 p < 0.0005 hρ² = 0.36
Main effect of group F (1,64) = .41 p = 0.52 hρ² = 0.006
Interaction F (1,64) = 2.87 p = 0.095 hρ² = 0.04
intervention
Others talked about how the scheduled
time in the week was something they looked
forward to as a ‘relief’ or ‘break’ from the
stress of school inferring that AT exercises
were a sort of respite from a frantic world
and a ‘break from reality’.

Physical change
Many participants reported an improvement
in the somatic symptoms of stress, such as less
panic attacks in crowded corridors or attacks
that were less intense than before. Less head-
aches and increased energy also increase
pro-activity and motivation for activities:
‘more up for the (like) lessons…’ There were
numerous comments about being able to fall
asleep quicker and, once asleep, sleep better
feeling more motivated in the morning,
along with noticing a reduction in aching
muscles, sports injuries and quicker recuper-
ation after glandular fever.
Increased self-awareness
Some participants felt their new knowledge
of how the body works had helped them to
understand the principles behind the exer-
cises and how they could play an important
part in maintaining wellbeing. Sub-themes
reflected feelings of increased control and
self-confidence through recognising the
warning signs that they were becoming
stressed, what form their state of stress
took, increased understanding of what was
happening to the body, and experiencing
feelings that they could now cope.
Participants reported increased self-
confidence in a variety of ways, talking about
their ability to let go of small things that used
to occupy their minds and hold them back.
They implied that a certain trust and confi-

dence in the future had also grown enabling
them to get on with life and live in the
moment. Some talked of having the confi-
dence to express how they were feeling to
others more, relieving the burden of worry
and without feeling self-conscious.
One participant felt that the process of
alleviating her anxiety started from the very
first time she brought the introductory letter
home to her parents.
There was a sense of empowerment and
an ability to make choices and decisions
about which exercise to use and how this
could be fitted into their practice. AT was
recognised as a self-help skill that was prac-
tical, versatile and portable, and a tool for
people to take responsibility for themselves.
Cognitive change
Participants found that they could concen-
trate better and this had been helpful
in school, even to the point that one partic-
ipant had noticed that she was sitting up
straighter in lessons. She felt that this small
Figure 1: Thematic analysis map
Table 7: Overarching themes and examples of dialogue

Overarching Theme Sub-theme Examples of dialogue
Relationships Better friendships I think that my friendships
have got better… Yeah,
I just been a lot happier and better… Um – I feel my
friendships have got, become a lot nicer to me but
I think they’ve always been nice to me but before
I was just curious so maybe she wasn’t sitting next to
me because of that or she’s not doing that but now
I’ve just become (pause) and opened up and just been
aware of just (pause) my friendships and become a lot
less stressed – haven’t broken down in a while.
…it’s more to do with for me it’s like socialising I find
quite difficult I’ve just been able to… I’ve been more
easy-going with other people as well… so – that’s been
interesting.
Recognising
difficulties
in others
I just see the world in a more positive light now… Yeah
I just, I just, like I would always feel judged or like as if
everything going around me was about like someone
was doing it to me. If someone was like sad, I would
think, ‘Oh gosh, I’ve done something to them…’. But
now I don’t view it as me I just view it as them. I really
like that – and I think everyone around me likes that.
Increase in bonding
and connectivity
…it’s kind of… we have done the whole journey... we’ve
all been able to help each other, I think it’s been quite

good to connect us individually as well and not just
develop our own things…
Group participation Normally I wouldn’t have wanted to leave
my parents
at all. Other trips that I have done, I have not wanted
to leave my parents so I won’t have eaten anything.
I wouldn’t have really done much either but with this
I got stuck in and did everything.
There was less pressure on me specifically and that
made it significantly easier to understand.
Desire to share
and help others
It was fun, it was good, it was like, I thought it would
be rubbish but it was actually really really good –
I told my mum and my mum done it…
Yeah, I’ll show them cos I think some of my friends,
they get really stressed and if I just read it out to them
they can get calm.
...it’s definitely helped me to relay my feelings to other
people… uh, kind of with the being able to express
how I’m feeling. I’ve actually started writing a blog.
Emotional
awareness and
control
Slower emotional
reactions

If somebody upsets me or anything I can move away
from them and use the meditation and stuff to calm
myself down before going back to like speak with
people… Normally, something violent may have
happened.
intervention
Feelings of safety
and reassurance
Coming in on Mondays was kind of like a safe, a safe
kind of like a retreat, so I’m quite visual so I usually
think, um, this is a line between being anxious and
not being anxious… and then my day consists of,
you know, going out of the zone at different lengths
and then it’s kind of like a retreat back, it’s like
a reassurance, a um yeah it’s kind of like a safe zone
for me.
Physical change Reduced somatic
symptoms of stress
…I don’t really dream as vividly any more so it’s kind
of like helping me to actually sleep and not, and not
like waste all that energy you like imagine you would
do… I think I feel more like it sounds really like what
can I say, I feel like I can get up like I can do things.
…it would have been longer to get better because

obviously the more you worry the more stressed
you get and the ‘iller’ you get so it’s definitely, it’s
definitely been helpful for my health especially so…
I just get so tired during the day, usually, and it’s
quite good to, it kind of like reboots yourself – if that
makes sense?
Increased
self-awareness
Psycho-educational
understanding
…it just helps – it helps, you can feel it in the muscles
in the shoulders and your arms it’s kind of – being
more relaxed afterwards.
…I’m using it even if I’m not stressed cos it’s kind of
like in a roof – you don’t get rid of the drainpipes
when it’s not raining you know, you keep those as
a safeguard so like a sort of a maintenance thing,
a maintenance of wellbeing.
…I often think I’m like choking on air and then
I think, like Oh!… and then I’ll get panicked about
that and that I can’t breathe and yeah then it all
kind of snowballs… it’s a lot more relaxed. If I’m
(in) somewhere that’s like crowded and I do feel
claustrophobic and I’m kind – like step back and can
free myself and actually take time to breathe.
Empowerment I liked that instead of like having to rely on
someone
else to help us – it was like you telling us how we
could help ourselves.

Well actually, as I’ve got an injury at the moment
and like when it’s really hurting I sit there and I think
about other parts of the body and then it doesn’t
hurt… cos I do sport quite a lot I always get like aches
and pains and its quite good to use to relax muscles
then… yeah yeah because whenever I come out I feel
like I’m floating (laughs).
Confidence …and I’m much more calm and relaxed and I feel
that
this has given me a positive effect in lessons because
I can concentrate more rather than think – oh my
gosh, I’ve got to remember this and then I’ve got to do
this, and then I’ve got to do this… and it just builds up
and now I’m just cool about it.
Because before, like before I was doing it I didn’t really
tell anyone how I was feeling… a lot of the time I feel
quite queezy and a lot of butterflies in my stomach
all the time and then when I brought home the letter
like Oh Yeah! I’m doing a relaxing thing I was able to
tell my mum that I was feeling like that… yeah and it’s
definitely helped me to be able to relay my feelings
to other people.
Cognitive change Improved
concentration
…cos I think all over the place way like a very busy
kind of mind map but, um, maybe autogenics helps

to kind of take a few moments to help my brain
just to put things in order so it’s more kind of like
a linear process…
Increase in positive
thinking
I just see the world in a better more positive light
now… before when I did tests I usually get all worried
about and then like on the way home oh I’m all
worried… but when I was walking home I thought I’m
not nervous about this so, and then um I’m going to
do well so I find out today, but I think I’m not thinking
all the negative stuff – just the positive stuff.
Clarity of thought So it’s just easier to get through um I think
it’s, it’s
changed the way I kind of think about things quite
a lot, cos I used to, like when things happen and you
just can’t really do anything about it you just got like,
you know you just have to like worry about it but now
I just, I’m more like I just let things happen and I can
just… well you can only control what you can control
I think that’s what I’ve learned.
Increased problem
solving skills
Um I think it’s just because I am able to like really
think about it and then I just kind of realise that it is
just not that important.
Increased
self-monitoring
Well, I know that this autogenics is supposed to relax

you and everything yeah, you done those sheets to
take home and try to practice – I can’t find a time
cos I’ve got loads of work to do at home, it’s really
stressful … Yeah, I managed a bit but too stressful at
time…
I just concentrated a bit more that’s all… I realise how
good my work is so… I’ve concentrated more before
I done autogenics but…
intervention
change was also helping her to engage more
in class.
Participants reported more clarity, noticing
that less stress meant that work seemed to be
easier to do. Many started to notice that they
were thinking differently and seeing life more
positively and from other perspectives, with
some specifically commenting on how they
were now more able to discern what they
could reasonably take responsibility for and
what they could not, putting everyday situa-
tions into perspective.
Two participants were able to re-evaluate
situations in terms of how significant they
were in the grand scheme of things. For
instance, one felt more relaxed about
exams, firstly because he was secure in the

knowledge that he could relax himself, but
also because he had done his revision and
reasoned that if this was so, there was no
need to get stressed.
On the other hand, one male participant
reported that he continued to feel stressed
throughout the programme and that this
had prevented him from finding the time
to practice the exercises at home.
Some examples of participant responses
can be found in Table 7.
Discussion
Although there was a main effect of time for
both groups, no significant main interaction
effect was found between time and group,
indicating that the AT intervention was
no more effective in reducing overall anxiety
levels in adolescents compared to the wait-list
group. While the results are promising, there
is no way to rule out that there may have
been other factors that supported partici-
pants with their anxiety in both groups, aside
from the intervention. Interestingly, similar
results were found in studies by Garvin et al.
(2001) and Goldbeck and Schmidt (2003)
for AT; and for other school-based early
intervention programmes for anxiety (Neil
& Christensen, 2009).
One explanation may be that both the
wait-list group and the intervention group
experienced a Hawthorne effect (Barker et

al., 2012), whereby the research itself height-
ened expectancy to produce beneficial
changes. Reactivity of measurement effects
(Barker et al., 2012) have been known
to produce psychological benefits.
The qualitative results suggest that
this part of the research was just as impor-
tant as the intervention itself in providing
an opportunity to share and talk about feel-
ings. They also revealed that the information
and consent letter provided one participant
with the opportunity to talk about her anxiety
to her family and to discover that she was
not alone. Psychological coherence can be
understood as the experience of emotional
comfort when views of the self are matched
or validated (Wright et al., 2014). The bene-
fits of identifying with a group and feelings
of belonging and commonality are also docu-
mented by Sani et al. (2015). This may have
been the case for the wait-list groups since
there was no way of knowing whether their
opportunities to express their feelings or mix
within a supportive group had increased.
Equally, participation in the research
may have raised awareness amongst school
staff. Schools who had opted into the study
indicated that they recognised pupil anxiety
which could have made them more predis-
posed to provide a nurturing environment,
especially to those who they knew were waiting
for their intervention. Previous research find-
ings show that increased teacher interest in
the emotional wellbeing of students is highly

valued and improves subjective wellbeing
(Suldo et al., 2009) as well as the importance of
increased school identification as a predictor
of better mental health outcomes (Miller et
al., 2018) and the benefits of talking to an
attuned adult who can offer unconditional
positive regard (Reichardt, 2016).
Qualitative analysis from the study indi-
cates perceived changes in some participants
in a range of physiological and psychological
areas. Participants perceived an increased
ability to take a step back from situations
with less emotional reaction to provocation,
better connectivity and analytic thought
into other people’s social behaviour and
needs, and improvements in self-monitoring
and planning behaviours. Participants also
reported not only a reduction in somatic
symptoms but also a faster recovery rate from
illness, better sleep, and an increase in moti-
vation to look after one’s health overall. Such
reports reflect current attention towards
a wider perspective on what it means to be
mentally healthy with the importance of sleep
and practical relaxation techniques specifi-
cally highlighted in the government’s advice
for mental health and behaviour in schools
(DfE, 2016, pp.13). Results also comply with

the findings of Llorca et al. (2017), who
recommend that besides the acquisition of
coping skills, all adolescent anxiety inter-
ventions or preventative programmes should
include specific teaching in the development
of emotional self-regulation and the recogni-
tion and acceptance of feelings.
This study adds to the evidence avail-
able about AT and addresses a gap in the
research field for the adolescent population
in UK mainstream schools. Despite no main
interaction effect, the perceived impact
of the intervention seen in the qualitative
data is promising. Furthermore, the study
provides illuminating information from the
wait-list groups, who also showed significant
reductions in anxiety levels, and may have
opened a door for further research and
investigation to take place.
Limitations
Several factors were found to account for
potential limitations of the study. It must
be recognised that representation of the
population was compromised as some of
the data from one of the schools were not
normally distributed at the outset. Demo-
graphic details also showed a lack of cultural
diversity, and although ethical reasons
dictated sampling strategy, convenience and
volunteer bias meant that it would be impos-
sible to be able to infer generalisability of
the sample (Cohen et al., 2013). The type
of participants who volunteer may not be
representative of the target population for

a number of reasons. They may be more
likely to engage with adult initiated activity,
be more motivated to take part in projects
such as research studies or their own motives
may clash with those of the researcher (Borg
& Gall, 1989). Similarly, those who did not
come forward for involvement may have
done so to avoid criticism and stigmatisation,
but equally be in need of support (Cohen et
al, 2013, Kaushik et al., 2016).
There was also a lack of information on
other supporting strategies and interventions
that may have been provided at the same time
as the intervention group. In schools where
a commitment to developing the social and
emotional wellbeing of young people is woven
into the curriculum, it is likely that these strat-
egies will also have a positive effect on devel-
opment (Fabiano et al., 2014). Future studies
or replications would benefit from including
detailed information on concurrent types of
support for wellbeing in each school, espe-
cially where school settings differ.
Although randomisation was intended
to minimise as many confounding variables
as possible, and maximise equivalency, the
possibility that information and strategies
were leaked between members of the inter-
vention group to members of the wait-list
group within each educational setting prior
to post-intervention data collection cannot be
ruled out. Similarly, the absence of qualitative
information sought from the wait-list group

makes it difficult to attribute effects to AT.
Another limitation of the study was that
only one self-report questionnaire was used
to measure overall anxiety levels, which
poses a question over the validity of the data
(Barker, et. al., 2012). Future research could
include the use of other measures from
other sources (such as parents and teachers).
Qualitative results suggesting perceived
improvements in social skills, relationships,
and ability to cope, also highlight the poten-
tial usefulness of additional measures in the
future such as the Strengths and Difficulties
Questionnaire, Beck Youth Inventories, and
Resiliency Scales, as well as non-standardised
rating scales to measure personal and specific
anxiety provoking situations.
intervention
Implications for practice
The current study contributes to a better
understanding of researcher effects, aware-
ness raising and the impact that interven-
tions such as AT in schools might have.
This study specifically explored an EP-
facilitated, group-based relaxation interven-
tion within a school setting. School-based
interventions have the advantage of bringing

mental health support directly to the young
people at school, avoiding common barriers
such as costs and transport to attend alter-
native settings (Swan et al., 2014). They
provide greater consistency, reliability, and
adherence to programme protocols (Langley
et. al., 2010) and may provide the oppor-
tunity to alleviate anxiety levels in the very
places where learning is taking place. Since
there may be no evidence for any significant
difference between delivering interventions
to groups or individuals (Flannery-Schroeder
et al, 2005), it is suggested that group-based
interventions could increase the reach for
mental health and wellbeing in schools
(Weare & Gray, 2003).
The study was only able to provide
the interviewed sub-sample (n = 12) with
the opportunity to talk about their expe-
riences. Many of the comments indicated
that the debriefing process was an impor-
tant element of intervention delivery and an
opportunity to gather pupil voice and pupil
collaboration. Future delivery of the inter-
vention could include discussions with all
group members to set goals and suggest ways
forward, not only to meet their individual
needs but to implement change at a systemic
level. Forman et al. (2009) suggest fitting
programmes seamlessly into school settings
by considering the curriculum, teaching
styles, school ethos and resources available,
and nurturing strong and ongoing relation-
ships. Involving pupils in decision-making
around how their mental health will be

promoted is vital at secondary school level
where teachers find it more difficult to iden-
tify internalised symptoms (Auger, 2004).
The findings that many participants
found the psychoeducation aspect of the
intervention helpful is also something for
EPs to consider. Participants felt this had
a positive effect on their ability to recognise
the early warning signs of stress and feel
in control of their anxiety. It would, there-
fore, be useful for EPs to raise awareness of
the key changes that take place in adolescent
brain development amongst all adolescents
to promote adaptive behaviours that reduce
risk and increase positive outcomes for youth
(Dahl, 2004).
The qualitative results indicate other
aspects of the intervention that might be
supportive. Valuable elements were felt
by participants to be working in a group,
acknowledging anxiety, and sharing and
expressing feelings within a supportive
environment. Self-compassion has been
found to be a protective factor in rela-
tion to mental health issues (Marshall et
al., 2015), and the acknowledgement and
acceptance of symptoms to be facilitators
of increased perceived control (Arch &
Craske, 2008). Young people experiencing
problems with anxiety and depression may
be reluctant to request help due to concern
about burdening others or the stigma they
may face (Kaushik et. al., 2016). Further

research could investigate the impact of
researcher effects in relation to anxiety in
particular, considering what might facilitate
change in young people whether they are
part of an intervention or not. EPs could
also consider working with schools with this
wider set of factors in mind. Possible mech-
anisms could include developing supportive
environments where there are safe areas
to talk, opportunities to bond and connect
with like-minded others, and increasing
positive supportive relationships between
peers and peers, peers and members of staff,
and members of staff themselves.
Authors
Dr Tracey Atkins, Educational Psychologist,
East Sussex; [email protected]
Dr Ben Hayes, Senior Educational Psycholo-
gist, Kent & Associate Professor, University
College London
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Executive Summary
Guidelines with Scoring Rubric
Purpose
The purposes of this assignment are to: a) identify and
articulate the results of a Magnet report received from the
American Nurses Credentialing Center (ANCC) for Saint Louis
Medical Center (SLMC). You, the nurse director, will present
your findings to the SLMC board of directors, in an executive
summary format (CO 2, 3), b) articulate and include the key
components of an executive summary in your report (CO 5), and
c) provide empirical, scholarly evidence to support your
assignment (CO 4).
NOTE: As the nurse executive of SLMC, you may choose one
item from any of the following Magnet Model Components to
discuss and present to the SLMC board of directors, in your
executive summary. There is no written report of a Magnet
Survey; you have the flexibility to choose what you would like
to discuss in this assignment. For example, you may state in
your report that your Magnet model component is structural
empowerment and you wish to implement a new nurse model
since the results of your Magnet report were not acceptable in
this area.
Magnet Model Components:
Transformational Leadership
Structural Empowerment
Exemplary Professional Practice
New Knowledge, Innovations & Improvements
Empirical Outcomes
Due Date: Sunday 11:59 p.m. MT at the end of Week 7
Total Points Possible: 225Requirements:
1. This paper will be graded on quality of paper information,
use of citations, use of Standard English grammar, sentence
structure, and organization based on the required components.
2. Create this assignment using Microsoft (MS) Word, which is

the required format for all Chamberlain documents. You can tell
that the document is saved as a MS Word document because it
will end in “.docx”.
3. Submit to the appropriate assignment area by 11:59 p.m. MT
on Sunday of the week due. Any questions about this paper may
be discussed in the weekly Q & A Discussion topic.
4. The length of the paper is to be no greater than three (3)
pages, excluding title page and reference page.
5. APA format using the sixth edition manual is required in this
assignment, including a title page and reference page. Use APA
level 1 headings for the organizational structure of this
assignment. Remember that the introduction does not carry a
heading that labels it as a level heading in APA format. The
first part of your paper is assumed to be the introduction. See
the APA manual sixth edition for details. Use the suggested
format and headings to organize your assignment:
a. Include introduction (do not label as a heading in APA
format)
b. Issue and Magnet Model Component Identified
c. Key Components of Executive Summary
d. Supporting Evidence
e. ConclusionPreparing the paper
Note: Please use the resources in your Roussel textbook,
Chapter 15, to assist with how to write an executive summary
format to articulate the results of your Magnet report from
ANCC.
1. Clearly introduce your executive summary in the introduction
paragraph. Include a sentence that states the purpose of your
assignment.
2. Clearly identify and articulate the issue and component from
the Magnet model to be communicated to the board of directors
at SLMC by you, the nurse executive. Discuss how your choice
may affect your healthcare environment and transform
healthcare.
3. Key components of an executive summary format, related to
the results of the Magnet report, should be included and clearly

articulated. (Examples are in your textbook or you may search
for them on the web). Include in your executive summary how
this assignment relates to the Person-centred Framework by
McCormack and McCance (2017).
4. Include of a minimum of three sources of scholarly, empirical
evidence to support the issue to be communicated.
5. Provide concluding statements that should summarize your
overall assignment content.
6. The paper will be no longer than three pages maximum,
excluding title and reference page(s).
Note: There are several formats of an executive summary in
your text or on the internet. As the nurse executive, you may
choose which style you prefer.
7. Title and reference page(s) must be in APA format using the
sixth edition manual.
8. Use 12 Times New Roman font and one-inch margins on all
sides of the paper.
9. Note: After submitting your assignment to the Week 7
assignment area, please also upload your completed assignment
to the Week 8 designated threaded discussion to share with your
peers.
Category
Points
%
Description
Introduction
30
13%
Introduction clearly introduces your executive summary and
purpose of the assignment.
Issue and Magnet Model Component
30
13%
Issue and component from the Magnet model to be

communicated to board of directors is identified and clearly
articulated.
Key Components
80
38%
The key components of the executive summary are included and
clearly articulated.
Evidence
30
13%
Minimum of three scholarly, empirical evidence sources to
support issue.
Conclusion
30
13%
Concluding statements summarizing content are present.
Text, title page, and references are consistent with APA format
10
4%
Text, title page, and references are consistent with APA format.
Ideas and information from other sources are cited correctly
10
4%
Ideas and information from other sources are cited correctly.
Rules of grammar, word usage, and punctuation are followed
5
2%
Rules of grammar, word usage, and punctuation are followed.
Total
225
100
A quality assignment will meet or exceed all of the above
requirements.
Chamberlain College of Nursing NR531 Nursing
Leadership in Healthcare Organizations

NR531 Guidelines with rubric.docx Revised 1 2019
3
Grading Rubric
Assignment Criteria
Exceptional
(100%)
Outstanding or highest level of performance
Exceeds
(88%)
Very good or high level of performance
Meets
(80%)
Competent or satisfactory level of performance
Needs Improvement
(38%)
Poor or failing level of performance
Developing
(0)
Unsatisfactory level of performance
Content
Possible Points = 200 Points
Introduction
30 points
26 points
24 points
11 Points

0 points
Introduction introduces your executive summary and purpose
clearly.
Introduction introduces your executive summary with minor
lack of clarity or elements.
Introduction of executive summary lacks occasional important
element or specificity.
Introduction of executive summary has multiple instances of
inaccuracies.
Introduction of executive summary is not present.
Issue and Magnet Model Component
30 points
26 points
24 points
11 Points
0 points
Identification of issue and Magnet model component to be
communicated to the board of directors is articulated clearly
with no inaccuracy.
communicated to the board of directors is articulated with rare
inaccuracy.
communicated to the board of directors lacks occasional
important elements or specificity.
communicated to the board of directors has multiple instances
of inaccuracies.
communicated to the board of directors is not present.
Key Components
80 points

70 points
66 points
30 points
0 points
Key components of executive summary are included and clearly
articulated
Key components of executive summary are articulated with rare
inaccuracy.
Key components of executive summary lack occasional
important element or specificity
Key components of executive summary have multiple instances
of inaccuracies.
Key components of executive summary are not present.
Evidence
30 points
26 points
24 points
11 Points
0 points
At least three empirical, scholarly evidence sources supporting
your issue are included.
Empirical, scholarly evidence sources supporting your issue are
clearly critiqued and have rare inaccuracy; or only two sources
included.
Empirical, scholarly evidence sources supporting your issue
lack occasional important element or specificity; or less than
two sources included.
Empirical, scholarly evidence sources supporting your issue
have multiple instances of inaccuracies.
Empirical, scholarly evidence sources supporting your issue are
not present.
Conclusion
30 points
26 points

24 points
11 Points
0 points
Concluding statements summarizing content are present and
accurate.
Concluding statements summarizing content are present with
rare inaccuracy or missing elements.
Concluding statements summarizing content lack occasional
important element or specificity.
Concluding statements summarizing content has multiple
instances of inaccuracies.
Concluding statements summarizing content are missing.
Content Subtotal
_____ of 200 points
Format
Possible Points = 20 points
10 points
9 points
8 points
4 points
0 points
Text, title page, and references are consistent with APA format,
with two to four exceptions.
There are five to seven APA format errors in the text, title page,
and reference pages.

There are eight to nine APA format errors in the text, title page,
and reference pages
There are more than 10 APA format errors in the text, title
page, and reference pages.
10 points
9 points
8 points
4 points
0 points
Ideas and information from other sources are cited correctly,
Ideas and information from other sources are cited with five to
seven errors.
Ideas and information from other sources are cited with eight to
nine errors.
Ideas and information from other sources are cited with more
than 10 errors.
Grammar
Possible Points = 5 points
5 points
4 points
3 points
2 points
0 points
Rules of grammar, word usage, and punctuation are followed,

Rules of grammar, spelling, word usage, and punctuation are
consistent with formal written work, with five to seven
exceptions.
consistent with formal written work, with eight to nine
exceptions.
followed with more than 10 exceptions.
Format Subtotal
_____ of 25 points
Total Points
_____ of 225 points
NR531 Guidelines with Rubric.docx
5
Week 7: Executive Summary
Submit Assignment
· Due Sunday by 11:59pm
· Points 225
· Submitting a file upload
NR531 W7 Executive Summary Guidelines and Rubric
Purpose
The purposes of this assignment are to: a) identify and
articulate the results of a Magnet report received from the
American Nurses Credentialing Center (ANCC) for Saint Louis
Medical Center (SLMC). You, the nurse director, will present

your findings to the SLMC board of directors, in an executive
summary format (CO 2, 3), b) articulate and include the key
components of an executive summary in your report (CO 5), and
c) provide empirical, scholarly evidence to support your
assignment (CO 4).
NOTE: As the nurse executive of SLMC, you may
choose one item from any of the following Magnet Model
Components to discuss and present to the SLMC board of
directors, in your executive summary. There is no written report
of a Magnet Survey; you have the flexibility to choose what you
would like to discuss in this assignment. For example, you may
state in your report that your Magnet model component is
structural empowerment and you wish to implement a new nurse
model since the results of your Magnet report were not
acceptable in this area.
Magnet Model Components:
Transformational Leadership (Links to an external site.)
Structural Empowerment (Links to an external site.)
Exemplary Professional Practice (Links to an external site.)
New Knowledge, Innovations & Improvements (Links to an
external site.)
Empirical Outcomes (Links to an external site.)
Course Outcomes
Through this assignment, the student will demonstrate the
ability to:
(CO2) Synthesize management and leadership theories with a
caring, holistic, collaborative approach in preparation of nurse
administrator roles: utilizing critical thinking, communication
skills and therapeutic intervention strategies, of the professional
role related to health outcomes. (PO2, 5).
(CO3) Compare and contrast the effect of organizational
structures, e.g. organizational charts, standards, resources,
philosophy, procedures, and culture on work processes and
organizational and patient outcomes; utilizing critical thinking,
interprofessional collaboration, communication skills and

strategies of the professional role. (PO1, 2)
(CO4) Apply the use of research in the evaluation of healthcare
outcomes; utilizing critical thinking skills, and interprofessional
research strategies. (PO4)
(CO5) Examine effective verbal and written communication;
utilizing communication skills of the professional role to
promote and improve quality and safety in healthcare. (PO1, 2,
5)
Due Date: Sunday 11:59 p.m. MT at the end of Week 7
Students are given the opportunity to request an extension on
assignments for emergent situations. Supporting documentation
must be submitted to the assigned faculty. If the student's
request is not approved, the assignment is graded and a late
penalty is applied as follows:
· Monday = 10% of total possible point reduction
· Tuesday = 20% of total possible point reduction
· Wednesday = 30% of total possible point reduction
If the student's request is approved, the student will be informed
of the revised due date. Should the student fail to meet the
revised due date, the assignment is graded and a late penalty is
applied as follows:
· Monday = 10% of total possible point reduction
· Tuesday = 20% of total possible point reduction
· Wednesday = 30% of total possible point reduction
Total Points Possible: 225
Requirements:
1. This paper will be graded on quality of paper information,
use of citations, use of Standard English grammar, sentence
structure, and organization based on the required components.
2. Create this assignment using Microsoft (MS) Word, which is
the required format for all Chamberlain documents. You can tell
that the document is saved as a MS Word document because it
will end in ".docx".
3. Submit to the appropriate assignment area by 11:59 p.m. MT
on Sunday of the week due. Any questions about this paper may

be discussed in the weekly Q & A Discussion topic.
4. The length of the paper is to be no greater than three (3)
pages, excluding title page and reference page.
5. APA format using the sixth edition manual is required in this
assignment, including a title page and reference page. Use APA
level 1 headings for the organizational structure of this
assignment. Remember that the introduction does not carry a
heading that labels it as a level heading in APA format. The
first part of your paper is assumed to be the introduction. See
the APA manual sixth edition for details. Use the suggested
format and headings to organize your assignment:
a. Include introduction (do not label as a heading in APA
format)
b. Issue and Magnet Model Component Identified
c. Key Components of Executive Summary
d. Supporting Evidence
e. Conclusion
Preparing the paper
Note: Please use the resources in your Roussel textbook,
Chapter 15, to assist with how to write an executive summary
format to articulate the results of your Magnet report from
ANCC.
1. Clearly introduce your executive summary in the introduction
paragraph. Include a sentence that states the purpose of your
assignment.
2. Clearly identify and articulate the issue and component from
the Magnet model to be communicated to the board of directors
at SLMC by you, the nurse executive. Discuss how your choice
may affect your healthcare environment and transform
healthcare.
3. Key components of an executive summary format, related to
the results of the Magnet report, should be included and clearly
articulated. (Examples are in your textbook or you may search
for them on the web). Include in your executive summary how
this assignment relates to the Person-centred Framework by
McCormack and McCance (2017).

4. Include of a minimum of three sources of scholarly, empirical
evidence to support the issue to be communicated.
5. Provide concluding statements that should summarize your
overall assignment content.
6. The paper will be no longer than three pages maximum,
excluding title and reference page(s).
Note: There are several formats of an executive summary in
your text or on the internet. As the nurse executive, you may
choose which style you prefer.
7. Title and reference page(s) must be in APA format using the
sixth edition manual.
8. Use 12 Times New Roman font and one-inch margins on all
sides of the paper.
9. Note: After submitting your assignment to the Week 7
assignment area, please also upload your completed assignment
to the Week 8 designated threaded discussion to share with your
peers.
Anxiety and its disorders as risk factors for suicidal thoughts
and behaviors: A meta-analytic review
Kate H. Bentleya,*, Joseph C. Franklinb, Jessica D. Ribeirob,c,
Evan M. Kleimanb, Kathryn R.
Foxb, and Matthew K. Nockb
aCenter for Anxiety and Related Disorders, Boston University,
USA
bDepartment of Psychology, Harvard University, USA
cMilitary Suicide Research Consortium, USA
Abstract

Suicidal thoughts and behaviors are highly prevalent public
health problems with devastating
consequences. There is an urgent need to improve our
understanding of risk factors for suicide to
identify effective intervention targets. The aim of this meta-
analysis was to examine the
magnitude and clinical utility of anxiety and its disorders as
risk factors for suicide ideation,
attempts, and deaths. We conducted a literature search through
December 2014; of the 65 articles
meeting our inclusion criteria, we extracted 180 cases in which
an anxiety-specific variable was
used to longitudinally predict a suicide-related outcome. Results
indicated that anxiety is a
statistically significant, yet weak, predictor of suicide ideation
(OR=1.49, 95% CI: 1.18, 1.88) and
attempts (OR=1.64, 95% CI: 1.47, 1.83), but not deaths
(OR=1.01, 95% CI: 0.87, 1.18). The
strongest associations were observed for PTSD. Estimates were
reduced after accounting for
publication bias, and diagnostic accuracy analyses indicated
acceptable specificity but poor
sensitivity. Overall, the extant literature suggests that anxiety
and its disorders, at least when these

constructs are measured in isolation and as trait-like constructs,
are relatively weak predictors of
suicidal thoughts and behaviors over long follow-up periods.
Implications for future research
priorities are discussed.
Keywords
Suicide; Anxiety; Risk factor; Meta-analysis
1. Introduction
Suicidal behavior is a leading cause of injury and death across
the globe (Centers for
Disease Control and Prevention, 2011), with upwards of one
million individuals who take
their own lives annually (World Health Organization, 2012). In
the United States alone, over
40,000 people die by suicide each year. In addition to
completed suicides, approximately 3%
of individuals make a suicide attempt during their lifetime
(Borges et al., 2010; Nock et al.,
*Corresponding author at: Center for Anxiety and Related
Disorders, Boston University, 648 Beacon Street, 6th Floor,
Boston, MA
02215, USA. [email protected] (K.H. Bentley).
HHS Public Access

Author manuscript
Clin Psychol Rev. Author manuscript; available in PMC 2016
February 29.
Published in final edited form as:
Clin Psychol Rev. 2016 February ; 43: 30–46.
doi:10.1016/j.cpr.2015.11.008.
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2008). It is also estimated that approximately 9% of people
report experiencing serious
thoughts of suicide during their lives. Unfortunately, the U.S.
suicide rate has risen steadily

over the past decade (Centers for Disease Control and
Prevention, 2011) and is projected to
continue increasing over upcoming years (Mathers & Loncar,
2006).
One promising avenue toward reducing the global impact of
suicide is to identify risk
factors that predict suicidal thoughts and behaviors. Risk
factors are not to be confused with
correlates; whereas correlates represent concomitants or
consequences of a phenomenon of
interest and can be identified through cross-sectional methods,
establishing risk factors
necessitates longitudinal designs (Kraemer et al., 1997). For
example, from a study showing
that individuals who attempt suicide are more likely to be
diagnosed with an anxiety
disorder than those who do not attempt suicide, one may
conclude that anxiety is a correlate
of suicidal behavior. However, to determine that anxiety
functions as a risk factor for
suicidal behavior, it would need to be established that anxiety
disorders precede and
heighten future risk for suicide attempts. Establishing risk
factors for suicidality is essential

for a number of reasons, including improved understanding of
underlying mechanisms,
identification of at-risk individuals, and development of
evidence-based prevention and
treatment programs. Most previous studies have focused
exclusively on correlates, which are
unlikely to be as informative for prediction and intervention
purposes. Accordingly, the
primary goal of this study was to conduct a meta-analytic
review of prospective studies that
have evaluated anxiety and its disorders as risk factors for
suicidal thoughts and behaviors.
In a narrative review, it can be difficult to provide a
comprehensive account of all relevant
studies, reconcile contradictory findings, account for
methodological variations across the
literature, and ascertain overall magnitudes of risk factors under
investigation. A meta-
analysis can overcome these limitations, and thus would be very
helpful in summarizing
current knowledge about anxiety as a risk factor for suicidality.
There are several reasons why we chose to focus on anxiety in
this meta-analysis. First,
anxiety and its disorders are listed as important risk factors for

suicide by a number of
national organizations (e.g., American Association of
Suicidology, 2015; American
Foundation for Suicide Prevention, 2015; National Suicide
Prevention Lifeline, 2015).
Determining the strength of empirical evidence to support this
information, which is widely
disseminated to clinicians, researchers, and the public, is
necessary.
Second, anxiety is implicated in many prominent theories of
suicide. For example, according
to Beck's cognitive model of suicide, once a suicide schema is
activated, anxiety (and
agitation) can serve as an expression of attentional fixation on
suicide, which interacts with
hopelessness to increase suicide risk (e.g., Wenzel & Beck,
2008; Wenzel, Brown, & Beck,
in press). Although anxiety is not explicitly addressed in
Joiner's interpersonal theory of
suicide (Joiner, 2005; Van Orden et al., 2010), this model's
emphasis on the fearsome nature
of suicidal behavior is consistent with evidence showing that
acute anxious states (e.g.,
heightened arousal/agitation, severe panic attacks) are often

present immediately prior to
lethal or near-lethal suicidal acts (e.g., Britton, Ilgen, Rudd, &
Conner, 2012; Busch,
Fawcett, & Jacobs, 2003; Conrad et al., 2009; Fawcett et al.,
1990; Hall, Platt, & Hall, 1999;
Ribeiro et al., 2015; Ribeiro, Silva, & Joiner, 2014). These
findings align with Fawcett's
influential conceptualizations of anxiety/agitation as a
determinant for acute suicide risk
Bentley et al. Page 2
February 29.
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(e.g., Fawcett, 2001; Fawcett, Busch, Jacobs, Kravitz, & Fogg,
1997), and expert clinical
consensus identifying agitation as a “warning sign” for suicide
(e.g., Rudd et al., 2006).
Furthermore, Baumeister (1990) conceptualizes suicide as the
ultimate escape from aversive
self-awareness and associated negative affect, which often
includes anxiety. Along similar
lines, Riskind and colleagues have theorized that a specific
cognitive risk factor for anxiety
(looming vulnerability), when coupled with hopelessness,
enhances urges to escape
psychological pain and elevates risk for suicide (e.g., Rector,
Kamkar, & Riskind, 2008;
Riskind, 1997; Riskind, Long, Williams, & White, 2000).
Third, anxiety and related disorders (broadly defined here as
anxiety, obsessive–compulsive,
trauma and stressor-related, and somatic symptom disorders)
have received theoretical and
empirical attention as potential risk factors for suicide. First
and foremost, these disorders

are characterized by aversive, avoidant reactions to emotional
experiences (Barlow, Sauer-
Zavala, Carl, Bullis, & Ellard, 2014). Suicidal thoughts and
behaviors have similarly been
conceptualized as avoidant or escape-based responses to the
experience of strong emotions
(Baumeister, 1990; Boergers, Spirito, & Donaldson, 1998;
Briere, Hodges, & Godbout,
2010; Bryan, Rudd, & Wertenberger, 2013; Shneidman, 1993),
highlighting the potential
functional similarities of these phenomena. Further, behavioral
avoidance, a hallmark
feature of anxiety disorders, often results in significant
isolation, reduced quality of life, and
impaired functioning (e.g., Massion, Warshaw, & Keller, 1993;
Olatunji, Cisler, & Tolin,
2007), which confer additional risk to suicidality (Kanwar et
al., 2013; Kaplan, McFarland,
Huguet, & Newsom, 2007). Other avoidance strategies (e.g.,
suppression) often used by
individuals with an anxiety disorder have also been shown to
exacerbate vulnerability to
suicidal thoughts and behaviors (Amir, Kaplan, Efroni, &
Kotler, 1999).

In addition to promising theoretical relevance of anxiety
disorders to suicidality, empirical
investigations of this relationship generally show that anxiety
disorders are independently
associated with suicidal thoughts and behaviors. Although
several earlier studies indicated
that anxiety disorders are not related to suicidality (e.g., Hornig
& McNally, 1995;
Warshaw, Massion, Peterson, Pratt, & Keller, 1995), converging
empirical evidence
suggests that a broad range of anxiety and related disorders
(including panic disorder,
posttraumatic stress disorder [PTSD], social anxiety disorder,
and generalized anxiety
disorder [GAD]) function as statistically significant risk factors
for suicidal thoughts and
behaviors (Boden, Fergusson, & Horwood, 2007; Bolton et al.,
2008; Borges, Angst, Nock,
Ruscio, & Kessler, 2008; Gradus et al., 2010; Nepon, Belik,
Bolton, & Sareen, 2010; Nock
et al., in press, 2009, 2010a; Noyes, 1991; Sareen, 2011; Sareen
et al., 2005; Thibodeau,
Welch, Sareen, & Asmundson, 2013; Weissman, Klerman,
Markowitz, & Ouellette, 1989;

Wilcox, Storr, & Breslau, 2009).
For example, Nock and colleagues (2010a) observed that
anxiety disorders significantly
predicted future suicide attempts in a large, nationally
representative sample (N = 9282),
when controlling for psychiatric comorbidity. Indeed, anxiety
disorders produced larger
population attributable risk proportions (PARPs), which take
into account the prevalence of
predictors and distribution of comorbidity, for suicide ideation
and attempts than impulse-
control and substance use disorders. Among suicide ideators,
anxiety disorders played a
larger role than mood disorders, impulse-control disorders, and
substance use disorders in
February 29.
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accounting for subsequent suicide attempts. Findings from a
cross-national study by Nock
and colleagues (2009) are similar, with anxiety serving as a
more powerful predictor of
suicide attempts among ideators than mood, impulse-control,
and substance use disorders. A
recent meta-analysis of 42 studies further supports the notion
that anxiety disorders and
suicidal behavior are related (Kanwar et al., 2013); however, by
including a combination of
cross-sectional and longitudinal studies, the conclusions that
can be drawn from this
previous meta-analysis regarding anxiety (and specific
disorders) as risk factors are

tempered.
In summary, researchers, theorists, and clinicians have
evidenced a longstanding interest in
the role of anxiety and its disorders in suicide. A meta-analysis
of longitudinal studies is
necessary to synthesize the available literature on anxiety as a
risk factor for suicidal
thoughts and behaviors. Specifically, we aimed to: (1) estimate
the predictive power (i.e.,
risk factor magnitude and accuracy) of anxiety as a risk factor
for suicide-related outcomes,
(2) compare the strength of effect sizes across types of anxiety
(e.g., disorders, symptoms),
and (3) examine potential moderators of the association between
anxiety and suicide-related
outcomes, including sample type, sample age, and length of
follow-up period. To our
knowledge, this represents the first effort to provide a
comprehensive, quantitative review of
the predictive ability of anxiety and its disorders for suicidal
thoughts and behaviors.
2. Method
This meta-analysis complies with the Preferred Reporting Items
for Systematic Reviews and

Meta-Analyses statement (PRISMA; Moher, Liberati, Tetzlaff,
& Altman, 2009).
2.1. Search strategy and selection
We conducted a comprehensive literature search of PsycINFO,
PubMed, and Google
Scholar from database inception through December 2014 to
identify studies eligible for the
current review. The prediction-related terms longitudinal,
longitudinally, predicts,
prediction, prospective, prospectively, future, later, and follow-
up were entered
simultaneously with the self-injury-related terms self-injury,
suicidality, self-harm, suicide,
suicidal behavior, suicide attempt, suicide death, suicide plan,
suicide thoughts, suicide
ideation, suicide gesture, suicide threat, self-mutilation, self-
cutting, cutting, self-burning,
self-poisoning, deliberate self-harm, DSH, nonsuicidal self-
injury, and NSSI. Given the
inconsistent and ambiguous terminology used to describe self-
injury (with or without
suicidal intent) in the literature (Nock, 2010), we employed a
wide range of self-injury-

related terms to reduce the likelihood of missing relevant
studies. The reference sections of
identified articles were also searched for other relevant
publications.
Fig. 1 presents a PRISMA diagram of the study selection
process. A total of 2385 unique
publications were identified by initial literature searches; after
reviewing each abstract, 642
studies were deemed eligible for further review. The authors
then reviewed each full-text
study and identified 65 publications that met criteria for
inclusion in the meta-analysis (see
Appendix A for references for articles included in meta-
analyses).
February 29.
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2.2. Inclusion and exclusion criteria
To be included in this meta-analysis, studies had to first include
a longitudinal analysis
predicting one or more of the following suicide-related
outcomes: suicide ideation, suicide
plan, suicide gesture, suicide attempt, or suicide death.
Correspondingly, we excluded
studies with outcomes that included nonsuicidal self-injury
(NSSI) only. We also excluded
studies that lumped nonsuicidal and suicidal behavior together
into a single outcome (e.g.,
“deliberate self-harm”) because including these combined
variables would render it difficult
to draw strong conclusions about the association between
anxiety and suicidal outcomes
specifically. Second, included studies had to use one or more of

the following anxiety-
specific predictors: any individual anxiety diagnosis (i.e.,
agoraphobia, anxiety disorder not
otherwise specified, GAD, panic disorder, social anxiety
disorder, specific phobia) or
anxiety diagnosis grouping (e.g., “any anxiety disorder” as
defined by study authors), any
obsessive–compulsive or related disorder (e.g., OCD), any
trauma or stressor-related
disorder (e.g., adjustment disorder, PTSD), any somatic
symptom disorder, symptoms of
anxiety (diagnosis-specific and general; e.g., scores on self-
report and clinician-rated
measures such as the Beck Anxiety Inventory [BAI; Beck,
Epstein, Brown, & Steer, 1988],
Hamilton Anxiety Rating Scale [HARS; Hamilton, 1959], or
Yale-Brown Obsessive
Compulsive Scale [Y-BOCS; Goodman et al., 1989], panic
attacks). Correspondingly, we
excluded studies only examining constructs or symptoms
broadly related but not specific to
anxiety (e.g., neuroticism, negative affect, emotion
dysregulation). We also excluded studies
combining anxiety and mood disorders into a single variable

(e.g., internalizing problems,
“mood or anxiety diagnosis”) because including these
overlapping predictors would
undermine our conclusions regarding the specific effect of
anxiety on suicidal thoughts and
behaviors. Finally, studies had to provide sufficient statistical
information to conduct the
present analyses, appear in a publication, and present original
data not already reported in
another study.
2.3. Data abstraction
Authors systematically extracted relevant information from each
article included in the
present meta-analysis using a predefined coding strategy.
Recorded information included:
(a) year of study publication, (b) sample age (i.e., adult,
adolescent, mixed), (c) sample size,
(d) sample type (i.e., general, clinical, or history of prior
SITBs), (e) length of study follow-
up (in months), (f) statistical information for each unique
prediction case (i.e., any instance
using an anxiety-specific variable to longitudinally predict a
suicide-related outcome), and

Educational & Child Psychology; Vol. 36 No. 3 33Evaluating.docx

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