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International Journal of Mental Health Nursing (2014) 23, 221–231
doi: 10.1111/inm.12049
Feature Article
‘How do we know if this is the best?’ Mental health-care professionals’ views on national guidelines for psychosocial interventions Boel Sandström,1,2,3 Ania Willman,1,4 Bengt Svensson3 and Gunilla Borglin1,5 1
School of Health Science, Blekinge Institute of Technology, 2Blekinge Center of Competence, Karlskrona, Department of Health Sciences, University of Lund, Lund, 4Department of Care Science, Malmö University, Malmö, and 5Department of Health Sciences, Karlstad University, Karlstad, Sweden 3
ABSTRACT: National guidelines are released regularly, and professionals are expected to adopt and implement them. However, studies dealing with mental health-care professionals’ views about guidelines are sparse. The aim of the present study was to highlight mental health-care staff’s views on the Swedish national guidelines for ‘psychosocial interventions for schizophrenia or schizophrenia-type symptoms’ and their implementation. The study took place in the southeast parts of Sweden, and data were collected through five group interviews consisting of 16 professionals working either in the county council or in the municipalities. The transcribed text was analysed by content analysis, revealing two categories. The first category ‘a challenge to the practice of care as known’ reflected that the release of guidelines could be perceived as a challenge to prevailing care and culture. The second category ‘anticipating change to come from above’ mirrored views on how staff expected the implementation process to flow from top to bottom. To facilitate working in accordance with guidelines, we suggest that future guidelines should be accompanied by an implementation plan, where the educational needs of frontline staff are taken into account. There is also a need for policy makers and managers to assume responsibility in supporting the implementation of evidence-based practice. KEY WORDS: evidence-based practice, group interview, guideline, mental health, nurse.
INTRODUCTION National guidelines are nowadays viewed as a vital component in evidence-based practice (EBP) (Grol et al. 2005; Oxman et al. 1995; Thomas et al. 1999). To enhance the quality and effectiveness of mental health care for persons diagnosed with schizophrenia or schizophreniatype symptoms, in 2011, the Swedish National Board of Health and Welfare 2011 (NBHW) published the first Correspondence: Boel Sandström, School of Health Science, Blekinge Institute of Technology, Campus Gräsvik, Valhallavägen 1, Karlskrona SE-371 79, Sweden. Email: [email protected] Boel Sandström, RN, MSc. Ania Willman, RN, BEd, PhD. Bengt Svensson, RN, MSc, PhD. Gunilla Borglin, RN, MSc, PhD. Accepted September 2013.
© 2013 Australian College of Mental Health Nurses Inc.
national guidelines for psychosocial interventions to target this group (hereinafter referred to as the guidelines). They were developed to guarantee that people with schizophrenia have equal access to high-quality care. In all, they cover 43 psychosocial interventions in the following areas: early intervention, individual participation and influence, family intervention, psychological treatment, social skills training, accommodation, and vocational rehabilitation. The release of these guidelines is coupled with the expectation that all mental health-care professionals will transform them into standard care. The NBHW produce guidelines first and foremost based on systematic reviews and meta-analysis, and secondly on separate studies of good quality. When there is insufficient scientific evidence, the prioritization is made by multiprofessional expertise groups. Their recommendations
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are then run by a group of people active in clinical practice (i.e. a consensus panel). In this way, the NBHW investigates if a general agreement exists about the recommendations: the suggested interventions effect. Thus, guidelines are drawn up on the basis of current research and the lessons of experience. Presently, no implementation guidance, such as the guidance published by the National Institute of Clinical Excellence (NICE) in the UK, accompanies the national guidelines. In the end, it is up to the local and regional decision makers to ensure the implementation of the guidelines. Guidelines should be viewed as broad principles of best practice. To be effective, they need to be converted into local practice guidelines. Guidelines can thus be understood to be a means to an end, where the latter is EBP. Internationally, the consensus is that mental health care should be based on evidence (Gordon & Ellis 2013). At present, there is little proof of how guidelines of this kind actually influence practice, or how the mental health community views and experiences them (Proctor et al. 2009). The adoption of guidelines has been known, without any reasonable explanation, to be particularly slow within mental health care (Tansella & Thornicroft 2009). Furthermore, EBP, as it is currently structured, has been questioned and criticized, especially within mental health care. Capturing the essence in this context is said to require complementary methodological approaches, as evidence deriving from studies with a quantitative design might be insufficient (Fisher & Happell 2009). Even if guidelines are viewed as important tools for EBP, they are not ‘magic bullets’, as passive diffusion (i.e. releasing national guidelines) does not lead to a change in practice by osmosis (cf. Rycroft-Malone et al. 2004). Successful transformation of guidelines into local practice depends on several key factors, and the professionals are just one of those factors. We know that success relies on an informed target group and a positive attitude to the guidelines (Corrigan et al. 2003; Grol et al. 2005). However, to date, there is a lack of studies that focus on mental health care and the views of professionals, especially studies conducted with a qualitative design. Certain factors are barriers that obscure the uptake and implementation of EBP. The main barriers are related to the organizational context and to the individuals in this context (Aarons et al. 2012; Corrigan et al. 2003; Proctor et al. 2009). On an organizational level, barriers could take the form of lack of support from managers, a change-averse culture, and bureaucratic constraints (Corrigan et al. 2003). On the individual level, a lack of understanding and insufficient knowledge of the guidelines have been shown to stifle the EBP process
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(Bahtsevani et al. 2004; Francke 2008). Views and personal beliefs can also be associated positively or negatively with uptake of new knowledge (Estabrooks et al. 2003; Greenhalgh et al. 2005) and the use of guidelines (Alanen et al. 2009; Quiros et al. 2007). Professionals’ views on guidelines have been explored mainly in studies with a quantitative design; for example, studies dealing with guidelines about smoking-cessation advice (Puffer & Rashidian 2004), hand hygiene (Quiros et al. 2007), hypertension (Alanen et al. 2009), and prevention of falls (Stenberg & Wann-Hansson 2011). It is worth noting that these studies refer to ‘somatic’ healthcare staff. On the surface, certain dissimilarities seem to exist between mental health-care and other healthcare contexts. In general, the composition of a mental health-care team tends to reflect a higher degree of multiprofessional involvement than a somatic care team (Fiddler et al. 2010). This multiprofessional environment also includes a ward round, which is rarely conducted at the bedside or on a daily basis, as in somatic care. Finally, the mental health-care professionals’ focus, and the basis of their care, is interpersonal therapeutic engagement (Cutcliffe & Happell 2009; Peplau 1952), while somatic care professionals can be said to focus more on the ‘physical body’. Thus, it would seem reasonable to propose that this reflects two different cultures. We do not know how the findings presented above actually transfer to or truly reflect mental health-care professionals. Lakeman (2013) recently put forward Fancher’s (1995) idea that we should view mental healthcare services as cultures of care with their own norms, traditions, and rituals. Gershon et al. (2004) stated that the culture of an organization is shaped by the attitudes and assumptions of its inhabitants. Adopting this view could help to understand and explain variations in practice and how it can be changed, while still bearing in mind that ‘what service improvement really means in many places is a shift in culture’ (Lakeman 2013, p. 10). Gaining an insight into mental health-care professionals’ views and practice in localized communities is of importance, especially if the goal is EBP. Thus, the aim of the present study was to highlight professionals’ views about recently-released guidelines for schizophrenia and the implementation of those guidelines.
METHOD This study employed a qualitative design, collecting data by group interviews (Morgan 1997) and analysing the texts by qualitative content analysis, as described by Burnard (1996). © 2013 Australian College of Mental Health Nurses Inc.
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Context
Sample and recruitment
Lakeman (2013) highlights the importance of offering a careful description of the general context in which the research has been conducted. Only then can those who are beyond the immediate horizon understand practice. Mental health care in Sweden is provided through two systems. County council mental health-care providers are responsible for medical care and medical treatment, while the municipal authorities and their social welfare systems are responsible for generic services, such as individuals’ accommodation, activities, finances, and need for support in their daily lives. The multidisciplinary teams, regardless of their location, consist of registered nurses (RN), often specializing in psychiatry, and enrolled nurses, where the latter are the majority. Other members of the team include occupational therapists, psychologists, social workers, practice development coaches, and psychiatrists. For the past 15 years in Sweden, the only route to the nursing profession has been through a bachelor’s degree in nursing science (i.e. 3 years at university). Specialization involves a further year at university. In general, the enrolled nurses have a 3-year high school education. They have similar responsibilities and work tasks as the assistant practitioners working in band four in the UK (Spilsbury et al. 2009). Enrolled nurses are not professionally regulated as RN, but Swedish health-care regulations stipulate that all health-care professionals are responsible for working in accordance with the latest scientific evidence and lessons of experience. Working in accordance with national guidelines is accordingly considered to be every health-care professional’s responsibility.
A total of 16 informants participated in the study (Table 1). A purposive sample (Polit & Beck 2012) consisting of five RN, five enrolled nurses, four practice development coaches, one occupational therapist, and one social worker was used with the intention of obtaining informants who were directly involved professionally with the guidelines. Inclusion criteria were mental health-care professionals who worked directly with people diagnosed with schizophrenia or schizophrenia-type symptoms. Ten different mental health-care facilities in the county council were initially targeted. Five of the 10 facilities accepted the invitation (eligible staff: n = 67). Reasons given by the facilities not participating were lack of time, lack of familiarity with the contents of the guidelines, and heavy workload. In three of the five facilities, oral and written information was given during a workplace meeting. In two facilities, the managers informed their staff and handed out the written information and the request to participate.
Data collection Five group interviews were conducted during April and May 2012 (approximately 12 months after the release of the national guidelines); two in community mental health care and three in psychiatric outpatient departments. All interviews began with two overarching questions: ‘Tell me about your views on the guidelines’ and ‘Tell me about their implementation’. Probing questions were used to support the interviewees (Polit & Beck 2012). All group interviews took place during working hours in a separate room at the informants’ workplaces, thus in a place
TABLE 1: Overview of the informants’ characteristics Participant A B C D E F G H I J K L M N O P
Group
Sex
Age (years)
Education
Profession
Years in current position
1 1 1 2 2 2 3 3 3 3 4 4 4 5 5 5
Female Female Female Female Female Female Male Female Male Male Female Female Female Female Female Female
57 41 57 60 55 33 49 33 33 44 58 38 42 56 58 40
Diploma & specialist education BSN & specialist education Diploma Diploma & university education Upper secondary school BSN & specialist education University education University education University education Residential college for adult education Upper secondary school University education Upper secondary school University education Upper secondary school BSN & specialist education
RN – psychiatry RN – psychiatry Allied health professional RN – accredited psychotherapist Enrolled nurse RN – psychiatry Practice development coach Practice development coach Practice development coach Practice development coach Enrolled nurse Allied health professional Enrolled nurse Enrolled nurse – accredited psychotherapist Enrolled nurse RN – psychiatry
25 8 21 26 28 6 4 4 4 4 28 8 14 36 23 8
BSN, bachelor’s degree in nursing science; RN, registered nurse.
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familiar to the informants and at a time that would maximize participation. All informants had received oral and written information about the study. The group interviews were tape-recorded and lasted approximately 60 min.
Data analysis The transcribed texts were analysed by content analysis, as described by Burnard (1996), with the aim of identifying key issues in data, and interpreting meaning from the content of data. The method is an inductive process consisting of four steps. First, the transcripts were read through several times to gain an understanding of the whole, and sentences or paragraphs that had a reference to the study aim that appeared to capture key thoughts or concepts were identified and highlighted. Second, the highlighted parts were condensed into shorter phrases, while still preserving the meaning. In the third step, these meaning units were analysed and open coded one by one while asking the following questions: What are they actually talking about? What does it mean? What else is similar to this? What is it distinct from? Thereafter, in the fourth step, the meaning units were grouped into
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subcategories, based on similarities and differences, and then compared and contrasted with the text to ensure credibility (Burnard 1996). Finally, the subcategories were reduced by abstraction, labelled using poetic expressions or metaphors when adequate (Lindseth & Norberg 2004). The first and last authors were both involved in the analysis. Both authors read the raw data thoroughly and the emerging interpretations. Regular discussions were additionally held with the other authors to enhance the thoroughness in the interpretation of the text and to secure the best possible account of the views found in the text (Table 2).
Researchers’ reflexivity To guard against personal biases in judgment making, all authors relied on reflexivity (Polit & Beck 2012). By doing so, the authors took into account their previous experiences as RN working within mental health care (BS, BS) and in somatic care. (GB, AW) Thus, by acknowledging being part of the setting and the context, as well as using the process of self-reflection about personal biases and preferences, the quality of the study could be enhanced (Schwandt 2007).
TABLE 2: Sub-categories and categories Quotations
Subcategories
The first time we talked about this . . . well we were two who raised our hands, who had looked at the guidelines. (1:C) We ourselves are poorly updated, and then it’s not surprising that patients and families are poorly updated. (5:N) But here we make up . . . our own little (guidelines) . . . sometimes, or often, we do just that, because we don’t know of anything else. (1:A) And I think it’s a little dependent on the doctor, if you have a doctor at all, and the attitude and the experience the doctor has. (1:B) When you have researched this using psychotherapy, then one has come to the conclusion that it’s the alliance between the patient and the therapist that is the active part and how do you measure that? (5:P) And there is nothing that says that this is the best (method), but it’s the only one that has been researched. (3:I) It should probably come from somewhere . . . higher up, and I think it should come from the court in the county council where they work with knowledge, development, and skills development. (2:F) It is of paramount importance that full details of all methods are disseminated, and that is up to the managers, so it is. (4:K) Then it’s a job every time. As soon as a new guideline is released, we have to reorganize practice, and then it’s going to be a reorganization with every new guideline. (2:D) I mean, we are already working in that way. We don’t call it by that name, but we are doing just that. (2:F) Somehow, with a review of the practical application of the various methods, the two principles need to be on board; both the municipality and the county council. (2:E) It is the fact that we have got the money, and we have a project, a project . . . perhaps foremost, and then there is the training too. (3:J)
Not common knowledge
Categories A challenge to the practice of care as known
Threading the same path
Questioning the base
Anticipated pathway
Anticipating change to come from above
Demands for change
A process sensitive to organization and culture
Acronyms refer to the participants (A–K), and numbers refer to the groups.
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Ethical considerations The study was conducted in compliance with the established ethical guidelines of the Declaration of Helsinki (World Medical Association Inc 2009). Verbal and written consent was obtained. Under the Swedish Ethical Review Act, this study did not require ethical clearance.
FINDINGS The analysis indicated that mental health-care professionals’ views on the guidelines and their implementation could be understood in the light of the categories ‘a challenge to the practice of care as known’ and ‘anticipating change to come from above’, with their supporting subcategories (Table 2). The subcategories are illustrated by quotations from the group interviews, where 1–5 correspond to the groups, and A-K correspond to the participants, as described in Table 1.
A challenge to the practice of care as known The ‘challenge to the practice of care as known’ category reflected the view that the guidelines, or their content, were not something everyone were aware of; that is, the subcategory ‘not common knowledge’. It also reflected how the guidelines were considered to emphasize the importance of staff working in the same way; that is, the subcategory ‘treading the same path’. Here, views also revealed a lack of reliability with regard to the evidence underpinning the released guidelines; that is, the subcategory ‘questioning the base’ (Table 2). Overall, the category showed that guidelines could be perceived as a challenge to embedded practices; that is, prevailing care and culture. Not common knowledge
In the subcategory ‘not common knowledge’, the informants’ views reflected their knowledge of the guidelines. The degree ranged from not being aware at all to familiarity with the content, and ultimately already working in accordance with one of the recommended interventions. The informants shared the view that the guidelines were not common knowledge among the teams, expressed as: ‘No, I have to say I have not considered them’. (4:K) Despite a commonly-held view of the importance of the guidelines, one reason given for not having any knowledge of them was the lack of general discussion within the teams. The informants stated that discussions focused mainly on the staff ’s obligations and areas of responsibility. The informants wanted to go through the guidelines, discuss their content, and decide how to make best use of the recommendations: © 2013 Australian College of Mental Health Nurses Inc.
225 What aspects in these guidelines would benefit our patients the most? What would enhance their current quality of life? What are we doing at present? Why are we doing it? How do we know if this is the best? (1:B)
Contrasting views were reflected on in terms of the accessibility of the guidelines. Views represented those who stated that the guidelines were written in a complicated, formal language, and they wanted a ‘lay’ version. Others stated that the guidelines were easy to understand and were written in plain Swedish. Views relating to awareness and knowledge among service users were also reflected. Informants stated that the small numbers that were actively involved in user associations would be informed, but this would not be the case for the majority of service users. Discussions about ethical aspects, more specifically, the issue of informing service users about recommended interventions not yet commonly known among the professionals, let alone implemented, were also highlighted. Treading the same path
The subcategory ‘treading the same path’ reflected the benefits of underpinning decision-making with guidelines. Here, the informants raised the absence of discussion about the fundamental values underlying the care offered to service users and the lack of a uniform working approach. Guidelines were viewed as useful tools that provide a base for the teams to work in a more coordinated way. The guidelines were also viewed as recommendations for treatment, and something on which practice could be based. They were described as something to relate to, and something one might or might not be obliged to follow. Furthermore, they were referred to as ‘rights for the service users’; that is, what could be expected from mental health care and its professionals. Informants discussed the problem that the care offered was often dependent on the attitudes and experiences of physicians or of a specific therapist. The national expectation to deliver ‘care on equal terms’ was highlighted, as the informants stated that care could not live up to that standard if the teams made up their own set of guidelines: If you look at a private company, I guess it would be different. Everyone is familiar with the business and what they should and should not do. Knowing how to make a Volvo, for example. You can’t do it in any old way; it’s a car. There must be guidelines that everyone is aware of and that need to be followed. (1:A)
Questioning the base
The subcategory ‘questioning the base’ was interpreted as reflecting views on the concept of ‘evidence’. A great deal
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of criticism was aired regarding the importance of a method and the emphasis on the method being evidence based. Strong views were put forward about the time it takes to get to know the value of interventions or treatments, which meant that by the time they become established, they are already outdated. Perceptions about the type of research design that was viable also became discernible, and concern was expressed. If only randomized, controlled trials (RCT) were considered rigorous enough to equal evidence, what about knowledge originating from other types of designs not suitable for randomization? The informants also expressed concern about the risk of knowledge from studies with a quantitative design being used to answer questions about service users’ experiences: There is a difference in how . . . you conduct research and whether you have a quantitative or qualitative design. By quantitative I mean things you can measure, things that are difficult for us to adjust to the patients’ experiences. You can’t squeeze that into a quantitative template or measure it using columns. You have to ask about experience, but then you might end up with just a small sample and that would not count as evidence, because that might not be. . . . You might think: ‘Is it these quantitative studies that will be the foundation of what will count as evidence based and the treatment you can adopt? It’s difficult to research things that are a little different. (2:D)
Here, the views reflected concern that working in accordance with evidence-based methods would endanger the alliance between the professional and the service user. This can be discerned from statements, such as: Then again, you can do ever so much in a . . . non-aligned way or, how should I put it, where I don’t have an alliance with the service user then . . . it wouldn’t be good, even if it was evidence based. (5:P)
In addition, there was also the perception that activities the professionals believed would benefit the service users, regardless of whether or not they were underpinned by evidence: I think it’s good to evaluate, and it’s good to have evidence-based stuff, but we’re doing things that we can scarcely measure . . . I think about mindfulness, something I really believe in . . . and there’s actually research relating to this, but maybe not enough to call it evidence based. I don’t know for sure, but I do believe in this a lot, and I transfer this belief to the patients, who I feel would benefit from this (belief ). (5:P)
Anticipating change to come from above The category ‘anticipating change to come from above’ could be understood from the three subcategories ‘antici-
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pated pathway’, ‘demands for change’, and ‘a process sensitive to organization and culture’. Here, the perceived expectations of staff were revealed about how the implementation process should be initiated; that is, top to bottom and organized: ‘an anticipated pathway’. It was also reflected in the requirements that would emerge from a change in working approach; that is, ‘demands for change’. The subcategory ‘a process sensitive to organization and culture’ reflected views on factors that could enhance the implementation process. Anticipated pathway
In the subcategory ‘anticipated pathway’, the informants expressed the expectation that vital information and new knowledge from the government, local authorities, and regions would be passed on to them automatically. This expectation was also discernible in statements pinpointing the managers’ responsibility to present the guidelines and ensure all the staff were updated. The discussions reflected the fact that several levels were felt to be involved in the implementation of the guidelines. It was acknowledged and expected that the ‘starting signal’ had to come from higher up; preferably from someone specially appointed to keep track of new laws and regulations and the release of guidelines. It was suggested that the decision to change practice in accordance with the recommendations must be a political decision, and the dissemination process should, therefore, commence with that decision. It then needed to be passed on to the managers, and eventually to the teams. Although acknowledging their responsibility to remain updated on research, the expectation still remained that someone higher up in the organization bore primary responsibility: However, the manager needs to be updated. It is for her to know about this and that. If she doesn’t know, it’s out in the ether somewhere. (1:B)
Demands for change
In the subtheme ‘demands for change’, the general perception was that the guidelines recommended interventions that were too rigid and too inflexible, thus making it awkward to implement them in the multidisciplinary teams’ clinical reality. Informants stressed a belief that implementing any of the interventions demanded a reorganization of practice. Reorganization was not regarded as a realistic option but was nevertheless thought to be necessary if the new guidelines were to be implemented. The informants stated that it was important not to transform a well-described intervention into something mediocre and then assume it was the same, or that © 2013 Australian College of Mental Health Nurses Inc.
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it would produce the result originally anticipated. Some informants stated that some of the recommended methods were similar to activities or interventions already used. Here, the perceived lack of reliable channels in the organization was also highlighted; channels that would ensure that vital information would not become blocked and not be passed on. It was stated that the guidelines were known and debated in the organization in response to the national referral. Despite this, more than 1 year after release, they had still not been disseminated within the organization. The need for some kind of quality system was stressed: Still, you have to decide that you want it; that you want a quality system to relate to; to have matters under control and not just believe that someone will fix it. It must be decided who’s going to do it, when, and in what way. (1:C)
Process sensitive to organization and culture
The subcategory ‘sensitive to organization and culture’ highlighted a general perception regarding implementation of the guidelines and ways in which implementation could be impeded by the organization and the culture. One factor that was raised was time, and views were mixed regarding the importance of time. Some informants thought that lack of time might be an impeding factor, whereas others thought it would not. It was a matter of prioritizing and deciding how to spend the time available. However, they agreed that time was a factor that needed to be taken into account: It (implementation) does not take place just because you take 2 minutes at a workplace meeting to announce that there are new guidelines being published. (1:A)
Receiving support in the form of money, training, and help to monitor the implementation of a recommended intervention was considered beneficial. The significance of education and training was clearly expressed by the informants. The informants felt that training resulted in a clear mission, and that they felt secure and strong when working in accordance with the guidelines. This subcategory also covered views that revealed that assistance from a facilitator would be helpful in the implementation process. It was suggested that the facilitator should be skilled in informing and explaining guidelines and their implementation. The informants stated that someone familiar with the guidelines or concerned about practice development would be suitable. Participating in seminars or conferences dealing with the recommended guidelines was also considered as useful. © 2013 Australian College of Mental Health Nurses Inc.
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DISCUSSION Our findings can be seen in the light of the two categories ‘a challenge to the practice of care as known’ and ‘anticipating change to come from above’, with their underpinning subcategories (Table 2). The first category illustrated staff’s views on the national guidelines for schizophrenia in general, and the second category reflected their views on the implementation of these guidelines. Both categories mirrored views permeated by contradictions. Staff could relate to the guidelines and view them as possible power tools. The recommendations could facilitate a more coordinated working approach, and staff acknowledged them as fundamental rights for service users. However, they could also be viewed as rigid and inflexible, and staff felt that implementing them would demand a change of current practice; a change they, at the moment, did not seem prepared to participate in. Their contradictory responses might be explained by the fact that the guidelines had not yet been ‘bedded down’. Staff’s confession of lack of knowledge and awareness about the guidelines might be another explanation. As earlier mentioned, we know that lack of awareness and lack of knowledge have been recognized as major barriers to implementation (Bahtsevani et al. 2004; Francke 2008). According to Lakeman (2013), people crave certainty, and working in accordance with EBP requires that staff are unceasingly involved in reflecting on their activities of care that otherwise might be taken for granted. One of our most noteworthy findings was the apparent clash between the views of mental health-care professionals and what they perceived as ‘science’. Although staff admitted they did not have much knowledge of the content of the guidelines, despite the fact that they had been released 12 months earlier, they nevertheless expressed scepticism about the evidence base underpinning them. They questioned the ways in which the evidence was developed, and its reliability. They also believed that only quantitative studies supported the recommendations, and expressed their concern that the service users’ views might be overlooked. Many felt that the NBHW recommendations were mainly based on systematic surveys, as meta-syntheses in this area are scarce. Furthermore, in Sweden, service users are unfortunately not yet included in the development of guidelines to such an extent as one could wish for. Moreover, staff felt that their activities could not be measured and tended to favour soft values; that is, theirs and the service users’ experiences. One plausible explanation for staff’s scepticism towards the guidelines could be, as
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Richards and Hammers (2009, p. 1159) suggests, that ‘many practitioners believe that each therapeutic relationship is so unique that it cannot be observed, measured and copied to the benefit of other patients. Process rules over content.’ Thus, research evidence about efficacy (i.e. RCT) might be regarded as challenging for the practitioners, and increased emphasis on this type of knowledge is opposed (Fisher & Happell 2009; Rycroft-Malone et al. 2004). Departing from a broader evidence base for practice has been suggested, blending research, clinical and patient experiences, and information from the local context. This was already emphasized by Sackett et al. (1996), who defined EBM as integration between individual clinical expertise and best external clinical evidence from systematic research, together with the use of individual patients’ predicaments, rights, and preferences in making decisions about their care. If EBP is ever to be implemented, professionals must understand that it is they, together with service users, who are supposed to integrate EBP into their clinical expertise. Instead, working in accordance with guidelines was perceived as a possible threat to the core of mental health care; that is, interpersonal therapeutic engagement. Accordingly, to avoid ‘rocking the boat’, informants suggested that it was more important to rely on their own professional experiences and to trust themselves, despite the fact that this was done at the expense of research evidence. They also felt that having faith in the activities that had already been integrated into the services, together with the interpersonal relationship, was more beneficial for the service users than any of the recommended guidelines. Their emphasis on the therapeutic relationship is not surprising, as it has a strong position, and is viewed as the core of the culture (Cutcliffe & Happell 2009; O’Brien 1999). However, a good, therapeutic relationship on its own will hardly help patients into stable housing, competitive work, more effective symptom control, or a more functional family situation. These are what the guidelines are supposed to help to achieve. A possible explanation for the staff viewing the issue in terms of either an interpersonal relationship or evidence-based methods was admitting to having insufficient knowledge of the guidelines. Consequently, none of the informants seemed to be able to provide an informed critical view of the guidelines. Another possible explanation could be that the professionals might lack the skills needed to be active and critical research consumers. Our finding about the informants’ strong perceptions of faith and its importance to practice is supported by Lakeman (2013, p. 106), who suggests: ‘Many beliefs held by mental
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health professionals might be considered to be based on faith rather than science’. It is important to note that the professionals’ experiences are suggested to be a vital part of the development of EBP (Rycroft-Malone et al. 2004); however, allowing faith alone, possibly at the expense of evidence, to be the driving force in care seems a dangerous path to follow. It would appear crucial to take into account hierarchical structures when trying to implement guidelines. Our findings indicate that the professionals expected that a reorganization was needed to implement the guidelines, and that the initiative for change would have to come from above. Despite this, they still questioned the guidelines, and did not feel that furthering the development of care in accordance with the recommendations was part of their remit. Thus, their views once again reflected a sense of ambivalence. Others have already highlighted that the bureaucratic environment in which healthcare professionals typically practise is likely to promote top-down decision-making (Thyer 2003). We also know that unlike most modern organizations with their flatter, less hierarchical organizational structures, the majority of health-care organizations still support the classical hierarchical model (Tracey 2006). This kind of environment is known to foster an attitude that leads to unwillingness to be involved in the EBP process and perpetuates the top-down mentality among health-care staff (Fineout-Overholt et al. 2005). Looking at our findings, the paradox here seems to be that it would appear that the professionals wanted a change, but did not want to change themselves. Their reliance on hierarchical implementation was perhaps a way of expressing their ambivalence towards the guidelines and their implementation. Our findings need to be understood as a key element embedded within a specific context and culture. Lakeman (2013) proposes that when viewing mental health care through a cultural lens as a culture of care, it is necessary to understand how and why practice changes. Culture is shaped by the people who are part of it, as well as by their attitudes and assumptions (Gershon et al. 2004). Thus, we suggest that the challenge here will be how to change the hierarchical structure and the culture, and instead promote a bottom-up mentality that will favour and encourage professionals to embrace EBP more readily. Not unexpectedly, some of our findings reinforce earlier research, highlighting a need for resources in the form of time, education and training, and assistance from an external expert to facilitate the implementation process, as well as the importance of leaders and managers (Rycroft-Malone 2004; Rycroft-Malone et al. 2004). © 2013 Australian College of Mental Health Nurses Inc.
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Others have acknowledged the intricate interplay between several factors and have highlighted the importance of research designs that take all of these variables into account. There is reason to believe that those who have the greatest impact are nurse managers, as they can affect the professionals’ culture and context (Gifford et al. 2006; Sandström et al. 2011; Scott-Findlay & Golden-Biddle 2005). However, managers are often better equipped and trained in management issues than they are at being responsible for care improvement (Boström et al. 2013; Lorensen et al. 2002). Strategies that involve a sense of ownership in the whole team need to be developed.
Study limitations This study’s relatively small sample (n = 16) has implications for the trustworthiness of the findings. Although the sampling was purposively conducted, it was homogenous in aspects, such as sex. This implies that the result can be specific for women within this context, and that homogeneity can affect transferability of the result. However, the informants’ different ages, education, and time in position might have counterbalanced this. Our goal was to gain a contextualized understanding of informants working in multidisciplinary mental health-care teams’ views on a certain phenomenon; that is, the guidelines. Therefore, the amalgam of realities presented here might be regarded as the views of the informants, and as such, they might be transferable to similar settings. The choice to conduct group interviews instead of focus groups was based on the fact that ‘mini groups’ are likely to increase interaction, but also, due to the topic, we wished to emphasize the questions– responses between the interviewer and the informants and not the interaction within the group (Morgan 1997, p. 12). In this study, the small number was found to contribute to a relaxed conversation (Carey 1994), allowing everyone to be actively involved. Content saturation (Polit & Beck 2012) was achieved after four group interviews, although one more was conducted to confirm the findings. Finally, there is always a risk of subjectivity in data interpretation, and there is always more than one possible way to interpret a text. The first author, who took the lead in the analysis, acknowledged her pre-understanding of the research setting consisting of her previous experience as an RN in a similar context. Additionally, all authors critically reflected on the interpretative process; their role in the analytic process and their preconceived ideas (Mauthner & Doucet 2003) were regularly discussed throughout the analysis to ensure trustworthiness. © 2013 Australian College of Mental Health Nurses Inc.
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CONCLUSIONS AND RELEVANCE TO PRACTICE Analysing the target group and knowing what drives and impedes change in their specific culture are of great importance for successful implementation, but this is rarely done. Consequently, more studies that investigate attitudes and views on changes in embedded practice are needed to gain an insight into what strategies might work. In-depth interviews exploring staff’s experiences of guidelines and of working in accordance to guidelines could be one approach to gain further insight into the topic. The narratives illustrate that the professionals were ambivalent, and that they did not believe the evidence underpinning the guidelines. Systematic reviews and meta-analysis did not reflect their practice, and they felt that the recommendations might collide with the therapeutic relationship. They preferred to trust in their own belief in what was right for the service user, and anticipated change to come from above. A broader knowledge base, where evidence from clinical practice, service users, and local culture becomes more visible, could make professionals more involved and willing to embrace the guidelines. However, ways to turn this process around and encourage professionals to be more proactive in the development of the care offered to the service users warrants further study.
ACKNOWLEDGEMENT We would like to thank the staff who participated in the study, and Patrick O’Malley for his help with language revision. We are also grateful to Blekinge Research Council, Blekinge Competence Centre, Blekinge Institute of Technology, Karlskrona, and Karlstad University, Sweden who funded this study.
REFERENCES Aarons, G. A., Glisson, C., Green, P. D., Hoagwood, K., Kelleher, K. J., Landsverk, J. A. & The Research Network on Youth Mental Health (2012). The organizational social context of mental health services and clinician attitudes toward evidence-based practice: A United States national study. Implementation Science, 7, 56. Alanen, S., Kaila, M. & Välimäki, M. (2009). Attitudes toward guidelines in Finnish primary care nursing: A questionnaire survey. Worldviews on Evidence-Based Nursing, 4, 229–236. Bahtsevani, C., Udén, G. & Willman, A. (2004). Outcomes of evidence-based clinical practice guidelines: A systematic review. International Journal of Technological Assessment in Health Care, 20 (4), 427–433. Boström, A.-M., Rudman, A., Ehrenberg, A., Gustavsson, J. P. & Wallin, L. (2013). Factors associated with evidence-based
230 practice among registered nurses in Sweden: A national cross-sectional study. BMC Health Service Research, 13, 165. Burnard, P. (1996). Teaching the analysis of textual data: An experiential approach. Nurse Education Today, 16, 278–281. Carey, M. (1994). The group effect in focus groups: Planning, implementing, and interpreting focus group research. In: J. Morse (Ed.). Critical Issues in Qualitative Research Methods. (pp. 225–241). London: Sage Publications. Corrigan, P., McCracken, S. & Blaser, B. (2003). Disseminating evidence-based mental health care practices. Evidence Based Mental Health, 6, 4–5. Cutcliffe, J. & Happell, B. (2009). Psychiatry, mental health nurses, and invisible power: Exploring a perturbed relationship within contemporary mental health care. International Journal of Mental Health Nursing, 18, 116–125. Estabrooks, C. A., Floyd, J. A., Scott-Findlay, S., O’Leary, K. A. & Gushta, M. (2003). Individual determinants of research utilization: A systematic review. Journal of Advanced Nursing, 45 (5), 506–520. Fancher, R. T. (1995). Cultures of Healing: Correcting the Image of American Mental Health Care. New York: W H Freeman/Times Books/Henry Holt & Co. Fiddler, M., Borglin, G., Galloway, A., Jackson, C., McGowan, L. & Lovell, K. (2010). Once-a-week psychiatric ward round or daily inpatient team meeting? A multidisciplinary mental health team’s experience of new ways of working. International Journal of Mental Health Nursing, 19, 119–127. Fineout-Overholt, E., Levin, R. F. & Mazurek Melnyk, B. (2005). Strategies for advancing evidence-based practice in clinical settings. Journal of the New York State Nurses Association, 35, 28–32. Fisher, J. E. & Happell, B. (2009). Implications of evidencebased practice for mental health nursing. International Journal of Mental Health Nursing, 18, 179–185. Francke, A. (2008). Attitudes of nursing staff towards electronic patient records: A questionnaire survey. International Journal of Nursing Studies, 47 (7), 846–854. Gershon, R., Stone, P., Bakken, S. & Larson, E. (2004). Measurement of organizational culture and climate in healthcare. Journal of Nursing Administration, 34 (1), 33–40. Gifford, W. A., Davies, B., Edwards, N. & Graham, I. D. (2006). Leadership strategies to influence the use of clinical practice guidelines. Nursing Leadership, 19, 72–88. Gordon, S. E. & Ellis, P. M. (2013). Recovery of evidence-based practice. International Journal of Mental Health Nursing, 22, 3–14. Greenhalgh, T., Robert, G., Bate, P., Macfarlane, F. & Kyriakidou, O. (2005). Diffusion of Innovations in Health Service Organisations. A Systematic Literature Review. Oxford: BMJ Books, Blackwell Publishing. Grol, R., Wensing, M. & Eccles, M. (2005). Improving Patient Care. The Implementation of Change in Clinical Practise. London: Elsevier Limited.
B. SANDSTRÖM ET AL. Lakeman, R. (2013). Talking science and wishing for miracles: Understanding cultures of mental health practice. International Journal of Mental Health Nursing, 22, 106–115. Lindseth, A. & Norberg, A. (2004). A phenomenological hermeneutic method for researching lived experience. Scandinavian Journal of Caring Science, 18, 145–153. Lorensen, M., Sinkkonen, S., Lichtenberg, A. et al. (2002). Required and possessed competencies of nurse leaders in the primary health care settings of the Nordic countries. Vård I Norden. NursingScience & Research in the Nordic Countries, 22 (4), 31–37. Mauthner, N. S. & Doucet, A. (2003). Reflexive accounts and accounts of reflexivity in qualitative data analysis. Sociology, 37 (3), 413–431. Morgan, D. L. (1997). Focus Groups As Qualitative Research, 2nd edn. Qualitative research methods series, 16. London: Sage Publications Co. O’Brien, A. J. (1999). Negotiating the relationship: Mental health nurses’ perceptions of their practice. Australian and New Zealand Journal of Mental Health Nursing, 8, 153– 161. Oxman, A. D., Thomson, M. A., Davis, D. A. & Haynes, R. B. (1995). No magic bullets: A systematic review of 102 trials of interventions to improve professional practice. Canadian Medical Association Journal, 153 (10), 1423–1431. Peplau, H. (1952). Interpersonal Relations in Nursing. New York, NY: Putnam. Polit, D. F. & Beck, C. T. (2012). Nursing Research: Generating and Assessing Evidence for Nursing Practice, 9th edn. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Proctor, E. K., Landsverk, J., Aarons, G., Chambers, D., Glisson, C. & Mittman, B. (2009). Implementation research in mental health services: An emerging science with conceptual, methodological and training challenges. Administration and Policy in Mental Health, 36, 24–34. Puffer, S. & Rashidian, A. (2004). Practice nurses’ intentions to use clinical guidelines. Journal of Advanced Nursing, 45 (5), 500–509. Quiros, D., Lin, S. & Larson, E. (2007). Attitudes toward practice guidelines among ICU personnel: A cross-sectional anonymous survey. Hearth Lung, 36 (4), 287–297. Richards, D. A. & Hamers, J. P. H. (2009). The importance of RCTs and laboratory experimental studies for nursing. Reply to the commentary by Rolfe (2009) on Richard and Hammers (2009). International Journal of Nursing Studies, 46, 1156–1158. Rycroft-Malone, J. (2004). The PARIHS framework – A framework for guiding the implementation of evidence-based practice. Journal of Nursing Care Quality, 19 (4), 297– 304. Rycroft-Malone, J., Seers, K., Titchen, A., Harvey, G., Kitson, A. & McCormack, B. (2004). What counts as evidence in evidence-based practice? Journal of Advanced Nursing, 47 (1), 81–90. © 2013 Australian College of Mental Health Nurses Inc.
VIEWS ON NATIONAL GUIDELINES Sackett, D. L., Rosenberg, W., Gray, M. J., Haynes, R. B. & Richardson, W. S. (1996). Evidence based medicine: What it is and what it isn’t. British Medical Journal, 312, 71–72. Sandström, B., Borglin, G., Nilsson, R. & Willman, A. (2011). Promoting the implementation of evidence-based practice: A literature review focusing on the role of nursing leadership. Worldviews on Evidence-Based Nursing, 8 (4), 212–223. Schwandt, T. (2007). The Sage Dictionary of Qualitative Inquiry, 3rd edn. Thousand Oaks, CA: Sage. Scott-Findlay, S. & Golden-Biddle, K. (2005). Understanding how organizational culture shapes research use. Journal of Nursing Administration, 35 (7/8), 359–365. Spilsbury, K., Stuttard, L., Adamson, J. et al. (2009). Mapping the introduction of assistant practitioner role in acute NHS (hospital trusts) in England. Journal of Nursing Management, 17, 615–626. Stenberg, M. & Wann-Hansson, C. (2011). Health care professionals’ attitudes and compliance to clinical practice guidelines to prevent falls and fall injuries. Worldviews on Evidence-Based Nursing, 8 (2), 87–95.
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231 Swedish National Board of Health and Welfare (2011). National Guidelines for Psychosocial Interventions for Schizophrenia Or Schizophrenia-Type Symptoms (in Swedish). Västerås: Edit Västra Aros. Tansella, M. & Thornicroft, G. (2009). Implementation science: Understanding the translation of evidence into practice. British Journal of Psychiatry, 195, 283–285. Thomas, L. H., McColl, E., Cullum, N., Rosseau, N. & Soutter, J. (1999). Clinical guidelines in nursing, midwifery and the therapies: A systematic review. Journal of Advanced Nursing, 30 (1), 40–50. Thyer, G. L. (2003). Dare to be different. Transformational leadership may hold the key to reducing nursing shortage. Journal of Nursing Management, 11 (2), 73–79. Tracey, C. (2006). The glass ceiling in Irish healthcare: A nursing perspective. Journal of Health Organization and Management, 20 (6), 502–511. World Medical Association Inc. 2nd edn. 2009). Medical ethics manual. [Cited 30 March 2012]. Available from: URL: http://www.wma.net/en/30publications/30ethicsmanual/pdf/ ethics_manual_en.pdf
International Journal of Mental Health Nursing (2014) 23, 221–231
doi: 10.1111/inm.12049
Feature Article
‘How do we know if this is the best?’ Mental health-care professionals’ views on national guidelines for psychosocial interventions Boel Sandström,1,2,3 Ania Willman,1,4 Bengt Svensson3 and Gunilla Borglin1,5 1
School of Health Science, Blekinge Institute of Technology, 2Blekinge Center of Competence, Karlskrona, Department of Health Sciences, University of Lund, Lund, 4Department of Care Science, Malmö University, Malmö, and 5Department of Health Sciences, Karlstad University, Karlstad, Sweden 3
ABSTRACT: National guidelines are released regularly, and professionals are expected to adopt and implement them. However, studies dealing with mental health-care professionals’ views about guidelines are sparse. The aim of the present study was to highlight mental health-care staff’s views on the Swedish national guidelines for ‘psychosocial interventions for schizophrenia or schizophrenia-type symptoms’ and their implementation. The study took place in the southeast parts of Sweden, and data were collected through five group interviews consisting of 16 professionals working either in the county council or in the municipalities. The transcribed text was analysed by content analysis, revealing two categories. The first category ‘a challenge to the practice of care as known’ reflected that the release of guidelines could be perceived as a challenge to prevailing care and culture. The second category ‘anticipating change to come from above’ mirrored views on how staff expected the implementation process to flow from top to bottom. To facilitate working in accordance with guidelines, we suggest that future guidelines should be accompanied by an implementation plan, where the educational needs of frontline staff are taken into account. There is also a need for policy makers and managers to assume responsibility in supporting the implementation of evidence-based practice. KEY WORDS: evidence-based practice, group interview, guideline, mental health, nurse.
INTRODUCTION National guidelines are nowadays viewed as a vital component in evidence-based practice (EBP) (Grol et al. 2005; Oxman et al. 1995; Thomas et al. 1999). To enhance the quality and effectiveness of mental health care for persons diagnosed with schizophrenia or schizophreniatype symptoms, in 2011, the Swedish National Board of Health and Welfare 2011 (NBHW) published the first Correspondence: Boel Sandström, School of Health Science, Blekinge Institute of Technology, Campus Gräsvik, Valhallavägen 1, Karlskrona SE-371 79, Sweden. Email: [email protected] Boel Sandström, RN, MSc. Ania Willman, RN, BEd, PhD. Bengt Svensson, RN, MSc, PhD. Gunilla Borglin, RN, MSc, PhD. Accepted September 2013.
© 2013 Australian College of Mental Health Nurses Inc.
national guidelines for psychosocial interventions to target this group (hereinafter referred to as the guidelines). They were developed to guarantee that people with schizophrenia have equal access to high-quality care. In all, they cover 43 psychosocial interventions in the following areas: early intervention, individual participation and influence, family intervention, psychological treatment, social skills training, accommodation, and vocational rehabilitation. The release of these guidelines is coupled with the expectation that all mental health-care professionals will transform them into standard care. The NBHW produce guidelines first and foremost based on systematic reviews and meta-analysis, and secondly on separate studies of good quality. When there is insufficient scientific evidence, the prioritization is made by multiprofessional expertise groups. Their recommendations
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are then run by a group of people active in clinical practice (i.e. a consensus panel). In this way, the NBHW investigates if a general agreement exists about the recommendations: the suggested interventions effect. Thus, guidelines are drawn up on the basis of current research and the lessons of experience. Presently, no implementation guidance, such as the guidance published by the National Institute of Clinical Excellence (NICE) in the UK, accompanies the national guidelines. In the end, it is up to the local and regional decision makers to ensure the implementation of the guidelines. Guidelines should be viewed as broad principles of best practice. To be effective, they need to be converted into local practice guidelines. Guidelines can thus be understood to be a means to an end, where the latter is EBP. Internationally, the consensus is that mental health care should be based on evidence (Gordon & Ellis 2013). At present, there is little proof of how guidelines of this kind actually influence practice, or how the mental health community views and experiences them (Proctor et al. 2009). The adoption of guidelines has been known, without any reasonable explanation, to be particularly slow within mental health care (Tansella & Thornicroft 2009). Furthermore, EBP, as it is currently structured, has been questioned and criticized, especially within mental health care. Capturing the essence in this context is said to require complementary methodological approaches, as evidence deriving from studies with a quantitative design might be insufficient (Fisher & Happell 2009). Even if guidelines are viewed as important tools for EBP, they are not ‘magic bullets’, as passive diffusion (i.e. releasing national guidelines) does not lead to a change in practice by osmosis (cf. Rycroft-Malone et al. 2004). Successful transformation of guidelines into local practice depends on several key factors, and the professionals are just one of those factors. We know that success relies on an informed target group and a positive attitude to the guidelines (Corrigan et al. 2003; Grol et al. 2005). However, to date, there is a lack of studies that focus on mental health care and the views of professionals, especially studies conducted with a qualitative design. Certain factors are barriers that obscure the uptake and implementation of EBP. The main barriers are related to the organizational context and to the individuals in this context (Aarons et al. 2012; Corrigan et al. 2003; Proctor et al. 2009). On an organizational level, barriers could take the form of lack of support from managers, a change-averse culture, and bureaucratic constraints (Corrigan et al. 2003). On the individual level, a lack of understanding and insufficient knowledge of the guidelines have been shown to stifle the EBP process
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(Bahtsevani et al. 2004; Francke 2008). Views and personal beliefs can also be associated positively or negatively with uptake of new knowledge (Estabrooks et al. 2003; Greenhalgh et al. 2005) and the use of guidelines (Alanen et al. 2009; Quiros et al. 2007). Professionals’ views on guidelines have been explored mainly in studies with a quantitative design; for example, studies dealing with guidelines about smoking-cessation advice (Puffer & Rashidian 2004), hand hygiene (Quiros et al. 2007), hypertension (Alanen et al. 2009), and prevention of falls (Stenberg & Wann-Hansson 2011). It is worth noting that these studies refer to ‘somatic’ healthcare staff. On the surface, certain dissimilarities seem to exist between mental health-care and other healthcare contexts. In general, the composition of a mental health-care team tends to reflect a higher degree of multiprofessional involvement than a somatic care team (Fiddler et al. 2010). This multiprofessional environment also includes a ward round, which is rarely conducted at the bedside or on a daily basis, as in somatic care. Finally, the mental health-care professionals’ focus, and the basis of their care, is interpersonal therapeutic engagement (Cutcliffe & Happell 2009; Peplau 1952), while somatic care professionals can be said to focus more on the ‘physical body’. Thus, it would seem reasonable to propose that this reflects two different cultures. We do not know how the findings presented above actually transfer to or truly reflect mental health-care professionals. Lakeman (2013) recently put forward Fancher’s (1995) idea that we should view mental healthcare services as cultures of care with their own norms, traditions, and rituals. Gershon et al. (2004) stated that the culture of an organization is shaped by the attitudes and assumptions of its inhabitants. Adopting this view could help to understand and explain variations in practice and how it can be changed, while still bearing in mind that ‘what service improvement really means in many places is a shift in culture’ (Lakeman 2013, p. 10). Gaining an insight into mental health-care professionals’ views and practice in localized communities is of importance, especially if the goal is EBP. Thus, the aim of the present study was to highlight professionals’ views about recently-released guidelines for schizophrenia and the implementation of those guidelines.
METHOD This study employed a qualitative design, collecting data by group interviews (Morgan 1997) and analysing the texts by qualitative content analysis, as described by Burnard (1996). © 2013 Australian College of Mental Health Nurses Inc.
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Context
Sample and recruitment
Lakeman (2013) highlights the importance of offering a careful description of the general context in which the research has been conducted. Only then can those who are beyond the immediate horizon understand practice. Mental health care in Sweden is provided through two systems. County council mental health-care providers are responsible for medical care and medical treatment, while the municipal authorities and their social welfare systems are responsible for generic services, such as individuals’ accommodation, activities, finances, and need for support in their daily lives. The multidisciplinary teams, regardless of their location, consist of registered nurses (RN), often specializing in psychiatry, and enrolled nurses, where the latter are the majority. Other members of the team include occupational therapists, psychologists, social workers, practice development coaches, and psychiatrists. For the past 15 years in Sweden, the only route to the nursing profession has been through a bachelor’s degree in nursing science (i.e. 3 years at university). Specialization involves a further year at university. In general, the enrolled nurses have a 3-year high school education. They have similar responsibilities and work tasks as the assistant practitioners working in band four in the UK (Spilsbury et al. 2009). Enrolled nurses are not professionally regulated as RN, but Swedish health-care regulations stipulate that all health-care professionals are responsible for working in accordance with the latest scientific evidence and lessons of experience. Working in accordance with national guidelines is accordingly considered to be every health-care professional’s responsibility.
A total of 16 informants participated in the study (Table 1). A purposive sample (Polit & Beck 2012) consisting of five RN, five enrolled nurses, four practice development coaches, one occupational therapist, and one social worker was used with the intention of obtaining informants who were directly involved professionally with the guidelines. Inclusion criteria were mental health-care professionals who worked directly with people diagnosed with schizophrenia or schizophrenia-type symptoms. Ten different mental health-care facilities in the county council were initially targeted. Five of the 10 facilities accepted the invitation (eligible staff: n = 67). Reasons given by the facilities not participating were lack of time, lack of familiarity with the contents of the guidelines, and heavy workload. In three of the five facilities, oral and written information was given during a workplace meeting. In two facilities, the managers informed their staff and handed out the written information and the request to participate.
Data collection Five group interviews were conducted during April and May 2012 (approximately 12 months after the release of the national guidelines); two in community mental health care and three in psychiatric outpatient departments. All interviews began with two overarching questions: ‘Tell me about your views on the guidelines’ and ‘Tell me about their implementation’. Probing questions were used to support the interviewees (Polit & Beck 2012). All group interviews took place during working hours in a separate room at the informants’ workplaces, thus in a place
TABLE 1: Overview of the informants’ characteristics Participant A B C D E F G H I J K L M N O P
Group
Sex
Age (years)
Education
Profession
Years in current position
1 1 1 2 2 2 3 3 3 3 4 4 4 5 5 5
Female Female Female Female Female Female Male Female Male Male Female Female Female Female Female Female
57 41 57 60 55 33 49 33 33 44 58 38 42 56 58 40
Diploma & specialist education BSN & specialist education Diploma Diploma & university education Upper secondary school BSN & specialist education University education University education University education Residential college for adult education Upper secondary school University education Upper secondary school University education Upper secondary school BSN & specialist education
RN – psychiatry RN – psychiatry Allied health professional RN – accredited psychotherapist Enrolled nurse RN – psychiatry Practice development coach Practice development coach Practice development coach Practice development coach Enrolled nurse Allied health professional Enrolled nurse Enrolled nurse – accredited psychotherapist Enrolled nurse RN – psychiatry
25 8 21 26 28 6 4 4 4 4 28 8 14 36 23 8
BSN, bachelor’s degree in nursing science; RN, registered nurse.
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familiar to the informants and at a time that would maximize participation. All informants had received oral and written information about the study. The group interviews were tape-recorded and lasted approximately 60 min.
Data analysis The transcribed texts were analysed by content analysis, as described by Burnard (1996), with the aim of identifying key issues in data, and interpreting meaning from the content of data. The method is an inductive process consisting of four steps. First, the transcripts were read through several times to gain an understanding of the whole, and sentences or paragraphs that had a reference to the study aim that appeared to capture key thoughts or concepts were identified and highlighted. Second, the highlighted parts were condensed into shorter phrases, while still preserving the meaning. In the third step, these meaning units were analysed and open coded one by one while asking the following questions: What are they actually talking about? What does it mean? What else is similar to this? What is it distinct from? Thereafter, in the fourth step, the meaning units were grouped into
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subcategories, based on similarities and differences, and then compared and contrasted with the text to ensure credibility (Burnard 1996). Finally, the subcategories were reduced by abstraction, labelled using poetic expressions or metaphors when adequate (Lindseth & Norberg 2004). The first and last authors were both involved in the analysis. Both authors read the raw data thoroughly and the emerging interpretations. Regular discussions were additionally held with the other authors to enhance the thoroughness in the interpretation of the text and to secure the best possible account of the views found in the text (Table 2).
Researchers’ reflexivity To guard against personal biases in judgment making, all authors relied on reflexivity (Polit & Beck 2012). By doing so, the authors took into account their previous experiences as RN working within mental health care (BS, BS) and in somatic care. (GB, AW) Thus, by acknowledging being part of the setting and the context, as well as using the process of self-reflection about personal biases and preferences, the quality of the study could be enhanced (Schwandt 2007).
TABLE 2: Sub-categories and categories Quotations
Subcategories
The first time we talked about this . . . well we were two who raised our hands, who had looked at the guidelines. (1:C) We ourselves are poorly updated, and then it’s not surprising that patients and families are poorly updated. (5:N) But here we make up . . . our own little (guidelines) . . . sometimes, or often, we do just that, because we don’t know of anything else. (1:A) And I think it’s a little dependent on the doctor, if you have a doctor at all, and the attitude and the experience the doctor has. (1:B) When you have researched this using psychotherapy, then one has come to the conclusion that it’s the alliance between the patient and the therapist that is the active part and how do you measure that? (5:P) And there is nothing that says that this is the best (method), but it’s the only one that has been researched. (3:I) It should probably come from somewhere . . . higher up, and I think it should come from the court in the county council where they work with knowledge, development, and skills development. (2:F) It is of paramount importance that full details of all methods are disseminated, and that is up to the managers, so it is. (4:K) Then it’s a job every time. As soon as a new guideline is released, we have to reorganize practice, and then it’s going to be a reorganization with every new guideline. (2:D) I mean, we are already working in that way. We don’t call it by that name, but we are doing just that. (2:F) Somehow, with a review of the practical application of the various methods, the two principles need to be on board; both the municipality and the county council. (2:E) It is the fact that we have got the money, and we have a project, a project . . . perhaps foremost, and then there is the training too. (3:J)
Not common knowledge
Categories A challenge to the practice of care as known
Threading the same path
Questioning the base
Anticipated pathway
Anticipating change to come from above
Demands for change
A process sensitive to organization and culture
Acronyms refer to the participants (A–K), and numbers refer to the groups.
© 2013 Australian College of Mental Health Nurses Inc.
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Ethical considerations The study was conducted in compliance with the established ethical guidelines of the Declaration of Helsinki (World Medical Association Inc 2009). Verbal and written consent was obtained. Under the Swedish Ethical Review Act, this study did not require ethical clearance.
FINDINGS The analysis indicated that mental health-care professionals’ views on the guidelines and their implementation could be understood in the light of the categories ‘a challenge to the practice of care as known’ and ‘anticipating change to come from above’, with their supporting subcategories (Table 2). The subcategories are illustrated by quotations from the group interviews, where 1–5 correspond to the groups, and A-K correspond to the participants, as described in Table 1.
A challenge to the practice of care as known The ‘challenge to the practice of care as known’ category reflected the view that the guidelines, or their content, were not something everyone were aware of; that is, the subcategory ‘not common knowledge’. It also reflected how the guidelines were considered to emphasize the importance of staff working in the same way; that is, the subcategory ‘treading the same path’. Here, views also revealed a lack of reliability with regard to the evidence underpinning the released guidelines; that is, the subcategory ‘questioning the base’ (Table 2). Overall, the category showed that guidelines could be perceived as a challenge to embedded practices; that is, prevailing care and culture. Not common knowledge
In the subcategory ‘not common knowledge’, the informants’ views reflected their knowledge of the guidelines. The degree ranged from not being aware at all to familiarity with the content, and ultimately already working in accordance with one of the recommended interventions. The informants shared the view that the guidelines were not common knowledge among the teams, expressed as: ‘No, I have to say I have not considered them’. (4:K) Despite a commonly-held view of the importance of the guidelines, one reason given for not having any knowledge of them was the lack of general discussion within the teams. The informants stated that discussions focused mainly on the staff ’s obligations and areas of responsibility. The informants wanted to go through the guidelines, discuss their content, and decide how to make best use of the recommendations: © 2013 Australian College of Mental Health Nurses Inc.
225 What aspects in these guidelines would benefit our patients the most? What would enhance their current quality of life? What are we doing at present? Why are we doing it? How do we know if this is the best? (1:B)
Contrasting views were reflected on in terms of the accessibility of the guidelines. Views represented those who stated that the guidelines were written in a complicated, formal language, and they wanted a ‘lay’ version. Others stated that the guidelines were easy to understand and were written in plain Swedish. Views relating to awareness and knowledge among service users were also reflected. Informants stated that the small numbers that were actively involved in user associations would be informed, but this would not be the case for the majority of service users. Discussions about ethical aspects, more specifically, the issue of informing service users about recommended interventions not yet commonly known among the professionals, let alone implemented, were also highlighted. Treading the same path
The subcategory ‘treading the same path’ reflected the benefits of underpinning decision-making with guidelines. Here, the informants raised the absence of discussion about the fundamental values underlying the care offered to service users and the lack of a uniform working approach. Guidelines were viewed as useful tools that provide a base for the teams to work in a more coordinated way. The guidelines were also viewed as recommendations for treatment, and something on which practice could be based. They were described as something to relate to, and something one might or might not be obliged to follow. Furthermore, they were referred to as ‘rights for the service users’; that is, what could be expected from mental health care and its professionals. Informants discussed the problem that the care offered was often dependent on the attitudes and experiences of physicians or of a specific therapist. The national expectation to deliver ‘care on equal terms’ was highlighted, as the informants stated that care could not live up to that standard if the teams made up their own set of guidelines: If you look at a private company, I guess it would be different. Everyone is familiar with the business and what they should and should not do. Knowing how to make a Volvo, for example. You can’t do it in any old way; it’s a car. There must be guidelines that everyone is aware of and that need to be followed. (1:A)
Questioning the base
The subcategory ‘questioning the base’ was interpreted as reflecting views on the concept of ‘evidence’. A great deal
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of criticism was aired regarding the importance of a method and the emphasis on the method being evidence based. Strong views were put forward about the time it takes to get to know the value of interventions or treatments, which meant that by the time they become established, they are already outdated. Perceptions about the type of research design that was viable also became discernible, and concern was expressed. If only randomized, controlled trials (RCT) were considered rigorous enough to equal evidence, what about knowledge originating from other types of designs not suitable for randomization? The informants also expressed concern about the risk of knowledge from studies with a quantitative design being used to answer questions about service users’ experiences: There is a difference in how . . . you conduct research and whether you have a quantitative or qualitative design. By quantitative I mean things you can measure, things that are difficult for us to adjust to the patients’ experiences. You can’t squeeze that into a quantitative template or measure it using columns. You have to ask about experience, but then you might end up with just a small sample and that would not count as evidence, because that might not be. . . . You might think: ‘Is it these quantitative studies that will be the foundation of what will count as evidence based and the treatment you can adopt? It’s difficult to research things that are a little different. (2:D)
Here, the views reflected concern that working in accordance with evidence-based methods would endanger the alliance between the professional and the service user. This can be discerned from statements, such as: Then again, you can do ever so much in a . . . non-aligned way or, how should I put it, where I don’t have an alliance with the service user then . . . it wouldn’t be good, even if it was evidence based. (5:P)
In addition, there was also the perception that activities the professionals believed would benefit the service users, regardless of whether or not they were underpinned by evidence: I think it’s good to evaluate, and it’s good to have evidence-based stuff, but we’re doing things that we can scarcely measure . . . I think about mindfulness, something I really believe in . . . and there’s actually research relating to this, but maybe not enough to call it evidence based. I don’t know for sure, but I do believe in this a lot, and I transfer this belief to the patients, who I feel would benefit from this (belief ). (5:P)
Anticipating change to come from above The category ‘anticipating change to come from above’ could be understood from the three subcategories ‘antici-
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pated pathway’, ‘demands for change’, and ‘a process sensitive to organization and culture’. Here, the perceived expectations of staff were revealed about how the implementation process should be initiated; that is, top to bottom and organized: ‘an anticipated pathway’. It was also reflected in the requirements that would emerge from a change in working approach; that is, ‘demands for change’. The subcategory ‘a process sensitive to organization and culture’ reflected views on factors that could enhance the implementation process. Anticipated pathway
In the subcategory ‘anticipated pathway’, the informants expressed the expectation that vital information and new knowledge from the government, local authorities, and regions would be passed on to them automatically. This expectation was also discernible in statements pinpointing the managers’ responsibility to present the guidelines and ensure all the staff were updated. The discussions reflected the fact that several levels were felt to be involved in the implementation of the guidelines. It was acknowledged and expected that the ‘starting signal’ had to come from higher up; preferably from someone specially appointed to keep track of new laws and regulations and the release of guidelines. It was suggested that the decision to change practice in accordance with the recommendations must be a political decision, and the dissemination process should, therefore, commence with that decision. It then needed to be passed on to the managers, and eventually to the teams. Although acknowledging their responsibility to remain updated on research, the expectation still remained that someone higher up in the organization bore primary responsibility: However, the manager needs to be updated. It is for her to know about this and that. If she doesn’t know, it’s out in the ether somewhere. (1:B)
Demands for change
In the subtheme ‘demands for change’, the general perception was that the guidelines recommended interventions that were too rigid and too inflexible, thus making it awkward to implement them in the multidisciplinary teams’ clinical reality. Informants stressed a belief that implementing any of the interventions demanded a reorganization of practice. Reorganization was not regarded as a realistic option but was nevertheless thought to be necessary if the new guidelines were to be implemented. The informants stated that it was important not to transform a well-described intervention into something mediocre and then assume it was the same, or that © 2013 Australian College of Mental Health Nurses Inc.
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it would produce the result originally anticipated. Some informants stated that some of the recommended methods were similar to activities or interventions already used. Here, the perceived lack of reliable channels in the organization was also highlighted; channels that would ensure that vital information would not become blocked and not be passed on. It was stated that the guidelines were known and debated in the organization in response to the national referral. Despite this, more than 1 year after release, they had still not been disseminated within the organization. The need for some kind of quality system was stressed: Still, you have to decide that you want it; that you want a quality system to relate to; to have matters under control and not just believe that someone will fix it. It must be decided who’s going to do it, when, and in what way. (1:C)
Process sensitive to organization and culture
The subcategory ‘sensitive to organization and culture’ highlighted a general perception regarding implementation of the guidelines and ways in which implementation could be impeded by the organization and the culture. One factor that was raised was time, and views were mixed regarding the importance of time. Some informants thought that lack of time might be an impeding factor, whereas others thought it would not. It was a matter of prioritizing and deciding how to spend the time available. However, they agreed that time was a factor that needed to be taken into account: It (implementation) does not take place just because you take 2 minutes at a workplace meeting to announce that there are new guidelines being published. (1:A)
Receiving support in the form of money, training, and help to monitor the implementation of a recommended intervention was considered beneficial. The significance of education and training was clearly expressed by the informants. The informants felt that training resulted in a clear mission, and that they felt secure and strong when working in accordance with the guidelines. This subcategory also covered views that revealed that assistance from a facilitator would be helpful in the implementation process. It was suggested that the facilitator should be skilled in informing and explaining guidelines and their implementation. The informants stated that someone familiar with the guidelines or concerned about practice development would be suitable. Participating in seminars or conferences dealing with the recommended guidelines was also considered as useful. © 2013 Australian College of Mental Health Nurses Inc.
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DISCUSSION Our findings can be seen in the light of the two categories ‘a challenge to the practice of care as known’ and ‘anticipating change to come from above’, with their underpinning subcategories (Table 2). The first category illustrated staff’s views on the national guidelines for schizophrenia in general, and the second category reflected their views on the implementation of these guidelines. Both categories mirrored views permeated by contradictions. Staff could relate to the guidelines and view them as possible power tools. The recommendations could facilitate a more coordinated working approach, and staff acknowledged them as fundamental rights for service users. However, they could also be viewed as rigid and inflexible, and staff felt that implementing them would demand a change of current practice; a change they, at the moment, did not seem prepared to participate in. Their contradictory responses might be explained by the fact that the guidelines had not yet been ‘bedded down’. Staff’s confession of lack of knowledge and awareness about the guidelines might be another explanation. As earlier mentioned, we know that lack of awareness and lack of knowledge have been recognized as major barriers to implementation (Bahtsevani et al. 2004; Francke 2008). According to Lakeman (2013), people crave certainty, and working in accordance with EBP requires that staff are unceasingly involved in reflecting on their activities of care that otherwise might be taken for granted. One of our most noteworthy findings was the apparent clash between the views of mental health-care professionals and what they perceived as ‘science’. Although staff admitted they did not have much knowledge of the content of the guidelines, despite the fact that they had been released 12 months earlier, they nevertheless expressed scepticism about the evidence base underpinning them. They questioned the ways in which the evidence was developed, and its reliability. They also believed that only quantitative studies supported the recommendations, and expressed their concern that the service users’ views might be overlooked. Many felt that the NBHW recommendations were mainly based on systematic surveys, as meta-syntheses in this area are scarce. Furthermore, in Sweden, service users are unfortunately not yet included in the development of guidelines to such an extent as one could wish for. Moreover, staff felt that their activities could not be measured and tended to favour soft values; that is, theirs and the service users’ experiences. One plausible explanation for staff’s scepticism towards the guidelines could be, as
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Richards and Hammers (2009, p. 1159) suggests, that ‘many practitioners believe that each therapeutic relationship is so unique that it cannot be observed, measured and copied to the benefit of other patients. Process rules over content.’ Thus, research evidence about efficacy (i.e. RCT) might be regarded as challenging for the practitioners, and increased emphasis on this type of knowledge is opposed (Fisher & Happell 2009; Rycroft-Malone et al. 2004). Departing from a broader evidence base for practice has been suggested, blending research, clinical and patient experiences, and information from the local context. This was already emphasized by Sackett et al. (1996), who defined EBM as integration between individual clinical expertise and best external clinical evidence from systematic research, together with the use of individual patients’ predicaments, rights, and preferences in making decisions about their care. If EBP is ever to be implemented, professionals must understand that it is they, together with service users, who are supposed to integrate EBP into their clinical expertise. Instead, working in accordance with guidelines was perceived as a possible threat to the core of mental health care; that is, interpersonal therapeutic engagement. Accordingly, to avoid ‘rocking the boat’, informants suggested that it was more important to rely on their own professional experiences and to trust themselves, despite the fact that this was done at the expense of research evidence. They also felt that having faith in the activities that had already been integrated into the services, together with the interpersonal relationship, was more beneficial for the service users than any of the recommended guidelines. Their emphasis on the therapeutic relationship is not surprising, as it has a strong position, and is viewed as the core of the culture (Cutcliffe & Happell 2009; O’Brien 1999). However, a good, therapeutic relationship on its own will hardly help patients into stable housing, competitive work, more effective symptom control, or a more functional family situation. These are what the guidelines are supposed to help to achieve. A possible explanation for the staff viewing the issue in terms of either an interpersonal relationship or evidence-based methods was admitting to having insufficient knowledge of the guidelines. Consequently, none of the informants seemed to be able to provide an informed critical view of the guidelines. Another possible explanation could be that the professionals might lack the skills needed to be active and critical research consumers. Our finding about the informants’ strong perceptions of faith and its importance to practice is supported by Lakeman (2013, p. 106), who suggests: ‘Many beliefs held by mental
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health professionals might be considered to be based on faith rather than science’. It is important to note that the professionals’ experiences are suggested to be a vital part of the development of EBP (Rycroft-Malone et al. 2004); however, allowing faith alone, possibly at the expense of evidence, to be the driving force in care seems a dangerous path to follow. It would appear crucial to take into account hierarchical structures when trying to implement guidelines. Our findings indicate that the professionals expected that a reorganization was needed to implement the guidelines, and that the initiative for change would have to come from above. Despite this, they still questioned the guidelines, and did not feel that furthering the development of care in accordance with the recommendations was part of their remit. Thus, their views once again reflected a sense of ambivalence. Others have already highlighted that the bureaucratic environment in which healthcare professionals typically practise is likely to promote top-down decision-making (Thyer 2003). We also know that unlike most modern organizations with their flatter, less hierarchical organizational structures, the majority of health-care organizations still support the classical hierarchical model (Tracey 2006). This kind of environment is known to foster an attitude that leads to unwillingness to be involved in the EBP process and perpetuates the top-down mentality among health-care staff (Fineout-Overholt et al. 2005). Looking at our findings, the paradox here seems to be that it would appear that the professionals wanted a change, but did not want to change themselves. Their reliance on hierarchical implementation was perhaps a way of expressing their ambivalence towards the guidelines and their implementation. Our findings need to be understood as a key element embedded within a specific context and culture. Lakeman (2013) proposes that when viewing mental health care through a cultural lens as a culture of care, it is necessary to understand how and why practice changes. Culture is shaped by the people who are part of it, as well as by their attitudes and assumptions (Gershon et al. 2004). Thus, we suggest that the challenge here will be how to change the hierarchical structure and the culture, and instead promote a bottom-up mentality that will favour and encourage professionals to embrace EBP more readily. Not unexpectedly, some of our findings reinforce earlier research, highlighting a need for resources in the form of time, education and training, and assistance from an external expert to facilitate the implementation process, as well as the importance of leaders and managers (Rycroft-Malone 2004; Rycroft-Malone et al. 2004). © 2013 Australian College of Mental Health Nurses Inc.
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Others have acknowledged the intricate interplay between several factors and have highlighted the importance of research designs that take all of these variables into account. There is reason to believe that those who have the greatest impact are nurse managers, as they can affect the professionals’ culture and context (Gifford et al. 2006; Sandström et al. 2011; Scott-Findlay & Golden-Biddle 2005). However, managers are often better equipped and trained in management issues than they are at being responsible for care improvement (Boström et al. 2013; Lorensen et al. 2002). Strategies that involve a sense of ownership in the whole team need to be developed.
Study limitations This study’s relatively small sample (n = 16) has implications for the trustworthiness of the findings. Although the sampling was purposively conducted, it was homogenous in aspects, such as sex. This implies that the result can be specific for women within this context, and that homogeneity can affect transferability of the result. However, the informants’ different ages, education, and time in position might have counterbalanced this. Our goal was to gain a contextualized understanding of informants working in multidisciplinary mental health-care teams’ views on a certain phenomenon; that is, the guidelines. Therefore, the amalgam of realities presented here might be regarded as the views of the informants, and as such, they might be transferable to similar settings. The choice to conduct group interviews instead of focus groups was based on the fact that ‘mini groups’ are likely to increase interaction, but also, due to the topic, we wished to emphasize the questions– responses between the interviewer and the informants and not the interaction within the group (Morgan 1997, p. 12). In this study, the small number was found to contribute to a relaxed conversation (Carey 1994), allowing everyone to be actively involved. Content saturation (Polit & Beck 2012) was achieved after four group interviews, although one more was conducted to confirm the findings. Finally, there is always a risk of subjectivity in data interpretation, and there is always more than one possible way to interpret a text. The first author, who took the lead in the analysis, acknowledged her pre-understanding of the research setting consisting of her previous experience as an RN in a similar context. Additionally, all authors critically reflected on the interpretative process; their role in the analytic process and their preconceived ideas (Mauthner & Doucet 2003) were regularly discussed throughout the analysis to ensure trustworthiness. © 2013 Australian College of Mental Health Nurses Inc.
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CONCLUSIONS AND RELEVANCE TO PRACTICE Analysing the target group and knowing what drives and impedes change in their specific culture are of great importance for successful implementation, but this is rarely done. Consequently, more studies that investigate attitudes and views on changes in embedded practice are needed to gain an insight into what strategies might work. In-depth interviews exploring staff’s experiences of guidelines and of working in accordance to guidelines could be one approach to gain further insight into the topic. The narratives illustrate that the professionals were ambivalent, and that they did not believe the evidence underpinning the guidelines. Systematic reviews and meta-analysis did not reflect their practice, and they felt that the recommendations might collide with the therapeutic relationship. They preferred to trust in their own belief in what was right for the service user, and anticipated change to come from above. A broader knowledge base, where evidence from clinical practice, service users, and local culture becomes more visible, could make professionals more involved and willing to embrace the guidelines. However, ways to turn this process around and encourage professionals to be more proactive in the development of the care offered to the service users warrants further study.
ACKNOWLEDGEMENT We would like to thank the staff who participated in the study, and Patrick O’Malley for his help with language revision. We are also grateful to Blekinge Research Council, Blekinge Competence Centre, Blekinge Institute of Technology, Karlskrona, and Karlstad University, Sweden who funded this study.
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