RESEARCH REPORTS Measuring outcomes in learning disability ...

Publication review: Foresight Mental Capital and Wellbeing reportsAffiliationsProfessor Dave Dagnan, Consultant Clinical Psychologist &Clinical Director, The Learning Network, Cumbria PartnershipNHS Foundation TrustContact informationProfessor Dave Dagnan, dave.dagnan@cumbria.nhs.ukReferencesFor all reports associated with the project go tohttp://www.bis.gov.uk/foresight/our-work/projects/currentprojects/mental-capital-and-wellbeing/reports-andpublicationsBeddington, J., Cooper, C. L., Field, J., Goswami, U., Huppert,F. A., Jenkins, R., Jones, H. S. et al. (2008). The mental wealthof nations. Nature, 465, 1057-1060. Retrieved December 1,2010,http://www.bis.gov.uk/assets/bispartners/foresight/docs/mental-capital/ment0al-wealth-nations-nature.pdfRESEARCH REPORTSMeasuring outcomes in learning disability challenging behaviourservices: Exploring barriers to outcome measurement in northernchallenging behaviour teamsJane Birrell & Dave DagnanAbstractThis paper describes a qualitative study that explores the barriers and drivers to the use of outcome measures in challengingbehaviour teams for people with learning disabilities in the north of England. The paper makes use of a ‘force-field analysis’ toidentify possible areas of intervention to facilitate the use of such measures.Keywordsoutcomes; challenging behaviour; force-field analysis; learning disabilitiesIntroductionMeasuring outcome of clinical interventions is essential froma number of perspectives:1. Current government policy puts outcome as one of thethree core areas of quality (the other two being patientsafety and patient experience; Darzi, 2008);2. Within a service line management approach, outcome ispart of the quality profile that is balanced with activityand cost in the delivery of a pathway(http://www.monitornhsft.gov.uk/sites/default/files/Monitor_Conf_briefing_sheet%20FINAL.pdf); and3. Regardless of government or organisational focus it isprofessionally and ethically essential that cliniciansensure that the services that they provide meet servicesusers needs in the most effective and appropriatemanner.However, despite a number of ‘drivers’ to utilise routineoutcome measures, clinicians routinely report theirinfrequent use (e.g., Hatfield & Ogles, 2004). There aremodels that might be useful in understanding why outcomemeasures are not more frequently used. For example,Moulding, Silagy and Weller (1998) suggest a model ofpractice change, which draws upon “diffusion of innovationtheory, the trans-theoretical model of behaviour change,health education theory, social influence theory and socialecology”. Their proposed framework emphasises theimportance of a multi-faceted pre-implementationassessment of:“(a) readiness of clinicians to adopt the guidelines intopractice, (b) barriers to change as experienced by cliniciansand (c) the level at which interventions should be targeted”(Moulding, Silagy & Weller, 1999, p.177).One method for assessing the barriers to change is forcefieldanalysis. This method is based upon Lewin’s (1951)model of change, which states that any situation can beunderstood as a ‘frozen’ equilibrium maintained by abalance of driving and restraining forces (see Figure 1).The Cumbria Partnership Journal of Research, Practice and Learning 1(1) 5

Measuring outcomes in learning disability challenging behaviour servicesTable 1: Scores allocated to issues encouraging implementation of outcome measures (driving forces)Level Item Score Total ScoreIndividualPersonal Professional Development 36Desire to observe improvement for clients/feedback to self 38Drive to improve team performance/increase team cohesion 33Direct interaction with clients/carersNeed to provide feedback to clients/carers 21Desire to improve the quality of service provided to clients/carers 24Need to promote the role of the practitioner/team 10OrganisationalPolicy 25Service changes/redesign 33Need to demonstrate effectiveness and efficiency 42Government/wider fieldResearch/increasing evidence base 10Government pressures/legislation 1828Total Score 29010755100Similarly to the driving forces, the restraining forces at theindividual level were endorsed more strongly that those atany other level. The score for the individual level restrainingforces (141) was significantly higher than the score for theindividual level driving forces (107). The client-based andwider barriers were considered least important, obtainingscores of 41 and 20 respectively. The items that achieved thehighest scores were individual level items, including a lack ofknowledge and skills (41) and a lack of time (43).Interestingly, the overall score for driving forces (290) issignificantly higher than that for the restraining forces (203).Table 2: Scores allocated to issues preventing implementation of outcome measurement (restraining forces)Level Item Score Total ScoreIndividualLack of knowledge/skills 41Lack of time 43Individual attitudes 28Differences in clinical practice 18Team dynamics 11141Direct interaction with clients/carersDifferences in outcomes prioritised 7Complexity of working with these clients 16Joint-working with private and other providers 1841OrganisationalLack of funds/resources 34Pressure for turnover 7Service design issues 18Changing priorities 1271Government/wider fieldLack of priority/interest in this field 5Lack of evidence for individual measures 12Complexity of the field 320Total Score 203The Cumbria Partnership Journal of Research, Practice and Learning 1(1) 7

Measuring outcomes in learning disability challenging behaviour servicesDiscussionThis study has described the use of force-field analysis toidentify barriers and drivers to the routine implementationof outcome measurement in learning disability challengingbehaviour teams. The analysis has shown that teams identifythe drivers and barriers that have the strongest effects, andthe biggest discrepancy between drivers and barriers, asbeing at the level of the individual clinician and individualclinical practice. Thus it seems likely that the most effectivepoints to intervene to change practice would be those at thelevel of the individual clinician.One of the most frequently cited barriers to change atthe individual level was a lack of knowledge and skillssurrounding the use of outcome measures. It is, therefore,suggested that regular training in the use of particularmeasures would be highly beneficial. It may be helpful todraw upon the existing knowledge and experience withinstaff teams. In this way, groups of clinicians could be trainedto use new measures on a regular basis, by members withinthe team who are familiar with and/or routinely useparticular measures. It is proposed that such methods wouldenhance the knowledge and skills of the clinicians, but alsothat observing examples of the use of measures by theircolleagues would build confidence and staff cohesion.Individual attitudes to change were identified as anintrapersonal barrier to improving routine outcomemeasurement. Thus, it may be useful for clinicians to beprovided with a forum in which to voice their concerns andfears (such as at the shared practice day at which thisresearch was conducted) and to discuss difficulties in usingoutcome measures with colleagues and peers. Theidentification of a named clinician with some knowledge, aparticular interest or significant experience in using outcomemeasures to which colleagues could bring queries andconcerns may help to overcome some of the negativeattitudes towards this particular change in practice.Factors at other psychosocial levels that mightparticularly merit intervention include further strengtheningof the driver “need to demonstrate effectiveness andefficiency” and challenging a perceived “lack of resourcesand funds”. It is possible that these two issues (both ofwhich score highly in terms of their impact upon the currentequilibrium) could be linked in helping the teams explorethe efficiencies possible as a result of good quality outcomeassessment that might demonstrate the “resource value” ofoutcome measurement systems.This paper has described the use of force-field analysis asa method to examine the challenges around theintroduction of effective outcome measurement. The paperhas provided important insights into clinical understandingof this issue. It is suggested that the method is a useful toolin developing understanding of organisational issues and inproducing implementation plans based upon the experienceof participants.AffiliationsJane Birrell, Clinical Psychologist, Cumbria Partnership NHSFoundation TrustProfessor Dave Dagnan, Consultant Clinical Psychologist &Clinical Director, The Learning Network, Cumbria PartnershipNHS Foundation TrustContact informationProfessor Dave Dagnan, dave.dagnan@cumbria.nhs.uk.Key ReferencesBritish Psychological Society (2004). Psychologicalinterventions for severely challenging behaviours shown bypeople with learning disabilities: Clinical Practice Guidelines.Leicester: BPSDagnan, D. (2007). Psychosocial interventions for peoplewith learning disabilities. Advances in Mental Health andLearning Disabilities, 2, 3-7.Darzi, A. (2008). High quality care for all: NHS next stagereview final report. London: Department of Health.Hatfield, D. R., & Ogles, B. M. (2004). The use of outcomemeasures by psychologists in clinical practice. ProfessionalPsychology, 35, 485-491.Lewin, K. (1951). Field theory in social science. New York:Harper & Row.Moulding, N. T., Silagy, C. A., & Weller, D. P. (1999). Aframework for effective management of change in clinicalpractice: Dissemination and implementation of clinicalpractice guidelines. Quality in Health Care, 8, 177-183.West, M. A., & Farr, J. L. (1989). Innovation at work:Psychological perspectives. Social Behaviour, 4, 15-30.8 The Cumbria Partnership Journal of Research, Practice and Learning 1(1)