Journal of Nursing Management, 2014, 22, 884–893
Mapping attitudes and awareness with regard to national guidelines: an e-mail survey among decision makers 1 € BOEL SANDSTR OM R N , M S c , ANIA WILLMAN GUNILLA BORGLIN R N , M S c , P h D 4
RN, BEd, PhD
2
, BENGT SVENSSON
RN, MSc, PhD
3
and
1
PhD Student, Blekinge Institute of Technology, School of Health Science, Karlskrona, Department of Health Science, Lund University, Lund and Blekinge Center of Competence, Karlskrona, 2Professor, Blekinge Institute of Technology, School of Health Science, Karlskrona and Department of Care Science, Malm€ o University, Malm€ o, 3 Associate Professor, Department of Health Science, Lund University, Lund, and 4Associate Professor, Blekinge Institute of Technology, School of Health Science, Karlskrona and Department of Nursing, Karlstad University, Karlstad, Sweden
Correspondence Boel Sandstr€ om Blekinge Institute of Technology School of Health Science SE–37179 Karlskrona Sweden E-mail:
[email protected]
(2014) Journal of Nursing Management 22, 884–893. Mapping attitudes and awareness with regard to national guidelines: an e-mail survey among decision makers
SANDSTRÖM B., WILLMAN A., SVENSSON B. & BORGLIN G.
Introduction The adoption of evidence-based guidelines within the mental health field has been slow. Changing inadequate practice is therefore a formidable challenge for mental health-care managers. Aim To explore decision-makers’ attitudes and awareness regarding the national guidelines for psychosocial interventions targeting people with schizophrenia. Method A questionnaire distributed by e-mail to 592 Swedish decision-makers was analysed using descriptive and comparative techniques. Results Significantly more of the top-level mental health-care managers than politicians stated that they knew about the national guidelines (i.e. their release and content) and they considered the guidelines to be a good source of support for planning and allocating resources. Conclusion If those responsible for allocating resources (i.e. politicians) are unaware of the dissemination of national guidelines or their content, and they do not perceive the national guidelines to be a good source of support for planning and allocating resources, this is likely to have a negative influence on the remit of nurse managers as well as nursing practice. Implications for nursing management Top-level mental health-care managers have a vital role to play in the implementation of national guidelines. However, our findings indicate that implementing national guidelines in practice could be virtually impossible without strategic government support. Keywords: attitude, electronic survey, evidence-based practice, guidelines, mental health Accepted for publication: 17 December 2012
Introduction It is well known that the implementation of evidencebased guidelines, regardless of clinical specialization, is a cumbersome process and the adoption of guide884
lines within the mental health field has been especially slow (Tansella & Thornicroft 2009). There is still a huge gap in mental health between what we know and what we do (Proctor et al. 2009) even though evidencebased practice (EBP) and evidence-based methods for DOI: 10.1111/jonm.12061 ª 2013 John Wiley & Sons Ltd
Attitudes towards guidelines targeting mental health care
treatment have become more readily available within mental health care in recent years (Proctor et al. 2007). However, replacing ineffective treatment with effective treatment that has been evaluated and documented in national guidelines is a formidable challenge for all health-care leaders and managers (cf. Levi et al. 2010). Guidelines have been presented as a tool to make research findings more easily available to health-care practitioners (Grol & Grimshaw 2003, Miller & Kearney 2004, Wallin et al. 2005). Guidelines are defined as ‘systematically developed statements to help practitioners make patient decisions about appropriate health care for specific clinical circumstances’ (Lohr & Field 1992). The purpose of the guidelines is to reduce inappropriate variation in clinical practice, enhance quality, provide safe care (Sacket et al. 1996, Taylor & Allen 2007) and reduce health-care costs (Dopson et al. 2003). Implementation of EBP often demands a change in practice and a change of behaviour, which can take a long time and may require a great deal of energy, especially when the effort involves a large number of people on national, regional and local levels. It is, however, vital to distinguish between dissemination and implementation. While successful dissemination can result in the target group being informed and having knowledge of and a positive attitude towards a set of guidelines, the result of implementation lies in the actual use and continuous application of the new routines (Grol et al. 2005). Many European countries now produce and release national guidelines on a regular basis (Bero et al. 1998, Grimshaw et al. 2004). In the UK, for example, the National Institute for Health and Clinical Excellence (NICE) seems to be at the forefront in Europe by not only creating guidelines but also by publishing guidance and practical advice on implementation. In Sweden, the Swedish Council on Technology Assessment in Health Care (SBU) produces systematic reviews and recommendations for changes in clinical practice (Wallin & Ehrenberg 2004). In addition, in Sweden it is the National Board of Health and Welfare (NBHW) that produces national guidelines based on (1) available research and (2) on the prioritization by multiprofessional expertise groups. It is important to separate national clinical guidelines from other guidelines, such as protocols, checklists and local standards, as the latter are not usually based on rigorous research evidence (Miller & Kearney 2004). Hence, the Swedish national guidelines that have been produced evaluate systematically the strength of the scientific evidence on which the recommendations are based. ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 884–893
In March 2011, the NBHW released the first national guidelines for psychosocial interventions targeting people diagnosed with schizophrenia or schizophrenia-like conditions (NBHW 2011) (hereinafter the national guidelines for schizophrenia). Their purpose is to direct politicians and top-level mental health-care managers in the planning of care as well as in their allocation and prioritizing of what treatments and services to offer (NBHW 2011). This is especially important as many individuals with schizophrenia live under pressing life circumstances and have an extensive need for support from society (Brunt & Hansson 2005). Thus, to alleviate some of the difficulties this group can experience, there is an urgent need for these guidelines to be implemented into clinical practice as soon as possible. It should be noted that Sweden does not yet provide any dissemination or implementation guidance, such as the guidance published by NICE in the UK, to accompany the national guidelines and to ensure a trickle-down effect and implementation. Ultimately, it is up to the local and regional decision-makers (i.e. top-level mental health-care managers and politicians) to prioritize and allocate resources in a way that enhances the dissemination and implementation of such guidelines. The organisation, its leadership and culture have been shown to influence health-care professionals’ intention to use guidelines in practice (Puffer & Rashidian 2004, Kortteisto et al. 2010, Sandstr€ om et al. 2011). Organisational culture is shaped by the norms, attitudes and assumptions of those working in it and it is therefore vital to the quality of the care offered (Gershon et al. 2004). Managers, regardless of level, have extensive responsibility for creating a culture that supports the implementation of national guidelines (Scott-Findlay & Golden-Biddle 2005, Gifford et al. 2006, 2007), as have politicians when deciding how to use limited public funding. Support from decisionmakers on the national and regional level would appear to be critical, especially when aimed at changing established practice in democratically governed organisations such as health and municipal care. Decision-makers can support the implementation process in several ways: through allocation of material and human resources, by making financial priorities and by reaching political decisions (Grol & Wensing 2004, Greenhalgh et al. 2005). It is obvious that without political support and decisions, no resources for planning, conducting and evaluating change will be provided (Guldbrandson 2007). Nevertheless, knowledge to date is sparse about how those who possess the power to initiate and reward a change of practice, 885
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namely politicians and top-level mental health-care managers, perceive national guidelines. In addition to the importance of the above, positive attitudes have been confirmed as a significant predictor of the aim to implement published guidelines (Puffer & Rashidian 2004, Quiros et al. 2007, Alanen et al. 2009). Along with attitudes and routines, lack of awareness and knowledge of new guidelines among professionals, and a lack of familiarity with the latest evidence in their field (Cabana et al. 1999, Bahtsevani et al. 2004, Francke 2008) have been recognized as major barriers to implementation. Hence, altering, reshaping or enforcing different behaviour (i.e. change) requires knowledge about people’s attitude to the issues at hand. Few studies to date have investigated attitudes and awareness among decisionmakers regarding national guidelines. Notably, they are the ones who bestow the power to exert significant influence over the organisational culture, its staff and their readiness to take on new ways of working. Knowledge and insight regarding the perception of key players (i.e. the decision-makers) can provide us with important information about how to facilitate dissemination and implementation of guidelines within the field of mental health care.
Aim This study aimed to explore attitudes and awareness among top-level mental health-care managers and politicians regarding recently released (March 2011) national guidelines for psychosocial interventions targeting people diagnosed with schizophrenia or schizophrenia-like conditions.
Method Context and sample A national census was carried out through a brief, descriptive, cross-sectional e-mail questionnaire. In Sweden, there are 290 municipalities in 21 counties. On the regional level, responsibility for financing and providing health care is decentralized to the county council, a political body whose representatives are elected by the public every 4 years. The hospital board of a county council exercises authority over the hospital structure and management and ensures efficient health-care provision. On the local level, each municipality has an elected assembly, the municipal council, which makes decisions in municipal matters. The municipal council appoints the municipal executive 886
board, which leads and coordinates municipal work (Government Offices of Sweden 2011). In the Swedish context, the elected politicians are in charge of the finances (i.e. the money handed down from the government to each county council and municipality) and consequently they are the ones setting the budget for the mental health services run by the top-level mental health-care managers. The sample (n = 592), is drawn from Sweden’s 290 municipalities and 21 county councils, and consists of politicians, chairpersons for the disabled and public care administrations and/or the social welfare boards (n = 299) as well as top-level mental health-care managers (n = 293). To be included, the respondents needed to be ultimately responsible for decisions concerning people diagnosed with mental health disorders and who are under the care of the municipal authority and/or health authority, county council or hospital. They also needed to answer ‘Yes’ to a screening question (i.e. ‘Are you aware of the recently released national guidelines?’) and they must have a public e-mail address. The respondents’ details, (names and e-mail addresses) were collected from the official municipal and county council websites and through contact with their secretariats. E-mail addresses for the municipalities and county councils were taken from the official website of the Swedish Association of Local Authorities and Regions (SALAR). The questionnaire was enclosed as a link in an e-mail containing information about the study. The information emphasized that participation was voluntary and the recipient was asked to activate the attached link, complete the survey and return. If they thought someone else in the organisation was more suitable to respond they were instructed to either forward the survey to that person or to name the person and return the survey to the sender (i.e. the researchers), who would then send the questionnaire to the new contact. The questionnaire was circulated in March 2011. Reminders, including the readministration of the questionnaire, were sent to non-respondents at 3 weeks (April 2011) and 7 weeks (May 2011).
E-mail questionnaire and data collection The e-mail questionnaire was developed specially for this study as no suitable existing questionnaire could be found during the literature search. After reviewing the literature within the subject area, eleven items were formulated based on the Theory of Planned ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 884–893
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Behaviour (Ajzen 1991) and NICE (2007) guidance focusing on barriers for change. The questions inspired by the latter (NICE 2007), concerned awareness and knowledge of the national guidelines, motivation, acceptance and beliefs. Three items covered socio-demographics (gender, age and years in current position). There was also a screening item where if the person answered ‘No’, they were instructed to end and return the questionnaire. The next set of 11 items comprised attitude questions (Ajzen 1991, Trost 1994) and contained items with responses ranging from 1 (Don’t agree at all) to 7 (Agree completely). Considerable attention was given to developing clear and unambiguous items. When items were developed, care was taken to use a simple language and short sentences that were neither double-barrelled nor leading. The questionnaire was kept short and simple with the aim of encouraging a response rate that was as high as in other studies that used a similar method and which indicated that e-mail questionnaires were effective (Spilsbury et al. 2009). Further points for consideration included the ease of distribution of the link to the questionnaire by e-mail. This was achieved with the aid of the web-based tool Websurvey (https://Websurvey. textalk.se). Individual items in the questionnaire were examined in a group of clinical nurses and nurse researchers who were asked to rate the relevance of each item to the construct being measured – they were also asked to comment on clarity, format and ease of completion and their suggestions were incorporated into the final version (cf. Rattray & Jones 2007).
Data analysis Data were imported into SPSS for Windows, (IBM SPSS Statistics 18; IBM, New York, USA) and analysed using descriptive, comparative and correlational analysis techniques. For descriptive statistics, percentages or median and interquartiles were used for nominal and ordinal scales. We also chose to add together each participant’s individual item scores to summated scores (Polit & Beck, 2012) to be able to present the mean summary score for the attitude scale. Although attitude scales provide ordinal data it is common to also present mean scores (Kasje et al. 2004, Quiros et al. 2007, Alanen et al. 2009) as according to Polit and Beck (2012) this enables comparisons between groups while making it possible to detect fine and important differences between the attitudes in the groups studied. As the responses to item 7 were negative, the scores were reversed so that higher scores represented a more positive attitude. Non-parametric tests (Pearson chi-square ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 884–893
test) were used when comparing differences in the proportions of nominal data. In comparisons between independent groups, such as politicians and mental health-care managers, a Student’s t-test was used. Values were considered statistically significant at P < 0.05 (Altman 1997).
Ethical considerations The study was conducted in compliance with the established ethical guidelines of the Declaration of Helsinki (World Medical Association Inc. 2009). Under the Swedish Ethical Review Act, this study does not need ethical clearance, although we nevertheless sought and received ethical guidance and advisory opinions from the Ethical Advisory Board in Southeast Sweden (ref. 67–2011). To ensure compliance with the Swedish Data Protection Act, data were stored securely and anonymized. Only the research team had access to the data.
Results A total of 314 politicians and top-level mental healthcare managers participated and the response rate was 55%. There were no significant differences between the included (n = 314) or excluded (n = 245) participants with regard to gender (P = 0.107) or representation from different parts of Sweden (P = 0.264). However, as regards profession, significantly more politicians (65.3%, P < 0.000) than top-level mental health-care managers (hereinafter managers) (34.7%) did not return the questionnaire. Significantly (P < 0.000) more politicians, than managers answered ‘No’ to the initial screening question (i.e. they were not aware of the released guidelines for schizophrenia) and were therefore excluded. The reasons for dropping out were: did not respond to any of the invitations, (84.5%); could not answer the questions because of lack of awareness of the guidelines (11.9%); the participant actively declined to participate (3.6%). Among those included in the analysis, female representation was significantly higher among the managers (P < 0.001) than among the politicians, where representation was equal (Table 1). Two-thirds (66%) of the politicians fell into the age groups 51–60 years and 61–70 years and were thus significantly older than the managers (P < 0.001). No other significant differences were found between the groups of participants. Representation from the northern, central and southern parts of Sweden was in line with the number of counties in the particular part of the country (Table 1). 887
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Table 1 Characteristics of the total sample and comparison based on profession Variables
Total sample (n = 314)
Female/male (%) Age groups (%)
