RRN Meeting November 10 th 2015 Focus on

RRN Meeting November 10 th 2015 Focus on Implementation of recovery Research Findings Shula Ramon University of Hertfordshire and Anglia Ruskin University

Implementation is not a new issue The issue of implementation in the context of research is not new. Focused upon by research funding organisations, such as the NIHR. The ESRC established centre in Southampton University The Journal of Implementation is thriving A shared interest internationally, especially in English speaking countries Has it become a more pressing issue in an austerity period?

The focus of the new meaning of recovery It is a development that differs in a number of important dimensions from that of medicine as we know it. It focuses on care rather than on cure On individual journeys rather than on a uniformed outcome, Strengths rather than weaknesses or deficits, On social inclusion, The value of experiential knowledge alongside scientific knowledge, And the centrality of the service user voice.

The new meaning of recovery has come about to an extent as a critique of past and present practices in mental health, As well as of the medical model of mental ill health; This embedded critique is bound to make the approach difficult to accept by practitioners trained otherwise. It is always asking for complex interventions, due to the need to encompass a bio-psycho-social domain.

Approaches to implementation of innovation The issue of implementation used to be referred to under the heading of diffusion of innovation (Rogers, 2004, Grennhalgh et al (2004) Appropriated into management theory and practice; Organisational change; Focus on the learning organisation (Senge, 1990). Under these headings the focus was on identifying early adopters of a specific innovation and working with them as the change agents, identifying barriers to and facilitators of the innovation, considering strategies to resolve or neutralise barriers and to enhance facilitators.

Application to mental health innovation and recovery innovation Thus Brooks, Pilgrim and Rogers (2011) in their research of innovative practices in mental health which focused on projects funded by NESTA, highlight barriers and facilitators of innovation in this field which largely relate to organisational structure, demonstrating that voluntary organisations have greater flexibility within their structure which facilitates the adoption of innovation. Leamy et al (2014) apply a similar framework to the analysis of interviews with practitioners as to what will promote recovery oriented practice in mental health services. They indicate the centrality of organisational readiness for change and training effectiveness as the key factors in enabling innovation to be taken up. Interestingly both studies did not attempt to include service users or carers as participants, perhaps tacitly assuming that in both contexts innovation is primarily organisational in nature and impact, even though these researchers are known to be committed to the promotion of users and carers’ perspectives, and given that the aim of the innovation is to improve the lives of these two groups.

Translational Value of Research The focus on translational aspects of research is a more recent development from the 1990 s. The definition of translational research by the US medical academy is: Translational research fosters the multidirectional and multidisciplinary integration of basic research, patient-oriented research and population based research, with the long term aim of improving the health of the public (Mc. Gartland Rubio et al, 2011). The authors highlight that translational research is dynamic in that it has a circular structure which leads to further development, in a process spanning lab research, application in trials with humans to enhancing the adoption of best practices in the community, including cost-effectiveness of prevention and treatment.

The Normalisation Process Theory (NPT) approach to implementation Unlike the approaches outlined above, which come from either organisational management or from experimental medicine, NPT comes from a more sociological background and from social sciences methodologies. Most of the research utilising this approach has focused on “chronic illnesses” such as diabetes and cardiovascular illness. While the focus on long term illness has some resonance in the field of mental health, caution is necessary here due to the lack of focus on the new meaning of recovery in mental health. Not only is mental illness a much more contested area, but the recovery focus negates the assumption of chronicity as a taken for granted outcome of mental ill health.

The questions NPT asks: What is the work (of implementation, change of practice)? Who does the work? How is the work getting done? Why did the work happen like that? NPT is a further development of the Normalisation Process Model (NPM) , aiming to be a middle range theory, or analytical tool, that focuses specifically on the how and why of embedding new approaches to become “normalised”, routinized, practice (May and Finch, 2009). It provides an explanatory framework to be used in planning and evaluating the introduction of a new way of working.

NPT constructs NPT uses the following constructs in its analysis of a particular attempt to embed an innovation, be it technological, clinical, or community oriented, into integrated practice: Coherence: shared set of ideas about the meaning , uses, utility of the proposed change, and by socially defined competencies Cognitive participation: in the interaction chain that makes up an implementation process, a practice is framed through cognitive participation Collective Action: powers of invention and agency of a Community of Practice, embedded work shaped by factors that promote or inhibit actors’ participation Reflexive monitoring: a continuous, informal and formal, evaluation of practice Interestingly the factor of emotional work is not mentioned by theorists of NPT.

Operationalising NPT Table 2 from May and Finch 2009 article (p. 549) provides a framework for operationalising the key concepts, by breaking down the meaning of each of these concepts along the lines of: 1. systematic explanation of mechanisms and components at work 2. Knowledge about the sources and operation of investments at work 3. Investigation of core questions that could be included – two key questions per each key concept.

Mc. Avoy et al (2014) carried out a qualitative systematic review of studies that applied NPT analysis. 29 such studies were identified between 2006 to 2012, mostly on e-health and primary care, with several that look also at mental health interventions in primary care. The conclusion from this systematic review is that NPT constructs have high stability across settings, and provide evidence of its beneficial heuristic capability to explain and guide implementation processes. What is the prospective value of NPT?

Prospective NPT research Most NPT research projects are taking a retrospective approach, partly because it is a new theory. An example of first attempt at the prospective use of NPT is provided in the EU Framework 7 project Healthcare for migrants, participatory health research and implementation science – better health policy and practice through inclusion. The Re. STORE project (Mac. Farlane et al, 2014). The project aims to fill in a translational gap as its objective is to investigate and support the implementation of guidelines and training initiatives to support communication in cross-cultural consultation in selective European primary care settings. Ireland, England, the Netherland, Austria and Greece

Design Qualitative and participatory health project. Combined use of NPT and Participatory Learning Action Research (PLAR) Following and shaping the implementation journeys of the guidelines and training initiative In parallel a policy analysis using the same mixture is taking place in Scotland (Nicola Burns, Glasgow). All project staff were trained in NPT and PLAR

Learning from Success This is a relatively new focus to be included in evaluation and analysis of research that has practice implications. The protagonists of this approach argue that while learning from failure focuses on what not to do, learning from success enables learning what could be done that would lead to successful outcomes. This approach focuses intuitively on strengths, rather than on deficits and weaknesses, and as such is more akin to the recovery paradigm than the learning from failure would be. Success can encompass not only outcomes, but also processes, and the perspectives of a variety of stakeholders. Success can be both a subjective construct, as well as an intersubjective one.

Issues and examples It is not always easy to define what success is, and it may depend on reaching an agreement among different stakeholders, but usually it is defined as WHAT WORKS in achieving agreed objectives. The existing research in this area comes mainly from social work, but has been also applied to mental health. For example, Marie Diggins’ research examined success in parental mental health and child care from the perspectives of parents, children above the age of 11, mental health and child care practitioners, as well as analysing existing mental health and child care files of the study participants (Diggins, 2016). Researching success includes looking at success in other types of family work, safeguarding children, and working with higher education students experiencing learning difficulties ( Rosenfeld et al, 1998, Schechter et al 2008). The PROMISE project which will be presented today provides another example of focusing on practitioners’ success.

Types of successful mental health practice organisational success, crisis resolution, relationships, turnarounds Collaboration is perceived as a pre-condition for success Recovery processes and outcomes.

Research has highlighted that the definition of success differs significantly between practitioners and service users/carers, though there a number of converging areas. The main two differences are: 1. practitioners find it much harder to identify success than service users or carers. 2. while service users identify some outcomes as successful, satisfaction (a process variable) is often perceived as success too, and small successes count not less than big ones. Thus for the children of parents experiencing considerable mental ill health having shared enjoyable activities is a success, and not only keeping the parent out of a hospital admission.

Recovery as success; Success in recovery We do know that success is a motivating factor, with each small success encouraging making the effort to achieve a bigger one, while failure is a demotivating factor leading to avoidance and reduced effort. Thus far learning from success is not perceived as relevant to implementation, but I would beg to differ and to suggest that we should include it not only in training commissioners, practitioners, service users and carers, but also as an analytical factor in enabling implementation and in its evaluation (Westrmarland Kelly, 2013, Ramon, 2016).

REFERENCES Brookes, H. Pilgrim, D. , Rogers, A. (2011) Innovation in mental health services: what are the key components of success? Implementation Science, 6, Diggins, M. (2016) Learning from success in parental mental health and child care. In: Diggins, M. (ed) Parental Mental Health and Child Welfare. Brighton: Pavilion Annals 2016, forthcoming. Elwyn, G. E. et al (2008) Arduous Implementation: Does the Normalisation Process Model explain why it’s so difficult to embed decision support technologies in routine clinical practice? Implementation Science, 3: 57. Gallagher, K. et al (2011) Understanding Patients Experience of Treatment Burden in Chronic Hart Failure using Normalisation Process Theory. Annals Family Medicine, 9, 3, 235 -243. Greenhalgh, T. C. et al (2004) Diffusion of Innovation in Service Organisation: systematic review and Recommendations. Milbank Quarterly, 82 (4), 581 -629 Leamy, M. et al (2014) Implementing a Complex Intervention to Support Personal Recovery: A qualitative Study Nested Within a cluster Randomised Trial. PLOS ONE vol 9, 5, Mac. Farlane, A. et al (2014) Health care for migrants, participatory health research and implementation science – better health policy and practice through inclusion. The Re. STORE project. European Journal of General Practice, 2014, 20, 148 -152. May, C. , Finch, T. (2009) Implementation, Embedded and Integrated Practice: An outline of Normalisation Process theory. Sociology, 43, 3, 535 -544.

References 2 Mc. Avoy, R. et al (2014) A Qualitative Systematic Review of Studies Using the Normalisation Process Theory to Research Implementation Process. Implementation Science, 9, 2, 1 -13. Mc. Gartland Rubio, D. et al (2010) Defining Translational Research: Implications for Training. Academic Medicine 85, 3, 470 -475 Ramon, S. (2016) Learning from Success: Conceptual Introduction. In: Diggins, M. (ed) Parental Mental Health and Child Welfare. Brighton: Pavilion Annals 2016, forthcoming. Rogers, E. M. (2004) A prospective and retrospective look at the Diffusion Model. Journal of Health Communication, 9, 9, 13 -19. Rosenfeld, J. M. , Sykes, I. J. (1998) Towards Good Enough Services for inaptly served children and families. European Journal of Social Work, 193), 285 -300. Schechter, C. Sykes, I. J. , Rosenfeld, J. M. (2008) Learning from success as leverage for school learning: lessons from a national programme in Israel. International Journal of Leadership in Education, 11, 3, 301 -318. Westmarland, N. Kelly, L. (2013) Why extending measurement of “success” in domestic violence perpetrators programmes matters for social work. British Journal of Social work, 43, 1092 -1110.