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      Understanding clinician attitudes towards implementation of guided self-help cognitive behaviour therapy for those who hear distressing voices: using factor analysis to test normalisation process theory

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          The Normalisation Process Theory (NPT) has been used to understand the implementation of physical health care interventions. The current study aims to apply the NPT model to a secondary mental health context, and test the model using exploratory factor analysis. This study will consider the implementation of a brief cognitive behaviour therapy for psychosis (CBTp) intervention.


          Mental health clinicians were asked to complete a NPT-based questionnaire on the implementation of a brief CBTp intervention. All clinicians had experience of either working with the target client group or were able to deliver psychological therapies. In total, 201 clinicians completed the questionnaire.


          The results of the exploratory factor analysis found partial support for the NPT model, as three of the NPT factors were extracted: (1) coherence, (2) cognitive participation, and (3) reflexive monitoring. We did not find support for the fourth NPT factor (collective action). All scales showed strong internal consistency. Secondary analysis of these factors showed clinicians to generally support the implementation of the brief CBTp intervention.


          This study provides strong evidence for the validity of the three NPT factors extracted. Further research is needed to determine whether participants’ level of seniority moderates factor extraction, whether this factor structure can be generalised to other healthcare settings, and whether pre-implementation attitudes predict actual implementation outcomes.

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          The online version of this article (doi:10.1186/s12913-017-2449-z) contains supplementary material, which is available to authorized users.

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          Most cited references 11

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          11 - Cluster Analysis

           P.A. Gore,  A FIELD,  A. Field (2000)
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            Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders.

            The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority. This paper presents CPGs for schizophrenia and related disorders. Over the past decade schizophrenia has become more treatable than ever before. A new generation of drug therapies, a renaissance of psychological and psychosocial interventions and a first generation of reform within the specialist mental health system have combined to create an evidence-based climate of realistic optimism. Progressive neuroscientific advances hold out the strong possibility of more definitive biological treatments in the near future. However, this improved potential for better outcomes and quality of life for people with schizophrenia has not been translated into reality in Australia. The efficacy-effectiveness gap is wider for schizophrenia than any other serious medical disorder. Therapeutic nihilism, under-resourcing of services and a stalling of the service reform process, poor morale within specialist mental health services, a lack of broad-based recovery and life support programs, and a climate of tenacious stigma and consequent lack of concern for people with schizophrenia are the contributory causes for this failure to effectively treat. These guidelines therefore tackle only one element in the endeavour to reduce the impact of schizophrenia. They distil the current evidence-base and make recommendations based on the best available knowledge. A comprehensive literature review (1990-2003) was conducted, including all Cochrane schizophrenia reviews and all relevant meta-analyses, and a number of recent international clinical practice guidelines were consulted. A series of drafts were refined by the expert committee and enhanced through a bi-national consultation process. This guideline provides evidence-based recommendations for the management of schizophrenia by treatment type and by phase of illness. The essential features of the guidelines are: (i) Early detection and comprehensive treatment of first episode cases is a priority since the psychosocial and possibly the biological impact of illness can be minimized and outcome improved. An optimistic attitude on the part of health professionals is an essential ingredient from the outset and across all phases of illness. (ii) Comprehensive and sustained intervention should be assured during the initial 3-5 years following diagnosis since course of illness is strongly influenced by what occurs in this 'critical period'. Patients should not have to 'prove chronicity' before they gain consistent access and tenure to specialist mental health services. (iii) Antipsychotic medication is the cornerstone of treatment. These medicines have improved in quality and tolerability, yet should be used cautiously and in a more targeted manner than in the past. The treatment of choice for most patients is now the novel antipsychotic medications because of their superior tolerability and, in particular, the reduced risk of tardive dyskinesia. This is particularly so for the first episode patient where, due to superior tolerability, novel agents are the first, second and third line choice. These novel agents are nevertheless associated with potentially serious medium to long-term side-effects of their own for which patients must be carefully monitored. Conventional antipsychotic medications in low dosage may still have a role in a small proportion of patients, where there has been full remission and good tolerability; however, the indications are shrinking progressively. These principles are now accepted in most developed countries. (vi) Clozapine should be used early in the course, as soon as treatment resistance to at least two antipsychotics has been demonstrated. This usually means incomplete remission of positive symptomatology, but clozapine may also be considered where there are pervasive negative symptoms or significant or persistent suicidal risk is present. (v) Comprehensive psychosocial interventions should be routinely available to all patients and their families, and provided by appropriately trained mental health professionals with time to devote to the task. This includes family interventions, cognitive-behaviour therapy, vocational rehabilitation and other forms of therapy, especially for comorbid conditions, such as substance abuse, depression and anxiety. (vi) The social and cultural environment of people with schizophrenia is an essential arena for intervention. Adequate shelter, financial security, access to meaningful social roles and availability of social support are essential components of recovery and quality of life. (vii) Interventions should be carefully tailored to phase and stage of illness, and to gender and cultural background. (viii) Genuine involvement of consumers and relatives in service development and provision should be standard. (ix) Maintenance of good physical health and prevention and early treatment of serious medical illness has been seriously neglected in the management of schizophrenia, and results in premature death and widespread morbidity. Quality of medical care for people with schizophrenia should be equivalent to the general community standard. (x) General practitioners (GPs)s should always be closely involved in the care of people with schizophrenia. However, this should be truly shared care, and sole care by a GP with minimal or no specialist involvement, while very common, is not regarded as an acceptable standard of care. Optimal treatment of schizophrenia requires a multidisciplinary team approach with a consultant psychiatrist centrally involved.
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              Implementing the NICE guideline for schizophrenia recommendations for psychological therapies: a qualitative analysis of the attitudes of CMHT staff.

              Despite national guidelines recommending cognitive-behavioural therapy (CBT) and family intervention (FI) in the treatment of schizophrenia, levels of implementation in routine care remain low. The present study investigates attitudinal factors amongst community mental health team (CMHT) staff affecting guideline implementation. CMHTs were audited to measure the capacity and delivery of CBT and FI, and semi-structured interviews were conducted with staff from the teams. Methods. Four CMHTs were audited, and five care coordinators from each team were interviewed. A purposive approach to sampling was used to represent the range of professional training of care coordinating staff. Data were analysed using thematic content analysis. Positive views towards guidelines were evident, although tempered by specific implementation issues. Employing simple psychological interventions and approaches as part of the care coordinating role also emerged as highly valued by staff. Severe workload, time pressure and the need for specialist staff were crucial barriers to implementation. Pessimistic views of recovery for clients with psychosis were also apparent and may affect implementation. Staff attitudes and knowledge are an important area of research when examining guideline implementation and require further study. Key themes that have emerged could inform future training agendas and should be considered when developing guideline implementation strategies for the updated 2009 guidelines. Copyright © 2010 John Wiley & Sons, Ltd.

                Author and article information

                01273 265896 ,
                BMC Health Serv Res
                BMC Health Serv Res
                BMC Health Services Research
                BioMed Central (London )
                24 July 2017
                24 July 2017
                : 17
                [1 ]ISNI 0000 0004 1936 7590, GRID grid.12082.39, School of Psychology, , University of Sussex, ; Falmer, Brighton, BN1 9QJ UK
                [2 ]R&D Department, Sussex Partnership NHS Foundation Trust, Sussex Education Centre, Hove, BN3 7HZ UK
                © The Author(s). 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

                Funded by: FundRef, Economic and Social Research Council;
                Award ID: ES/J500173/1
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                © The Author(s) 2017


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