Anderson, N

Colbourn, Christopher

Davis, C

Howey, L

English

The aim of this research was to explore the phenomenon of missed appointments in Child and Adolescent Mental Health Services (CAMHS). It explored how clinicians experience and make sense of non-attendance by assimilating organisational and therapeutic perspectives

Teeside University's Research Repository

Dr. Nichola Anderson, Clinical Psychology Forum: Sent 28 October 2015   1  How CAMHS Clinicians Make Sense of Missed Appointments:  An Interpretative Phenomenological Analysis  Abstract  The aim of this research was to explore the phenomenon of missed appointments in Child and Adolescent Mental Health Services (CAMHS). It explored how clinicians experience and make sense of non-attendance by assimilating organisational and therapeutic perspectives.   Introduction  Appointment non-attendance has been discussed at length in the research literature, policy and in the media. The dominant discourse on non-attendance considers it in relation to its financial impact. Missed appointments are typically conceptualised as waste; not only do they waste NHS money and resources but they also increase waiting times for other service users. In an era where payment will soon follow successful clinical outcomes and healthcare budgets continue to be cut, non-attendance is a particularly salient issue. The current prevailing message across the NHS and within local mental health services emphasises the need for lean working and “doing more for less” (Jones & Mitchell, 2006).    Available evidence suggests that in mental health settings appointment reminders either by phone, letter (Reda et al., 2010) and, via text message (Sims, et al., 2012), can produce a modest increase in attendance (between 10% - 20%). However the evidence is inconsistent and replications are limited (Clougha & Caseya, 2014). The majority of strategies are based on the premise that service users simply forget their Dr. Nichola Anderson, Clinical Psychology Forum: Sent 28 October 2015   2  appointments, although there is limited empirical evidence to support this assumption (Benway et al., 2003). The assumption is challenged further by the fact that despite the abundance of reminder strategies, significant non-attendance rates remain. This suggests that other factors are at play, ones which are unaffected by current interventions. Thus, research dedicated to exploring psychological explanations of why service users miss appointments may be beneficial.   The child therapeutic literature estimates that approximately 40-60% of children and families dropout of treatment prematurely (Kazdin, 1996; Midgley & Navridi, 2006) and that this is typically preceded by numerous cancelled and missed appointments (Mirabito, 2003). Relative to the adult literature however, there is a paucity of research explicitly designed to investigate attendance and engagement with child and young people’s mental health services. Furthermore, given the dissimilar nature of services, and the increased complexity of providing support on a systemic, rather than individual level, the extent to which findings from adult research can be applied to the child population has been debated in the literature (Kazdin, 1996). The existing evidence offers a limited insight into the processes and mechanisms involved in attendance and engagement, especially in child services. The need for more qualitative research with professionals has been highlighted (Arai, et al, 2013).    Research from paediatric settings suggests that clinicians often hypothesise on an idiosyncratic basis regarding potential factors relating to engagement with treatment (Cameron et al, 2013). Untapped knowledge may reside within the therapeutic relationship; clinicians have specialist training that allows them to identify and work with these psychological processes to promote engagement. Thus clinicians are Dr. Nichola Anderson, Clinical Psychology Forum: Sent 28 October 2015   3  more able to identify and communicate therapeutic processes which may influence engagement and subsequent appointment attendance. The current research aims to generate new knowledge from a professional therapeutic perspective, and to build upon the existing corporate perspective of missed appointments, a viewpoint service users are less aware of. Due to their professional role within a service context, clinicians are inherently familiar with the corporate perspective and ideally positioned to explore other existing perspectives.  Method A sample of seven participants was recruited, consisting of multidisciplinary professionals from psychiatry, psychology, nursing and management. Recruitment was carried out indirectly though service and team managers. Information about the research was distributed to clinicians by individual team managers via the service manager. Clinicians were invited to opt in by contacting the researcher via email.   Semi-structured interviews (of 40-70 minutes) were carried out and transcripts were analysed using Interpretative Phenomenological Analysis (IPA); a rigorous qualitative methodology which can yield rich explorative information and in doing so provide a deeper understanding of engagement (Smith, Flowers, & Larkin, 2009). In IPA data analysis is an iterative process which begins with reading and re-reading each of the individual transcripts while making initial notes which will later be used to develop emergent themes. The researcher then searches for connections across themes within a single transcript. The process is repeated for each transcript, after which patterns are identified across cases and overarching themes are developed.   Dr. Nichola Anderson, Clinical Psychology Forum: Sent 28 October 2015   4  To acknowledge the researcher’s role in the analytic process, a reflexive journal was maintained throughout the research process. Triangulation was carried out between all four authors in an attempt to validate emergent themes; this involved contributions of different perspectives from academic, clinical, and managerial backgrounds.   Appropriate ethical and governance approvals were obtained from the local NHS Trust.  Results Overall three superordinate and ten subordinate themes were identified (Table 1) and represented differential levels of clinical awareness and understanding as well professional context.   Table 1. Superordinate and Subordinate Themes  Frontline Clinical Work Therapeutic Process Organisational Influences  Emotions  Complexity  Barriers  Clinician Role  Acceptance  Psychological Understanding  Reflection  Clinician Response  Power  Compatibility of Perspectives     Dr. Nichola Anderson, Clinical Psychology Forum: Sent 28 October 2015   5  Frontline Clinical Work  This superordinate theme includes information around the more overt aspects of clinical practice and how these are related to attendance and engagement.   Emotions  Clinicians discussed the overarching emotional experience of CAMHS involvement, including the emotions they experience in response to missed appointments, and the internal conflict this can often create. While clinicians generally hope service users attend appointments, they admitted that in reality non-attendance frees up valuable time to complete indirect work, providing some relief in an otherwise busy work environment.   Clinicians acknowledged the emotions experienced by service users upon entering and engaging with services. In response to missed appointments clinicians typically described a similar reaction of balancing feelings of relief and rejection. Clinicians also demonstrated empathy towards service users and acknowledged how coming to CAMHS and engaging in treatment can be a difficult, and often intimate experience, demonstrating insight into how this may impact attendance.   Complexity  The inherent complexity associated with working with families and wider systems (e.g. schools, social care etc.) was also discussed. Complexity can be conceptualised as representing the multifaceted and idiosyncratic nature of CAMHS working, as well as the challenging task of developing an understanding of each service user’s difficulties, their attendance, and engagement.  Dr. Nichola Anderson, Clinical Psychology Forum: Sent 28 October 2015   6   Barriers  Barriers to accessing CAMHS were identified, these included practical issues of attending appointments, differential referral routes, as well as mental health considerations, including stigma. The experience of engaging with CAMHS was also captured, specifically the lack of awareness and uncertainty surrounding mental health services, and how this may influence service users’ and their families’ attendance at appointments.   Clinician Role Clinicians reflected upon their own identity, how they view themselves in a professional role, and how they manage their drive to do all they can for service users. This expands on the Emotions subordinate theme and considers how clinicians make sense of their conflicting emotional responses to missed appointments. Clinicians described experiencing conflict between the drive to be a ‘good’ clinician and to provide direct clinical contact, and the desire to effectively manage service demands including clinical documentation and indirect pieces of work. They also described striving to balance doing ‘everything’ possible to engage service users while acknowledging the limits of their professional role.  Acceptance  The inevitability of missed appointments was consistently acknowledged as part of routine clinical practice and clinicians reflected upon how this is inconsistent with corporate drivers to reduce non-attendance.   Dr. Nichola Anderson, Clinical Psychology Forum: Sent 28 October 2015   7  Therapeutic Process This superordinate theme considers how clinicians understand, reflect upon, and respond to missed appointments within a therapeutic context. It outlines the sequential processes involved in how clinicians experience and make sense of missed appointments.   Psychological Understanding  Clinicians synthesise their own clinical experience, current evidence, and professional training to develop an understanding of service users. They discussed the application of psychological theory to facilitate formulation, as well as reciprocal communication, mutual expectations, collaboration, and the importance of beginnings, endings, and dynamics in the therapeutic process.   Reflection Clinicians revealed how they make sense of missed appointments within the context of the therapeutic dynamic. This includes the reflective processes clinicians experience in an attempt to understand the reasons underlying non-attendance, the information that provides about service user need, and ultimately how this informs re-engagement.    Clinician Response Clinicians then went on to discuss the application of the processes described in the previous themes (Psychological Understanding and Reflection) to clinical practice. In doing so they illustrated how their understanding of service user need can be informed by dynamics within the therapeutic relationship. Dr. Nichola Anderson, Clinical Psychology Forum: Sent 28 October 2015   8   Organisational Influences This superordinate theme relates to where service users feature in the power hierarchy and the powerful positions clinicians find themselves in within clinical sessions. There is also a consideration of how clinicians experience, make sense of, and manage the competing narratives and demands around missed appointments.  Power Parallel power imbalances between the service and the clinician and the clinician and service user were identified, alongside descriptions of how clinicians make sense of working as part of a hierarchical organisation and how they managed the demands and pressures inherent in their role.  Compatibility of Perspectives  Clinicians were able to reflect upon the incongruence between the corporate perspective of missed appointments, and how they assimilate this alongside their own psychological understanding, clinical training and judgements around why service users do not attend.   Discussion  The findings, specifically within the Psychological Understanding superordinate theme, highlight the importance of developing a psychological formulation to understand service user need and inform treatment. Participants often described processes through which they attempt to make sense of service user’s difficulties and needs by drawing on available therapeutic and theoretical models. Formulation Dr. Nichola Anderson, Clinical Psychology Forum: Sent 28 October 2015   9  is essential for CAMHS clinicians to fully understand service user difficulties and need, make sense of their presentation, and to effectively manage and contain their own, as well as service user’s emotional responses. In terms of the Frontline Clinical Work superordinate theme, an effective formulation would also help clinicians make sense of the emotions surrounding their responses to non-attendance and the dissonance this creates within their clinical role. Formulation can also serve to capture systemic complexity associated with CAMHS working as well as informing ways to overcome barriers to engagement.  The evidence suggests that non-attendance may also have implications for safeguarding (Arai, et al., 2013); formulation can help clinicians to determine to what extent non-attendance is representative of risk. Lastly, understanding engagement as part of a psychological formulation, may serve to challenge the notion that non-attendance is an inevitable part of clinical practice, and allow clinicians to reconceptualise non-attendance and reflect upon different ways of supporting service users to engage or disengage.  Findings from this research suggest that formulation is intrinsic to effective clinical practice as it allows clinicians to fully understand the individual needs of service users and their families. Formulation also supports clinicians to draw on current psychological principles and evidence to make sense of, and tailor their approach towards, promoting attendance and engagement. The emphasis on formulation highlights a valuable focus for future multidisciplinary workforce development.   The findings also emphasise the importance of reflective practice in understanding and meeting the needs of service users. The literature suggests that reflection is essential for effective clinical practice (Hawkins & Shohet, 2012). Throughout the transcripts clinicians described reflecting upon their own clinical practice as well as Dr. Nichola Anderson, Clinical Psychology Forum: Sent 28 October 2015   10  their interpersonal and emotional reactions to services users in an attempt to make sense of missed appointments. These reflective processes and the increased insight they generate can facilitate clinicians in adapting their clinical practice to best meet the needs of service users. Thus is it is important to support the development of reflective practice within CAMHS, this can be done through the provision of psychological supervision for all CAMHS clinicians and the introduction of routine outcome measures into clinical practice. The use of routine outcome measures including the Outcome Rating Scale (Miller & Duncan, 2000) and Session Rating Scale (Miller, Duncan, & Johnson, 2002) offer a tangible tool  to foster reflective practice as they provide real time feedback to clinicians and are intended to be discussed openly within the session with the service user.   Finally, the research has revealed clinicians’ understanding of engagement and in doing so has made a significant contribution to the existing literature. The findings from this study have the potential to open up dialogue between clinical and service level individuals through which mutual learning between can take place.   Dr. Nichola Anderson, Clinical Psychology Forum: Sent 28 October 2015   11  Acknowledgements  The authors would like to thank the clinicians who volunteered to participate in this study. This research was completed within Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) and was undertaken as part of the first author’s Doctorate in Clinical Psychology training at Teesside University.   Affiliations  Dr Nichola Anderson, Clinical Psychologist, Northumberland Tyne and Wear NHS Foundation Trust; Nichola.Anderson@ntw.nhs.uk.  Dr Lynne Howey, Consultant Clinical Psychologist, Tees, Esk and Wear Valleys, NHS Foundation Trust.  Prof Chris Colbourn, Research Tutor, Doctorate of Clinical Psychology, Teesside University.  Chris Davis, Service Manager, Tees, Esk and Wear Valleys, NHS Foundation Trust.     Dr. Nichola Anderson, Clinical Psychology Forum: Sent 28 October 2015   12  References  Arai, L., Stapley, S., & Roberts & Roberts, H. (2012). „Did not attends‟ in children 0-10: a scoping review. Child: Care, Health and Development, 40(6), 797-805.   Benway, C.B., Hamrin, V., & McMahon, T.J. (2003). Initial appointment non-attendance in child and family mental health clinics. American Journal of Orthopsychiatry, 73(4), 419-428.   Cameron, E., Heath, G., Redwood, S., Greenfield, S., Cummins, C., Kelly, D., & Pattison, H. (2013). Health care professionals’ views of paediatric outpatient non-attendance: implications for general practice. Family Practice, 31(1), 111-117.   Clougha, B.A. & Caseya, L.M. (2014). Using SMS Reminders in Psychology Clinics: A Cautionary Tale. Behavioural and Cognitive Psychotherapy, 42(3), 257-268.   Hawkins, P., & Shohet, R. (2012). Supervision in the helping professions (4th Ed). Berkshire: Open University Press.   Jones, D., & Mitchell, A. (2006). Lean thinking for the NHS. Available from www.nhsconfed.org/   Kazdin, A.E. (1996). Dropping out of child psychotherapy: Issues for research and implications for practice. Clinical Child Psychology and Psychiatry, 1(1), 133-156.   Dr. Nichola Anderson, Clinical Psychology Forum: Sent 28 October 2015   13  Midgley, N., & Navridi, E. (2006). An exploratory study of premature termination in child analysis. Journal of Infant, Child and Adolescent Psychotherapy, 5(4), 437-458.   Miller, S.D., & Duncan, B.L. (2000). The outcome rating scale. Retrieved from http://www.scottdmiller.com   Miller, S.D., Duncan, B.L., & Johnson, L. (2002). The session rating scale. Retrieved from http://www.scottdmiller.com   Mirabito, D.M. (2001). Mining treatment termination data in an adolescent mental health service: A quantitative study. Social Work in Health Care, 33, 71-90.   Reda, S., Rowett, M., & Makhoul, S. (2010). Prompts to encourage appointment attendance for people with serious mental illness. The Cochrane Database of Systematic Reviews, (2). DOI: 10.1002/14651858.CD002085.   Sims, H., Sanghara, H., Hayes, D., Wandiembe, S., Finch, M., Jakobsen, H., Tsakanikos, E., Okocha, C.I., & Kravariti, E. (2012). Text message reminders of appointments: a pilot intervention at four community mental health clinics in London. Psychiatric Services, 63(2), 161-168.   Smith, J.A., Flowers, P., & Larkin, M. (2009). Interpretative Phenomenological Analysis. Theory, Method and Research. London: Sage.    

How CAMHS clinicians make sense of missed appointments: An interpretative phenomenological analysis

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How CAMHS clinicians make sense of missed appointments: An interpretative phenomenological analysis

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