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They’re NICE and neat but are they
useful? A grounded theory
of clinical psychologists’ beliefs about,
and use of NICE guidelines.
A DClinPsychol research project by Alex Court, 3rd year Trainee
Clinical Psychologist.
Supervised by Anne Cooke, Canterbury Christ Church University
and Dr Amanda Scrivener, KMPT.
• Why do we need to conduct research into the
use of NICE guidelines in mental health
services?
NICE Aims
• To improve clinical effectiveness and reduce
variations in practice across NHS Trusts (DH,
1998).
Not so NICE Implementation
• Consistent reports that uptake of NICE guidelines
in UK mental health services is low.
(e.g. Lewis et al., 2012; Mankiewicz & Turner, 2012; Mears et al., 2008; Prytys et
al., 2011; Evaluation and Review of NICE Implementation Evidence (ERNIE)
database – “Doubts about or mixed impact in practice” / “Practice appears not to
be in line with guidance”)
Conflicting Views
•“The way in which they have been developed and
presented should be such that few recipients would
ever have cause to dispute the basis of the
recommendations.” (Littlejohns, 2000).
•“NICE guidelines are misleading, unscientific, and
potentially impede good psychological care and
help.” (Mollon, 2009)
• Berry and Haddock (2008) highlighted the
paucity of research into factors affecting the
use of NICE guidelines in UK mental health
services and stressed the need for such
research.
• In relation to NICE guidelines for mental
health conditions, research has investigated
adherence to guidelines by:
– GPs, (Gyani et al., 2011; Gyani, et al., 2012; Toner et al., 2010),
– care co-ordinators (Prytys et al., 2011; Sin & Scully, 2008),
– CMHT staff (Michie, et al., 2007; Rhodes, et al., 2010),
– psychiatrists and paediatricians (Kovshoff et al., 2012) and
– counselling psychologists (Hemsley, 2013).
My Study
•Interviewed 11 clinical psychologists.
•Grounded theory (Charmaz, 2006) was utilised
to guide the data collection and analysis.
•Aimed to develop a theoretical model,
conceptualising the clinical psychologists’
beliefs, decision making processes and clinical
practices.
Results
Overall Emerging Theme:
“Considering NICE guidelines to have benefits
but to be fraught with dangers.”
Considering NICE guidelines to have benefits but to be fraught with dangers
Recognising the context of the current economic climate
Valuing the
benefits of
NICE
guidelines
Plus
Influences
Worrying that NICE
guidelines can
create an unhelpful
illusion of neatness
Plus
Influences
Beliefs about the purpose of,
and future of clinical psychology
Perceived level
of pressure to
be NICE
compliant
Leads to
Having a flexible
relationship with
guidelines
Impacts
upon
Impacts
upon
Key Points
• Guidelines were seen as a useful guide to the evidence
base.
• The power of NICE endorsement was valued.
• The CPs worried that guidelines could easily be
misunderstood and used in a rigid and limiting manner.
• CPs managed the tension between the helpful and
unhelpful aspects of guidelines by relating to them in a
flexible manner.
• There were concerns about the harm that misuse of
guidelines could do to service users and also to the
profession of clinical psychology.
Beliefs About the Purpose of & Future of CP
• A difficult fit between the actual practice of CPs
and the language of NICE.
– Diagnosis vs formulation.
– Manualised therapy vs idiosyncratic, collaborative,
integrative approaches.
• As a result of pressure, and also the rewards that
follow from being seen to comply with NICE
guidelines, they tended to practice in ways that
prevent these skills from being recognised.
• “Well I, well I certainly wouldn't advertise what I do to
the managers.” (Amy).
• “I would probably say I’m doing CBT, even if I’m not
doing, you know, even if it’s a bit fudgy around the
edges.” (Jenny).
• “You can integrate – I quite often make use of
psychodynamic or systemic ideas which I might, you
know, bring into my CBT work…which I think is
perfectly fine within a CBT model. I mean you’re talking
about thoughts and feelings and you’re talking about it
in an interpersonal context.” (Sam).
Threat to Professional Identity
• Why train CPs in a variety of therapeutic
models if the “illusion” is that CBT is all that is
practiced?
• Why do we need CPs at all if services only
need CBT therapists?
Conclusions
• CPs need to improve the way that they advertise
their specialist skills.
• This is the first theoretical framework that
attempts to explain why NICE guidelines are not
consistently utilised in UK mental health services.
• Attention is drawn to the proposed benefits and
limitations of guidelines and how these are
managed.
Final Thoughts on Guidelines
• A common conclusion from the participants
was wanting NICE to be viewed as guidelines
and not instructions.
• The CPs wanted NICE guidelines to be seen as
a work in progress with numerous limitations.
“I think it deserves further research. So perhaps
I would say that I’m not sure that it (NICE)
should be there, I’m not sure it shouldn’t be
there. I think it needs to be absolutely
reviewed.” (Jan).
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