Intervention fidelity in the care for clients
with intellectual disabilities
A grounded theory study
Name student:
N. Stielstra (NS), 3505693
Course:
Afstudeeronderzoek
Version:
Final article
Date:
6 juli 2012
Supervisor:
Dr. R. van Linge (RvL)
Course instructor:
Drs. G. van der Hooft-Leemans
Journal:
Journal of Intellectual Disability Research
Max. amount of words journal:
4500
Reference style:
Harvard
Amount of words:
3496
Amount of words abstract:
253
Aantal woorden samenvatting:
234
Department of Clinical Health Sciences;
Master Nursing Science at University Medical Center Utrecht
Nienke Stielstra
February 8, 2016
Introduction
Today’s health care has to deal with its own rapid development. Research continuously
delivers innovative evidence based interventions (Sackett et al., 2000; Santesso & Tugwell,
2006; Turner et al., 2008). An intervention is defined as any act, performed to prevent harm
to a client or to improve the mental, emotional, or physical health of a client (Mosby, 2009).
Implementation of these interventions often fails due to a lack of intervention fidelity, which
negatively affect clients’ health (Moncher & Prinz, 1991, Bond et al., 2001). Intervention
fidelity is defined as the adherent and competent accomplishment of an intervention in daily
practice (Moncher & Prinz, 1991; Waltz et al., 1993).
Due to the effect of intervention fidelity on clients’ health, there is an increased interest in
retaining intervention fidelity (Song et al., 2010). Many factors which influence intervention
fidelity are identified. These factors concern themes as leadership, supervision, education
and training, funding and finance, attitude and culture, and team characteristics (Rollins et
al., 2010; Hasson, 2010; Rapp et al., 2010; Swain et al., 2010; Salyers et al., 2009, Mancini
et al., 2009; Bond et al., 2008; Brunette et al., 2008; Marshall et al., 2008; Marty et al., 2008;
Sin & Scully, 2008; Van Erp et al., 2007). However, these studies did not focus on theoretical
development of the concept intervention fidelity. Besides summaries of influencing factors,
no information about the process or interaction is available. Full understanding of this
concept is necessary to influence intervention fidelity positively and improve clients’ health.
In the care for clients with intellectual disabilities, it is assumed caregivers experience various
factors which influence their intervention fidelity. In this setting, interventions are complex
and caregivers find it hard to perform adequate interventions (Zijlmans et al., 2011). Besides
the complex interventions, clients with intellectual disabilities often react impulsive and
intensive on low stimulus and show challenging behaviour such as aggression, self-injury,
property damage or inappropriate sexual conduct (Zijlmans et al., 2011; Mutkins et al., 2011;
Skirrow & Hatton, 2007; Emerson, 2001). This behaviour often leads to emotional reactions
by caregivers, such as fear, anger, anxiety and annoyance (Bromley & Emerson, 1995;
Hastings, 1995; Hatton et al., 1995). Thus, caregivers have to deal with personal emotions
caused by clients challenging behaviour while performing a difficult intervention (Zijlmans et
al., 2011). In the care for intellectual disabled clients, no studies are accomplished
concerning intervention fidelity.
Intervention fidelity in the care for clients with intellectual disabilities
2
Nienke Stielstra
February 8, 2016
The Behaviour Intervention Plan (GIP, in Dutch: gedragsinterventieplan) is an example of a
difficult intervention in the care for clients with intellectual disabilities. The GIP is a document
which outlines levels of arousal, the state of consciousness and alertness (Moruzzi &
Magoun, 1949) and is based on the stress-attachment theory (Sterkenburg et al., 2007).
Signs which a client shows while he or she is experiencing a certain level of arousal, are
identified in the GIP. Furthermore, actions for caregivers to respond appropriate on these
signs, associated to a specific level arousal, are described. Through performing these
actions, levels of arousal can be reduced or raised to a basic state of mind. In this state of
mind, the client experience a healthy amount of stress and shows less challenging
behaviour. The GIP demands caregivers to observe the client accurately and respond quickly
on signs which a client shows.
Rationale
It is unknown how caregivers of intellectual disabled clients experience intervention fidelity.
Full comprehension about the concept intervention fidelity is necessary to bring forth a
theoretical framework. With a solid theoretical framework, clients’ health can be improved by
influencing determined theoretical aspects. Health organizations and caregivers who
understand and acknowledge the concept of intervention fidelity, have the keystones to
improve health care through refining the implementation of innovative interventions. In the
care of intellectual disabled clients, this would lead to an effective implementation of
interventions concerning the specialism’s nursing and social work.
Aim
Aim of this study was to generate a theory concerning the concept of intervention fidelity in
the care for intellectual disabled clients, which explains how different perspectives of
intervention fidelity are achieved regarding to the performance of the GIP. Secondary, trough
the usability of the theory in practice, intervention fidelity can be influenced positively.
Research question
The research question was: How do caregivers of intellectual disabled clients experience
intervention fidelity and what factors do influence their own intervention fidelity regarding to
the performance of the GIP?
Intervention fidelity in the care for clients with intellectual disabilities
3
Nienke Stielstra
February 8, 2016
Methods
Design
A qualitative grounded theory design is chosen because of its rigor in identifying social
processes and problems and conceptualization of a phenomenon which has not been
developed well (Glaser, 1978; Glaser, 1992; Glaser, 1994; Glaser & Holton, 2004).Therefore,
a grounded theory would contribute to the aim of the study. Purpose of a grounded theory is
to construct a theory grounded in collected and analyzed data (Charmaz, 2006).
Setting and population
The study was conducted in a large organization in the Netherlands, which provides
healthcare for clients with intellectual disabilities. In this organization, the GIP is implemented
on 53 communities. Inclusion criteria were: caregivers who 1) were performing the GIP and
stood directly in contact with clients; 2) were working on a community where the GIP was
implemented for at least two months, so novelty reactions did not overrule actual influencing
factors. Caregivers who were employed on a community where the researcher worked as a
nurse were excluded to decrease result bias. For enhancing the generalizability of the
results, maximum two caregivers of one community were selected. Baseline characteristics
of caregivers and their communities were collected for judging the generalizability (see table
1).
Ethical Approval
The Central Committee on Research Involving Human Subjects had confirmed that this study
did not have to be approved by the Medical Research Ethics Committee because of the low
burden of the interviews.
Data collection
Data was collected through open ended interviews and a focus group. During the process of
theory development, interview participants from who was expected to have new theoretical
information were selected. Before this theoretical sampling, no developing theory was
present. Therefore, an initial purposeful sample of four participants was accomplished to
facilitate theoretical sampling. Theoretical sampling continued till the theory had enough
basis for conducting a focus group. Aim of the focus group was to fill in the gaps of the
developing theory and to saturate the data as far as possible. A total of ten caregivers
participated in the focus group, so productivity and depth was sufficient.
Intervention fidelity in the care for clients with intellectual disabilities
4
Nienke Stielstra
February 8, 2016
The researcher NS conducted the interviews. The interviews were initiated by one starting
question and a topic list (see appendix I). Therefore, the concept of intervention fidelity was
broad approached. The interviews were conducted on a quiet and familiar location for the
participants, so they not got interrupted or felt uncomfortable. Before starting the data
collection, rehearsal interviews with two convenience selected caregivers were accomplished
to identify conceivable problems. Questions about intervention fidelity can be experienced by
caregivers as judgemental. Therefore, the researcher emphasized the objectives of the study
and clarified the caregiver will not be criticized and data will be handled anonymous. The
questions were stated non-judgmental.
The researcher NS facilitated the focus group, kept the group on task, made sure that
divergent viewpoints and ideas were heard. NS made sure that less vocal and less assertive
group members had a chance to participate. An independent observer joined the focus
group. This observer recorded the focus group and took notes to supplement the audio
record. The observer paid special attention to non-verbal cues that indicate agreement or
disagreement, interest or disinterest. In the focus group, participants were asked to write
down independently factors which influence their intervention fidelity, participants discussed
and completed the interview categories. The theory in development was criticized by the
participants and was adapted if necessary.
Memo’s were written during the data collection and data analysis. Memo’s cached
researchers’ thoughts, captured comparisons, connections, questions and directions made
by
the
researcher
concerning
the
theory
(theoretical
memos)
or
methodology
(methodological memos). Self-reflective memo’s were written as well and documented
personal reactions of the researcher on participants’ narratives and own experiences
according to intervention fidelity.
Approaching participants
For reaching the caregivers, team managers of the 53 communities were approached by NS.
The team managers informed caregivers about the study by using an extended letter and
gave caregivers the opportunity to refuse information exchange between NS and team
manager. This information exchange enclosed baseline characteristics and theoretical
aspects concerning intervention fidelity of a caregiver. When a caregiver was selected, NS
contacted the caregiver by telephone or mail for collaboration and informed consent for an
interview or participation of the focus group. All participants joined an interview or focus
group during a working shift. Baseline characteristics were collected trough a questionnaire.
All participants had given informed consent before data collection started. All participants had
Intervention fidelity in the care for clients with intellectual disabilities
5
Nienke Stielstra
February 8, 2016
knowledge of the position of NS inside the organization. Although in practice, they did not
stood directly in contact with NS.
Data analysis
The qualitative data management software program NVivo9 was used for transcribing
interviews and analyzing qualitative data. Data and memos were transcribed verbatim.
Notes, filled forms and fragments of the audio records of the focus group were used for
completing the analysis. Data analysis was conducted through the phases: open, axial and
selective coding as described by Strauss and Corbin (1990) which is common in grounded
theory. The open coding was accomplished by NS. RvL analyzed three interviews
independently for triangulation. Consensus about differences was reached by discussion. At
the axial coding, categories were divided in covering categories by NS and supervised by
RvL for triangulation. At the selective coding, the major categories were linked to each other
and were presented in a visual model in which a central category was identified. NS wrote a
theory that explained the visual model and was supervised by RvL. After completing the data
analysis, a meeting was accomplished with a cluster manager, staff member, team manager
and two caregivers for perceiving establishment of the theory. At this way, the theory was
triangulated and judged from different point of views. These participants were selected
convenience.
Intervention fidelity in the care for clients with intellectual disabilities
6
Nienke Stielstra
February 8, 2016
Results
A total of 20 caregivers were included in this study. One participant dropped out for unknown
reasons. Nine participants were interviewed and ten participated in the focus group. Baseline
characteristics are stated in table 1.
As a result, 48 categories were identified as a influence on intervention fidelity and yielded
six major categories presented in figure 1 as a model. The model will be explained through
six categories: personal factor of the caregiver, interaction with the client, interaction with
colleagues, supporting disciplines, intervention, and organization. In the model, interaction is
visualized trough arrows in both direction. A one way influence is drawn as a single arrow.
Personal factors of the caregiver
All participants had experienced the influence of personal factors on intervention fidelity. For
example, all participants stated that personal emotions influence their intervention fidelity.
Participant 4: When you are being attacked by a client, it is hard to act on the way you
supposed to do. It is difficult because your reactions are based on frustration or
aggression. At that point, I have to correct myself and try to react calm.
The intervention fidelity was reduced when participants reacted on own intuition and sense.
Participant 1: If my client is relaxed, I make jokes with her and we have a nice time
together. When she is tensed, I retrieve because I feel it is the best thing to do. At that
moment, I am not interested in what is stated in the GIP.
Factors which influence intervention fidelity concerning personal factors of the caregiver are
stated in table 2.
Interaction with the client
Interaction between the caregiver and client is identified as the central category. During this
interaction, the caregiver has to perform the GIP in practice. This interaction was
experienced as an influence on personal factors of the caregiver. In some cases, the client
influences indirectly intervention fidelity of a caregiver by showing behaviour which they
never had seen before. Caregivers are surprised and have sometimes a shortage of
experience to react accurately on this behaviour which influences the client directly.
Caregivers stated that a trusting bond with a client helps them to react appropriate.
Intervention fidelity in the care for clients with intellectual disabilities
7
Nienke Stielstra
February 8, 2016
Participant 1: My bond with this client is strong. She knows exactly which behaviour I
tolerate and which I do not approve. She trusts me and shows minimal complicated
behaviour when I am around. When she has less trust in a caregiver, she is difficult to
handle. I have seen this with labile colleagues.
Factors influencing intervention fidelity concerning interaction with the client are presented in
table 3.
Interaction with colleagues
All participants saw their colleagues as an important factor concerning intervention fidelity.
Colleagues were seen as a source of feedback, intervision, trust and support, which
influences personal factors through interaction and influence their intervention fidelity
indirectly.
Participant 3: When I have a problem I review it with colleagues. We have a nice bonding
team and we all feel free to provide feedback to each other. With this feedback I can
decide how to act next time I face the same problem.
Agreement within a team and all members acting identical is stated to be very important.
Participant 6: We all order him to come down and now he is eating dinner every day. The
feeling that we all react at the same way contributes to a nice harmony and motivate us to
keep doing this.
Table 4 presents all mentioned influencing factors on intervention fidelity concerning
interaction with colleagues.
Involved disciplines
The disciplines team manager and behaviour expert are valuable to the caregivers. These
disciplines are seen as a source of information, which can influence personal factors.
Participant 8: The behaviour expert provides information about handling this client with the
GIP. She gives us insight how to react when this client behave aggressive. Now, we know
that we have to ignore the client when he is throwing with stuff. This is described in the
GIP.
Intervention fidelity in the care for clients with intellectual disabilities
8
Nienke Stielstra
February 8, 2016
In the organization where the study is conducted, an intervention team provides education
and training concerning acting on difficult behaviour and accomplishing the GIP. Caregivers
who received this training are positive about it.
Participant 7: The training was very useful. I have learned to observe and recognize signs
more accurate. I always accomplished the intervention by the way colleagues said me to
do. I had a wakeup call during this training.
Factors which influence intervention fidelity concerning involved disciplines are stated in
table 5.
Intervention
The GIP itself can influence directly the intervention fidelity. For example, the majority of the
participants had troubles with the quality of the GIP. Participant said that the documents were
not updated or signs were described poor and abstract.
Participant 2: Once, we had a GIP which contained very little information. It was difficult
for me to identificate good or bad behaviour. I could not work properly with this GIP.
Table 6 contains influencing factors concerning the intervention.
Organization
The organization is the context in which accomplishment of the GIP takes place. The
organization is seen by participants as responsible for the factors presented in table 7.
Participants judged the role of the organization to be minor but growing.
Focus group participant: Some caregivers feel quality of care as responsibility of the team.
They think they have to deal with problems on their own. I do not agree with that. I have
experienced that conversation with higher management leads to improvement. For
example, I have got more time for correcting the GIPs.
Intervention fidelity in the care for clients with intellectual disabilities
9
Nienke Stielstra
February 8, 2016
Discussion
Regarding to the GIP, intervention fidelity of caregivers in the care for clients with intellectual
disabilities is influenced through caregivers’ personal factors and indirectly through
interaction with clients and colleagues. Other involved disciplines can provide support and
information. The GIP itself must be practical useful. The organization can create the right
boundary conditions. With this insight intervention fidelity can be improved through exploiting
and reducing influencing factors.
Interaction between the caregiver and client is stated as a central category where
intervention fidelity comes in practice. The participating organization delivers 24hours care,
thus caregivers are interacting with clients continuously. One caregiver guiding a group of six
or seven clients without presence of colleagues is quite common in the Netherlands.
Therefore, it is essential that caregivers have the capacity for self reflection and take
responsibility for a possible lack of intervention fidelity through asking support from
colleagues, involved disciplines or the organization.
The significant role of social interaction with clients and colleagues is, so far as we found,
never identified explicit in research in the care for clients with intellectual disabilities before.
Even presuming that the context of mental health care is comparable to the care for
intellectual disabled client, only a few studies mentioned caregivers’ attitude or teams’ culture
as a minor influencing factor (Swain et al., 2010; Salyers et al., 2009, Mancini et al., 2009;
Marshall et al., 2008).
Participants of communities with a severe amount of aggression incidents (>20 per month)
mentioned the importance of social interaction with colleagues more often than caregivers
who had to deal with less aggression. This last named group mentioned the presence of a
GIP of good quality more often. It’s thinkable that caregivers who have to deal with much
aggression need more support from colleagues for handling clients’ behaviour correctly.
Although interaction with colleagues pointed out as an important positive influencing factor,
this interaction is complicated. Tuckman (1965) stated that a team has to endure five phases
where conflicts have to be solved and group boundaries have to be created for being an
adequate functioning team. Many teams fail accomplishing these phases. Persons who have
knowledge of the team roles of Belbin (1981) will confirm that it is complicated to construct a
sufficient communicating team. A team needs members with various characteristics for
fulfilling shortcomings of each other.
Intervention fidelity in the care for clients with intellectual disabilities
10
Nienke Stielstra
February 8, 2016
Participants who received training from the intervention team stated its great influence on
their intervention fidelity. In the contrary, caregivers who did not received training had not the
feeling they needed training to improve their intervention fidelity. In addition, they judged the
role of the organization to be minor and felt accomplishment of the GIP as their own
responsibility. Surprisingly, a majority of the participants who did not received the training,
approached the GIP as a reporting system, not as a behaviour intervention. Training of these
participants can contribute to the effect of the intervention.
The sample of participants was a heterogeneous selection. Therefore, the results are broadly
applicable on caregivers working within a team in the care for clients with intellectual
disabilities within an organization which delivers 24hours care. It is even thinkable that the
results can be used in other settings of 24hours care, like a nursing home where a nurse
continuously interact with clients and participate in a team as well. Nevertheless, further
research is required. This study focused on accomplishment of the GIP. However, it is
assumed that the results are relevant for all interventions where interaction with a client is
present. All participants had the Dutch nationality and it is possible this has influenced the
results through their openness towards colleagues about personal factors
The fact that communication between NS and the team managers took much time became a
limitation of the study. In some cases, it took months before NS could approach a caregiver.
For reaching the deadlines of the study, NS contacted team managers for selecting
caregivers before previous collected data was analyzed. Therefore, participants were
selected not as theoretical based as intended. Caregivers and team managers from one
location of the organization hardly co-operated. There contribution was not as large as other
locations. Hence, this could affect the generalizability of the results. Through using various
data collection methods, there is a good chance data is saturated. Nevertheless, this was not
tested trough other interviews.
Conclusion
A theory concerning intervention fidelity in the care for client with intellectual disabilities is
constructed. The importance of social interaction in this concept, is not explicit identified in
research before. Further research is necessary to verify its relevance to other settings of
care.
Intervention fidelity in the care for clients with intellectual disabilities
11
Nienke Stielstra
February 8, 2016
Recommendations
Health organizations have to acknowledge the difficulty for caregivers for reaching
intervention fidelity. Every caregiver has experience with complex situations with heavy
workload, difficult behaviour of clients and personal struggles. Generally, caregivers dealing
with such situations need help to enhance intervention fidelity. It is important that a caregiver
feel supported by the organization and colleagues and do not feel judged on his human
acting.
All caregivers, nurses or social workers, who experience difficulties with their own
intervention fidelity have to admit the importance of discussing it with colleagues. Successful
implementation of evidence based interventions depends on collaboration and a supporting
climate within a team. Although a team manager is pointed out as a influencing factor in this
study by a minority, good leadership of a team manager is essential in these processes. An
organization which enhances this social interaction can progress implementation of
interventions which will lead to an improved health of clients.
Intervention fidelity in the care for clients with intellectual disabilities
12
Nienke Stielstra
February 8, 2016
References
Belbin, M. (1981). Management Teams. London; Heinemann.
Bond, G.R., Becker, D.R., Drake, R.E., Rapp, C.A., Meisler, N., Lehman, A.F., Bell, M.D. &
Blyler, C.R. (2001). Implementing supported employment as an evidence-based practice.
Psychiatric Services, 52, 313.
Bond, G.R., McHugo, G.J., Becker, D.R., Rapp, C.A., & Whitley R. (2008). Fidelity of
Supported Employment: Lessons Learned from the National Evidence Based Practice
Project. Psychiatric Rehabilitation Journal, 4, 300-305.
Bromley, J., & Emerson, E. (1995). Beliefs and emotional reaction of care staff working with
people with challenging behaviour. Journal of Intellectual Disability Research, 39, 341-352
Brunette, M.F., Asher, D., Whitley, R., Lutz, W.J., Wieder, B.L., Jones, A.M., & McHugo, G.J.
(2008). Implementation of Integrated Dual Disorders Treatment: A Qualitative Analysis of
Facilitators and Barriers. Psychiatric Services, 59, 989-995.
Charmaz, K. (2006). Constructing Grounded Theory: A Practical Guide Through Qualitative
Analysis. Sage Publications, London
Emerson, E., (2001). Challenging behaviour: Analysis and intervention in People with Severe
Learning Disabilities. Cambridge University Press, Cambridge
Hasson, H. (2010). Systematic evaluation of implementation fidelity of complex interventions
in health and social care. Implementation Science, 5, 67.
Hastings, R.P., (1995). Understanding factors that influence staff responses to challenging
behaviours: an exploratory interview study. Mental Handicap Research, 8, 296-320
Hatton, C., Brown, R., Caine, A., & Emerson, E. (1995). Stressors, coping, strategies, and
stress-related outcomes among direct staff in staffed houses for people with learning
disabilities. Mental Handicap Research, 40, 148-156
Glaser, B., & Strauss A.L. (1967). The Discovery of Grounded Theory: Strategies for
Qualitative Research. Aldine, Chicago.
Intervention fidelity in the care for clients with intellectual disabilities
13
Nienke Stielstra
February 8, 2016
Glaser, B. (1992). Basics of grounded theory analysis. Mill Valley, CA: Sociology Press.
Glaser, B. (1994). More grounded theory methodology. Mill Valley, CA: Sociology Press.
Glaser, B., & Holton, J.A. (2004). Remodeling grounded theory. The Grounded Theory
Review: An International Journal, 4, 1–24.
Mancini, A.D., Moser, L.L., Whitley, R., McHugo, G.J., Bond, G.R., Finnerty, M.T., & Burns,
B.J. (2009). Assertive Community Treatment: Facilitators and Barriers to Implementation in
Routine Mental Health Settings. Psychiatric Services, 60, 189-195
Marshall, T., Rapp, C.A., Becker, D.R., & Bond, G.R. (2008). Key Factors for Implementing
Supported Employment. Psychiatric Services, 59, 886-892.
Marty, D., Rapp, C., McHugo, G., & Whitley, R. (2008). Factors Influencing Consumer
Outcome Monitoring in Implementation of Evidence-Bases Practices: Results from the
national EBP Implementation Project. Administration and Policy in Mental Health, 35, 204211.
Moncher, F.J., & Prinz, R.J. (1991). Treatment fidelity in outcome studies. Clinical
Psychology Review, 11, 247-266.
Moruzzi, G. & Magoun, H.W. (1949). Brain stem reticular formation and activation of the
EEG. Electroencephalography and Clinical Neurophysiology, 1, 455-473.
Mosby (2009). Mosby’s Medical Dictionary, 8th edition. Elsevier Health Sciences
Mutkins, E., Brown, R.F., & Thorsteinsson, E.B. (2011). Stress, depression, workplace and
social supports and burnout in intellectual disability support staff. Journal of Intellectual
Disability Research, 55, 500-510
Rapp, C.A., Etzel-Wise, D., Marty, D., Coffman, M., Carlson, L., Asher, D., Callaghan, J., &
Holter, M. (2010). Barriers to Evidence-Based Practice Implementation: Results of a
Qualitative Study. Community Mental Health Journal, 46, 112-118.
Intervention fidelity in the care for clients with intellectual disabilities
14
Nienke Stielstra
February 8, 2016
Rollins, A.L., Salyers, M.P., Tsai, J., & Lydick, J.M. (2010). Staff Turnover in Statewide
Implementation of ACT: Relationship with ACT Fidelity and Other Team Characteristics.
Administration and Policy in Mental Health, 37, 417-426.
Sackett, D., Straus, S., Richardson, W., Rosenberg, W., & Haynes, R. (2000). Evidence
based medicine: how to practice and teach EBM. Edinburh Churchill Livingstone
Santesso, N., & Tugwell, P. (2006). Knowledge translation in developing countries. Journal of
continuing educations in the health professions, 26, 87-96
Salyers, M.P., Rollins, A.L., McGuire, A.B., & Gearhart, T. (2009). Barriers and Facilitator in
implementing Illness Management and Recovery for Consumers with Severe Mental Illness:
Trainee Perspectives. Administration and Policy in Mental Health, 36, 102-111
Sin, J., & Scully, E. (2008). An Evaluation of education and implementation of psychosocial
interventions within one UK mental healthcare trust. Journal of Psychiatric and Mental Health
Nursing, 15, 161-169
Skirrow, P., & Hatton, C. (2007). Burnout amongst direct care workers in services for adults
with intellectual disabilities: a systematic review of research findings and initial normative
data. Journal of Applied Research in Intellectual Disabilities, 20, 131-144
Song, M.K., Happ, M.B., & Sandelowski, M. (2010). Development of a toll to assess fidelity to
a psycho-educational intervention. Journal of Advanced Nursing, 66, 673-82
Sterkenburg, P.S., Janssen, C.G.C, & Schuengel, C. (2008) The Effect of an AttachmentBased Behaviour Therapy for Children with Visual and Severe Intellectual Disabilities.
Journal of Applied Research in Intellectual Disabilities, 21, 126–135
Strauss, A., & Corbin, J. (1990). Basics of Qualitative Research: Techniques and Procedures
for Developing Grounded Theory. Sage Publications, London
Swain, K., Whitley, R., McHugo, G.J., & Drake, R.E. (2010). The sustainability of EvidenceBased Practices in Routine Mental Health Agencies. Community Mental Health Journal, 46,
119-129
Intervention fidelity in the care for clients with intellectual disabilities
15
Nienke Stielstra
February 8, 2016
Tuckman. (1965). Developmental sequence in small groups. Psychological Bulletin, 63, 284399
Turner, T., Misso, M., Harris, C., & Green, S. (2008). Development of evidence-based clinical
practice guidelines (CPGs):comparing approaches. Implementation Science, 3:45
Van Erp, N.H.J., Giesen, F.B.M., Van Weeghel, J., Kroon, H., Michon, H.W.C., Becker, D.,
McHugo, G.J., & Drake, R.E. (2007). A Multisite Study of Implementing Supported
Employment in the Netherlands. Psychiatric Services, 58, 1421-1426.
Waltz, J., Addis, M.E., Koerner, K., & Jacobson, N.S. (1993). Testing the integrity of a
psychotherapy protocol: Assessment of adherence and competence. Journal of Consulting
and Clinical Psychology, 61, 620-630.
Zijlmans, L.J., Embregts, P.J., Gerits, L., Bosman, A.M., & Derksen, J.J. (2011). Training
emotional intelligence related to treatment skills of staff working with clients with intellectual
disabilities and challenging behaviour. Journal of intellectual disability research, 55, 219-230
Intervention fidelity in the care for clients with intellectual disabilities
16
Nienke Stielstra
February 8, 2016
Abstract: Intervention fidelity in the care for clients with intellectual disabilities
Introduction: In health care, implementation of interventions often fails due to a lack of
intervention fidelity. In literature, influencing factors are identified. However, no theories
about the concept are generated. In the care for intellectual disabled clients, caregivers face
difficult behaviour en personal emotions while performing difficult interventions, for example
the behaviour intervention plan. It is unknown if these aspects affect intervention fidelity.
Insight in the concept intervention fidelity is necessary to improve intervention
implementation and clients’ health.
Objective: The aim was to generate a theory concerning the concept of intervention fidelity
in the care for intellectual disabled clients. Secondary, trough the usability of the theory in
practice, intervention fidelity can be influenced positively.
Research question: How do caregivers of intellectual disabled clients experience
intervention fidelity and what factors do influence their own intervention fidelity regarding to
the performance of the GIP?
Method: Qualitative grounded theory design. The study included caregivers in the care for
intellectual disabled clients, who performed the GIP for at least two months. Data was
collected trough open interviews and a focus group. Data were analysed trough the phases
of Strauss and Corbin.
Results: The study included 19 participants. Six influencing categories were identified:
personal factors of the caregiver, interaction with the client, interaction with colleagues,
involved disciplines, intervention, organisation.
Conclusion: A theoretical model is conducted. Further research is necessary to verify its
relevance to other settings of care.
Recommendations: Organizations have to acknowledge the complexness for reaching
intervention fidelity. Caregivers have to admit the importance of supporting colleagues.
Keywords: intervention adherence, intervention integrity, nursing, social work, mentally
disabled
Intervention fidelity in the care for clients with intellectual disabilities
17
Nienke Stielstra
February 8, 2016
Samenvatting: Interventiegetrouwheid in de verstandelijk gehandicaptenzorg.
Introductie: Door een tekort aan interventiegetrouwheid worden in de gezondheidszorg
nieuwe interventies onvoldoende geïmplementeerd. In de literatuur zijn factoren die de
interventiegetrouwheid beïnvloeden bekend. Een theorie over interventiegetrouwheid is
echter nooit ontwikkeld. In de verstandelijke gehandicaptenzorg hebben begeleiders te
maken met moeilijk verstaanbaar gedrag, persoonlijke emoties en de uitvoering van
complexe interventies zoals het gedragsinterventieplan. Het is niet bekend of deze aspecten
invloed hebben op de interventiegetrouwheid. Meer inzicht is nodig om implementaties en
kwaliteit van zorg te verbeteren.
Doel: Een theorie ontwikkelen over interventiegetrouwheid in de verstandelijk
gehandicaptenzorg. Secundaire doel is het positief beïnvloeden van interventiegetrouwheid
doordat de theorie inzetbaar is in de praktijk.
Onderzoeksvraag: Hoe ervaren begeleiders in de verstandelijke gehandicaptenzorg
interventiegetrouwheid tijdens de uitvoering van het gedragsinterventieplan en welke
factoren hebben hierop invloed?
Methode: Kwalitatief grounded theory design. Begeleiders in de verstandelijk
gehandicaptenzorg die het GIP voor tenminste twee maanden uitvoeren zijn geïncludeerd.
Data is verzameld door interviews en een focusgroup. De data is geanalyseerd volgens de
fasen van Strauss en Corbin.
Resultaten: Het onderzoek telt 19 participanten. Zes categorieën die interventiegetrouwheid
beïnvloeden zijn vastgesteld: persoonlijke factoren van de begeleider, interactie met de
cliënt, interactie met collega’s, betrokken disciplines, interventie en organisatie.
Conclusie: Een theoretisch model over interventiegetrouwheid in ontwikkeld. Verder
onderzoek moet de generaliseerbaarheid in kaart brengen.
Aanbevelingen: Organisaties moeten beseffen dat het voor begeleiders moeilijk is om
interventiegetrouw te zijn. Begeleiders moeten het belang van ondersteuning van collega’s
erkennen.
Sleutelwoorden: verpleegkunde, pedagogisch werk, verstandelijke beperkingen,
signaleringsplan
Intervention fidelity in the care for clients with intellectual disabilities
18
Nienke Stielstra
February 8, 2016
Figures and tables
Table 1: Baseline characteristics
Baseline characteristics
Gender
Female: 13
Male: 6
Age in years
Range: 22-55
Education
Nursing: 8
Mean: 32.3
Social work: 6
Residential work: 2
Other: 3
Work experience in years
Range: 1-26
Mean: 11.1
Amount of reported
Range: 0-130
Mean: 36.6
aggression incidents on
the community (3 months)
Training during
Yes: 7
implementation
No: 12
Figure 1: Model intervention fidelity
Intervention fidelity in the care for clients with intellectual disabilities
19
Nienke Stielstra
February 8, 2016
Table 2: Influencing factors concerning personal factors of the caregiver
Caregiver
1. Personal emotions
8.
Work experience
2. Acting on own intuition and sense
9.
Being up-to-date of the GIP
3. Ability to self-reflection
10. Character and personality
4. Experiences from the past
11. Remembering contents of the GIP
5. Skills
12. Personal values
6. Knowing the client
13. Normalizing clients’ behaviour
7. Attitude
14. Acknowledging the GIP
Table 3: Influencing factors concerning interaction with the client
Client
1. Deviant behaviour from GIP
5. Stability
2. Trusting bond
6. Good responding
3. Complex behaviour
7. Unknown diagnosis
4. Spending good amount of time together
Table 4: Influencing factors concerning interaction with colleagues
Colleagues
1. Support
6. Agreement
2. Feedback
7. Collaboration
3. Intervision
8. Stability
4. Trust
9. Learn each other
5. Acting identical
Table 5: Influencing factors concerning involved disciplines
Involved disciplines
1. Support and information from behaviour expert
4. Agreement of vision
2. Support and information from team manager
5. Turnover behaviour expert
3. Training from the intervention team
6. Turnover team manager
Table 6: Influencing factors concerning the intervention
Intervention
1. Quality GIP
5. Usage of other interventions
2. Objectivity signs
6. Remembering contents of the GIP
3. Does not work in practice
7. Agreement of family of the client about the GIP
4. Not fully implemented
Intervention fidelity in the care for clients with intellectual disabilities
20
Nienke Stielstra
February 8, 2016
Table 7: Influencing factors concerning the organization
Organization
1. Workload
4. Bureaucracy
2. Substitutes
5. Functioning of materials
3. Accommodation
Intervention fidelity in the care for clients with intellectual disabilities
21
Nienke Stielstra
February 8, 2016
Appendix I
Topic List
1.
2.
3.
4.
5.
6.
7.
Starting question: How do you experience the performance of the GIP?
Positive influencing factors
Negative influencing factors
Personal role in intervention fidelity
Influence of the client
Influence of environment
How do factors affect each other?
Intervention fidelity in the care for clients with intellectual disabilities
22