Holburn, S., Jacobson, J., Vietze, P., Schwartz, A., & Sersen, E.,

2000,

Reviewed by Janet Robertson, Institute for Health Research,
Lancaster University

Methodology

This paper describes the development and validation of a set of variables to measure the process of person-centred planning and a set of variables to measure the outcome of person-centred planning . The variables were constructed in 5 phases.

1.       Firstly, information was gathered to develop three preliminary instruments. The Indicators of Principles Scale assessed adherence to 8 standards which were developed by a working group of 17 people during a one day session. The 8 standards were: services and supports derive from the person's preferences, interests, and capacities; the person and important others are involved in planning; the person makes real choices and decisions based on experience; activities and services foster inclusion, respect, and relationships; the person uses natural community supports; planning is collaborative and recurring; opportunities, experiences and flexibility are maximised; and the person is satisfied with services and supports. The PCP Quality of Life Indicators assessed 8 areas of quality of life using 40 multiple choice questions. These areas were derived from a previous evaluation of a Positive Futures Project. The Personal Futures Planning Indicators included 12 conditions which respondents designate as either being present or absent from the planning process. The 12 items, which mainly originated from existing literature, were: desire for change; a skilled facilitator; a positive view of personal capacities; a committed champion; a personal vision for a rich community life; a community builder; connections to a wider community; an agency committed to change; influence with people in authority; flexible resources for personal support; a support circle; and a productive ongoing process.

2.       Items from the three instruments above were classified as either a process or an outcome variable. This was done by getting 7 expert raters to assign each of the total 77 items into one of four possible categories: process only; primarily process and secondarily outcome; primarily outcome and secondarily process; and outcome only. Classifications were based on the mean rating for each item. The most ambiguous items were omitted resulting in 20 Process Index items and 51 Outcome Index items.

3.       The first author heuristically assigned items within each index to categories, forming 6 categories in the Process Index and 9 categories in the Outcomes Index. Six expert raters sorted all items into these categories to measure consensual agreement. As a result of these ratings, 7 items were moved to other categories, following which overall rater agreement was 87%.

4.       To obtain a measure of reliability, test-retest administrations were completed two weeks apart by 20 interdisciplinary team members representing 20 service users. In addition, data were collected from 37 planning teams giving multiple responses for particular service users.

5.       Questionnaire data from the 37 planning teams was used to compare a statistically derived classification resulting from factor analysis to the classification resulting from phase 3 (above).

Critical appraisal

Whilst the reviewer has not had sight of the complete indices, they do represent the first attempt to produce a validated measure of PCP process and outcome. The test-retest validity and internal consistency of the indices appears sufficient. One problem with the study, as noted by the authors, is the low sample size (n=37) for the factor analysis. Further, they note that the Outcome Index focuses on individuals' quality of life and as such does not address the entire range of outcomes that may be associated with PCP. For example, it does not look at changes in organisational practices and structure, team participation and effectiveness, or the extent to which the roles of staff and clinicians might change as a result of PCP. Finally, by its nature, the Process Index does not have a threshold score that indicates whether PCP is taking place or not, but it could nonetheless be valuable as a guide to identifying and improving areas where implementation is failing.

Key findings

Reliability of the instruments appeared adequate, with test-retest Pearson correlations being r=.88 (p<.01) for the Process Index and r=.94 (p<.01) for the Outcome Index. For internal consistency, Cronbach's alpha was .87 for the Process Index and .97 for the Outcome Index indicating acceptable internal consistency. Component variables of both the Process Index and Outcome Index were highly associated with their own index suggesting good internal consistency of the variables comprising each index. Factor analysis identified two primary factors which corresponded closely with the assignment of variables to the Process and Outcome indices, with the exception of two variables.

Social work practice/ policy implications

The authors note that measuring the process of PCP is important due to the possibility of PCP being undermined by implementation errors. O'Brien et al . (1997) cited 8 implementation errors:

• a general lack of mindful planning and reflection;
• mandated meeting attendance;
• planning by team members who have little experience with or knowledge about the person;
• omitting crucial participants such as immediate family members;
• proceeding with the process at an unnatural tempo;
• an absence of real problem solving;
• planning in agencies that are not committed to significant change;
• focusing on system-oriented objectives instead of essential principles to guide the process.

The instruments and indices described in the paper are noted to be available from the first author. Services looking to monitor the implementation of PCP may find the tools useful as a guide to adherence to the principles of PCP, and in seeing whether changes in quality of life are made and sustained.

References

O'Brien, J., O'Brien, L., & Mount, B. (1997). Person-centred planning has arrived ... or has it? Mental Retardation , 35 , 480-488