Provider Expectations for Recovery Scale: refining a measure of provider attitudes.

Recovery is increasingly recognized as an important goal in the treatment of people with severe mental illnesses. Recovery is “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential” (SAMHSA, 2011). Although recovery can happen outside the mental health system, treatment providers can play an important role in facilitating recovery. For example, a strong working alliance with a mental health professional was among the factors identified by Liberman and colleagues (2002) as integral to promoting recovery. Similarly, Ryan and colleagues (1994) found that case manager differences were significantly related to consumer outcome even when controlling for service type and client characteristics. Provider attitudes, specifically, can play an important role in the recovery process. For example, a recent study drawing on the perspectives of multiple stakeholders demonstrated that providers played a crucial role by employing recovery-oriented strategies and attitudes (Russinova et al., 2011). In summarizing a large body of research on interpersonal expectancy effects and self-fulfilling prophecy, Rosenthal (2002) demonstrated that expectations held by professionals, including treatment providers, can exert a powerful influence on the behaviors of those they are in a position to influence. Mechanisms underlying the relationship between expectations and outcomes have also been elucidated. In meta-analyses of teacher expectancies, evidence suggests that expectations may be mediated primarily by climate and input -- that with higher expectations of students, teachers interact more warmly and provide more teaching; other mediating paths include giving more opportunities and differential feedback (Harris & Rosenthal, 1985; Rosenthal, 1994). In the field of mental health, Bledsoe and colleagues (2008) identified provider characteristics that were recovery-facilitating (e.g., being hopeful, positive, and holding a belief that recovery is possible), and recovery-hindering (e.g., having low expectations and negative attitudes). Research also suggests that changing such expectations can change mental health outcomes. One study in nursing homes found that raising caretakers’ expectations about individuals they worked with resulted in lower depression levels for residents (Learman, Avorn, Everitt, & Rosenthal, 1990). These studies suggest that staff expectations of consumer recovery are important to measure, particularly in systems striving to be recovery-oriented. Although there are several scales available to measure general recovery orientation among various stakeholders (Burgess, Pirkis, Coombs, & Rosen, 2011), there are only a handful of scales that specifically measure provider expectations. One such scale is the Case Manager Expectancy Inventory, a 42-item scale assessing the degree to which case managers expect consumers to perform well in three domains: community integration, personal agency, and valued social roles (O'Connell & Stein, 2011). In that study, high case manager expectancies were associated with greater days of consumer employment two years later, but not independent living or goal attainment after controlling for baseline factors. Regarding staff characteristics, case managers with higher expectations had a shorter tenure at the agency and in the mental health field and reported lower emotional exhaustion and depersonalization. The Case Manager Expectancy Inventory is promising, but shorter scales, if psychometrically sound, could provide a more efficient way to assess provider attitudes. A 7-item Optimism Scale was developed by Grusky and colleagues (1989) to measure treatment providers’ optimism regarding consumers. In one study, the 7-item Optimism Scale had moderately low internal consistency (Cronbach’s α=0.62) and was not related to case manager-reported activities (Young, Grusky, Sullivan, Webster, & Podus, 1998). In another study, Chinman and colleagues (2003) found adequate internal consistency (α=0.77) and test-retest reliability over two weeks (r=.73) Salyers et al. (2007) expanded the original scale to a 16-item “Consumer Optimism Scale,” including medication use, drug and alcohol use, housing, and competitive employment. Internal consistency was stronger (α=0.91, compared to α=0.83 for the original 7-item version) as was test-retest reliability over a 2-week period (r=0.92, compared to r=0.81). In addition, scores were significantly related to staff ratings of agency recovery orientation and personal optimism. Additional studies have used the 16-item scale in various settings. Tsai and Salyers (2010) assessed recovery orientation, consumer optimism, and personal optimism in three state hospitals (n=729) and four community mental health centers (n=181). Staff at state hospitals scored significantly lower on all three measures even after controlling for background differences. In a subset of hospital staff who completed a follow-up survey a year later, optimism was positively correlated with the number of recovery-related trainings attended (Tsai, Salyers, & Lobb, 2010). Similarly, optimism was associated with attending recovery-oriented trainings in community mental health center staff (Tsai, Salyers, & McGuire, 2011). Salyers and colleagues (Salyers, Hudson, et al., 2011) used the 16-item scale in evaluating a burnout reduction program for mental health professionals. Eighty-four providers participated in the day-long program, with follow-up data available for 74. Participants showed significant decreases in emotional exhaustion and depersonalization, and significant increases in optimism about consumers, six-weeks post-intervention. Overall, the 16-item optimism scale appears to perform better than the original 7-item scale in terms of internal consistency, stability, sensitivity to training, and correlations with related constructs. Although the expanded optimism scale shows promise, we were interested in assessing whether we could refine the scale to a concise measure of provider expectations of clients’ recovery without sacrificing reliability. By pooling data from several studies using the scale, we were able to create a large sample with diverse settings (hospitals, community mental health, and VA medical center) to better test the internal structure of the scale and the ability of the items to differentiate provider expectations. To this end, we used a Rasch measurement model from the family of Item Response Theory models. Item Response Theory (IRT), also known as latent trait theory or modern test theory, comprises an increasingly used set of methods to develop or refine measures of latent traits (e.g., attitudes, cognitive abilities). IRT holds several advantages over Classical Test Theory (Shultz & Whitney, 2005), including sample independence and interval-level measurement. Rasch models estimate latent traits as a function of person ability (the degree to which persons are differentiated by the likelihood of endorsing items or “person separation”) and item difficulty (the degree to which items are differentiated by their endorsement). They are useful for transforming ordinal scores--of the kind often seen in psychological self-report measures--into linear, interval-level variables. In addition to refining the measure to a more concise scale, we also examined convergent validity. We hypothesized that: (1) staff expectations of consumers would be higher in outpatient settings and in staff with higher levels of education, but would not be related to age, gender and race; and (2) more positive expectations would be associated with higher levels of job satisfaction and lower levels of burnout.