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What is Vocalise?

The aim of Vocalise is to investigate the barriers to change on the ward, as perceived by nursing staff working on acute inpatient wards in the South London and Maudsley NHS Foundation Trust (SLaM), using qualitative and quantitative methods.

Further Aims

Caroline Laker

"In order to support staff led improvements it is important to understand how change itself, impacts on staff perceptions of barriers to change, morale and working practicies."

Caroline Laker - Nurse Researcher


Change is a constant theme for staff working in the NHS. Over the last 15 years the mental health services have undergone major operational changes with community services becoming more comprehensive. Acute in-patient services have experienced various knock-on effects including a shortage of nursing staff, pressure to discharge patients (bed shortages) and a consequent increase in frequency of patients with more severe clinical presentations.

Research shows that despite these changes on to wards, inpatient staff aim to work therapeutically with service users by engaging in activities and brief therapies. However, maintaining a balance between this important work and the other day to day aspects of ward management presents staff with numerous challenges.

Vocalise - additional information ... (click here)

Qualitative Measure Development

Participatory method
The measure has been developed from direct contact with the research participants so that their opinions are represented as fully and accurately as possible. The 'participatory method' is adapted from an approach developed by Dr Diana Rose.

Topic Guide
Focus group data from LIAISE was analysed to develop a topic guide. In consultation with a senior nurse, the following questions were devised:

  • What is preventing things from changing in your clinical environment?
    • What makes it hard for you to do something differently?
    • What makes it hard for the team to do things differently?
  • What could be done to enable change?
    • What would enable you to change your practice?
    • What would enable the team to change its practices?

Pilot study
The topic guide was tested in a pilot interview with a clinical charge nurse.  She reported that the questions were easy to understand and sufficiently open to ensure, with prompting, that the topic could be covered adequately.

Individual Interviews
Following a criterion sampling technique, 32 in-depth interviews were conducted with eight nursing staff from Band 2 (health care assistants), to Band 7 (team leaders). The intention was to identify barriers to service improvements. The topic guide was flexible to allow participants to bring in new ideas.

Item reduction and Measure Development
NVivo software (a programme used to analyse qualitative data) was used to analyse the interview material.  Those themes with the highest number of references or those that staff indicated they felt the most strongly about were included as items on the measure.

Expert validation
Three interview participants rated the draft questionnaire using a Likert scale (Strongly Agree, Agree, Slightly Agree, Slightly Disagree, Disagree, and Strongly Disagree) to indicate whether it had captured the themes from the interviews.  They were invited to amend or add to the suggested questions. Three new acute ward staff then gave comment on the second draft.

Quantitative Measure Development


A total of 40 staff have completed VOCALISE to ensure that it is acceptable, understandable and easy to self-complete.

Psychometric Assessment: (reliability: internal consistency, test retest; validity: face, content, construct) was undertaken for both measures.

40 staff completed the questionnaire.

  • The internal consistency of the questionnaire was tested using Cronbach’s alpha to determine whether the items in the vocalise measure all contribute to the same construct.
  • A test-retest exercise was undertaken, whereby individuals were asked to complete the questionnaire twice, separated by 6-10 days.  Reproducibility was assessed using Lin’s Concordance coefficient on total scores and Cohen’s Kappa on individual items.


A self-report instrument (VOCALISE) was successfully developed, with good reliability and validity, and which staff found easy to understand and complete. The factor analysis revealed 3 underlying constructs: ‘confidence’, ‘de-motivation’ and ‘powerlessness’. Staff with negative perceptions of barriers to change also held more junior positions in the organisation, and had poorer job satisfaction.

The full details of the psychometric testing process and results for VOCALISE will be reported in an article which will be made available on this website upon publication (see publications section). This will include a copy of the measure.

Next Steps

Further psychometric assessments will be undertaken on a sample size of approximately 300 staff as part of BETTER PATHWAYS, The 10 criteria to be used include interpretability, acceptability and precision as well as the usual categories of reliability and validity.

Longitudinal Study
This part of the study will run within the DOORWAYS project and will last for 12 months, where responses from a further 300 staff will be captured. The relationships between variables will be analysed cross-sectionally and their strength will be tested within structured equation models. Follow this link for more details of the additional measures used in the DOORWAYS project


Laker, C; Callard F; Flach C; Sayer J; Wykes, T (2011). VOCALISE: measuring staff perceptions of barriers to change in acute ward settings. International Journal of Nursing Studies (under review).


  • VOCALISE Poster:


15th International Network for Psychiatric Nursing Research Conference (RCN).

  • VOCALISE Poster:


Working Conference - HSR Europe - 'Where Policy & Research Meet' - The Hague

  • VOCALISE Poster:


NIHR Training Conference

For further information, please contact:
Til Wykes, Chief Investigator on 0207 848 0596 or fill the contact form here.
Caroline Laker, Nurse Researcher on 0207 848 5065 or fill the contact form here.