Qualitative Investigation of the Wellness Recovery Action Plan in a UK NHS Crisis Care Setting

Sustaining a therapeutic environment within mental health in-patient settings during COVID-19. Results of a Delphi study

AIM

Develop a strengths-based, person-centred, trauma-informed and recovery-oriented framework to mitigate any potential increase in conflict resulting from the implementation of C19 restrictions.

BACKGROUND

Guidance addressing the unique challenges posed by Covid-19 within mental health in-patient settings, including how to support those whose distress may present as behaviour that challenges including violence and self-harm, remains urgently needed.

METHODOLOGY/APPROACH

A Delphi design involving four iterative stages was adopted. Stage 1 involved a review and synthesis of COVID-19-related public health and ethical guidance and a narrative literature review. A formative operational framework was then developed. Stage 2 sought to establish the face validity of the framework through engagement with frontline and senior staff in mental health services in Ireland, Denmark and Netherlands. Stage 3 investigated the content validity of the final framework through a plenary presentation and discussion of the framework at a scientific symposium of the European Violence in Psychiatric Research Group (EViPRG, 2020). Stage 4 sought expert appraisal of the framework using a structured evaluation completed by a panel of eighteen multidisciplinary experts from nine countries, including four academics, six clinicians and eight holding dual clinical/academic appointments to assess content validity.

RESULTS

The guidance adopts the widely advocated approach to support those whose distress may present as behaviour services find challenging in identifying the need for primary, secondary, tertiary and recovery measures. It emphasizes person-centred care while integrating specific Covid-19 public health requirements into service planning. It also aligns with contemporary best practice in in-patient mental health care, incorporating the principles of Safewards, the core values of trauma-informed care, and an explicit on recovery.

CONCLUSION

The guidance developed has face and content validity.

A scoping review of studies into crisis resolution teams in community mental health services

BACKGROUND AND PURPOSE OF ARTICLE

Crisis Resolution Teams (CRT) for rapid assessment and short-term treatment of mental health problems have increasingly been implemented internationally over the last decades. Among the Nordic countries, the CRT model has been particularly influential in Norway, where 'Ambulante akutteam (AAT)' is a widespread psychiatric emergency service for adult patients. However, the clinical practice of these teams varies significantly. To aid further development of the service and guide future research efforts, we carried out a scoping review to provide an up-to-date overview of research available in primary studies focusing on phenomena related to CRTs in English and Scandinavian literature.

METHODS

A systematic literature search was conducted in the bibliometric databases MEDLINE, Embase, PsychINFO, Scopus, and SveMed+. Included studies were thematically analyzed using a qualitative method.

RESULTS

The search identified 1516 unique references, of which 129 were included in the overview. Thematic analysis showed that the studies could be assigned to: (1) Characteristics of CRTs (k = 45), which described key principles or specific interventions; (2) Implementation of CRTs (k = 54), which were descriptive about implementation in different teams, or normative about what clinical practice should include; and (3) Effect of CRTs (k = 38).

CONCLUSIONS

The international research literature on CRTs or equivalent teams is extensive. Many sub-themes have been studied with various research methodologies. Recent studies provide a better evidence base for how to organize services and to select therapeutic interventions, but there is still a need for more controlled studies in the field.

Mapping mad maps and recovery tools developed by mental health service users and survivors of psychiatry: a scoping review

BACKGROUND

Since 1997, several tools based on the experiences of users and survivors of psychiatry have been developed with the goal of promoting self-determination in recovery, empowerment and well-being.

OBJECTIVES

The aims of this study were to identify these tools and their distinctive features, and to know how they were created, implemented and evaluated.

METHOD

This work was conducted in accordance with a published Scoping Review protocol, following the Arksey and O'Malley approach and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. Five search strategies were used, including contact with user and survivor networks, academic database searching (Cochrane, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, PsycARTICLES, SCOPUS, PubMed and Web of Science), grey literature searching, Google Scholar searching and reference harvesting. We focused on tools, elaborated by users and survivors, and studies reporting the main applications of them. The searches were performed between 21 July and 22 September 2022. Two approaches were used to display the data: descriptive analysis and thematic analysis.

RESULTS

Six tools and 35 studies were identified, most of them originating in the USA and UK. Thematic analysis identified six goals of the tools: improving wellness, navigating crisis, promoting recovery, promoting empowerment, facilitating mutual support and coping with oppression. Of the 35 studies identified, 34 corresponded to applications of the Wellness Recovery Action Plan (WRAP). All of them, but one, evaluated group workshops implementations. The most common objective was to evaluate symptom improvement. Only eight studies included users and survivors as part of the research team.

CONCLUSIONS

Only the WRAP has been widely disseminated and investigated. Despite the tools were designed to be implemented by peers, it seems they have been usually implemented without them as trainers. Even when these tools are not aimed to promote clinical recovery, in practice the most disseminated recovery tool is being used in this way.

Factors influencing the implementation of mental health recovery into services: a systematic mixed studies review

BACKGROUND

Countries around the world have committed in policy to transforming their mental health services towards a recovery orientation. How has mental health recovery been implemented into services for adults, and what factors influence the implementation of recovery-oriented services?

METHODS

This systematic mixed studies review followed a convergent qualitative synthesis design and used the best-fit framework synthesis method. Librarians ran searches in Ovid- MEDLINE, Ovid-EMBASE, Ovid-PsycInfo, EBSCO-CINAHL Plus with Full Text, ProQuest Dissertations and Theses, Cochrane Library, and Scopus. Two reviewers independently screened studies for inclusion or exclusion using DistillerSR. Qualitative, quantitative, and mixed methods peer-reviewed studies published since 1998 were included if they reported a new effort to transform adult mental health services towards a recovery orientation, and reported findings related to implementation experience, process, or factors. Data was extracted in NVivo12 to the 38 constructs of the Consolidated Framework for Implementation Research (CFIR). The synthesis included a within-case and a cross-case thematic analysis of data coded to each CFIR construct. Cases were types of recovery-oriented innovations.

RESULTS

Seventy studies met our inclusion criteria. These were grouped into seven types of recovery-oriented innovations (cases) for within-case and cross-case synthesis. Themes illustrating common implementation factors across innovations are presented by CFIR domain: Intervention Characteristics (flexibility, relationship building, lived experience); Inner Setting (traditional biomedical vs. recovery-oriented approach, the importance of organizational and policy commitment to recovery-transformation, staff turnover, lack of resources to support personal recovery goals, information gaps about new roles and procedures, interpersonal relationships), Characteristics of Individuals (variability in knowledge about recovery, characteristics of recovery-oriented service providers); Process (the importance of planning, early and continuous engagement with stakeholders). Very little data from included studies was extracted to the outer setting domain, and therefore, we present only some initial observations and note that further research on outer setting implementation factors is needed.

CONCLUSION

The CFIR required some adaptation for use as an implementation framework in this review. The common implementation factors presented are an important starting point for stakeholders to consider when implementing recovery-oriented services.

The contribution of the voluntary sector to mental health crisis care: a mixed-methods study

Background

Weaknesses in the provision of mental health crisis support are evident and improvements that include voluntary sector provision are promoted. There is a lack of evidence regarding the contribution of the voluntary sector and how this might be used to the best effect in mental health crisis care.

Aim

To investigate the contribution of voluntary sector organisations to mental health crisis care in England.

Design

Multimethod sequential design with a comparative case study.

Setting

England, with four case studies in North England, East England, the Midlands and London.

Method

The method included a scoping literature review, a national survey of 1612 voluntary sector organisations, interviews with 27 national stakeholders and detailed mapping of the voluntary sector organisation provision in two regions (the north and south of England) to develop a taxonomy of voluntary sector organisations and to select four case studies. The case studies examined voluntary sector organisation crisis care provision as a system through interviews with local stakeholders (n = 73), eight focus groups with service users and carers and, at an individual level, narrative interviews with service users (n = 47) and carers (n = 12) to understand their crisis experience and service journey. There was extensive patient and public involvement in the study, including service users as co-researchers, to ensure validity. This affected the conduct of the study and the interpretation of the findings. The quality and the impact of the involvement was evaluated and commended.

Main findings

A mental health crisis is considered a biographical disruption. Voluntary sector organisations can make an important contribution, characterised by a socially oriented and relational approach. Five types of relevant voluntary sector organisations were identified: (1) crisis-specific, (2) general mental health, (3) population-focused, (4) life-event-focused and (5) general social and community voluntary sector organisations. These voluntary sector organisations provide a range of support and have specific expertise. The availability and access to voluntary sector organisations varies and inequalities were evident for rural communities; black, Asian and minority ethnic communities; people who use substances; and people who identified as having a personality disorder. There was little evidence of well-developed crisis systems, with an underdeveloped approach to prevention and a lack of ongoing support.

Limitations

The survey response was low, reflecting the nature of voluntary sector organisations and demands on their time. This was a descriptive study, so evaluating outcomes from voluntary sector organisation support was beyond the scope of the study.

Conclusions

The current policy discourse frames a mental health crisis as an urgent event. Viewing a mental health crisis as a biographical disruption would better enable a wide range of contributory factors to be considered and addressed. Voluntary sector organisations have a distinctive and important role to play. The breadth of this contribution needs to be acknowledged and its role as an accessible alternative to inpatient provision prioritised.

Future work

A whole-system approach to mental health crisis provision is needed. The NHS, local authorities and the voluntary sector should establish how to effectively collaborate to meet the local population’s needs and to ensure the sustainability of the voluntary sector. Service users and carers from all communities need to be central to this.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 29. See the NIHR Journals Library website for further project information.

Understanding, choosing and applying grounded theory: part 1

BACKGROUND

Grounded theory is one of the most widely used qualitative research methodologies. However, it is complex and frequently misinterpreted and misapplied.

AIM

To provide a critical overview of grounded theory, to support neophyte researchers' understanding of a methodology for systematically generating theory from data.

DISCUSSION

The uniqueness of grounded theory is evident in the way researchers explicate concepts from the data during research, rather than entering the field with a list of predefined concepts. Adherence to its rigorous standards enables researchers to contribute to knowledge and practice.

CONCLUSION

Grounded theory is particularly useful in nursing and midwifery research, where it can be applied to a broad range of topics. Neophyte researchers should not be deterred by its rigorous standards, although time and effort are required to appreciate the similarities and differences between grounded theory approaches.

IMPLICATIONS FOR PRACTICE

A clear understanding of its philosophical foundations and attention to its main features should underpin researchers' efforts to conduct a high-quality grounded theory study.