Implementation of recovery-oriented practice in hospital-based mental health services: A systematic review

Improving the Use of Sensory Approaches in an Acute Inpatient Mental Health Unit Using a Co-Designed Multifaceted Implementation Strategy

Despite the therapeutic benefits of sensory approaches being well documented, little research has focused on improving their implementation in acute mental health units. The use of implementation frameworks to improve the use of evidence-based practices has shown promising results in healthcare; however, there is little evidence for their use in acute mental health units. A pre-post comparison design was used to determine the effect of an 11-month co-designed theory-informed multifaceted implementation strategy on the use of sensory approaches and the use of seclusion/restraint in one acute mental health ward. This study was guided by Integrated Knowledge Translation (IKT) and informed by the Behaviour Change Wheel (BCW) approach. Implementation strategies were co-designed and included provision of sensory materials/resources; education/training; prompts/reminders; modelling; audit and feedback; workplace coalition; and facilitation. Data were collected through pre- and post-project questionnaires (pre- n = 37, post- n = 40) and routine clinical data. Data were analysed using SPSS and thematic analysis. Data for matched pairs (n = 19) revealed significant improvements between pre- and post-perceived levels of knowledge and confidence in using sensory approaches. Significant increases were found in the use of sensory kits, weighted modalities and sensory assessment/plans. Post participants' recommendations to sustain the use of sensory approaches in their unit included ongoing training; funding; maintenance and supply of sensory equipment; increased staffing; and support from colleagues. This is the first study to use the IKT and BCW to design, facilitate and evaluate a co-designed, theory-informed implementation strategy to improve the use of sensory approaches in an acute mental health unit.

'To loosen up and talk': Patients´ and facilitators´ experiences of discovery group sessions from the Tidal Model as an introduction before engaging in a person-centred group intervention

WHAT IS KNOWN ABOUT THE SUBJECT

Treatment groups in Mental Health Service is cost-effective, increases patients´ self-understanding and stimulate change Research shows that people with mental illness have different barriers to attend group sessions which often originates from a lack of trust in other people, but it is known that the possibility to build gradual trust among the participants encourages attendance.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

This study is based on the experience from outpatients and illuminates how discovery groups from the Tidal Model can be used as introductory sessions to build gradual trust among people with mental illness before engaging in a person-centred group intervention. The study fills a research gap in methods to create a safe and trusting environment in treatment groups for people with mental illness working with recovery-oriented person-centred interventions.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

This study emphasizes the importance of meeting concerns about social interactions in persons with mental illness when joining treatment groups. It presents a recovery-oriented method which meets this requirement and is easy to implement in practice.

ABSTRACT

INTRODUCTION: Recovery-oriented interventions delivered individually or in groups are more and more common within mental health nursing. However, persons with mental illness may be cautious about engaging in groups. Therefore, it is important to provide a trusting basis in the group to allow for the best opportunities to promote engagement, attendance and impact of treatment.

AIM

The aim was to explore how discovery group sessions were experienced as introductory sessions from the perspectives of participants and facilitators before engaging in a person-centred group intervention.

METHOD

A qualitative interview study was conducted, involving four group facilitators and 16 participants with mental illness from five completed groups. Data were analysed with Ricoeur's theory of interpretation.

RESULTS

The findings showed that the two discovery group sessions were experienced as useful and meaningful to all and created a safe atmosphere and a trusted relationship among group participants and facilitators.

DISCUSSION

Feeling safe and sharing experiences and emotions contribute to the relational climate in a group.

IMPLICATION FOR PRACTICE

Addressing concerns about social interactions in persons with mental illness is important in group treatment. This study proved that engaging patients in designing or adapting interventions for mental health services is important to improve quality.

``Getting People Back Into the Community'': Forensic Mental Health Nurses' Perceptions and Experiences of the Recovery Model Within a High-Secure Hospital

BACKGROUND

The implementation of the recovery model into forensic mental health care promotes hope and has important implications for inpatients' community reintegration.

AIM

This study aimed to describe forensic mental health nurses' perceptions and experiences of providing care using the recovery model within a high-secure forensic hospital in Queensland, Australia.

METHODS

Twenty-seven forensic mental health nurses were interviewed regarding their perceptions and experiences of providing recovery-oriented care within a high-secure forensic hospital.

RESULTS

The participants described an individualized approach to recovery, both in the goals developed and in the level of support they required. There was an overarching shared goal across the participant group, which was focused on supporting patients to reintegrate back into the community. Inadequate resources (both internal and external), the severity of patient psychopathology, legal constraints, and the nursing role within the broader treating team were all perceived to present challenges to utilizing the recovery model within a high-secure forensic hospital.

IMPLICATIONS FOR CLINICAL FORENSIC NURSING PRACTICE

To fully realize the potential of the recovery model, a system-wide reconceptualization is necessary.

'Everything would have gone a lot better if someone had listened to me': A nationwide study of emergency department contact by people with a psychosocial disability and a National Disability Insurance Scheme plan

Australians with a psychosocial disability (PSD) and a National Disability Insurance Scheme (NDIS) plan may at times require emergency care due to the fluctuating nature of their physical and mental health conditions or when their supports have become insufficient. This nationwide study investigated the experiences of people presenting to an emergency department (ED) who have a PSD and an NDIS plan. The objective was to understand current care and communication practices and to provide recommendations for service integration. Twenty-four interviews were conducted with people who had a PSD and an NDIS plan. Participants were asked semi-structured questions about their experiences when engaging with NDIS processes and when engaging with the ED as an NDIS recipient and how communication practices could be improved between the two services. A qualitative, descriptive thematic analysis approach was used. A lived experience advisory group participated in the research and provided commentary. The findings of this study indicate that the NDIS, as a personalised budget scheme, presents challenges for people with complex PSD and physical needs. ED clinicians appear to be unclear about what the NDIS provides and communication between the two systems is fragmented and inconsistent. The themes identified from the analysed transcripts are: (a) People with PSD experience distress when dealing with the NDIS; (b) There's a blame game between the ED and the NDIS; and (c) Inadequate service integration between the ED and NDIS. Recommendations to assist with service integration include building service capacity, providing overlapping care and bridging the diverse biomedical, psychosocial and disability care services.

Factors influencing the recovery-oriented attitudes of nursing directors in psychiatric hospitals: A cross-sectional study in Japan

WHAT IS KNOWN ON THE SUBJECT?: Recovery-oriented services have been shown to promote recovery in people with mental illness; their implementation is important for current psychiatric practice and is being considered by many professional institutions. The Japanese government released the policy 'A Vision for Reform of Mental Health and Medical Welfare' (Ministry of Health, Labour and Welfare, 2004; https://www.mhlw.go.jp/topics/2004/09/dl/tp0902-1a.pdf), aiming to update public consciousness, reorganize the mental healthcare welfare system and strengthen the foundation of mental healthcare to promote a basic policy focusing on the transition 'from hospital to community life'. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first study to clarify recovery-oriented attitudes among psychiatric nursing directors and related factors in Japan. It shows an association between recovery-oriented attitudes and hospital size. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: A relationship exists between the recovery knowledge and recovery-oriented attitudes of psychiatric nursing directors. It may thus be valuable for directors to see and hear about the experiences of patients living in the community during their recovery process. As hospital size and organizational climate may hinder the successful implementation of recovery-oriented practices, these factors must be considered when introducing such practices. Further research is needed on the relationship between psychiatric nursing directors' recovery-oriented attitudes and practices. Moreover, to develop intervention studies that uncover success factors for enhancing recovery-oriented attitudes, organizational factors that enable recovery-oriented practices must be further investigated.

ABSTRACT

INTRODUCTION: Recovery-oriented practices in mental health services have become a global priority. Despite their proven effectiveness, Japanese hospitals have not widely implemented such practices.

AIM

This study clarified psychiatric nursing directors' recovery-oriented attitudes and factors regarding promoting recovery-oriented practices to identify methods for developing these practices in Japan.

METHOD

This cross-sectional study used a questionnaire survey with 250 nursing directors from 1287 Japanese psychiatric hospitals. Multivariable regression analysis assessed how socio-demographic variables and Recovery Knowledge Inventory (RKI) scores affected Recovery Attitudes Questionnaire (RAQ-7) scores.

RESULTS

The analysis revealed that more clinical and managerial experience was associated with more negative recovery-oriented attitudes. High RKI scores, knowledge of strength, hospital size and outpatient work experience were associated with more positive recovery-oriented attitudes.

DISCUSSION

Implementing recovery practices requires consideration of knowledge and experience in recovery and hospital size alongside recovery training based on a hospital's organizational structure. Although the low response rate could influence the study's generalisability, it could also indicate low interest in recovery-oriented practices among professionals.

IMPLICATIONS FOR PRACTICE

Acquiring more knowledge and experience regarding recovery promotes recovery-oriented attitudes among nursing directors. An appropriate organizational culture and consideration of hospital size are required when introducing such recovery practices.

From Model to Practice: A Qualitative Study on Factors Influencing the Implementation of the Active Recovery Triad (ART) Model in Long-Term Mental Health Care

Background: The Active Recovery Triad (ART) model provides a framework for recovery-oriented care in the long-term mental health setting. The aim of this study is to gain insight into factors influencing the implementation process of the ART model. Methods: Focus groups were conducted with fourteen multidisciplinary teams that were in the process of implementing the ART model. Data were thematically analyzed. Results: Three phases of implementation were identified. In the first phase, getting started, support from both the top of the organization and the care workers, sufficient information to care workers, service users, and significant others, and creating momentum were considered crucial factors. In the second phase, during implementation, a stable team with a good team spirit, leadership and ambassadors, prioritizing goals, sufficient tools and training, and overcoming structural limitations in large organizations were seen as important factors. In the third phase, striving for sustainability, dealing with setbacks, maintaining attention to the ART model, and exchange with other teams and organizations were mentioned as core factors. Conclusions: The findings may support teams in making the shift from traditional care approaches towards recovery-oriented care in long-term mental health care.

The experience of healthcare professionals implementing recovery-oriented practice in mental health inpatient units: A qualitative evidence synthesis

WHAT IS KNOWN ON THE SUBJECT?: The principles of personal recovery are primarily applied in outpatient and community settings as these settings provide continuity of care and recovery-based community programs supporting consumers' recovery journey. A range of healthcare professionals are involved in the care of people within mental health in-patient units, including nurses, psychiatrists, psychologists, occupational therapists and social workers. The integration of recovery-oriented care in mental health inpatient units may be impaired by a lack of confidence among mental health professionals. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Developing hope and a safe place is an integral part of recovery-oriented practice within mental health inpatient units. Instilling connectedness is a relevant recovery principle; however, there may be greater barriers in mental health settings which traditionally prioritise safety and risk mitigation practices to prevent perceived harmful behaviours. Staff workload and inadequate understanding of recovery concepts present challenges to promoting recovery-oriented care in everyday practice. Using strength-based practice is critical in promoting a safe space for consumers by providing psychosocial interventions and person-centred care. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The provision of recovery-oriented practice requires adopting a collaborative approach that places a strong emphasis on the involvement of consumers and their families. Empowering mental health professionals to believe that recovery-oriented practice is possible in mental health inpatient units is crucial. Mental health professionals need to create a safe environment and positive relationships through respect and empathy for consumers and their family members. ABSTRACT: Introduction Recovery-oriented practice underpins an individual's personal recovery. Mental health nurses are required to adopt a recovery-oriented approach. Globally, a paucity of literature exists on mental health professionals' experience of recovery-oriented practice in mental health inpatient units. Aim The aim of this synthesis was to explore the experiences of healthcare professionals regarding recovery-oriented care in mental health inpatient units by appraising and synthesising existing qualitative research. Method Three databases, including MEDLINE, PsycINFO and CINAHL were searched between 2000 and 2021. Data were extracted and synthesised using thematic integrative analysis. The quality of included studies was assessed with the CASP Critical Appraisal Checklist. Results Ten qualitative research projects met the inclusion criteria. Four themes were identified (i) developing a safe and hopeful space, (ii) promoting a healing space, (iii) instilling connectedness and (iv) challenges to realising recovery-oriented care. Discussion Mental healthcare professionals perceived the principles of recovery-oriented care to be positive and include: therapeutic space, holistic care and person-centred care. Nevertheless, findings revealed limited knowledge and uncertainty of the recovery concept to be key barriers that may hinder implementation into practice. Implications for Practice Recovery-oriented practice must underpin consumer and family engagement, treatment choices and continuity of care to facilitate consumer's personal recovery.

Measurement properties of the Thai translation of the Recovery Assessment Scale - Domains and Stages (RAS-DS) and comparison of recovery experiences between Thai and Australian consumers living with serious mental illness

Personal recovery, a western conceptualisation that focuses on hope and living meaningful lives of choice rather than focusing on symptom reduction, is a more recent concept in many Asian countries including Thailand. One way to promote recovery-oriented service delivery is to use outcome measures that capture self-reported personal recovery. This study aimed to evaluate a Thai translation of a self-report measure of mental health recovery, the Recovery Assessment Scale - Domains and Stages (RAS-DS). The study also explored the cultural similarities and differences between Thai (n  =  190) and Australian (n  =  301) recovery experiences by comparing Thai and Australian participant responses to RAS-DS items. Data were analysed using Rasch analysis. Analyses revealed that the Thai version of the RAS-DS had adequate measurement properties. Cultural comparisons suggested that most aspects contained within the RAS-DS appear to be applicable across both Thai and Australian contexts. Three findings suggest linguistic or cultural differences in Thai and Australian recovery experiences: (i) a ceiling effect for Thai participants, (ii) some items were "harder" or "easier" for one cultural group to endorse than the other, and (iii) a few items were "misfitting" for Thai participants.

Supporting self-determination in mental health recovery: Strategies employed by occupational therapists

INTRODUCTION

Self-determination is a core component of mental health recovery and a predictor of positive outcomes. The literature calls for occupational therapists to lead practice change to greater recovery-orientation, including facilitating people's self-determination. However, systemic challenges thwart translation of policy into practice and therapists report a lack of confidence in implementing recovery-oriented principles. This study aimed to understand the strategies that mental health occupational therapists employ to support people's self-determination.

METHODS

Data were collected through an international on-line questionnaire principally comprising two open-ended questions designed to elicit deep reflective personal accounts. Participants were asked about an experience in which they supported a person's self-determination and the factors that either facilitated or hindered this experience. Qualitative data were analysed using inductive thematic analysis, guided by constant comparative methods.

FINDINGS

Thirty-four therapists, predominantly from Australia (n = 30), participated. Therapists described supporting self-determination as a multifaceted process that involved: (1) working on myself, (2) working with the person, and (3) working with others. They emphasised that the combined use of various strategies across these three areas of work was important to support people's self-determination. Further, awareness of and addressing issues of power in their practice was key.

CONCLUSION

This study supports the translation of recovery-oriented principles into practice by revealing the nuanced strategies implemented by occupational therapists striving to support self-determination. Participants employed diverse strategies to empower people to take the 'driver's seat' in their mental health recovery journey. Insights from this study will support other occupational therapists to actualise recovery-oriented principles and better support self-determination in their practice. To effectively implement self-determination strategies, therapists must reflect on and address existing power differentials within mental health services, particularly between themselves and the people they support.

Associated factors of nurse-sensitive patient outcomes: A multicentred cross-sectional study in psychiatric inpatient hospitals

WHAT IS ALREADY KNOWN?: The nurse-patient relationship in mental health care is an important focus of mental health nursing theories and research. There is limited evidence about which factors influence nurse-sensitive patient outcomes of the nurse-patient relationship. This hinders the development, planning, delivering, and quality assurance of the nurse-patient relationship in nursing practice and nursing education. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: To our best knowledge, this is the first study to examine associations between nurse-sensitive patient outcomes of the nurse-patient relationship and a range of patient characteristics and relationship-contextual factors. In this study, we found that gender, age, hospital characteristics, nurse availability when needed, nurse contact, and nurse stimulation were associated with the scores on the nurse-sensitive patient outcome scale. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Having insight into the factors associated with nurse-sensitive patient outcomes of the nurse-patient relationship can help nurses, nursing students, nursing management and also patients to enhance the nurse-patient relationship, trying to influence outcomes of nursing care. ABSTRACT: Introduction The lack of evidence on patient characteristics and relational-contextual factors influencing nurse-sensitive patient outcomes of a nurse-patient relationship is a possible threat to the quality and education of the nurse-patient relationship. Aim To measure nurse-sensitive patient outcomes of the nurse-patient relationship and to explore the associations between nurse-sensitive patient outcomes and a range of patient characteristics and relational-contextual factors. Method In a multicenter cross-sectional study, 340 inpatients from 30 units in five psychiatric hospitals completed the Mental Health Nurse-Sensitive Patient Outcome Scale. Descriptive, univariate and Linear Mixed Model analyses were conducted. Results Overall, patient-reported outcomes were moderate to good. Female participants, nurse availability when needed, more nurse contact and nurse stimulation were associated with higher outcomes. Age differences were observed for some of the outcomes. Outcomes also varied across hospitals but were not related to the number of times patients were hospitalized or to their current length of stay in the hospital. Discussion The results may help nurses to become more sensitive and responsive to factors associated with nurse-sensitive patient outcomes of the nurse-patient relationship. Implications The nurse-sensitive results can support nurses in designing future nurse-patient relationships.

Implementation and evaluation of recovery-oriented practice interventions for people with mental illness in Asia: An integrative review

BACKGROUND

Recovery is a process involving empowering individuals to take control of their lives and develop meaningful and purposeful life, regardless of whether their mental health symptoms persist. Recovery-oriented practice has been widely implemented, particularly in Anglophone countries, during the past two decades. Mental health recovery in Asia is also moving towards recovery-oriented practice. Little is known about how recovery-oriented interventions originating in the West have been implemented and evaluated in Asian contexts.

OBJECTIVE

This review aimed to identify 1) types of recovery-oriented practice interventions that have been implemented in Asia, 2) how they have been culturally adapted, 3) barriers and facilitators to implementation, and 4) how the interventions have been evaluated.

DESIGN

This is an integrative review.

METHODS

This integrative review followed Whittemore and Knafl's five-stage framework. Six electronic databases (e.g., PsycINFO, MEDLINE, Embase, CINAHL, Web of Science, and the Cochrane Library) were systematically searched from their inception to January 2022 to identify eligible studies published in English language. The key search terms included "mental illness", "recovery-oriented intervention", and "Asia". Studies reporting on implementation and evaluation of recovery-focused interventions in Asian settings were eligible. Quality assessment and narrative synthesis were subsequently undertaken.

RESULTS

Thirty-eight studies were included. Seven main types of recovery-oriented intervention were identified: (1) peer programmes; (2) illness management and recovery; (3) individual placement and support; (4) strength model case management; (5) clubhouse model; (6) wellness recovery action plan and (7) psychiatric advance directive, alongside several novel recovery programmes. Studies reported cultural adaptations for language, content, cultural norms, religious beliefs, family, and local context. Barriers to implementation included a poor understanding of recovery concepts and inadequate organisational resources. A range of clinical and personal recovery outcome measures were reported.

CONCLUSIONS

Recovery-oriented interventions are increasing in Asia, with nearly half of reviewed studies featuring cultural adaptations. However, research is geographically skewed, and more rigorously conducted studies are needed across a wider range of Asian countries.

REGISTRATION

This review was registered with the PROSPERO International prospective register of systematic reviews (CRD42022310049).

TWEETABLE ABSTRACT

Recovery-oriented practice interventions for people with mental illness are on the rise in Asia @chonmananNN.

"A place without walls, only opportunities": personal accounts of attending Recovery Colleges in Norway

Introduction

Recovery colleges (RCs) are learning environments, first established in the UK, based on principles that support positive life changes and reduce stigma related to challenges with mental health and substance use problems. RCs offer courses based on co-production processes and are designed and delivered jointly by individuals with lived experience and professional experts. The courses are open to anyone, attracting people with a variety of life experiences. RCs are non-clinical environments that provide individuals with the identities of students and/or trainers as autonomous and independent agents. In this paper, we investigate experiences of being a part of a RC in Norway, either as a student and/or as a course trainer with lived experiences of mental health or substance use challenges. We ask the following research question: What kinds of personal and social processes are enabled by being part of a recovery college from the perspective of persons with experience-based competence?

Materials and methods

The study is qualitative and explorative based on 11 individual (N = 11) and two focus group interviews (N = 8). Participants were recruited from two of the first RCs in Norway between August 2021 and January 2022.

Results

Study participants describe how their involvement in a RC provided them with opportunities to assume new positions in their recovery process, both related to former institutional identities given in the course of treatment and related to the way they see themselves as people struggling with mental health and substances use challenges. Attending a RC represented significant transitions (1) from an institutional position as "sick" or as "what's on the paper" into a position as "a whole person"; (2) from being in in a position as a recipient of care to the position as actively responsible for life changes; (3) from seeing themselves as worthless to seeing themselves as persons with resources; (4) from being alone to being part of a fellowship. Participants describe being part of a RC as an invaluable addition to other kind of support or help.

Discussion

It is important to provide alternative arenas like RC for facilitating work with life changes, as an invaluable addition to regular services.

Using the Theoretical Domain Framework to understand what helps and hinders the use of different sensory approaches in Australian psychiatric units: A survey of mental health clinicians

BACKGROUND/AIM

Although sensory approaches are recommended to relieve distress and agitation and reduce the use of seclusion and restraint, many Australian psychiatric units have struggled to sustain their practice. The aim of this study was to investigate the barriers and enablers influencing the use of different sensory approaches across one health region in Australia and to obtain recommendations for strategies to improve their use.

METHOD

This cross-sectional survey was informed by the Theoretical Domain Framework. Likert scale questions considered barriers and enablers to the use of non-weighted sensory interventions, weighted modalities, sensory rooms, and sensory assessments/plans. Open-ended questions explored participant concerns and recommendations to improve the use of sensory approaches.

RESULTS

Participants (n = 211) were from nursing, allied health, medical, and peer support staff across inpatient psychiatric units. Factors most frequently identified as enablers for using sensory approaches were beliefs of positive benefits to consumers (e.g. decreasing distress and agitation); belief it was within the staff's role; and knowledge of the approaches. Limited time was the most common identified barrier. Factors statistically associated with more frequent use were knowledge, skills, confidence, availability, and easy access to sensory tools/equipment. Only 30% of participants were concerned about potential risks of sensory approaches, with this risk mitigated through adequate supervision and thorough risk assessment. Recommendations to improve practice included improved access to, and maintenance of, equipment, more training, and increased staffing.

CONCLUSION

This study revealed how barriers and enablers vary for different sensory approaches and how these factors impact their frequency of use in psychiatric units. It provides insights into staff recommendations to improve the use of sensory approaches in one health region in Australia. This knowledge will lead to the development of implementation strategies to address identified barriers and improve the use of sensory approaches in psychiatric units.

Toward an Experience-Based Model of Recovery and Recovery-Oriented Practice in Mental Health and Substance Use Care: An Integration of the Findings from a Set of Meta-Syntheses

A model of recovery and recovery-oriented practice has been developed based on three previously published meta-syntheses of experiences and processes of mental health and substance use recovery. The model integrates the findings of these three meta-syntheses into three components: experiences of recovery, processes of recovery-oriented practice, and social and material capital. The experiences of recovery involve being, doing, and accessing and are viewed as embedded in the processes of recovery. The processes of recovery-oriented practice aim to mobilize and apply various forms of capital to support the recovery journey. Social and material capital, in turn, constitute the context in which recovery occurs and requires mobilization for the individual and the service system. The model is grounded in the principles of well-being, person-centeredness, embedding, self-determination, and the interdependency of human living. The model is both descriptive and explanatory, as it depicts the experiential and processual aspects of recovery and recovery-oriented practice and their interrelationships. The model as a framework needs to be elaborated further through application in practice and research, especially for understanding how experiences, processes and practices interact over time, and how they are affected by access to material and social capital.

Staff perceptions of factors affecting the use of RAS-DS to support collaborative mental health practice

BACKGROUND

The Recovery Assessment Scale: Domains and Stages (RAS-DS) was designed to be both a recovery outcome measure and a tool to enhance service-user control over their recovery journey. While extensively and globally used in mental health services for the former purpose, routine use for the latter purpose is yet to be realised. The aim of this study was to identify barriers, facilitators and additional supports needed for RAS-DS to be used to support service user participation, goal setting and recovery action planning.

METHODS

An online survey was conducted of mental health workers who had engaged with RAS-DS, including fixed choice and open-ended questions. Data were analysed using descriptive statistics and interpretive content analysis respectively.

RESULTS

The 65 respondents reported more frequent use of RAS-DS as an outcome measure than as a collaboration tool and more than half reported difficulties in using it in this way. Factors that they described as influencing the use of RAS-DS as a tool for collaboration and support included: previous experiences with RAS-DS; organisational supports and policies; awareness of the RAS-DS amongst colleagues; RAS-DS related training and support; staff time and capacity; the format of RAS-DS; service user population or context; and respondents' own active efforts.

CONCLUSIONS

Extending the use of RAS-DS, an already widely used tool, to routinely support recovery-oriented practice has both efficiency and service user empowerment benefits. However further work is needed to enable this including: provision of co-designed, accessible training resources; a user platform including built in guidance; and strategies to promote management understanding and valuing of the enhanced recovery-orientation opportunities inherent in RAS-DS use.

Recovery-oriented mental health principles in psychiatric hospitals: How service users, family members and staff perceive the realization of practices

AIMS

The aim of the study was to describe and compare how recovery-oriented mental health principles have been realized in Finnish psychiatric hospitals from the viewpoint of different stakeholders (service users, family members and staff).

DESIGN

A multimethod research design was adopted to combine both quantitative and qualitative descriptive methods.

METHODS

A total of 24 focus group interviews were conducted with service users (n = 33), family members (n = 3) and staff (n = 53) on 12 psychiatric Finnish hospital wards (October 2017). The interview topics were based on six recovery-oriented principles (WHO QualityRights Tool Kit, 2012). A quantitative deductive analysis was conducted to describe and compare the realization of the recovery-oriented principles between three stakeholder groups. A qualitative deductive content analysis was used to describe participants' perceptions of the realization of recovery-oriented principles in practice. The GRAMMS guideline was used in reporting.

RESULTS

Out of six recovery-oriented principles, 'Dignity and respect' was found to have been realized to the greatest extent on the psychiatric wards. The most discrepancy between the participant groups was seen in the 'Evaluation of recovery'. Service users and family members found the realization of the practices of all principles to be poorer than the staff members did. Wide variation was also found at the ward level between perceptions among participants, and descriptions of the realization of the principles in psychiatric hospital practice.

CONCLUSION

Perceptions about the realization of recovery-oriented principles in practice in Finnish psychiatric hospitals vary between different stakeholder groups. This variation is linked to differing ward environments.

IMPACT

More research is needed to understand the factors associated with variation in perceptions of recovery principles.

PATIENT OR PUBLIC CONTRIBUTION

Service users and family members participated in this study.

"I thought it would just be, like, older men in white coats": A qualitative exploration of first encounters with mental health services

Individuals whose mental health is becoming a concern may not receive the care they require. Although efforts have been made to reduce barriers to accessing services, including stigma reduction campaigns and healthcare practitioner training, there remains a lack of understanding of individual perspectives regarding help-seeking behaviour. The aim of this study was to explore people's first experiences accessing mental health services. A qualitative descriptive approach was adopted. Interviews were conducted with eight service users. Data were analysed using reflexive thematic analysis. The COREQ checklist guided this study (Tong et al., 2007, International Journal for Quality in Health Care, 19, 349). Three themes were identified: learning to navigate an unfamiliar system, making sense of mental health services, and promoting a positive image for those in need of care. Uncertainty about mental health services and stigmatizing images could be mitigated by developing positive media-based interventions. Systemic barriers need to be addressed and services need to be better resourced to ensure the benefits of early intervention are available to those experiencing mental health challenges. To encourage people to access services earlier, services need to be promoted in a positive way.

Making the case for citizenship-oriented mental healthcare for youth in Canada

Purpose

Varying stakeholders have highlighted how recovery-oriented mental health services such as youth mental health services have traditionally focused on supporting individual resources to promote recovery (e.g., agency) to the exclusion of addressing structural issues that influence recovery (e.g. poverty). One response to this criticism has been work helping people with mental health problems recover a sense of citizenship and sense of belonging in their communities. Work on citizenship has yet to influence youth mental healthcare in Canada’s provinces and territories. This paper aims to highlight ways that youth mental healthcare can better help youth recover a sense of citizenship.

Design/methodology/approach

The arguments described in this paper were established through discussion and consensus among authors based on clinical experience in youth mental health and an understanding of Canada’s healthcare policy landscape, including current best practices as well as guidelines for recovery-oriented care by the Mental Health Commission of Canada.

Findings

Here, this study proposes several recommendations that can help young with mental health problems recover their sense of citizenship at the social, systems and service levels. These include addressing the social determinants of health; developing a citizenship-based system of care; addressing identity-related disparities; employing youth community health workers within services; adapting and delivering citizenship-based interventions; and connecting youth in care to civic-oriented organizations.

Originality/value

This paper provides the first discussion of how the concept of citizenship can be applied to youth mental health in Canada in multiple ways. The authors hope that this work provides momentum for adopting policies and practices that can help youth in Canada recover a sense of citizenship following a mental health crisis.

Exploring Factors Impacting the Implementation of Recovery-Oriented Treatment Planning on Acute Inpatient Mental Health Units

PURPOSE

The current literature on operationalizing and implementing recovery-oriented inpatient care in diverse settings remains limited. The present study systematically examined factors affecting the implementation of one aspect of recovery-oriented care in a large and diverse national sample of Veterans Health Administration (VHA) inpatient mental health units.

METHOD

VHA inpatient mental health units were scored on the Recovery-Oriented Acute Inpatient scale (RAIN). Sites scoring either one standard deviation above (n = 8; i.e., high-scoring sites) or one standard deviation below (n = 5; i.e., low-scoring sites) the mean on the RAIN factor of inpatient treatment planning subscale were included for additional analyses (N = 13). We used a qualitative approach known as emergent thematic analysis to assess the implementation of inpatient treatment planning elements (e.g., goal setting, shared decision-making) from qualitative interviews, observation notes, and chart reviews collected for the 13 sites. The analysis was guided by Normalization Process Theory.

RESULTS

The eleven themes that emerged across the elements of recovery-oriented inpatient treatment planning mostly represented commonalities across sites, such as a shared treatment philosophy of acute care. However, five themes emerged as "differentiators" that distinguished high- and low-scoring sites and included veteran input, elicitation of recovery goals, the value of group programming, and the purpose of family involvement.

CONCLUSION

Findings provide insight into contextual factors and processes that impacted the implementation of recovery-oriented treatment planning at these VHA inpatient mental health units. To further facilitate the implementation of recovery-oriented inpatient treatment planning elements, future research should examine staff's collective understanding of recovery-oriented inpatient care.

The Effectiveness of Peer Support in Personal and Clinical Recovery-Systematic Review and Meta-Analysis

OBJECTIVE

Peer support has been shown to support personal recovery from mental illness. It is unclear whether the effects of peer support across different mental illnesses depend on the organizational setting. The authors reviewed the effectiveness of peer support for both personal recovery and clinical recovery of adults with any mental illness and evaluated the effectiveness of peer support in different settings.

METHODS

A systematic review of randomized controlled trials (RCTs) was conducted in PubMed, PsycInfo, CINAHL, Cochrane Library, and Web of Science. A meta-analysis of outcomes of personal and clinical recoveries at the end of interventions was conducted.

RESULTS

In total, 49 RCTs with 12,477 participants with any mental illness were included. Most of the trials had a high risk for bias. Results of the meta-analysis indicated that peer support in general had a small positive effect on personal recovery (standard mean difference [SMD]=0.20; 95% CI=0.11-0.29) and decreased anxiety symptoms (SMD=-0.21; 95% CI=-0.40 to -0.02), with most trials evaluating peers added to mental health-related hospital services. No data for peers in established service roles were available for the meta-analysis. Peer-designed interventions developed to be provided independently of hospital services and delivered in community settings had a modest effect on self-advocacy. A small nonsignificant effect on personal recovery for peer support delivered online was also observed.

CONCLUSIONS

The effect on personal recovery from mental illness was most evident in peer support added to hospital services. High-quality RCTs with comparable cocreated interventions and clear descriptions of mechanisms of change are needed to further investigate peer support efficacy.

Patient-reported outcomes of the nurse-patient relationship in psychiatric inpatient hospitals: A multicentred descriptive cross-sectional study

WHAT IS KNOWN ON THE SUBJECT?: Psychiatric and/or mental health nurses are struggling to measure the outcomes of the nurse-patient relationship. Collecting nurse-sensitive patient outcomes is a strategy to provide outcomes of a nurse-patient relationship from patients' perspectives. Because there was no validated scale, the Mental Health Nurse-Sensitive Patient Outcome-Scale (six-point Likert-scale) was recently developed and psychometrically evaluated. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first study using the Mental Health Nurse-Sensitive Patient Outcome-scale to measure nurse-sensitive patient outcomes of the nurse-patient relationship in psychiatric hospitals. Moderate to good average scores for the MH-NURSE-POS total (4.42) and domains scores (≥4.09). are observed. Especially outcomes related to 'motivation' to follow and stay committed to the treatment received high average scores (≥4.60). Our results are consistent with the patient-reported effect(s) of relation-based nursing in qualitative research. The scores generate evidence to support the outcomes of the nurse-patient relationship and implicates that further investment in (re)defining and elaborating nurse-patient relationships in mental healthcare is meaningful and justified. More comparative patient-reported data can determine how nurse-sensitive patient outcomes are affected by the patient, nurse, and context. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Demonstrating patient-reported outcomes of the nurse-patient relationship can be important to enhance the therapeutic alliance between nurses and patients, organize responsive nursing care, and create nursing visibility in mental healthcare. Further nursing staff training on interpersonal competencies, such as self-awareness and cultural sensitivity, can be pivotal to achieving the patient-reported outcomes for inpatients with mental health problems.

ABSTRACT

INTRODUCTION: Identifying patient-reported outcomes of the nurse-patient relationship is a priority in inpatient mental healthcare to guide clinical decision-making and quality improvement initiatives. Moreover, demonstrating nurse-sensitive patient outcomes can be a strategy to avoid further erosion of the specialism of psychiatric and/or mental health nursing.

AIM/QUESTION

To measure nurse-sensitive patient outcomes of the nurse-patient relationship.

METHOD

In a multicentred cross-sectional study, 296 inpatients admitted to five psychiatric hospitals completed the recently developed and validated Mental Health Nurse-Sensitive Patient Outcome-Scale (MH-NURSE-POS). The MH-NURSE-POS consists of 21 items (six-point Likert-scale) in four domains: 'growth', 'expression', 'control', and 'motivation'.

RESULTS

Participants displayed moderate to good average scores for the MH-NURSE-POS total (4.42) and domain scores (≥4.09). Especially outcomes related to 'motivation' to follow and stay committed to the treatment received high average scores (≥4.60).

DISCUSSION

The results demonstrate that patients perceive the nurse-patient relationship and the care given by psychiatric and/or mental health nurses as contributing to their treatment.

IMPLICATIONS FOR PRACTICES

Patient-reported outcomes can guide nurses and managers to provide and organize nursing care and to build a nurse-patient relationship that has a positive impact on these outcomes. Additionally, outcomes can create nursing visibility as a profession in- and outside mental healthcare.

Staff Experiences of Integrating Peer Support Workers and Clinical Staff in Community-Based Residential Mental Health Rehabilitation: A Pragmatic Grounded Theory Analysis

Mental health services are increasingly incorporating the views and expertise of people with a lived experience of mental illness in service delivery. A novel approach to this is the 'integrated staffing model' being trialled at two Australian public residential mental health rehabilitation services (Community Care Units, CCUs) where peer support workers (PSWs) occupy the majority of staff roles and work alongside clinicians. Semi-structured interviews were completed with fifteen staff 12-to-18-months after service commencement. Transcripts were analysed following principles of grounded theory analysis. Key emergent themes were: (1) recovery is a deeply personal and non-linear process; (2) The CCU as a transitional learning environment; (3) the integrated staffing model facilitates an effective rehabilitation team; and (4) coming together under the integrated staffing model required a steep learning curve. The findings suggest that the integrated staffing approach may provide a pathway to facilitate the meaningful inclusion of PSWs in rehabilitation settings.

Staff experiences related to implementation of a recovery-oriented nursing programme in psychiatric inpatient care

Nursing in psychiatric inpatient care is peripheral to a dominating biomedical model of care. Efforts are being made to implement nursing models based on core values and theories for nursing, such as recovery-oriented practices. The aim of the study was to explore experiences of a recovery-oriented nursing programme (Steps Towards Recovery, STR) among nursing staff in psychiatric inpatient care and their ratings of stress (Maslach Burnout Inventory scores), quality of care (Quality of Psychiatric Care - Inpatient staff scores) and satisfaction with nursing care (Satisfaction with Nursing Care and Work scale scores), before and after the implementation-and compare with ratings from reference wards. A quasi-experimental and prospective, pretest-post-test design was used. Specific questions about the nursing programme were answered by staff at the intervention wards. Staff reported predominantly positive experiences of the nursing programme. At follow-up, higher ratings were reported in two dimensions of quality of care in the STR group, and lower ratings in one dimension of stress were evident in the reference group. No differences in ratings between the STR and reference wards were found. Staff members' positive experiences of STR and higher ratings regarding participation and secure environment after implementation suggest that STR is a well-accepted and promising nursing programme. It is important to implement and evaluate recovery-oriented interventions in psychiatric inpatient care, where a focus on symptom relief still prevails. The results indicate that there is potential for further exploration of STR in this context.

Evaluation of an Inpatient Psychiatric Mother-Baby Unit Using a Patient Reported Experience and Outcome Measure

Understanding the patient experience of admission to a psychiatric mother-baby unit (MBU) informs service improvement and strengthens patient-centered care. This study aims to examine patients’ experience, satisfaction, and change in mental health status related to MBU admission. At discharge, 70 women admitted to a public MBU completed the Patient Outcome and Experience Measure (POEM), rated the usefulness of therapeutic groups, and provided written qualitative feedback. Paired sample t-tests, correlations, and thematic content analysis were completed. Women were highly satisfied with the level of care and support received, particularly for those who were voluntarily admitted. Women reported an improvement in mental health from admission to discharge. Women appreciated the staff’s interpersonal skills, provision of practical skills, education, advice, support from other women, and therapeutic groups offered. Women suggested improvements such as having greater food choices, more MBU beds, more group sessions, family visitations, which had been restricted due to COVID-19, environmental modifications, and clarity of communication surrounding discharge. This study highlights the benefits of MBUs and the specific aspects of care that are favorable in treating women with mental illnesses who are co-admitted with their baby in an MBU.

Care coordination as a collaborative element of recovery oriented services for persons with severe mental illness

OBJECTIVE

To propose a model where care coordination can form part of recovery oriented care when it is included as a collaborative element of services for persons with severe mental illness.

CONCLUSION

A recovery-oriented service requires more than clinical interventions. It also needs to address social determinants and be individualised or person centred. Multiple health and community services need to be involved. A care coordination model is capable of addressing multiple needs. It gives the client the first and foremost voice. It facilitates intersectoral collaboration, reduces the burden on clinical mental health services and is supported by mental health and community service personnel.

Development of an Evidence-Informed and Codesigned Model of Support for Children of Parents With a Mental Illness- "It Takes a Village" Approach

Providing support to parents and their children to help address the cycle of intergenerational impacts of mental illness and reduce the negative consequences for children is a key focus of selective prevention approaches in public mental health. However, a key issue for children of parents with a mental illness is the lack of access to early intervention and prevention support when needed. They are not easily identifiable (until presenting with significant mental health issues of their own) and not easily accessing the necessary support that address the complex interplay of parental mental illness within families. There are significant barriers to the early identification of these children, particularly for mental health care. Furthermore, there is a lack of collaborative care that might enhance identification as well as offer services and support for these families. The "It takes a Village" project seeks to improve mental health outcomes for children through the co-development, implementation and evaluation of an approach to collaborative practice concerned with the identification of families where a parent has a mental illness, and establishing a service model to promote child-focused support networks in Austria. Here we describe the development of service delivery approach for the "It takes a Village" project that aims to improve identification and support of these children within enhancements of the existing service systems and informal supports. The paper describes the use of codesign and other implementation strategies, applied to a research setting, with the aim of impacting the sustainability of workforce reform to achieve lasting social impact. Results highlight the steps involved in translating evidence-based components, local practice wisdom and lived experience into the "It takes a Village" practice model for Tyrol, Austria. We highlight through this paper how regional context-specific solutions are essential in the redesign of care models that meet the complex needs of children of parents with a mental illness. Service system and policy formation with local and experienced stakeholders are also vital to ensure the solutions are implementation-ready, particularly when introducing new practice models that rely on organizational change and new ways of practice with vulnerable families. This also creates a solid foundation for the evaluation of the "It take a Village" approach for children of parents with a mental illness in Austria.

Part III: Recovery-Oriented Practices in Community Mental Health and Substance Abuse Services: A Meta-Synthesis

In recent decades, recovery-oriented practice has become the major approach in mental health and substance abuse care, especially in community mental health and substance abuse services. Various models of recovery-oriented practice have come to form the basis of the integration of this approach in service settings. The study aims to elucidate the characteristics of recovery-oriented practice as experienced by participants in the practice. The method used was a qualitative meta-synthesis that integrated the findings from thirty-four empirical papers published by one research group. Four meta-themes were developed: (a) helping and supporting, (b) collaborating and relating, (c) identity integration in practice, and (d) generating hope through nurturing and helping. These themes emphasize the value of relationships and connectedness, contextuality, and resources that can be mobilized in practice. The results emphasize the need to incorporate the elements in the four major themes as “working capital” for practitioners to realize recovery-oriented practice. The concepts of personal, social, and economic capital as working capital are elaborated, drawing from the meta-themes as the basis for recovery-oriented practice in mental health and substance abuse services.

Introducing the Needs in Recovery Assessment (NiRA) into clinical practice: protocol for a pilot study investigating the formal and systematic assessment of clinical and social needs experienced by service users at a tertiary, metropolitan mental health service

Background

The Needs in Recovery Assessment (NiRA) is a newly developed needs assessment tool, designed to identify the needs of people recovering from mental illness. This tool has been evaluated outside of the clinical context for validity and reliability. The aim of this study is to introduce the NiRA into clinical practice and to evaluate the value of the NiRA as an adjunct to service delivery from the perspectives of stakeholders and to evaluate the barriers and facilitators of embedding the NiRA in a mental health service.

Methods

The establishment of the NiRA in a tertiary mental health unit over a 6-month period will be evaluated using a multi-methods approach. Quantitative data will be collected using the NiRA itself and the Recovery Self-Assessment (RSA). Face-to-face interviews with service users and clinicians will be conducted following the initial completion of the NiRA, with a follow-up interview for service users on discharge from the service. Regular informal follow-up with clinicians throughout the study will support the introduction of the NiRA. Descriptive statistics will be used to analyse quantitative data, and descriptive qualitative methods will be used to analyse data from interviews.

Discussion

Aligning mental health services with recovery-oriented frameworks of care is imperative. The NiRA is a tool that has been designed in accordance with recovery principles and may assist services to be more recovery-oriented. If the NiRA is able to achieve the aims and objectives of this project, a larger implementation study will be conducted.

Trial registration

Australian and New Zealand Clinical Trial Registry (ANZCTR), ACTRN12621000316808

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00919-8.

Work-Related Satisfaction among Clinicians Working at Inpatient Treatment Facilities for Substance Use Disorder: The Role of Recovery Orientation

Several psychosocial factors have been suggested as facilitators of change among inpatients treated for substance use disorder (SUD). Research suggests that staff members are also influenced by the practice in which they are involved, and by contextual psychosocial factors at their treatment facilities. This cross-sectional questionnaire survey study was conducted to investigate the role of recovery-orientated interventions in describing work-related satisfaction among clinicians at inpatient SUD treatment facilities. The respondents (n = 407) rated items indicating work-related satisfaction and the degree of recovery orientation at their treatment facilities. The main findings of two block regression analyses indicated that clinicians’ work-related satisfaction was positively influenced by inpatients’ opportunities to pursue their goals and choices, and negatively influenced by inpatient involvement. The change in clinicians’ work-related satisfaction could not be described by the degree of individually tailored and varied interventions at the treatment facility. Clinicians should be supported and involved in the process of implementing measures to increase inpatient involvement in the treatment programmes, and treatment measures that enable inpatients to pursue their goals and choices should be enhanced. The findings of this and previous studies indicate that a recovery-oriented framework promotes clinicians’ work-related satisfaction and has an enabling influence on both inpatients and clinicians.

Barriers and facilitators of peer support work in a large psychiatric hospital: a thematic analysis

BACKGROUND

Peer support workers are an important addition to the mental healthcare profession. However, much of the literature and knowledge of the peer support role is derived from western countries. This concept is relatively new in Asian countries.

AIMS

The study sought to improve the understanding of the barriers and facilitators of peer support work in a large psychiatric hospital in Singapore.

METHODS

This study used qualitative data from a larger mixed-methods study. Thematic analysis was conducted based on the five steps recommended by Braun and Clarke (2006): (1) familiarisation of data whereby transcripts were read and reread, (2) generating initial codes, (3) searching for themes by gathering relevant codes, (4) reviewing themes and (5) defining and naming themes.

RESULTS

Four subthemes under the broader notion of facilitators (supportive figures, defined role, opportunities for personal growth and identifying personalised coping strategies) and three subthemes under the concept of barriers (unclear role, hostility from non-peer-support-specialist staff and unsupportive working environments) were identified.

CONCLUSION

Our findings echoed those of previous studies conducted in western countries providing some evidences for the cross-cultural nature of these barriers and facilitators. However, the way their impact can be mitigated or enhanced is likely to be different owing to cultural barriers, such as the general consensus and acceptance of larger personal recovery ideologies. Further research is required in community settings to better understand the boundaries and limitations of our findings. This information will allow us to continue improving peer support worker integration in diverse mental healthcare settings.