Promoting recovery-oriented practice in mental health services: a quasi-experimental mixed-methods study

Empowering Chinese university health service providers to become mental health champions: insights from the ACE-LYNX intervention

Background

Evidence shows that there is a high prevalence of mental health challenges including depression and anxiety, among Chinese university students. Providing mental health care providers with professional training is crucial to implementing effective mental health promotion initiatives in university settings. Globally, the focus of the mental health system is shifting to recovery and the importance of empowerment is increasingly being emphasized. There is a call to integrate empowerment education into professional training programs for health service providers with the goal of mobilizing them to become mental health champions capable of advancing mental health care.

Method

The ACE-LYNX (Acceptance and Commitment to Empowerment-Linking Youth and Xin i.e., "heart(s)" in Chinese) intervention took place at six universities in Jinan, Shandong Province, China. It aimed to promote mental health literacy and build capacity among mental health service providers (MHSPs) to enable them to become mental health champions at their universities and beyond. A total of 139 university MHSPs participated. We collected pre-, immediate post- and three-month-post-surveys. In addition, we recruited forty-five participants to take part in three-month- post-intervention focus group interviews to explore their experiences taking part in ACE-LYNX and applying the knowledge, skills, and insights they gained from the intervention.

Result

This paper reports on the effects of empowerment education, which is a key component of ACE-LYNX, on the MHSPs. Four themes were identified: 1) conscious awareness and behavioral change through psychological empowerment users; 2) professional insights and motivation for organizational empowerment; 3) non-self in the continuum of collective empowerment; and 4) interdisciplinary challenges and divergences in empowerment action.

Discussion

We found that it is critical to integrate empowerment education into professional training. The process of MHSPs developing their empowerment practice is characterized by their moving from individual to collective empowerment along a continuum, with organizational and collective empowerment taking place in a longer time frame. Experiential learning, empathy education, and critical reflection accelerated the continuous iterative transformative process of empowerment practices. To advance the integration of empowerment into mental health care, the engagement of organizational decision-makers and policy makers in empowerment training is critical to ensure alignment of empowerment values and competence at all levels of service provision.

Feasibility of Recovery Assessment Scale - Domains and Stages (RAS-DS) for everyday mental health practice

Introduction

Routine use of self-rated measures of mental health recovery can support recovery-oriented practice. However, to be widely adopted, outcome measures must be feasible. This study examined the feasibility of Recovery Assessment Scale - Domains and Stages (RAS-DS) from the perspectives of mental health workers.

Method

Mental health workers who had previously sought permission to use RAS-DS (n=58) completed an online survey that explored three aspects of feasibility: practicality, acceptability and applicability.

Results

The highest-rated feasibility items related to applicability, or usefulness in practice, with over 90% of participants reporting that RAS-DS helps "promote discussion" and covers areas that are "meaningful to consumers". Acceptability items indicated that the purpose of RAS-DS is clear but length was an issue for some participants. At a practical level, RAS-DS was seen as easy to access but training was seen by many as necessary to ensure optimal use.

Conclusion

Results suggest potential usefulness of RAS-DS as a routine outcome measure and identify aspects that can be addressed to further enhance feasibility including provision of training materials and opportunities, wide-reaching promotion of its use as a collaborative tool, and further investigation of issues around instrument length.

Mental Health Clinician Attitudes about Service User and Family Agency and Involvement in Recovery-Oriented Practice

BACKGROUND

Recovery-oriented practice (ROP) is a framework focusing on recovery through hope, choice, and meaning, to live with or without enduring symptoms and challenges.

AIMS

To examine clinicians' attitudes about the involvement of service users and family or supporters in ROP.

METHODS

A bespoke Qualtrics survey obtained views of mental health clinicians working in an Australian public mental health service about service user and family involvement in ROP, using a five-point Likert scale of agreement and free-text responses. Data were analysed with descriptive statistics and content analysis methods.

RESULTS

Two hundred and three clinicians completed the survey. Most (79%) clinicians agreed with the statement that service users want clinicians to use ROP principles, and the majority (63%) also 'strongly believed' that ROP made a difference to service users' mental health outcomes. Only 15% 'strongly agreed' and 57% somewhat agreed with the statement that service users know what treatment is best for them, and only 20% of clinicians 'strongly agreed' that supporters of service users believed in and wanted ROP for their family member or friend.

FUTURE DIRECTIONS

This study adds to the literature on clinicians' views about ROP and shows that although clinicians are supportive of ROP, they also express substantial ambivalence about whether service users and families know what treatment is best. For ROP implementation to be successful, workforce training needs to support clinicians to reflect on these views with service users and families, and to encourage supported decision making. Future studies should focus on changes in clinicians' views and practice post ROP training.

Beyond recovery: toward rights-based mental health care - A cluster randomized wait-list controlled trial of a recovery and rights training for mental health professionals with or without first person accounts

Introduction

Mental health models grounded in Recovery and Rights are driving the advancement of transformative care systems through multifaceted actions, which encompass Continuing Professional Development. The objective of this work is to evaluate a training activity developed through a participatory process that included people with lived experience of psychosocial distress, their relatives, and mental health professionals.

Methods

The training focused on alternatives to diagnosis, recovery principles, rights-based care, and peer support. The evaluation followed a cluster randomized wait-list controlled design. Four hundred eighty-eight health professionals from eight care centers were randomized to three experimental conditions: a wait list control, which underwent a one-month interval between the baseline assessment and the training activity, and two experimental groups, with or without first-person accounts, which accessed the training immediately after completing the baseline assessment. The dependent variables measured at all follow-ups were beliefs and attitudes toward mental health service users' rights. One hundred ninety-two professionals completed at least one follow-up and were included in the analyses.

Results

We observed different evolutions of experimental and control groups with statistically significant differences for tolerance to coercion and total beliefs and attitudes scores. No differences were observed between the groups with or who attended training activities with or without first person accounts. Upon receiving the training activity, the control group had an evolution equivalent to the experimental groups.

Discussion

The results of this evaluation project provide compelling evidence for the need to expand recovery and rights training activities to reach a larger audience of mental health professionals These training activities hold the potential to positively influence the beliefs and attitudes of mental health professionals, ultimately contributing toward a better future for individuals with lived experience of psychosocial distress.

Nurses' Perceptions on How Recovery-Oriented Mental Health Care Can Be Developed and Implemented

Aim

This study explored how nurses working in inpatient mental health units perceived the development and implementation of a recovery-oriented mental healthcare programme (ROMHCP).

Background

The recovery-oriented mental healthcare approach (ROMHCA) in mental health is regarded as the future of mental health services and has been implemented in different countries worldwide. However, regarding developing and implementing the recovery approach, Africa appears to have been left behind by the rest of the continents.

Design

The study used a qualitative approach to describe how a recovery-oriented mental healthcare approach could be developed.

Methods

Thirty nurses who worked in Botswana's four inpatient mental health facilities consented and voluntarily participated in the study. Data were collected from February to mid-March 2022 through online focus group discussions and analysed using thematic analysis. The COREQ checklist was used to report the findings.

Results

Two main themes emerged as follows: (i) developing and implementing a recovery-oriented mental healthcare programme is possible and (ii) certain elements are required to develop and implement ROMHCP.

Conclusion

The participants believed that people diagnosed with mental illness could recover from the illness and suggested how it could be achieved. They also contended that the programme's success would lie mainly with multisectoral support from policymakers, facilities, hospital personnel, patients, and the community. Clinical Relevance. ROMHCP has the potential to benefit people with mental illness in the country. In addition, it would allow nurses to improve their knowledge and skills in managing mental illnesses. Patient or Public Contribution. The patients and the general public did not contribute to the study's concept, design, and outcomes. However, the nurses working in mental health facilities volunteered to participate in the study.

The principles of recovery-oriented mental health services: A review of the guidelines from five different countries for developing a protocol to be implemented in Yogyakarta, Indonesia

BACKGROUND

Recovery-oriented mental health service has become the focus of global change in mental health services. Most of North industrialized countries have adopted and implemented this paradigm in the last two decades. Only recently that some developing countries are trying to follow this step. In Indonesia's case, there has been little attention to developing a recovery orientation by mental health authorities. The aim of this article is to synthesize and analyze the recovery-oriented guidelines from five industrialized countries that we can use as a primary model for developing a protocol to be implemented in community health centre in Kulonprogo District, Yogyakarta, Indonesia.

METHOD

We used a narrative literature review by searching for guidelines from many different sources. We found 57 guidelines, but only 13 from five countries met the criteria, including five guidelines from Australia, one from Ireland, three from Canada, two from the UK, and two from the US. To analyze the data, we used an inductive thematic analysis to explore the themes of each principle as described by the guideline.

RESULT

The results of the thematic analysis revealed seven recovery principles, including (1) cultivating positive hope, (2) establishing partnerships and collaboration, (3) ensuring organizational commitment and evaluation, (4) recognizing the consumer's rights, (5) focusing on person-centeredness and empowerment, (6) recognizing an individual's uniqueness and social context, and (7) facilitating social support,. These seven principles are not independent, rather they are interrelated and overlap each other.

CONCLUSION

The principle of person-centeredness and empowerment is central to the recovery-oriented mental health system, while the principle of hope is also essential to embracing all the other principles. We will adjust and implement the result of the review in our project focusing on developing recovery-oriented mental health service in the community health center in Yogyakarta, Indonesia. We hope that this framework will be adopted by the central government in Indonesia and other developing countries.

The impacts of implementing recovery innovations: a conceptual framework grounded in qualitative research

Background

Implementing mental health recovery into services is a policy priority in Canada and globally. To that end, a 5 year study was undertaken with seven organisations providing mental health and housing services to people living with a mental health challenge to implement guidelines for the transformation of services and systems towards a recovery-orientation. Multi-stakeholder implementation teams were established and a facilitated process guided teams to choosing and planning for the implementation of one recovery innovation. The recovery innovations chosen were hiring peer support workers, Wellness Recovery Action Planning (WRAP), a family support group, and staff recovery training.

Methods

This study reports on data collected at the post-implementation stage. 90 service users, service providers, family members, managers, other actors and knowledge users participated in 41 group, individual or dyad semi-structured interviews. The interview guides included open-ended questions eliciting participants’ impressions regarding the impact of implementing the innovation on service users, service providers and organisations. We applied a collaborative qualitative content analysis approach in NVivo12 to coding and interpreting the data generated from these questions.

Results

Eighteen impacts of implementing recovery innovations from the perspectives of diverse stakeholder groups were identified. Three impacts of working as an implementation team member and as part of a research project were also identified. Impacts were developed into a conceptual framework organised around four overall categories of impact: Ways of being, Ways of interacting, Ways of thinking, and Ways of operating and doing business.

Conclusions

The IMpacts of Recovery Innovations (IMRI) framework version 1 can assist researchers, evaluators and decision-makers identify, explore and understand impact in the context of recovery innovations. The framework helps fill a gap in conceptualising service and organisation-level impacts. Future research is needed to validate the framework and map it to existing methods for studying impact.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00559-2.

Recovery-Oriented Practices in a Mental Health Centre for Citizens Experiencing Serious Mental Issues and Substance Use: As Perceived by Healthcare Professionals

INTRODUCTION

Recovery-oriented practices have become a means of promoting user recovery during hospitalisation, but we do not know much about the concrete means of practicing recovery-orientation for the most vulnerable users with serious mental difficulty and substance use.

AIMS

We investigated the concrete means of practicing recovery-orientation in care work and the elements, dimensions, outcomes, or steps of it in a special department of mental health centres.

METHOD

Focus group interviews were conducted with 16 health professionals with experience with users with serious mental difficulty and substance use. Qualitative content analysis was undertaken.

RESULTS

The main theme was "holistic recovery on structural terms" based on two themes and four subthemes. The first theme was "recovery based on an individual approach" with subthemes "detective-find hope" and "how to do recovery-oriented practice". The next theme was "recovery subject to structural framework" with subthemes "tension between different interests" and "symptoms as a barrier".

CONCLUSIONS

recovery-oriented practice is understood as an approach where health professionals emphasise forming relationships based on trust, being hopeful for the users' future, spending time with users, and respecting users' experiences and knowledge from their own life. There are cross-pressures between different interests. The desire to meet the users' perspectives and respect these perspectives but at the same time live up to mental health centre purposes to stabilise the users' health and achieve self-care.

Implementing individual placement and support (IPS): the experiences of employment specialists in the early implementation phase of IPS in Northern Norway. The IPSNOR study

BACKGROUND

For decades there has been a continuous increase in the number of people receiving welfare benefits for being outside the work force due to mental illness. There is sufficient evidence for the efficacy of Individual Placement and Support (IPS) for gaining and maintaining competitive employment. Yet, IPS is still not implemented as routine practice in public community mental health services. Knowledge about implementation challenges as experienced by the practitioners is limited. This study seeks to explore the experiences of the front-line workers, known as employment specialists, in the early implementation phase.

METHODS

Qualitative data were collected through field notes and five focus group interviews. The study participants were 45 IPS employment specialists located at 14 different sites in Northern Norway. Transcripts and field notes were analysed by thematic analyses.

RESULTS

While employment specialists are key to the implementation process, implementing IPS requires more than creating and filling the role of the employment specialist. It requires adjustments in multiple organisations. The new employment specialist then is a pioneer of service development. Some employment specialists found this a difficult challenge, and one that did not correspond to their expectations going into this role. Others appreciated the pioneering role. IPS implementation also challenged the delegation of roles and responsibilities between sectors, and related legal frameworks related to confidentiality and access. The facilitating role of human relationships emphasised the importance of social support which is an important factor in a healthy work environment. Rural areas with long distances and close- knit societies may cause challenges for implementation.

CONCLUSION

The study provides increased understanding on what happens in the early implementation phase of IPS from the employment specialists' perspective. Results from this study can contribute to increased focus on job satisfaction, turnover and recruitment of employment specialists, factors which have previously been shown to influence the success of IPS. The greatest challenge for making "IPS efficacy in trials" become "IPS effectiveness in the real world" is implementation, and this study has highlighted some of the implementation issues.

Contextual Barriers and Enablers to Safewards Implementation in Victoria, Australia: Application of the Consolidated Framework for Implementation Research

Background: Safewards is a complex psychosocial intervention designed to reduce conflict and containment on inpatient mental health units. There is mounting international evidence of the effectiveness and acceptability of Safewards. However, a significant challenge exists in promising interventions, such as Safewards, being translated into routine practice. The Consolidated Framework for Implementation Research (CFIR) provides a framework through which to understand implementation in complex health service environments. The aim was to inform more effective implementation of Safewards using the CFIR domains and constructs, capitalizing on developing an understanding of variations across wards. Method: Seven Safewards Leads completed the Training and Implementation Diary for 18 wards that opted in to a trial of Safewards. Fidelity Checklist scores were used to categorize low, medium and high implementers of Safewards at the end of the 12-week implementation period. Results: Qualitative data from the diaries were analyzed thematically and coded according to the five CFIR domains which included 39 constructs. Twenty-six constructs across the five domains were highlighted within the data to have acted as a barrier or enabler. Further analysis revealed that six constructs distinguished between low, medium, and high implementing wards. Discussion: Our findings suggest that for implementation of Safewards to succeed, particular attention needs to be paid to engagement of key staff including managers, making training a priority for all ward staff, adequate planning of the process of implementation and creating an environment on each inpatient unit that prioritize and enables Safewards interventions to be undertaken by staff regularly.

Recovery and care continuity experiences of people in mental health care: A conciliatory approach to the challenge of implementing recovery-based services

This study investigates recovery and care continuity experiences of people with serious mental illness negotiating transforming services in the wake of recovery-based policy implementation. Data were collected in two phases involving (n = 16) service users who had transited from secondary to primary care and (n = 16) supporting workers. A qualitative methodology employed semi-structured interviews and thematic discourse analysis generating three themes. First, participants' expectations were misaligned with transforming services. Second, participants constructed competing versions of recovery in their talk. Third, analysis revealed care discontinuities concentrated at the primary care level. A singular notion of top-down recovery, a proliferation of bottom-up, competing recovery versions, and misaligned expectations of transforming services are closely allied with escalating service system complexity and fragmentation. This has detrimental implications for care continuity. Top-down, policy-based recovery implementation is viewed as a neoliberalist colonization of the recovery concept, understood in the Habermasian sense of colonization of the lifeworld. The detrimental effects of recovery colonization should not lead to repudiation of the concept altogether. Rather, the original radical idea of recovery should be reclaimed as a central concept within mental health care. This can be achieved by a conciliatory policy approach seeking to balance top-down and bottom-up forces of recovery appropriation.

Developing acute care-based mental health nurses' knowledge and skills in providing recovery-orientated care: A mixed methods study

Recovery-oriented principles have progressively been accepted as a standard of mental health practice in many countries, including Australia. A private mental health Clinic in Melbourne, Australia, is dedicated to embedding the principles of recovery-oriented practice into care by (i) providing recovery education and training for their staff and (ii) co-designing resources with consumers to promote active consumer engagement and participation. The purpose of this study was to evaluate the impact of these initiatives on staff knowledge and provision of recovery-oriented care in acute care. Two groups of study participants were recruited: the first group completed the staff training programme introducing the concept of recovery-oriented practice, and the second group was a convenience sample of nurses recruited 12 months later working on the acute inpatient wards at the study site. Nurses completed Recovery Knowledge Inventory (RKI) and Recovery Self-Assessment (RSA-Provider) surveys and participated in a focus group discussion. The three major themes identified from the focus group discussion were as follows: (i) nurses' understanding of personal recovery-orientated practice, (ii) how to embed personal recovery-oriented care into practice, and (iii) barriers to consumer participation in recovery-oriented activities in acute care. There were significant differences between the two groups on the RKI subscale scores of 'Expectations regarding recovery' and the 'Roles of self-definition and peers in recovery' and 'Life goals' and 'Choice' factors on the RSA subscale scores. There were some gaps in the nurses' knowledge and implementation of personal recovery-oriented concepts, highlighting the need for further training and cultural change.

Exploring recovery-focused educational programmes for advancing mental health nursing: An integrative systematic literature review

Recovery-focused educational programmes have been implemented in mental health services in an attempt to transform care from a purely biomedical orientation to a more recovery-oriented approach. Mental health nurses have identified the need for enhancing their abilities and confidence in translating recovery knowledge into mental health nursing practice. However, recovery-focused educational programmes have not fully address nurses' learning needs. Therefore, this review synthesized the evidence of the effectiveness of recovery-focused educational programmes for mental health nurses. A systematic search of electronic databases and hand-searched references was conducted. It identified 35 programmes and 55 educational materials within 39 studies. Synthesizing the literature revealed three themes and nine subthemes. The first theme, a framework for understanding and supporting consumers' recovery, had four subthemes: consumers' involvement, multidisciplinary approach, profession-specific training, and performance indicators. The second theme, contents of educational materials, included the subthemes: knowledge development and recovery-focused care planning. The final theme, nurses' learning experiences, included the subthemes: understanding recovery, the positive effects of recovery-focused educational programmes, and implementation of recovery-oriented practices. Based on these findings, a mental health nursing recovery-focused educational programme framework is proposed. Further research should investigate the effectiveness of the framework, especially in relation to recovery-focused care planning and consumer and carer involvement in the development, delivery, participation, and evaluation of these educational programmes.

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.

Using Q-methodology to explore mental health nurses' knowledge and skills to use recovery-focused care to reduce aggression in acute mental health settings

When nurses practise recovery-focused care, they contribute positively to the consumer's mental health recovery journey and empower the person to be actively engaged in the management of their illness. While using recovery-focused care is endorsed in mental health policy, many health professionals remain uncertain about its application with consumers who have a risk for aggression during their admission to an acute mental health inpatient setting. This paper reports on Australian research using Q-methodology that examined the knowledge and skill components of recovery-focused care that nurses use to reduce the risk for aggression. The data from forty mental health nurses revealed five factors that when implemented as part of routine practice improved the recovery outcomes for consumers with risk of aggression in the acute mental health settings. These factors were as follows: (I) acknowledge the consumers' experience of hospitalization; (II) reassure consumers who are going through a difficult time; (III) interact to explore the impact of the consumer's negative lived experiences; (IV) support co-production to reduce triggers for aggression; and (V) encourage and support consumers to take ownership of their recovery journey. These findings provide nurses with a pragmatic approach to use recovery-focused care for consumers with risk for aggression and contribute positively to the consumers' personal recovery.

Negotiating the Practical Meaning of Recovery in a Process of Implementation : An Empirical Investigation of How a Participatory-Inspired Research Approach to Implementation Might Facilitate a More Recovery-Oriented Practice: The Case of RENEW-DK

As implementation of recovery-oriented practices has proven difficult, this study investigates whether a participatory-inspired approach to implementing and adjusting a recovery-oriented model, RENEW-DK, might facilitate a more recovery-oriented practice among the professionals in public sector services. Ten narrative interviews with professionals was analyzed from a Science and Technology Studies perspective, and special attention was devoted to the concepts of distortion and stigmatization. Despite a one-year participatory process of model adjustment and implementation, professionals experienced RENEW-DK as a distortion and thus shaped their practice of RENEW-DK according to organizational requirements and professional beliefs instead of making their practice more recovery-oriented. The study calls attention to the need to acknowledge contradictions between intentions in general models and values in specific organizations with local norms and practices.

Beyond the moment: Influence of a co-facilitated education intervention on practitioners' recovery beliefs and practices

Despite health policy and research increasingly advocating for recovery-enabling principles to be better integrated into mental health services, finding solutions to enhance the translation of recovery policy into practice remains a challenge. This study sought to understand whether a co-facilitated group education intervention for service users and family members reached beyond the intervention and impacted the everyday recovery promoting beliefs and practices of the practitioners involved and the wider organization. The study employed a qualitative design involving semi-structured interviews with a purposively selected sample of 28 participants (mental health nurses and other members of the multidisciplinary team) who were involved in delivering the intervention. Data were analysed using thematic analysis, with the assistance of NVivo. Participants reported that not only did involvement with the programmes help them reconnect with the contextual realities of service user and family members lived experience, but it enabled them to move beyond traditional power relationships and pathologizing discourses. Having engaged with and experienced the feasibility and positive impact of the co-facilitation process practitioners' self-efficacy around partnership working and co-production was enhanced. In addition, those involved demonstrated a willingness to challenge paternalistic practices and advocate for the perspectives of service users and families to be further embedded within the organizational infrastructure and operational spaces. Providing mental health practitioners with real-life examples of partnership working and peer support in action within a co-facilitated psychoeducation context has potential to be a forum for promoting second-order change around recovery-oriented practice within mental health services.

A feasibility study of the effects of implementing a staff-level recovery-oriented training intervention in older people's mental health services

Objectives: The concept of recovery has exerted considerable traction in mental health services for adults of working age, but less so in older people's mental health services. The aim of this study was to evaluate the feasibility of a staff-level recovery intervention in older people's mental health services.Method: The study used a mixed-method pre-post design. The study took place in NHS older people's mental health services, UK. Staff participants were multi-disciplinary mental health team members from the same service. The intervention was a manualised staff-level recovery intervention called the Older Adults Recovery Intervention (OARI). Measurement included the Recovery Knowledge Inventory and the Recovery Attitudes Questionnaire (RAQ-7) as well as fidelity data and in-depth qualitative interviews.Results: OARI was delivered to 204 staff in 15 clinical teams. There was a statistically significant change towards improvement in four of the six recovery attitude and knowledge sub-scales. There were positive findings in change in practice at individual level, but not at team level. A number of context barriers were identified leading to the intervention not being delivered as intended.Conclusions: Further development of OARI will involve a clearer distinction about the practice implications for service users with dementia versus functional illnesses, a stronger focus on implementation support, more use of evidence in training materials and a tailoring of context to meet professional group training needs. Overall, this study contributes novel data to the evidence base for recovery within older people's mental health services.

Giving a voice to patient experiences through the insights of pragmatism

As a philosophical position, pragmatism can be critiqued to distinguish truth only with methods that bring about desired results, predominantly with scientific enquiry. The article hopes to dismiss this oversimplification and propose that within mental health nursing, enquiry enlightened by pragmatism can be anchored to methods helping to tackle genuine human problems. Whilst pragmatists suggest one reality exists, fluctuating experiences and shifting beliefs about the world can inhabit within; hence, pragmatists propose reality has the potential to change. Moreover, pragmatism includes being cognisant of what works to whom reality concerns, making reality context-driven, with a view to understand how actions shape experiences so what is generated has usefulness. Hence, it somewhat follows pragmatism can inform mental health nursing, after all, nursing is a discipline of action, and awareness is needed in how actions produce experiences that patients find helpful. Given the principles of recovery are preferably adopted in mental health care, the paper will explore how pragmatism can help nurses move towards that goal; specifically, with patients voicing their experiences. This is because like pragmatism, recovery subscribes to hope that reality can progress, and through meaningful experiences and beliefs, patients have expertise about personal difficulties alongside how life may flourish, despite mental illness.

A Systematic Review and Meta-analysis of Recovery Educational Interventions for Mental Health Professionals

The history of mental health care has been marked by various struggles in maintaining the dignity of service users. Some reform movements have started to use educational strategies aimed at the beliefs and attitudes of professionals, as well as changing the way that practice is carried out. This paper intends to systematically review and synthesize studies assessing awareness and training activities for mental health professionals covering aspects related to recovery, empowerment, and in general, rights-based care to achieve full citizenship of mental health services users. We reviewed 26 articles and were able to include 14 of them in meta-analytic calculations. Our results at the qualitative level show an evolution of the literature towards better quality designs and focus on aspects related to the impact and maintenance of the effects of these training activities. Meta-analytic calculations found high heterogeneity but no risk of biases and low-to moderate effect sizes with a statistically significant impact on beliefs and attitudes but not on practices. The importance of this information in improving and advancing these educational activities is addressed.

Knowledge and attitudes of mental health professionals and students regarding recovery: A systematic review

This review was conducted to synthesize and critically appraise the literature on knowledge, attitudes, understanding, perceptions, and expectations of mental health professionals (MHPs) and mental health professional (MHP) students' regarding recovery. A systematic search in Scopus, CINAHL, PsycINFO, Web of Science, Medline, and Embase as well as Google scholar and web-based repositories was conducted. The searches were conducted using a combination of key terms: "mental health professionals", "students", 'knowledge', "understanding", "perception" "attitude", "expectation", "recovery". After screening and quality assessment, the review included 29 studies (18 quantitative, 8 qualitative, and 3 mixed-method studies) published in English, from January 2006 to June 2019, and was analysed systematically using a mixed-method synthesis. The findings revealed that there is increasing evidence (especially among MHPs) of knowledge, attitudes, understanding, perceptions, and expectations regarding recovery. However, there are disparities in how MHPs perceive and understand recovery. While some understood it to mean a personal process, others explained it as a clinical process. In addition, there was limited knowledge among the MHPs and MHP students regarding the nonlinearity nature of the recovery process and expectations regarding recovery. The implications from these findings are the need for more in-service training for MHPs, and examination of the curriculum used to educate MHP students. In particular, they should be sufficiently informed about the nonlinearity nature of the recovery process and how to develop hopeful and realistic expectations for consumers throughout the recovery process. The review was preregistered with PROSPERO (Registration No: CRD42019136543).

Recovery in Psychosis: Perspectives of Clients with First Episode Psychosis

Introduction: Recovery from psychosis relates to connectedness, hope for the future, identity, meaning in life and empowerment. The process of recovery is often described as gradual and non-linear, with many stages and turning points, and without a definitive end point. This qualitative study aims to understand what recovery means to clients, to better understand their unique recovery process and what helps in recovery among clients with lived experience of first episode psychosis (FEP) in a developed Asian setting. Materials and Methods: The study design and interview guide development included inputs from persons with psychosis, following which 7 focus group discussions were conducted with 40 FEP clients of a tertiary care psychiatric institute. Results: Thematic qualitative analysis identified three themes: 1) meaning of recovery (where participants expressed their views on what recovery meant to them); 2) recovery as a journey (due to the constant ups and downs in the long process of recovery, it was often articulated as a “journey”); and 3) facilitators of recovery (related to resources, practices and experiences that supported their recovery). Conclusion: The emergent themes provide an understanding of the meaning of recovery to persons with FEP, their experiences as they proceed with their recovery journey and factors they found helpful. The importance of acceptance of the condition and the personal role the individual plays in his or her own recovery was evident in the narratives of the participants. The study suggests a need to incorporate recovery-relevant approaches right from the first episode of psychosis. Ann Acad Med Singapore 2020;49:186–98 Key words: Meaning of recovery, Qualitative, Thematic analysis

Stigma and discrimination related to mental health and substance use issues in primary health care in Toronto, Canada: a qualitative study

PURPOSE

Community Health Centres (CHCs) are an essential component of primary health care (PHC) in Canada. This article examines health providers' understandings and experiences regarding stigma towards mental health and substance use (MHSU) issues, as well as their ideas for an effective intervention to address stigma and discrimination, in three CHCs in Toronto, Ontario.

METHODS

Using a phenomenological approach, we conducted twenty-three interviews with senior staff members and peer workers, and three focus groups with front-line health providers. Ahybrid approach to thematic analysis was employed, entailing a combination of emergent and a priori coding.

RESULTS

The findings indicate that PHC settings are sites where multiple forms of stigma create health service barriers. Stigma and discrimination associated with MHSU also cohere around intersecting experiences of gender, race, class, age and other issues including the degree and visibility of distress. Clients may find social norms to be alienating, including behavioural expectations in Canadian PHC settings.

CONCLUSIONS

Given the turmoil in clients' lives, systematic efforts to mitigate stigma were inhibited by myriad proximate factors that demanded urgent response. Health providers were enthusiastic about implementing anti-stigma/recovery-based approaches that could be integrated into current CHC services. Their recommendations for interventions centred around communication and education, such as training, CHC-wide meetings, and anti-stigma campaigns in surrounding communities.

'Every single minute and hour is scrutinised': neoliberalism and Australian private mental health care

There is little understanding of how recovery-oriented approaches fit within contemporary mental healthcare systems, which emphasise biomedical approaches to care, increased efficiency and cost-cutting. This article examines the established models of service delivery in a private, youth, mental health service and the impacts of the current system on staff. It explores whether the service is prepared or capable of adopting recovery-oriented approaches to care. Qualitative interviews were undertaken with staff and thematically analysed to understand the everyday practices on the unit. Data suggest that economic efficiencies and biomedical dominance largely shaped how health care was organised and delivered, which was perceived by staff as inflexible to change. Additionally, findings suggest that market-oriented principles associated with neoliberalism restricted the capacity of individuals to transform services in line with alternative models of care and lowered staff morale. These finding suggest that, while neoliberal ideologies and biomedical approaches remain dominant in organisations, there will be challenges to adopting alternative recovery-oriented models of care and promoting healthcare systems that understand mental health issues in broader socio-political contexts and can flexibly respond to the needs of service users.

Partners in Recovery: an early phase evaluation of an Australian mental health initiative using program logic and thematic analysis

Background

Mental illness is a leading cause of illness and disability and around 75% of people suffering mental illness do not have access to adequate care. In Australia, nearly half the population experiences mental illness at some point in their life. The Australian Government developed a National program called Partners in Recovery (PIR) to support those with severe and persistent mental illness. The program was implemented through 48 consortia across Australia. One of these was led by the Nepean Blue Mountains Medicare Local who adapted the program according to its specific local needs.

Methods

We conducted an early evaluation of the PIR program in Nepean Blue Mountains (NBMPIR) using a program logic model (PLM) to frame the evaluation and complemented this with an additional thematic analysis. Participants (n = 73) included clients and carers, program management and staff of the Consortium and other partners and agencies, and clinical, allied health, and other service providers. Our PLM utilised multiple data sources that included document review, open and closed survey questions, and semi-structured interviews. Quantitative data received a descriptive analysis and qualitative data was analysed both in alignment with the PLM framework and inductively.

Results

We aligned our results to PLM domains of inputs, activities, outputs, outcomes and impacts. The NBMPIR consortium implemented a recovery approach and provided greater access to services by enhancing healthcare provider partnerships. Our thematic analysis further described five key themes of collaboration; communication; functioning of PIR; structural/organisational challenges; and understanding of PIR approaches. Facilitators and barriers to the NBMPIR program centred on the alignment of vision and purpose; building an efficient system; getting the message out and sharing information; understanding roles and support and training of staff; building capacity and systems change; addressing service gaps; and engaging peers.

Conclusions

Our study provided helpful insights into the coordinated management of complex mental illness. The NBMPIR’s focus on partnerships and governance, service coordination, and systems change has relevance for others engaged in this work. This PLM effectively mapped the program, including its processes and resources, and is a useful framework providing a baseline for future evaluations.

Full report available at https://researchdirect.westernsydney.edu.au/islandora/object/uws:33977/

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4360-2) contains supplementary material, which is available to authorized users.

Associations between provider communication and personal recovery outcomes

BACKGROUND

This study examined whether two types of provider communication considered important to quality of care (i.e., shows respect and explains understandably) are associated with mental health outcomes related to personal recovery (i.e., connectedness, hope, internalized stigma, life satisfaction, and empowerment). This study also tested whether these associations varied by the type of provider seen (i.e., mental health professional versus general medical doctor).

METHODS

This sample included participants from the 2014 California Well-Being Survey, a representative survey of California residents with probable mental illness, who had recently obtained mental health services (N = 429). Multiple regression was used to test associations between provider communication and personal recovery outcomes and whether these associations were modified by provider type.

RESULTS

Providers showing respect was associated with better outcomes across all five of the personal recovery domains, connectedness (β = 1.12; p < .001), hope (β = 0.72; p < .0001), empowerment (β = 0.38; p < .05), life satisfaction (β = 1.10; p < .001) and internalized stigma (β = - 0.49; p < .05). Associations between provider showing respect and recovery outcomes were stronger among those who had seen a mental health professional only versus a general medical doctor only.

CONCLUSIONS

Respectful communication may result in greater personal recovery from mental health problems. Respecting consumer perspectives is a hallmark feature of both recovery-oriented services and quality care, yet these fields have operated independently of one another. Greater integration between these two areas could significantly improve recovery-oriented mental health outcomes and quality of care.

Valuing recovery-oriented practice at the interface between mental health services and communities: The role of organisational characteristics and environments

BACKGROUND

Implementing recovery-oriented mental health services is a policy priority in many countries. In addition, some governments have prioritised new forms of organising, financing and governing the provision of mental health services with a stronger focus on co-delivery and involving communities. Most research in the recovery field has focused on interventions. There is limited knowledge about the role of organisational characteristics and environments in which people experience recovery.

AIM

To understand the organisational characteristics of initiatives that implement recovery-oriented practice at the interface between mental health services and communities, as well as the mechanisms they employ to alter the conditions in which they operate.

METHOD

Semi-structured interviews and a focus group workshop with managers of five initiatives in England that implemented recovery-oriented practice at the interface between mental health services and communities.

RESULTS

Our cross-sector initiatives shared a range of characteristics and employed mechanisms that created favourable conditions for recovery-oriented practice: strong social value and process (rather than performance) orientation; participatory approaches and shared decision-making; flat hierarchies; creating and seizing business opportunities; utilising networking and (social) marketing opportunities; risk-taking; valuing and supporting all members of their organisations; entrepreneurial and value-driven leadership.

CONCLUSION

Recovery-oriented practice takes place in certain organisational environments that importantly influence an individual's recovery. Our research highlights the need to consider organisational characteristics when evaluating recovery interventions as well as a broader shift of research towards understanding the environments in which people experience recovery as members of society, and how those can be altered.

Training professionals in a recovery-oriented methodology: a mixed method evaluation

BACKGROUND

Several studies have reported difficulties concerning the implementation of recovery-oriented interventions. In this study, the effect of training in the Comprehensive Approach to Rehabilitation (CARe) on daily practice was evaluated. Additionally, we aimed to acquire insight into the experiences with the implementation process involving professionals, management and trainers.

METHODS

Fourteen teams for sheltered and supported housing in the Netherlands participated in this study. As part of a cluster-randomised controlled trial (RCT) design, eight teams received training in the CARe methodology. Model fidelity (using the CARe fidelity audit) and professionals' knowledge of recovery (using the Recovery Knowledge Inventory) were measured for all teams until 20 months after the start. Afterwards, an evaluation meeting with participating stakeholders was organised in which barriers and facilitators of the implementation of the CARe methodology were inventoried.

RESULTS

Ten months after the training, the intervention teams scored higher than the control teams on the fidelity subscales: 'recovery', 'strengths orientation' and 'amount of training and coaching'. Twenty months after the training, only the effect of 'amount of coaching and training' remained. Additionally, 'methodological working' clearly differed between the groups after 20 months in favour of the intervention teams. In all teams, model fidelity was moderate at both measurements. The knowledge of recovery of the trained teams was slightly and significantly higher at 10 and 20 months after training. Although professionals were positive about recovery and strength-oriented working, they experienced several organisational and societal barriers.

CONCLUSION

Training in the CARe methodology improved the fidelity and knowledge of recovery among professionals. However, the differences were small, and fidelity decreased over time. More in-depth knowledge is needed on which barriers professionals experience in practice so that tailored training and implementation strategies can be developed. Furthermore, more attention is needed for professional development and the translation of theory into practice.

Prevention and Recovery Care Services in Australia: Describing the Role and Function of Sub-Acute Recovery-Based Residential Mental Health Services in Victoria

Background: Prevention and Recovery Care (PARC) services are relatively new sub-acute residential services that have supported people with mental ill-health in Victoria since 2003. Operated from a partnership model between non-governmental agencies and clinical mental health services, PARC services integrate intensive recovery-focused psychosocial input with clinical mental health care. Aim: To describe and contrast the 19 PARC services operating in Victoria at the time of the study, in terms of structures and function, resources, and content and quality of care. Method: Nineteen participants, one representing each PARC, completed two surveys: the first, a purpose-designed survey relating to the government guidelines for PARC services, and the second, the Quality Indicator for Rehabilitative Care. Results: Descriptive analyses highlighted that PARC services have operated in inner-city, urban, and regional areas of Victoria, from between 1 and 14 years. Participants reported that a recovery approach was at the core of service delivery, with a vast array of group and individual programs on offer. Across the state, there was variation in the quality of services according to the Quality Indicator for Rehabilitative Care domains. Conclusions: This study has identified that there is variation in the structure and function, resourcing, and content and quality of care offered across Victoria's PARC services even though, in the main, they are guided by government guidelines. Hence it appears that the services adapt to local needs and changes in service systems occurring over time. The findings indicate emerging evidence that PARCs are providing recovery-oriented services, which offer consumers autonomy and social inclusion, and therefore likely enable a positive consumer experience. The range of individual and group programs is in line with the Victorian guidelines, offering practical assistance, therapeutic activities, and socialization opportunities consistent with consumer preferences. Further research into implementation processes and their impacts on quality of care is warranted concerning this and similar service models.

Consumer and staff perspectives of the implementation frequency and value of recovery and wellbeing oriented practices

Background

Despite advances in our understanding of what mental health systems and services can do to enhance recovery and wellbeing outcomes for people seeking support, there is limited evidence demonstrating that this body of work has translated successfully into mental health service practice. The Collaborative Recovery Model (CRM) is a practice framework that has been designed to support application of recovery and wellbeing oriented principles and practices within mental health service delivery. The aims of this study were to assess consumer and staff perceptions of implementation frequency during service engagement and the value of this approach for assisting recovery within a setting where the CRM approach had been adopted.

Methods

The setting was a large Australian community managed mental health organisation. The study involved a cross-sectional analysis of consumer (n = 116) and staff practitioner (n = 62) perspectives. A series of paired sample t-tests assessed for differences between consumer and staff perceptions of the: (i) importance of key practice elements for assisting recovery, and the (ii) frequency that key practice elements are utilised during engagement sessions. Spearman's r correlational analysis explored associations between importance, frequency and helpfulness of sessions.

Results

Key practice elements of the model were applied during service interactions at a high level and perceived by the majority of consumers and staff participants as being important or very important for assisting recovery. Significant moderate correlations were found between the extent that practice elements were valued and the level at which they were applied. Higher levels of implementation of CRM practices were associated with higher ratings of perceived session helpfulness. The strongest association was between 'encouragement to set tasks to complete between support visits' and perceived helpfulness.

Conclusions

Consumer and staff responses revealed that the key practice elements of the CRM were frequently implemented during service engagement interactions and were seen as valuable for assisting recovery. The level of agreement between raters suggests firstly, that the key practice elements were apparent and able to be rated as occurring, and secondly that the CRM approach is seen as responsive to consumer needs. The results have implications for translating recovery and wellbeing oriented knowledge into mental health service practice.

The social capitals of recovery in mental health

In this article, we examine the process of recovery in people who have undertaken treatment for mental health problems, based on interviews with 34 participants. We describe their experiences through the lens of social capital, focusing on the social networks and relationships within which they are embedded and which they utilise to give purpose and meaning to their lives. The accounts give sense of movement from relationships, institutions and networks which were provided through their engagement with services towards relationships outside the health care system which were more freely chosen and which provided a sense that they were able to achieve recognition and make a contribution. The latter included activities such as art, theatre and sport. The relationships and institutions with which they were engaged via the statutory services were described as burdensome and inappropriate, whereas those which were freely chosen appeared more emancipatory and positively constitutive of identity. We have called this latter experience one of 'intentional social capital' because the participants were deliberately choosing and orienting to these networks and were able to derive pleasure and a sense of self from them. The findings have implications for how we see the situation of people recovering from mental health problems inasmuch as professional attitudes and practices could usefully be extended to more fully recognise and encourage wider patterns of social engagement and fulfilment occurring outside the limited contribution of clinical definitions and clinical interventions.

The housing first technical assistance and training (HFTAT) implementation strategy: outcomes from a mixed methods study of three programs

BACKGROUND

This paper discusses the initial testing of the Housing First Training and Technical Assistance (HFTAT) Program, a multifaceted, distance-based strategy for the implementation of the Housing First (HF) supportive housing model. HF is a complex housing intervention for serving people living with serious mental illness and a substance use disorder that requires significant individual- and structural-level changes to implement. As such, the HFTAT employs a combined training and consultation approach to target different levels of the organization. Training delivered to all organizational staff focuses on building individual knowledge and uses narrative storytelling to overcome attitudinal implementation barriers. Consultation seeks to build skills through technical assistance and fidelity audit and feedback.

METHOD

We employed a mixed method design to understand both individual-level (e.g., satisfaction with the HFTAT, HF knowledge acquisition and retention, and HF acceptability and appropriateness) and structural-level (e.g., fidelity) outcomes. Quantitative data were collected at various time points, and qualitative data were collected at the end of HFTAT activities. Staff and administrators (n = 113) from three programs across three states participated in the study.

RESULTS

Satisfaction with both training and consultation was high, and discussions demonstrated both activities were necessary. Flexibility of training modality and narrative storytelling were particular strengths, while digital badging and the community of practice were perceived as less valuable because of incompatibilities with the work context. HF knowledge was high post training and retained after 3-month follow-up. Participants reported training helped them better understand the model. Attitudes toward evidence-based interventions improved over 6 months, with qualitative data supporting this but demonstrating some minor concerns related to acceptability and appropriateness. Fidelity scores for all programs improved over 9 months.

CONCLUSION

The HFTAT was a well-liked and generally useful implementation strategy. Results support prior research pointing to the value of both (a) multifaceted strategies and (b) combined training and consultation approaches. The study also provides evidence for narrative storytelling as an approach for changing attitudinal implementation barriers. The need for compatibility between specific elements of an implementation strategy and the work environment was also observed.

Carers' and service users' experiences of early intervention in psychosis services: implications for care partnerships

AIM

To explore carers' and service users' experiences of UK Early Intervention Services following referral for first-episode psychosis.

METHODS

Thirty-two semi-structured interviews (16 interviews with service users and 16 corresponding interviews with their carers) were completed and analysed.

RESULTS

Carers spoke retrospectively and prospectively by framing their accounts into the periods before and since their engagement with Early Intervention Services. Desperation was evident as emotive experiences were recalled prior to referral. Relief then emerged as carers described support and engagement with key workers. Hope and optimism for the service user's prognosis and life trajectory were also expressed.Service users described similar positive experiences of Early Intervention Services and the support and insight they had gained through their relationships with key workers. They were however less focused on accounts of desperation and relief and more immersed in their current understanding and attempts to normalize their experiences of first-episode psychosis. Prognosis and future trajectories were only discussed tentatively.

CONCLUSION

Communication and 'partnerships' with service users and carers are essential for effective service engagement, delivery of care and the reduction in relapse following first-episode psychosis. This study highlights how key workers from Early Intervention Services are appropriately valued and situated to develop such relationships. Findings also reveal that service users' and carers' focus and expectations of recovery vary during the early stages of engagement with services. How key workers manage awareness and communication around such differing expectations is a crucial consideration for maintaining the 'partnerships' necessary for effective service provision.

Exploring Working Relationships in Mental Health Care via an E-Recovery Portal: Qualitative Study on the Experiences of Service Users and Health Providers

BACKGROUND

The quality of working relationships between service users and health providers is fundamental in the processes of recovery in mental health. How Internet-based interventions will influence these relationships for persons with long-term care needs, and the measures that can be taken to maintain and enhance working relationships through Internet, is still not well understood.

OBJECTIVE

The aim of this study was to gain insights into how service users and health providers experience their working relationships when they are offered the option of supplementing ongoing collaboration with an e-recovery portal.

METHODS

In this exploratory and descriptive study, an e-recovery portal was used by service users and their health providers in 2 mental health communities in Norway for at least 6 months and at most 12 months (2015-2016). The portal consists of secure messaging, a peer support forum, and a toolbox of resources for working with life domains including status, goals and activities, network map, crisis plan, and exercises. The portal was owned and managed by the service user while health providers could remotely access parts of the service user-generated content. The participants could use the portal in whatever way they wished, to suit their collaboration. Data from 6 focus groups, 17 individual interviews, and an interview with 1 dyad about their experiences of use of the portal over the study period were inductively coded and thematically analyzed.

RESULTS

The thematic analysis resulted in 2 main themes: (1) new relational avenues and (2) out of alignment, illustrated by 8 subthemes. The first main theme is about dyads who reported new and enriching ways of working together through the portal, particularly related to written communication and use of the goal module. Illustrative subthemes are ownership, common ground, goals and direction, and sense of presence and availability. The second main theme illuminates the difficulties that arose when service users' and health providers' expectations for portal use were not aligned, and the consequences of not addressing these difficulties. Illustrative subthemes are initiative and responsibility, waiting for the other, feeling overwhelmed, and clarifications and agreements.

CONCLUSIONS

The degree to which dyads benefited from using the e-recovery portal appeared to be mainly associated with the degree to which the dyads' relations were open and flexible before the portal was introduced. For those who experienced frustrations, the portal may have both exposed and added to suboptimal working relationships. Use of the goal module appeared to strengthen the person-centered nature of collaboration. A key question is how health providers balance between enabling service users' greater control over their care, without relinquishing responsibility for the quality of the working relationship, also when using an e-recovery portal. Implications for implementation are discussed.

Recovery-based Training in Mental Health: Effects on Staff Knowledge and Attitudes to Recovery

This longitudinal study describes the effects of recovery-based training on staff knowledge and attitudes to recovery. Mental health staff (n = 101) completed the study questionnaire (the Recovery Knowledge Inventory (RKI-20) and Recovery Attitudes' Questionnaire (RAQ-16)) before training and after six months. On the RKI, significant changes between pre- and post-training scores (p < 0.01) were found. On the RAQ, the scores showed significant changes in Factors 1 (p < 0.001) and 2 (p < 0.009). The results indicate a significant difference in confidence using a recovery model of care following training suggesting that recovery-based training positively affects staff knowledge and attitudes to recovery overall.

An Integrated Recovery-oriented Model (IRM) for mental health services: evolution and challenges

BACKGROUND

Over past decades, improvements in longer-term clinical and personal outcomes for individuals experiencing serious mental illness (SMI) have been moderate, although recovery has clearly been shown to be possible. Recovery experiences are inherently personal, and recovery can be complex and non-linear; however, there are a broad range of potential recovery contexts and contributors, both non-professional and professional. Ongoing refinement of recovery-oriented models for mental health (MH) services needs to be fostered.

DISCUSSION

This descriptive paper outlines a service-wide Integrated Recovery-oriented Model (IRM) for MH services, designed to enhance personally valued health, wellbeing and social inclusion outcomes by increasing access to evidenced-based psychosocial interventions (EBIs) within a service context that supports recovery as both a process and an outcome. Evolution of the IRM is characterised as a series of five broad challenges, which draw together: relevant recovery perspectives; overall service delivery frameworks; psychiatric and psychosocial rehabilitation approaches and literature; our own clinical and service delivery experience; and implementation, evaluation and review strategies. The model revolves around the person's changing recovery needs, focusing on underlying processes and the service frameworks to support and reinforce hope as a primary catalyst for symptomatic and functional recovery. Within the IRM, clinical rehabilitation (CR) practices, processes and partnerships facilitate access to psychosocial EBIs to promote hope, recovery, self-agency and social inclusion. Core IRM components are detailed (remediation of functioning; collaborative restoration of skills and competencies; and active community reconnection), together with associated phases, processes, evaluation strategies, and an illustrative IRM scenario. The achievement of these goals requires ongoing collaboration with community organisations.

CONCLUSIONS

Improved outcomes are achievable for people with a SMI. It is anticipated that the IRM will afford MH services an opportunity to validate hope, as a critical element for people with SMI in assuming responsibility and developing skills in self-agency and advocacy. Strengthening recovery-oriented practices and policies within MH services needs to occur in tandem with wide-ranging service evaluation strategies.

Implementation of a recovery-oriented model in a sub-acute Intermediate Stay Mental Health Unit (ISMHU)

Background

An ongoing service evaluation project was initiated following the establishment of a new, purpose-built, 20-bed sub-acute Intermediate Stay Mental Health Unit (ISMHU). This paper: provides an overview of the targeted 6-week program, operating within an Integrated Recovery-oriented Model (IRM); characterises the clients admitted during the first 16 months; and documents their recovery needs and any changes.

Methods

A brief description of the unit’s establishment and programs is initially provided. Client needs and priorities were identified collaboratively using the Mental Health Recovery Star (MHRS) and addressed through a range of in-situ, individual and group interventions. Extracted client and service data were analysed using descriptive statistics, paired t-tests examining change from admission to discharge, and selected correlations.

Results

The initial 154 clients (165 admissions, average stay = 47.86 days) were predominately male (72.1%), transferred from acute care (75.3%), with schizophrenia or related disorders (74.0%). Readmission rates within 6-months were 16.2% for acute and 3.2% for sub-acute care. Three MHRS subscales were derived, together with stage-of-change categories. Marked improvements in MHRS Symptom management and functioning were identified (z-change = −1.15), followed by Social-connection (z-change = −0.82) and Self-belief (z-change = −0.76). This was accompanied by a mean reduction of 2.59 in the number of pre-action MHRS items from admission to discharge (z-change = 0.98). Clinician-rated Health of the Nation Outcome Scales (HoNOS) improvements were smaller (z-change = 0.41), indicative of illness chronicity. Staff valued the elements of client choice, the holistic and team approach, program quality, review processes and opportunities for client change. Addressing high-levels of need in the 6-week timeframe was raised as a concern.

Conclusions

This paper demonstrates that a recovery-oriented model can be successfully implemented at the intermediate level of care. It is hoped that ongoing evaluations support the enthusiasm, commitment and feedback evident from staff, clients and carers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1939-8) contains supplementary material, which is available to authorized users.

Competing priorities: staff perspectives on supporting recovery

Recovery has come to mean living a life beyond mental illness, and recovery orientation is policy in many countries. The aims of this study were to investigate what staff say they do to support recovery and to identify what they perceive as barriers and facilitators associated with providing recovery-oriented support. Data collection included ten focus groups with multidisciplinary clinicians (n = 34) and team leaders (n = 31), and individual interviews with clinicians (n = 18), team leaders (n = 6) and senior managers (n = 8). The identified core category was Competing Priorities, with staff identifying conflicting system priorities that influence how recovery-oriented practice is implemented. Three sub-categories were: Health Process Priorities, Business Priorities, and Staff Role Perception. Efforts to transform services towards a recovery orientation require a whole-systems approach.

Service user experiences of REFOCUS: a process evaluation of a pro-recovery complex intervention

PURPOSE

Policy is increasingly focused on implementing a recovery-orientation within mental health services, yet the subjective experience of individuals receiving a pro-recovery intervention is under-studied. The aim of this study was to explore the service user experience of receiving a complex, pro-recovery intervention (REFOCUS), which aimed to encourage the use of recovery-supporting tools and support recovery-promoting relationships.

METHODS

Interviews (n = 24) and two focus groups (n = 13) were conducted as part of a process evaluation and included a purposive sample of service users who received the complex, pro-recovery intervention within the REFOCUS randomised controlled trial (ISRCTN02507940). Thematic analysis was used to analyse the data.

RESULTS

Participants reported that the intervention supported the development of an open and collaborative relationship with staff, with new conversations around values, strengths and goals. This was experienced as hope-inspiring and empowering. However, others described how the recovery tools were used without context, meaning participants were unclear of their purpose and did not see their benefit. During the interviews, some individuals struggled to report any new tasks or conversations occurring during the intervention.

CONCLUSION

Recovery-supporting tools can support the development of a recovery-promoting relationship, which can contribute to positive outcomes for individuals. The tools should be used in a collaborative and flexible manner. Information exchanged around values, strengths and goals should be used in care-planning. As some service users struggled to report their experience of the intervention, alternative evaluation approaches need to be considered if the service user experience is to be fully captured.

From providing a service to being of service: advances in person-centred care in mental health

PURPOSE OF REVIEW

This review explores the concept of person-centred care, giving particular attention to its application in mental health and its relationship to recovery. It then outlines a framework for understanding the variety of approaches that have been used to operationalize person-centred care, focusing particularly on shared decision-making and self-directed care, two practices that have significant implications for mental health internationally.

RECENT FINDINGS

Despite growing recognition of person-centred care as an essential component of recovery-orientated practice, the levels of uptake of shared decision-making and self-directed care in mental health remain low. The most significant barrier appears to be the challenge presented to service providers by one of the key principles of person-centred care, namely empowerment.

SUMMARY

Shared decision-making and self-directed support, two practices based upon the principles of person-centred care, have the potential for being effective tools for recovery. Full engagement of clinicians is crucial for their successful uptake into practice. More research is needed to address both outcomes and implementation.

Study protocol: a mixed methods study to assess mental health recovery, shared decision-making and quality of life (Plan4Recovery)

Background

Recovery in mental health care is complex, highly individual and can be facilitated by a range of professional and non-professional support. In this study we will examine how recovery from mental health problems is promoted in non-medical settings. We hypothesise a relationship between involvement in decisions about care, social support and recovery and quality of life outcomes.

Methods

We will use standardised validated instruments of involvement in decision-making, social contacts, recovery and quality of life with a random sample of people accessing non-statutory mental health social care services in Wales. We will add to this important information with detailed one to one case study interviews with people, their family members and their support workers. We will use a series of these interviews to examine how people build recovery over time to help us understand more about their involvement in decisions and the social links they build.

Discussion

We want to see how being involved in decisions about care and the social links people have are related to recovery and quality of life for people with experience of using mental health support services. We want to understand the different perspectives of the people involved in making recovery possible. We will use this information to guide further studies of particular types of social interventions and their use in helping recovery from mental health problems.

Recovery-based staff training intervention within mental health rehabilitation units: a two-stage analysis using realistic evaluation principles and framework approach

BACKGROUND

Long-term change in recovery-based practice in mental health rehabilitation is a research priority.

METHODS

We used a qualitative case study analysis using a blend of traditional 'framework' analysis and 'realist' approaches to carry out an evaluation of a recovery-focused staff training intervention within three purposively selected mental health rehabilitation units. We maximised the validity of the data by triangulating multiple data sources.

RESULTS

We found that organisational culture and embedding of a change management programme in routine practice were reported as key influences in sustaining change in practice. The qualitative study generated 10 recommendations on how to achieve long-term change in practice including addressing pre-existing organisational issues and synergising concurrent change programmes.

CONCLUSIONS

We propose that a recovery-focused staff training intervention requires clear leadership and integration with any existing change management programmes to facilitate sustained improvements in routine practice.

Exploring the Mechanisms of a Patient-Centred Assessment with a Solution Focused Approach (DIALOG+) in the Community Treatment of Patients with Psychosis: A Process Evaluation within a Cluster-Randomised Controlled Trial

Background

DIALOG+ is a new intervention to make routine community mental health meetings therapeutically effective. It involves a structured assessment of patient concerns and a solution-focused approach to address them. In a randomised controlled trial, DIALOG+ was associated with better subjective quality of life and other outcomes in patients with psychosis, but it was not clear how this was achieved. This study explored the possible mechanisms.

Methods

This was a mixed-methods process evaluation within a cluster-randomised controlled trial. Focus groups and interviews were conducted with patients and clinicians who experienced DIALOG+ and were analysed using thematic analysis. The content of DIALOG+ sessions was recorded and analysed according to (i) the type of actions agreed during sessions and (ii) the domains discussed. The subjective quality of life measure was analysed with mixed-effects models to explore whether the effect of DIALOG+ was limited to life domains that had been addressed in sessions or consistent across all domains.

Results

Four qualitative themes emerged regarding the mechanisms of DIALOG+: (1) a comprehensive structure; (2) self-reflection; (3) therapeutic self-expression; and (4) empowerment. Patients took responsibility for the majority of actions agreed during sessions (65%). The treatment effect on subjective quality of life was largest for living situation (accommodation and people that the patient lives with) and mental health. Two of these domains were among the three most commonly discussed in DIALOG+ sessions (accommodation, mental health, and physical health).

Conclusion

DIALOG+ initiates positive, domain-specific change in the areas that are addressed in sessions. It provides a comprehensive and solution-focused structure to routine meetings, encourages self-reflection and expression, and empowers patients. Future research should strengthen and monitor these factors.

Trial Registration

ISRCTN Registry ISRCTN34757603.

From the rhetoric to the real: A critical review of how the concepts of recovery and social inclusion may inform mental health nurse advanced level curricula - The eMenthe project

OBJECTIVES

This critical review addresses the question of how the concepts of recovery and social inclusion may inform mental health nurse education curricula at Master's level in order to bring about significant and positive change to practice.

DESIGN

This is a literature-based critical review incorporating a rapid review. It has been said that if done well, this approach can be highly relevant to health care studies and social interventions, and has substantial claims to be as rigorous and enlightening as other, more conventional approaches to literature (Rolfe, 2008).

DATA SOURCES

In this review, we have accessed contemporary literature directly related to the concepts of recovery and social inclusion in mental health.

REVIEW METHODS

We have firstly surveyed the international literature directly related to the concepts of recovery and social inclusion in mental health and used the concept of emotional intelligence to help consider educational outcomes in terms of the required knowledge, skills and attitudes needed to promote these values-based approaches in practice.

RESULTS

A number of themes have been identified that lend themselves to educational application. International frameworks exist that provide some basis for the developments of recovery and social inclusion approaches in mental health practice, however the review identifies specific areas for future development.

CONCLUSIONS

This is the first article that attempts to scope the knowledge, attitudes and skills required to deliver education for Master's level mental health nurses based upon the principles of recovery and social inclusion. Emotional intelligence theory may help to identify desired outcomes especially in terms of attitudinal development to promote the philosophy of recovery and social inclusive approaches in advanced practice. Whilst recovery is becoming enshrined in policy, there is a need in higher education to ensure that mental health nurse leaders are able to discern the difference between the rhetoric and the reality.

Development of the REFOCUS intervention to increase mental health team support for personal recovery

BACKGROUND

There is an emerging evidence base about best practice in supporting recovery. This is usually framed in relation to general principles, and specific pro-recovery interventions are lacking.

AIMS

To develop a theoretically based and empirically defensible new pro-recovery manualised intervention--called the REFOCUS intervention.

METHOD

Seven systematic and two narrative reviews were undertaken. Identified evidence gaps were addressed in three qualitative studies. The findings were synthesised to produce the REFOCUS intervention, manual and model.

RESULTS

The REFOCUS intervention comprises two components: recovery-promoting relationships and working practices. Approaches to supporting relationships comprise coaching skills training for staff, developing a shared team understanding of recovery, exploring staff values, a Partnership Project with people who use the service and raising patient expectations. Working practices comprise the following: understanding values and treatment preferences; assessing strengths; and supporting goal-striving. The REFOCUS model describes the causal pathway from the REFOCUS intervention to improved recovery.

CONCLUSIONS

The REFOCUS intervention is an empirically supported pro-recovery intervention for use in mental health services. It will be evaluated in a multisite cluster randomised controlled trial (ISRCTN02507940).