Background
Methods
Synthesis design
Searches
Study inclusion and exclusion criteria
Inclusion criteria | |
● Published peer-reviewed studies (qualitative/quantitative/mixed methods) investigating the implementation of recovery into adult mental health services for people with serious mental illness (e.g. schizophrenia, bipolar disorder, major depression) from the perspectives of staff, decision-makers, clients, and carers. | |
● Studies reporting a new effort (within the organization or system) to transform services towards recovery-orientation and that is recovery-oriented in line with the definition of personal recovery by Anthony (1993) [2] (not clinical recovery). | |
● Studies that include a description of the methodology for data collection/analysis in the abstract and full text. | |
● Studies that report findings related to implementation experience, process, or factors. | |
● Studies from any country and in any language. | |
● Studies published from 1998 onwards. | |
Exclusion criteria | |
● Studies that describe interventions aimed at enhancing clinical recovery rather than personal recovery. | |
● Studies on illness management and recovery (IMR), assertive community treatment (ACT), clubhouses, or psychosocial rehabilitation as these predate or do not emerge from the recovery movement and therefore were not considered “new efforts” (including more recent modifications of these—e.g. f-ACT). | |
● Studies about employment or vocational services and personal budgets (though these are recovery-oriented they represent parallel literatures worthy of separate reviews). | |
● Studies that describe innovations targeting the use of restraints and/or seclusion or studies whose primary outcome of interest was restraint and/or seclusion rates. | |
● Studies reporting findings only about personal mental health recovery outcomes. | |
● Studies solely about recovery in the context of addiction (substance abuse, gambling). | |
● Reviews or systematic reviews, grey literature (e.g. reports, theses, dissertations, conference abstracts, editorials, letters), or conceptual papers. | |
● Studies where the population of interest or service offered was specific to minors, youth, or young adults, including first-episode psychosis. | |
● Studies that were about recovery in the context of natural disaster (e.g. earthquake, flood), physical health problems (e.g. stroke or cancer), eating disorders, mild depression, agoraphobia, postpartum depression, or domestic violence. | |
● Studies about implementing education around recovery into undergraduate or postgraduate curricula (e.g. nursing, medicine, social work, occupational therapy). | |
● Intervention effectiveness studies, implementation strategy effectiveness studies, and cost studies that do not report findings about implementation experience, factors, or process. | |
● Author reflections on implementation process without evidence of a methodology. | |
● Pre-implementation studies (change not yet implemented). |
Study quality assessment
Data extraction strategy
Data synthesis and presentation
Innovation group (cases) | Definition | Studies* | |
---|---|---|---|
1 | E-innovations | Online innovations such as websites and smartphone apps. | |
2 | Family-focused innovations | Innovations specifically aimed at mental health service users who are parents. | |
3 | Peer workers | Innovations centred on the employment of people with lived experience of mental health problems. | |
4 | Personal recovery planning | New approaches to writing plans within service provider–service user encounters. | |
5 | Recovery colleges | Education programs offering courses to service users and service providers on recovery and other topics in mental health. | |
6 | Service navigation and coordination | Innovations aimed at wraparound care, care coordination, and client access to services across health and social services. | |
7 | Staff training | Training programs for staff in mental health recovery. | |
8 | Architecture | Not included in synthesis. See Additional file 7 for details. | |
9 | Community connections | ||
10 | Consumer-led advisory councils | ||
11 | Personal budgets | ||
12 | Sport | ||
Other | |||
Perspectives on implementing recovery-oriented services in general | Not included in synthesis. See Additional file 7 for details. |
Within-case analysis
Cross-case analysis
CFIR domains | Name of themes from the synthesis | CFIR construct(s) where data underlying this theme were coded to |
---|---|---|
Intervention characteristics | ● Flexibility | ● Design quality and packaging ● Relative advantage ● Adaptability |
● Relationship building | ● Design quality and packaging ● Complexity | |
● Lived experience | ● Design quality and packaging ● Relative advantage ● Source of the Intervention | |
Inner setting | ● Traditional biomedical vs. recovery-oriented approach | ● Culture ● Learning climate ● Compatibility ● Relative priority |
● The importance of organizational and policy commitment to recovery-transformation | ● Compatibility ● Leadership commitment ● Tension for change | |
● Staff turnover | ● Structural characteristics | |
● Lack of resources to support personal recovery goals | ● Available resources | |
● Information gaps about new roles and procedures | ● Access to knowledge and information | |
● Interpersonal relationships | ● New construct: Relationships | |
Characteristics of individuals | ● Variability in knowledge about recovery | ● Knowledge and beliefs ● Self-efficacy ● Individual stage of change |
● Characteristics of recovery-oriented service providers | ● Other personal attributes | |
Process | ● The importance of planning | ● Planning |
● Early and continuous engagement with stakeholders | ● Engage: (new construct) engaging with stakeholder ● Reflecting and evaluating ● Formally-appointed internal implementation leader |
Results
Included studies
Results of study quality assessment and sensitivity analysis
Synthesis
Intervention characteristics
Innovation group | Themea | Example |
---|---|---|
E-innovations | Flexibility | |
Lived experience | ||
Family-focused innovations | Flexibility | Flexible program content for group sessions enabled the facilitators to tailor the program to meet the unique needs and context of the particular group (for example based on the age of participantsʼ children) [93]. |
Peer workers | Flexibility | |
Relationship Building | Managing relationships with staff and service users can be a complex process due to peer workers having to shift identities from that of a service user to that of a service provider, while at the same time continuing to juggle these identities in their work [102, 105, 114]. Their role is to develop close trusting relationships with service users but managing boundaries and ending relationships can be emotionally complex [99, 104, 109, 114]. | |
Lived experience | Peer workers were thought to have an advantage compared to clinical staff because they enable greater control over choices rather than tell clients what to do [98, 104, 109], and were less controlling and intrusive and could be trusted because they did not have the power to take away service users’ rights [106]. Because of their lived experience they are more credible and trusted [104, 106, 109] and service users open-up more to them [103, 104, 106, 114]. | |
Personal recovery planning | Flexibility | Workbooks and guides could help structure the process of recovery planning, but flexibility was important for the acceptability of the intervention among staff and clients (in terms of being optional, tailoring it to service users’ interests, including unstructured space (e.g. for drawing) and adapting to service usersʼ pace) [115, 117]. |
Relationship building | Personal recovery planning involves close relationship building between service providers and service users that entailed a certain amount of complexity around managing the relationship, navigating boundaries, and dealing with a sense of loss when the relationship was required to end at the end of the intervention [109]. | |
Lived experience | ||
Recovery colleges | Flexibility | Designing the college so that all students could easily join and sign-up for courses without need for referral or prerequisites was highly appreciated, as was being able to make oneʼs own choices of what to take, how much to participate in class, and dropping a course without being penalized [125, 127, 129]. |
Relationship building | Practitioner tutors can experience some challenges related to negotiating their dual role of colleague and clinician if the peer co-tutor is also their client and becomes unwell while working together [126]. | |
Lived experience | Including people with lived -experience as peer tutors delivering recovery college courses was valued because of their insight into what people are going through, because students could identify with them, and because their stories of recovery inspired hope and optimism among staff and service user students [125, 128, 129]. | |
Service navigation and coordination | Flexibility | |
Relationship building | Relationships are formed between service navigators/coordinators and service users and there was concern on both sides about managing program exiting, transitions to other programs, and scaling back frequency of contacts [133]. | |
Staff training | Lived experience |
Outer setting
Inner setting
Innovation group | Theme* | Example |
---|---|---|
E-innovations | The importance of organizational and policy commitment to recovery-transformation | An e-innovation was welcomed by leaders because they saw it as helping the organization progress towards their policy goals of measuring and increasing user involvement in care plans [85]. |
Interpersonal relationships | Service users were excited to use the e-innovations but disappointed and frustrated when their providers did not participate in and support them as much as they expected them to. Some providers felt their clients’ expectations were difficult to fulfil [85, 88]. A positive learning climate was thought to be linked to good pre-existing working relationships between service users and service providers, particularly ones that were open and adaptable [85, 88]. | |
Family-focused innovations | Information gaps about new roles and procedures | The need for establishing guidelines, protocols, and procedures to help staff implement family-focused innovations was highlighted [91, 92]. Nurses in the family rooms innovation were unsure if they should or should not stay with families during visits, and what their role was during visits, which left them feeling uncertain and having to navigate as best they could [92]. |
Interpersonal relationships | The fact that the group members and the facilitator already knew each was thought to have helped establish the trusting relationships and cohesive group dynamic that were key to successful implementation [93]. | |
Peer workers | Traditional biomedical vs. recovery-oriented approach | Peer workers often felt that other staff, primarily mental health professionals and doctors, valued their own knowledge (gained through formal degrees) more than peer workersʼ knowledge (gained through lived experience) [94, 104, 108, 115], with some describing feeling “blown-off” [108] and treated like a “kid”, an “idiot”, or a “moron” [99] in the workplace, and that any change in mood or any day off work was assumed to be related to their mental health problems [99, 108]. |
The importance of organizational and policy commitment to recovery transformation | If there was a lack of compatibility between the peer worker philosophy and the existing paperwork, treatment plans, and requirements for stating goals and demonstrating progress that they were asked to use, peer workers could feel uncomfortable with, and critical of, the service they provided their clients [94, 99]. | |
Information gaps about new roles and procedures | Peer workers often lacked information about their roles and tasks [104, 108]. A commonly reported issue was the lack of training and information for non-peer staff about the peer worker role, recovery, and how to work with (or supervise) peers workers [94, 97, 100, 102, 108]. This could lead to the underutilization or misutilization of peer workers [97, 108], and role confusion and conflict [102, 108]. | |
Interpersonal relationships | Building good interpersonal relationships between peer workers and non-peer staff was important for increasing respect and acceptance of the peer worker role [98, 108], ensuring the peer workers' role and skills were fully utilized [105], and facilitating the transition of the peer worker from service user to service provider [106, 114]. Hiring peer workers from within an organization’s own client population came with certain challenges due to pre-existing relationships [99, 102]. | |
Personal recovery planning | Traditional biomedical vs. recovery-oriented approach | Traditional mental health services espouse independent and distinct responsibilities whereas recovery planning requires cooperative and collaborative teamwork that shares responsibility among staff [119]. |
The importance of organizational and policy commitment to recovery transformation | ||
Staff turnover | Difficulty retaining staff and filling key positions meant that building a continued vision for recovery planning as part of wider organizational change was difficult [119]. | |
Lack of resources to support personal recovery goals | Service providers perceived there to be a lack of resources for supporting clients’ individually-determined goals in a hospital setting because there was limited programming available [119]. | |
Information gaps about new roles and procedures | ||
Interpersonal relationships | Positive relationships were characterized by respect and mutual esteem and negative ones as being told what to do and being patronized [109, 117, 122]. When staff were disinterested in recovery plans or had negative attitudes towards the training and additional paperwork needed, clients perceived this lack of buy-in and felt disappointed, concerned, or equally dismissive of aspects of recovery planning [119, 121, 122]. | |
Recovery colleges | Information gaps about new roles and procedures | Guidance was needed for service provider students about how to manage boundaries in co-learning environments and whether they should or should not disclose their status as a member of staff to others [128]. |
Interpersonal relationships | Achieving good rapport between practitioner and peer tutors paired-up to teach courses may be more difficult to achieve if the practitioner tutor is normally the peer tutorʼs service provider [126]. | |
Service navigation and coordination | Traditional biomedical vs. recovery-oriented approach | Overcoming existing traditional work culture involved dispensing with hierarchical structures, competitiveness, and defensiveness that can silo or make invisible scarce community resources [129], working in a more intensive and individualized way with service users [132], and pre-empting challenges inherent to a historical separation between behavioural and physical health [132]. |
Staff turnover | Turnover could cause unclear leadership and inefficiencies since what staff are required to do may keep changing as people in leadership roles change [130]. | |
Lack of resources to support personal recovery goals | ||
Information gaps about new roles and procedures | Lack of access to information and training around the new service navigation and coordination programs and the role of its staff (processes, referrals, expectations, goals, outcomes, funding, philosophy) was mentioned across studies and was associated with stress, concerns, confusion, difficulties with service navigation, and more difficult relationships with other service providers [110, 130, 131, 133, 134]. | |
Interpersonal relationships | ||
Staff training | Traditional biomedical vs. recovery-oriented approach | |
The importance of organizational and policy commitment to recovery-transformation | Staff supported the view that organizational culture (mission, policies, procedures, record-keeping, staffing) needed to change in order for implementation of a recovery training program to be successful [135]. | |
Staff turnover | ||
Lack of resources to support personal recovery goals |
Characteristics of Individuals
Innovation group | Themea | Example |
---|---|---|
E-innovations | Variability in knowledge about recovery | Some doctors in an e-innovation study showed more interest in less-recovery-oriented aspects of the innovation, such as the tool’s capacity for clinical monitoring of sleep and symptoms [86]. |
Family-focused innovations | Variability in knowledge about recovery | In one study of a family-focused innovation, nurses tended to confound personal and clinical recovery (e.g. they referred to recovery as the clinical improvement of symptoms and a process of regaining physical and mental health to a point where the client could be discharged) [92]. |
Peer workers | Variability in knowledge about recovery | Some peer workers felt strongly that recovery and the roles of peer workers had been misunderstood and co-opted in the mental health system, that they were being asked to do tasks and roles that contradicted the recovery approach or that trivialized their role (being a clerk or a driver), and that some clinicians misused the term and confused clinical recovery with concepts of personal recovery [94, 99, 102]. |
Characteristics of recovery-oriented service providers | Personal attributes of peer workers that facilitated or optimized their work and impact included: patience [99, 111], being warm and understanding [106, 109], dependable and trustworthy [106, 111], professional, a good communicator and listener, respectful (didnʼt dictate), empathetic, positive, and optimistic [111]. | |
Personal recovery planning | Variability in knowledge about recovery | Staff and clients showed familiarity with the facts and truths about the recovery plan when they expressed understanding that it was both process and outcome [122], owned by clients [117] and personalized [109]. However, some staff made judgements about their service usersʼ goals, such as not being realistic or not meaningful [119] and some clients did not understand the underlying concept of mental health recovery and thought the plan was a once-off thing [121]. |
Characteristics of recovery-oriented service providers | Positive experiences were related to finding facilitators supportive, respectful, encouraging, helpful, collaborative, and warm [109, 117, 124]. Negative experiences were related to perceiving facilitators as patronizing in their approach, not genuine in their compassion or formulaic and generic in their approach, or having done an inadequate job discussing recovery [109, 121, 122]. | |
Recovery colleges | Variability in knowledge about recovery | Some service provider students in recovery colleges felt that service users needed to be well enough mentally to participate [129]. |
Service navigation and coordination | Variability in knowledge about recovery | Even when state officials are very clear on the distinction between dependency-producing case management and self-managed recovery, and providers excited by the new model and open to client empowerment, in practice the two can become blurred [134]. |
Characteristics of recovery-oriented service providers | Success of service navigation and coordination innovations appeared closely tied to personal characteristics of staff, in particular the ability to develop strong individual connections, trust, and rapport with both clients and other services through a personal approach, addressing competitive or defensive responses, empowering themselves, being hardworking, and having the skills to navigate fragmented systems [130, 131, 133]. | |
Staff training | Variability in knowledge about recovery | While the centrality of hope and recovery-oriented language was understood, some, despite training still thought of recovery as a linear journey with a start and end point, or as a type of care, or something they did for clients [135]. Some staff were concerned that many service users may not be at a level of recovery necessary to engage in a recovery training process [137]. |
Process
Innovation group | Themea | Example |
---|---|---|
Family-focused innovations | The importance of planning | Early anticipation of issues with hiring new staff and effective planning (particularly the challenge of hiring staff for an innovation based on a model that did not yet exist in the community) helped to enhance workforce criteria over time [91]. |
Early and continuous engagement with stakeholders | Engaging collaboratively with service providers to revise and refine the forms and protocols they would use as part of the innovation, helped ensure these were clear, simple, and adhered to [91]. | |
Peer workers | The importance of planning | Planning was essential for mitigating known implementation challenges through well-chosen strategies such as having processes for embedding peer workers into the team (e.g. formal introductions, photos on walls) [109], anticipating staff concerns about peer workersʼ boundaries by discussing these in pre-implementation meetings and subsequent supervision [103], reducing role conflict and confusion with clear recruitment strategies [95, 102], policies on staff/client relationships, and operationalization of the peer role, and by providing training [102]. |
Early and continuous engagement with stakeholders | Engaging with carer and clinician expert reference groups helped identify and select an intervention to be delivered by peer workers [109]. Peer workers felt they could have been engaged with more by being given a clearer leadership role in implementation to resolve issues of confusion, denial, and ineffective implementation of recovery practice [94]. | |
Personal recovery planning | Early and continuous engagement with stakeholders | |
Recovery colleges | Early and continuous engagement with stakeholders | Engaging with organization staff early in the implementation process for their input into processes and procedures helped to leverage existing resources and prompt staff to offer classes in recovery colleges [127]. |
Service navigation and coordination | The importance of planning | |
Early and continuous engagement with stakeholders | A lack of stakeholder engagement was highlighted as an implementation challenge. There was a need for greater engagement with stakeholders such as service users, families, and service providers in the planning stage to collaboratively develop elements such as protocols, work roles, responsibilities, required outcomes, information management, and service logistics and design [130, 134]. |