Training attendance
Twenty two mental health teams participated in the intervention, comprising early intervention for psychosis (n = 2), community mental health (n = 5), in-patient rehabilitation services (n = 3), assertive outreach (n = 2), and continuing care teams (n = 10). This represented the full range of non-crisis mental health teams operating in the two Boroughs.
The teams comprised a total of 428 mental health professionals at the start of the study. Of these 383 (91%) registered on the training programme, including 193 (50%) care coordinators (predominantly nursing staff), 81 (21%) support workers, 22 (6%) team leaders and 87 (23%) staff from other professional groups (psychologists, psychiatrists, approved social workers, chaplains and vocational workers). Non-registrants included the night-staff from one rehabilitation ward and a number of staff whose role had changed or had moved teams prior to the start of the training and were no longer eligible.
Of the 383 professionals who registered, 342 (89%) staff attended at least one training session, and 190 staff (48%) attended all four classroom-based workshops. There was a gradual decline in attendance for consecutive workshops from 272 (69%) in the first workshop, 261 (66%) for workshop 2 and 3 combined and 197 (50%) for workshop 4. Staff turnover during the training programme was 21%, with 46 new staff joining participating teams and 41 staff leaving those teams.
Care plan audit
Care plans for 700 patients (400 intervention, 300 control) were reviewed. A total of 673 paired pre- and post-training care plans were available, with 27 (15 intervention, 12 control) excluded due to missing data. The care plans contained 3,526 distinct action points at baseline (1,870 intervention, 1,656 control), and 3,629 at follow up (1,939 intervention, 1,690 control). Staff took sole responsibility for the majority of actions listed in care plans at baseline and follow up, as shown in Table
1.
Table 1
Number of action points at baseline and follow up by responsibility for action
Staff | 1090 (65.8) | 1399 (74.8) | 1106 (65.4) | 1382 (71.3) |
Service user | 130 (7.9) | 157 (8.4) | 140 (8.3) | 167 (8.6) |
Staff and service user | 413 (24.9) | 312 (16.7) | 416 (24.6) | 385 (19.9) |
Staff and carer | 12 (0.7) | 1 (0.1) | 13 (0.8) | 3 (0.2) |
Service user and carer | 8 (0.5) | 1 (0.1) | 11 (0.7) | 1 (0.1) |
Carer | 3 (0.2) | 0 | 4 (0.7) | 1 (0.1) |
Total
|
1656
|
1870
|
1690
|
1939
|
The topics present in the care plans related predominantly to care plan review meetings, medication and relapse prevention, as shown in Table
2.
Table 2
Topics addressed in baseline care plans (n = 673)
Care plan review meeting | 296 (100) | 326 (86.5) |
Relapse prevention | 293 (99.0) | 325 (86.2) |
Medication | 240 (81.1) | 263 (69.8) |
Physical health | 212 (71.6) | 180 (47.7) |
Activities of daily living skills # | 151 (51.0) | 156 (41.4) |
Accommodation | 101 (34.1) | 66 (17.5) |
Social needs | 76 (25.7) | 116 (30.8) |
Financial | 66 (22.3) | 74 (19.6) |
Emotional support | 65 (22.0) | 165 (43.8) |
Employment | 51 (17.2) | 44 (11.7) |
Healthy lifestyle | 40 (13.5) | 93 (24.7) |
Education | 37 (12.5) | 30 (8.0) |
Carer support | 28 (9.5) | 32 (8.5) |
A total of 46 changes were made to care plans in the comparison group and 573 changes in the intervention group, as shown in Table
3.
Table 3
Changes to care plan action points by topic at follow up
Care plan review meeting | 0 | 15.6 | 0 | 11.9 |
Relapse prevention | 0 | 12.2 | 0 | 9.3 |
Medication | 0 | 2.9 | 1.7 | 8.0 |
Physical health | 0 | 5.3 | 2.0 | 8.5 |
Activities of daily living skills | 0 | 5.0 | 1.4 | 8.2 |
Accommodation | 0.3 | 2.9 | 1.0 | 3.2 |
Social needs | 0.7 | 4.8 | 2.4 | 6.9 |
Financial | 0.3 | 3.7 | 0.3 | 5.3 |
Emotional support | 0 | 4.8 | 1.0 | 9.8 |
Employment | 0.3 | 1.9 | 1.4 | 4.0 |
Healthy lifestyle | 0 | 4.0 | 1.4 | 6.6 |
Education | 0.3 | 1.1 | 1.0 | 2.4 |
Carer support | 0 | 2.7 | 0 | 1.1 |
Total no of changes
|
6
|
252
|
40
|
321
|
Patients in the intervention group had increased odds of having a change in the topics covered in their care plan at follow up compared with the control group OR = 10.94 (95% CI 7.01-17.07). This represents both the addition and removal of topics to the care plan. There is no clear trend in particular topics of care being removed or added, for example, 15.6% of care plans had the entry related to care plan review removed, whilst 11.9% had an entry in the same category added in the intervention group.
The attributed responsibility was changed for 33 action points in the control group and 93 in the intervention group, as shown in Table
4.
Table 4
Changed, removed or added action points at follow up distributed by attributed responsibility for action
Staff | 11 (33) | 4 (66) | 22 (55) | 23 (25) | 222 (88) | 238 (74) |
Service user | 7 (21) | 0 | 6 (15) | 12 (13) | 7 (3) | 19 (6) |
Staff and service user | 11 (33) | 2 (33) | 11 (28) | 54 (58) | 22 (9) | 63 (20) |
Staff and carer | 1 (3) | 0 | 0 | 2 (2) | 0 | 1 |
Service user and carer | 3 (9) | 0 | 0 | 1 (1) | 1 | 0 |
Carer | 0 | 0 | 1 (2) | 1 (1) | 0 | 0 |
Total
|
33
|
6
|
40
|
93
|
252
|
321
|
Patients in the intervention group had increased odds of the responsibility for actions being changed in existing topics covered in their care plan at follow up compared with the comparison group OR = 2.95 (95% CI 1.68-5.18). The majority of these changes related to whether staff took sole responsibility for actions (33% control, 25% intervention) or shared responsibility with service users (33% control, 58% intervention). This trend is also reflected in the topics that had been removed or added to care plans at follow up with the majority of changes relating to topics in which responsibility for action was attributed solely to staff or to staff in collaboration with patients.
Recovery, individuals and practice
This theme describes the perception and provision of recovery orientated care by individuals and at a team level.
Care provision
All participants identified a range of interventions including medication, symptom management, and psychological therapies, in addition to practical elements such as meaningful activity, training and stress management that comprise a recovery approach. There was a strong emphasis on social inclusion interventions as integral to a recovery focus. Some identified that the care provided needed to be holistic, taking into account the emotional, spiritual, social, physical and realms which impact on patients’ quality of life including relationships. Training had led to staff considering wider areas of care to a greater extent with a consequent move from maintenance to improvement. Qualities required to deliver recovery focused care included the ability to be caring, helping, supporting, respectful and open. A minority highlighted a conceptual element to recovery orientated care involving the way you looked at people and thought about things.
Hope
Hope was highlighted as central to providing recovery-orientated care. The majority conceptualised hope as seeking positive change, while some participants working with people with long term severe mental illness felt it could also encompass a lack of change for the worse.
#40 “Hope means to me, I think for my clients we hope that people do change, and it is helpful you know in terms of one of the workshops I went on, it was about not giving up on people and introducing hope…”
Hope was seen as a universally positive value and integral to mental health work, although many reported low levels of morale and hope amongst staff within their services. The majority of participants talked about the role of hope for staff, a minority highlighting its role for patients. Hope involved valuing patients as individuals and having belief in patients. Many participants found it difficult to identify how it could be practically implemented. Those who did suggested that short term it was useful in reaching goals and outcome specific tasks through encouragement. Some participants were wary of the use of hope beyond this, engendering unachievable ‘blue sky’ goals.
Language
There was much confusion about what ‘recovery’ meant and this impacted directly on participants perceptions of what recovery-orientated practice comprised. Participants noted that many members of staff believed they ‘already did recovery’.
#29 “…there were comments that there is no theoretical base in the recovery approach, it is an approach it is not a model, there is no clear definition of recovery or there are several definitions, lots of comments what is the point of the training when we are already doing this.”
The provision of practical care focused on social inclusion, such as help with employment, was seen to support this stance. The word recovery was strongly associated with the verb ‘to recover’ and recovery was seen by the majority as a linear journey with a start and end point. A small number of participants identified the word recovery as inherent in a number of other Trust initiatives, such as ‘Support Time Recovery Workers’ and used these as examples of recovery practice. Language was also identified as an important component of recovery approaches. Two participants noted that with a new model, there was new language. Use of this new vocabulary could identify the unique nature of recovery, while some of the current language in use was seen as not being recovery focused. The training led some staff to reflect on their own use of language.
Ownership
Recovery was largely framed as something that staff do, with staff being the primary agents of change. Staff took ownership of recovery, its meaning and implementation, with care provision mediated by their perceptions of recovery.
#37 “…so sometimes we can improve their life with social inclusion working towards vocational activities, helping them to build up their lives in terms of psychosocial education activities, education and, also we give them, very fortunate here, we’ve got psychology”
Few interviewees noted the role of service users. Of those that did, service user involvement was seen as being part of the approach, with involvement ranging from being ‘included’, ‘being part of recovery’ to in one instance ‘taking charge’. In examples when involvement was identified as important, staff were identified as facilitators of patient-led care, where the ability to work in partnership and enable patients to think about recovery were important.
Multidisciplinary
Multidisciplinary working was highlighted as important in the provision of recovery focused care. Several interviewees highlighted different schools of thought and broad principles which predominate in, and to some extent define, different professional groups. Interviewees stated that purveyors of the medical model were least likely to be recovery-focused while those adhering to social models of illness were most likely. Doctors were seen as least recovery–focused and social workers as most.
#40 “I think traditionally it has always been a very medically based model, …I think social workers slightly have the edge in terms of using a recovery model using a social care model in terms of helping clients, I think nurses traditionally take on board what doctors say and sort of the care plan has traditionally been directed by consultants for example…”
It was clear that levels of hierarchy existed in many of the services. Where doctors were not on-board with the training and recovery in general, they could act as a barrier. Conversely, doctors who promoted the approach acted as role models. Despite a focus on professions, several interviewees noted that recovery had to be multidisciplinary, with professions learning from each other, and all clinical staff needing to adopt the approach for it to work effectively. While this theme focuses largely on the role of professions, some participants noted that although teams had been generally positive about recovery, there were some individuals who were resistant to change. Despite training and development of practice, these staff were unlikely to change their views and ways of working.
#48 “So I think it’s down to managers to ensure that they have embraced the model. And that it’s cascaded down and that staff also embrace it and apply it within their practise. But I don’t think that’s something that [the Trust] can do. I think that’s the individual’s responsibility. Because you teach someone as much as you wanna teach them, if they don’t wanna apply it, they won’t.”
It was on the individual level that interviewees reported changes since the training. They had observed that staff were beginning to consider wider and more holistic care provision, such as taking into consideration spirituality and looking at options such as activity and vocation. There was a move from a focus on maintenance towards improvement, looking forward beyond crisis management to what happens next, including when patients left their care and potentially the care of the mental health services altogether. Some staff had been adopting new recovery-related terminology and reconsidering the language commonly associated with predominating ideologies.
Systemic implementation
Interviewees highlighted a number of areas which had created barriers to a more substantial and wider felt impact across those services involved. These pertained more widely to structural elements of care provision and are demonstrated in the last four themes.
Hierarchy and role definition
Interviewees made it clear that in terms of practice, they exist not just as individual practitioners but within services, and the wider system of an NHS Trust. The relationship is described as hierarchical with Trusts determining the role and practice of services. A number of participants highlighted the ‘needs of the service’ to meet these. Recovery orientated approaches were often seen as conflicting with the overarching roles of the service. The most prominent role in community teams was ‘moving people on’. It was described as having a single vision for patients and comprised entering services highly symptomatic with poor functioning and leaving with improved management and functioning.
#26 “…we are about moving people through from very high support needs, people that have just moved in maybe to rehabilitation to residential services, to very low support and on into the community, so I guess we have always worked that model of moving people through a system…”
Other roles included detention (inpatient services) and risk management. While roles were widely accepted, the accompanying policies, procedures and targets were identified as presenting often ideological and practical barriers to recovery orientated care provision. Participants suggested that in order for services to become recovery orientated, recovery would need to be embedded in the service’s role and to underpin everything it did. Two exceptions were assertive outreach and early intervention teams, both of which had clear identities and roles largely determined by the client group and specific model of care provision.
Recovery was identified by several participants as a Trust ‘initiative’. Despite recognition that the Trust was committed to recovery, there was a lack of clarity about what the Trust meant by recovery, how it related to other initiatives and Trust strategies, and in particular what this meant in terms of the role of services. This led some interviewees to suggest that a recovery approach was being implemented for political reasons, to meet government targets, as a tool for reducing costs, and like previous initiatives, may soon be de-prioritised. Interviewees highlighted a lack of communication and shared understanding between management and staff in services of the vision, and implications, for care provision.
#46 “In terms of the commitment, I don’t know if everybody in [the Trust] is probably singing from the same sheet, I don’t think that that’s the case…”
Interviewees suggested that without commitment from the Trust as a whole to address these issues, a recovery approach was likely to be unsustainable within services in the long-term.
Training approaches
The training was highly rated, with over half of interviewees favouring mandatory recovery training. Participants particularly valued input from service users and the chaplaincy. The former were described as real life examples of recovery with often long histories of severe mental illness, now delivering training. This input was particularly effective when their experiences were representative of the services’ client group. The chaplaincy was identified as highlighting the role of spirituality and different world views. However, a focus on practical elements such as social interventions led to widespread scepticism of a recovery approach as a repackaging of something they already did.
#40 “I think we were doing it anyway the mental health teams, and in terms of care coordinators you do try and help clients access other services, you know become more independent, vocational and training and work needs.”
The reflexive practice embedded in the training was valued highly by staff with strong agreement that this activity should be incorporated into overall practice. Some team leaders had implemented regular sessions to examine day to day practice, values and conceptions as a result of the training. The provision of training was seen as denoting the importance of the approach and emphasis by the Trust. However, recovery was seen as a process and it was suggested that training needed to be ongoing with systemic changes and support from the wider Trust to implement and sustain recovery approaches.
Measures of recovery
Measurement and measures of recovery were identified as important factors in implementation. Systematic measurement of impact was highlighted as demonstrating the priority of an intervention for the Trust and more widely as a means of improving the evidence base and legitimacy of the approach. Measures also provided a means of ensuring the approach was being used, and of encouraging and recognising good practice.
#35 “…unless something is measured there’s no real inducement and encouragement to do it unfortunately…”
Staff focused on staff-rated changes for patients, such as improved functioning levels, generating hope and how this could lead to tangible outcomes. Staff-related outcomes included changes in attitudes and team approaches. Three members of staff highlighted the importance of patient-identified and patient-rated outcomes.
Resources
The majority of interviewees identified resources as a key consideration in the implementation of recovery and providing recovery orientated care. Identified resource constraints included: expertise such as vocational workers and recovery champions; community resources such as appropriate placements and accommodation; engagement activities; training; but most importantly resources to cover staff numbers and time. The majority of interviewees believed that a recovery approach would require increased staff numbers and time, initially in attending training but also that recovery approaches would involve working more intensively and for longer periods with patients. These resources are governed by money.
#29 “…you have to look at resources and how they impact or lack of resources, at times in an ideal world it is all well and good talking about a recovery approach and how we implement that but is, you know to look at and consider certainly resources and how that impacts on teams and then time and people’s workloads….”
Almost half identified that the qualities possessed by individual staff were also important in the implementation and practice of recovery. Among the qualities highlighted were skills, experience, motivation, energy, flexibility, creativity, commitment, open-mindedness, a positive attitude, caring, and amenable to change. Some of these qualities were identified as characteristics that could be developed, while others as inherent in a person’s beliefs, values and personality.