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

Abstract

BackgroundRecovery has become an increasingly prominent concept in mental health policy internationally. However, there is a lack of guidance regarding organisational transformation towards a recovery orientation. This study evaluated the implementation of recovery-orientated practice through training across a system of mental health services.MethodsThe intervention comprised four full-day workshops and an in-team half-day session on supporting recovery. It was offered to 383 staff in 22 multidisciplinary community and rehabilitation teams providing mental health services across two contiguous regions. A quasi-experimental design was used for evaluation, comparing behavioural intent with staff from a third contiguous region. Behavioural intent was rated by coding points of action on the care plans of a random sample of 700 patients (400 intervention, 300 control), before and three months after the intervention. Action points were coded for (a) focus of action, using predetermined categories of care; and (b) responsibility for action. Qualitative inquiry was used to explore staff understanding of recovery, implementation in services and the wider system, and the perceived impact of the intervention. Semi-structured interviews were conducted with 16 intervention group team leaders post-training and an inductive thematic analysis undertaken.ResultsA total of 342 (89%) staff received the intervention. Care plans of patients in the intervention group had significantly more changes with evidence of change in the content of patient’s care plans (OR 10.94. 95% CI 7.01-17.07) and the attributed responsibility for the actions detailed (OR 2.95, 95% CI 1.68-5.18). Nine themes emerged from the qualitative analysis split into two superordinate categories. ‘Recovery, individual and practice’, describes the perception and provision of recovery orientated care by individuals and at a team level. It includes themes on care provision, the role of hope, language of recovery, ownership and multidisciplinarity. ‘Systemic implementation’, describes organizational implementation and includes themes on hierarchy and role definition, training approaches, measures of recovery and resources.ConclusionsTraining can provide an important mechanism for instigating change in promoting recovery-orientated practice. However, the challenge of systemically implementing recovery approaches requires further consideration of the conceptual elements of recovery, its measurement, and maximising and demonstrating organizational commitment.

Supporting recovery in patients with psychosis through care by community-based adult mental health teams (REFOCUS): a multisite, cluster, randomised, controlled trial

“…For example, many staff in SLaM teams in both arms would previously have received some recovery training, 33 so sustained changes in control group cannot be excluded. However, the recovery orientation of participating teams as measured by RKI (control mean 2·94, intervention mean 2·97) was lower than the mean RKI score of 3·94 found in an Australian study, 34 suggesting there was not a high recovery orientation at baseline.…”

Qualitative and Mixed Methods in Mental Health Services and Implementation Research

“…The inductive approach typically includes a process of “coding by consensus”, which includes one or both of two activities, 1) regular meetings among coders to discuss procedures for assigning codes to segments of data and resolve differences in coding procedures, and 2) comparison of codes assigned on selected transcripts to calculate a percent agreement or kappa measure of inter-rater reliability. Most studies in the mental health services literature report the first method (e.g., Gilburt, Slade, Bird, Oduola & Craig, 2013; Mittal, Drummond, Blevins, Curran, Corrigan, & Sullivan, 2013; Turner et al, 2008), while others report measures of inter-rater reliability of coding of qualitative transcripts (e.g., Bradley et al, 2003; Lee et al, 2007; Palinkas et al, 2008). Rodriguez and colleagues (in press) appear to have used both methods to insure the reliability of coding assigned; however, they also acknowledge that they relied primarily on a priori codes rather than identify new or emergent codes.…”

“…They then conducted a Poisson linear regression that used element scores for each facility as independent variables and percentage of patients at each sites receiving any evidence-based therapy as the dependent variable. Gilburt et al (2013) used mixed methods to achieve complementarity in their evaluation of implementation of a recovery-oriented practice through training across a system of mental health services, using a quantitative audit of care plans in a random sample of 700 patients to assess change in core plan topics and in responsibility of action and semi-structured interviews with team leaders to explore understanding of recovery, implementation within the service and the wider system, and perceived impact of the training on individual practice and that of the team. The Delphi approach used by Beehler and colleagues (2013) is an example of mixed methods to achieve development and elaboration.…”

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

“…Evidenced-based practices are consistent with the recovery model provided that the client is encouraged and supported to assume responsibility in the domains of need, at the earliest possible opportunity. Providing adequate staff training in the flexible delivery of recovery-oriented programs is also an ongoing issue for mental health services [28, 29]. …”