The impact of risk management practice upon the implementation of recovery-oriented care in community mental health services: a qualitative investigation

Abstract

The impact of risk management practice upon the implementation of recovery-oriented care in community mental health services: a qualitative investigation. AbstractBackground: Recovery-oriented care has become guiding principle for mental health policies and practice in the UK and elsewhere. However, a pre-existing culture of risk management practice may impact upon the provision of recovery-oriented mental health services.Aims: To explore how risk management practice impacts upon the implementation of recovery-oriented care within community mental health services.Method: Semi-structured interviews using vignettes were conducted with 8 mental health worker and service user dyads. Grounded theory techniques were used to develop explanatory themes.Results: Four themes arose: 1) recovery and positive risk taking; 2) competing frameworks of practice; 3) a hybrid of risk and recovery; 4) real-life recovery in the context of risk. Discussion:In abstract responses to the vignettes, mental health workers described how they would use a positive risk taking approach in support of recovery. In practice, this was restricted by a risk-averse culture embedded within services. Mental health workers set conditions with which service users complied to gain some responsibility for recovery. Conclusion:A lack of strategic guidance at policy level and lack of support and guidance at practice level may result in resistance to implementing ROC in the context of RMP.Recommendations are made for policy, training and future research. Declaration of interest: None.2

Patient perspectives of helpful risk management practices within mental health services. A mixed studies systematic review of primary research

“…However, despite the purpose of risk management, promoting safety did not appear investigated with what practices patients found helpful, while one study examined recovery. The latter verified findings by Holley, Chambers, and Gillard () that the recovery concept is rarely researched with risk management practices.…”

“…Disputes, it seemed, were recognized by some patients as an authentic part of therapeutic relationships which openly discussed risks, especially when it might require confronting difficult issues (Dixon, ; Long et al, ). Hence, it was acknowledged that staff perseverance and commitment with maintaining interpersonal relationships, in the light of disagreements, was helpful to keep dialogue open and enable a concerted management of risks (Brown & Calnan, ; Holley et al, ). This necessitated a patient awareness that risk management was a visible and approachable feature of their care, whereby patients spoke of the worthwhile, yet straightforward discussions with staff to transverse risks, accompanied by mutual cooperation, so compromises could be made (Coffey et al, ; Dixon, );

“…I was quite happy with [compromises]…they are professionals…so I have to give it…out of respect” (Dixon, :672)

…”

“…Given the significance of autonomy and agency with interpersonal relationship, it was also recognized that drawing on the patient's wider community could be beneficial with risk management (Holley et al, ; Schembari et al, ). Studies revealed utilizing friends and family strengthened support networks, furthering patient choices to who they may speak to, while social connectivity with significant others evolved personal coping strategies (Mckeown et al, ; Schembari et al, ).…”

“…While this might reflect societal trends with risk involving negative outcomes, risk can be explained as the likelihood of loss or gain, of something valued (Curran, ), and perhaps, a shift in research is required that “gain” is more investigated. The latter might identify how risk management can be more inclusive of the personal growth associated with recovery, whereby promoting quality of life aids patients with navigating risks (Holley et al, ). This resonated with some findings in the review, in which patients illustrated helpful practices that evoked recovery, such as enhancing social connectivity.…”

“…"…I was quite happy with [compromises]…they are professionals…so I have to give it…out of respect" (Dixon, 2012:672) Clinicians diversifying their interpersonal approach were equally helpful, involving a thoughtful curiosity with questioning, so patients gained perspectives on their risks and explored ways that might aid coping (Mckeown et al, 2016;Schembari et al, 2016). This was detected with devising safety plans with patients and facilitating learning, to make sense of past difficulties and acquire proficiencies which could promote life satisfaction (Holley et al, 2016). Striking, however, was the study by Pulsford et al (2013), which located beneficial practices linked to managing risks via physical means, such as seclusion, as patients did not wish to be victims of risks, notably violent acts.…”