MENTAL HEALTH REFORMS AND THEIR IMPACT ON CONSUMER AND CARER PARTICIPATION: A PERSPECTIVE FROM VICTORIA,AUSTRALIA

Victoria, Australia has experienced significant changes in the structure and delivery of mental health services over the past three decades. As a result of these changes, there is now an expectation that consumers of services and their carers have increased opportunities to participate in the design and delivery of services. There currently exists a paucity of research that examines the degree to which this goal has been realized in practice. This article presents findings from a qualitative research study investigating the perceptions of consumers and carers regarding the degree to which the contemporary service system allows for their increased participation. Data were collected through in-depth interviews with consumers and carers. The findings suggest that consumers have identified an increased scope for their participation, although this varies considerably from service to service. Carers on the other hand described very little opportunity for participation at any level. The responses of carers suggest there may be some inherent difficulty in facilitating increased participation for both groups. Strategies to support carer participation are urgently required if the goals of state and national mental health policy in Australia are to be realized.     

Consumer and carer participation in mental health care: the carer's perspective: part 1 - the importance of respect and collaboration

The role of family carers in the delivery of mental health services in Australia has become more than an advantage over not having this sort of participation. Increasingly the involvement of non-paid carers (family members and significant others) has been recognised as central to the smooth delivery of care and treatment. Notwithstanding this acknowledgment, there is very little discussion of carer participation in mental health care delivery within the literature. The limited research in this area suggests that carers recognize very little opportunity for genuine participation, even less than is available to consumers. This paper presents part 1 of the findings of an exploratory, qualitative study seeking an in-depth understanding of the attitudes of carers from rural Victoria, Australia toward opportunities for participation with specific emphasis on the role of psychiatric nurses in encouraging or discouraging participation. The themes of respect and communication will be described in this paper. These findings demonstrate the variable experiences of carers in their opportunities to participate and the important role nurses can assume in supporting both carers and consumers through this process.     

Conflicting agendas between consumers and carers: the perspectives of carers and nurses

Increasingly, Australian government policy advances an expectation that consumer and carer participation will be present in all aspects of mental health service delivery. A review of the literature suggests that consumers and carers actively seek the opportunity to participate but are frequently hampered by barriers. However, government policy documents tend to discuss consumers and carers with regards to participation as though their needs and desires are essentially similar. This paper presents the findings of a qualitative research project involving in-depth interviews with carers and mental health nurses. The issue of conflict between the issues for consumers and carers emerged as a major theme. This issue is explored and discussed in light of the goals of current mental health policy. It is concluded that conflicting agendas are apparent and must be addressed if genuine participation in service delivery is possible for both consumers and carers.     

Telephone survey of service‐user experiences of a telephone‐based mental health triage service

The participation of service users in all aspects of mental health service delivery including policy development, service planning and evaluation is increasingly an expectation of contemporary mental health care. Although there are a growing number of publications reporting service‐user perspectives in the evaluation of mental health services, little attention has been paid to the views of service users about mental health triage services. The purpose of the study reported here was to examine service‐users' (consumers and informal carers) experiences of a telephone‐based mental health triage service. Using a framework developed from the World Health Organisation's elements of responsiveness, we conducted structured telephone interviews with service users who had contacted a telephone‐based mental health triage service in regional Victoria, Australia. The main findings of the study were that consumers experienced more difficulty than carers in accessing the service and that, although most participants were satisfied, only a minority reported being involved in decision‐making. Further work is needed to improve accessibility of mental health triage services and to investigate barriers to consumer self‐referral. Professional development and practice support systems should be established to support mental health triage nurses in the development of collaborative, consumer‐focused care.     

Research involving mental health consumers and carers: a reference group approach

Policy changes within the mental health system are creating an increasing expectation that service providers increase the opportunities for consumer and carer participation in the planning, delivery and evaluation of mental health services. If they are to reflect this change in philosophy, researchers have an obligation to ensure the involvement of consumers and carers, above and beyond involvement as a participant in all relevant mental health research. This paper describes the establishment and function of a reference group, established to guide and assist with the conduct of a research project examining the experiences of consumers and carers with psychiatric disability support services. The formation and operation of, and the valuable contribution made by, the reference group is discussed.     

Practice standards to improve the quality of family and carer participation in adult mental health care: an overview and evaluation

ABSTRACT:  Mental health services are required to involve family, carers, and service users in the delivery and development of mental health services but how this can be done in routine practice is challenging. One potential solution is to prescribe practice standards or clear expectation relating to family involvement. This paper describes practice standards introduced to an adult mental health service and a study that aimed to evaluate the impact of the standards on practice. Hospital and community files were audited before and after the introduction of standards for evidence of participation and surveys of carers and consumers relating to the quality of participation were undertaken. Increases in documented carer participation were found, particularly in relation to treatment or care planning. The expressed needs relating to participation varied in hospital and community settings. The majority of carers and service users were satisfied with their level of participation. The introduction of practice standards is an acceptable, inexpensive, and feasible way of improving the quality of family and carer participation, but gains may be modest.     

Determining the effectiveness of mental health services from a consumer perspective: part 2: barriers to recovery and principles for evaluation

The routine use of standardized outcome measures has been introduced to assess the effectiveness of mental health service delivery throughout Australia. The use of these measures has been criticized for failing to reflect those aspects of treatment consumers consider to affect their recovery. This is the second of a two-part paper. Its aim is to explore the views of consumers regarding factors that impede recovery and to explore the principles that ideally should underpin the evaluation of mental health services. Focus group interviews were conducted with consumers of mental health services (n = 16) from one rural and one metropolitan mental health service in Victoria, Australia. This paper presents the findings, pertaining to aspects of mental health services that pose barriers to recovery. The main themes to emerge were: staffing issues; hearing the person not the illness; lack of safety and security; and, isolation. The main themes to emerge regarding the evaluation of mental health services were: consumer involvement; peer support and more responsive care and treatment. The views of participants suggest that the effective evaluation of mental health services requires an increased focus on the views and opinions of consumers in order to develop more responsive mental health services.     

Psychiatric nurses enhancing consumer and caregiver participation in the state of Victoria: the impact of history and policy

Australian mental health policy now clearly articulates that consumer and carer (informal caregiver) participation in all aspects of service delivery is an expectation. As the largest professional group, nurses clearly play a key role in translating policy into practice. The aim of this article is to briefly overview the history of mental health service development in Victoria, with specific emphasis on the development of psychiatric nursing. Changing perspectives of consumers of mental health services and their informal carers is discussed. Policy development is described in the context of the development of mental health services. It is argued that an appreciation of the history of punishment and confinement is necessary for providing a climate conducive to consumer and carer participation.     

In our own words: consumers' views on the reality of consumer participation in mental health care

The opportunity for consumers to participate in all stages of mental health service delivery, including the planning of their individual care, is now clearly enshrined in Australian mental health policy. Published research which examines the extent to which this has been realised in practice is limited, and the paucity is even greater for research reflecting the views of the consumers themselves. This paper presents the findings of a qualitative study. In-depth interviews were undertaken with consumers of mental health services from two rural areas in Victoria to explore their views and opinions regarding their ability for genuine participation in the planning and delivery of their mental health care, and in particular on the role of nurses in facilitating this process. Data were analysed with the assistance of NVivo, using a content analysis approach. The main themes identified were: respect, encouragement, collaboration and systemic barriers. The findings suggest that consumer participants identify a number of barriers which limit their ability to participate effectively. The implications for the role of the nurse in facilitating genuine consumer participation are discussed.     

Laying new foundations for 21st century community mental health services: An Australian perspective

While there has been a significant increase in investment in community mental health in Australia since the advent of the National Mental Health Strategy in the early 1990s, there has been little guidance on service design and delivery. This has led to a growing diversity of approaches and concern about the adequacy of care with repeated calls for a system overhaul. Consumers and carers have very largely been absent from decision‐making about service design and development which has led to a system primarily designed by healthcare professionals. However, with the emergence of recovery as a core principle in mental health, it is time for consumers and carers to be centrally engaged in co‐designing services with service providers. This raises the question of whether dominant service delivery models – such as the growth of specialist teams/services, the changing balance between profession‐specific and generic case management roles in multidisciplinary teams, and the separation of inpatient from community care – will prevail. Contentious issues in these three service delivery areas are outlined to stimulate debate and highlight the pressing need for national guidance on the configuration of community mental health services. Building on the lessons learned from the first National Mental Health Strategy, we outline a proposal for a co‐designed National Framework for Community Mental Health Services to guide the delivery of care in a way which satisfies the aspirations of consumers, carers, and mental health professionals alike.     

Expanded practice roles for community mental health nurses: what do consumers and carers have to say?

Community-based mental health as the primary focus of treatment has influenced more autonomous roles for mental health nurses. A limited literature suggests that this has resulted in the expansion of community mental health nursing into territory usually the exclusive domain of the medical profession. Consumers and carers are the two groups most affected by changes to service delivery; however, their views regarding the changing role of community mental health nurses have not been sought. This paper presents the findings of a qualitative study involving indepth interviews with Australian consumers (n = 4) and carers (n = 6) designed to explore their views and opinions about the expanded practice roles of community mental health nurses. Four main themes were identified: accessibility and convenience; relationship with clinicians; beneficiaries of expanded nursing practice; and, are nurses up to it? The findings suggest expanded practice roles are perceived positively by consumers and carers and therefore worthy of further investigation.     

EXPANDED PRACTICE ROLES FOR COMMUNITY MENTAL HEALTH NURSES: WHAT DO CONSUMERS AND CARERS HAVE TO SAY?

Community-based mental health as the primary focus of treatment has influenced more autonomous roles for mental health nurses. A limited literature suggests that this has resulted in the expansion of community mental health nursing into territory usually the exclusive domain of the medical profession. Consumers and carers are the two groups most affected by changes to service delivery; however, their views regarding the changing role of community mental health nurses have not been sought. This paper presents the findings of a qualitative study involving indepth interviews with Australian consumers (n = 4) and carers (n = 6) designed to explore their views and opinions about the expanded practice roles of community mental health nurses. Four main themes were identified: accessibility and convenience; relationship with clinicians; beneficiaries of expanded nursing practice; and, are nurses up to it? The findings suggest expanded practice roles are perceived positively by consumers and carers and therefore worthy of further investigation.     

What is needed for Trauma Informed Mental Health Services in Australia? Perspectives of clinicians and managers

Trauma Informed Care is an approach to the delivery of mental health care that requires sensitivity to the prevalence and effects of trauma in the lives of people accessing services. While TIC is increasingly emphasized in mental health policy and frameworks in Australia, people working in mental health settings have reportedly struggled to translate the values and principles into their everyday practice. This qualitative study used an experience‐based co‐design methodology to explore the potential for implementation of Trauma Informed Care into mental health services in Australia. The experiences of consumers, carers, clinicians, and managers were gathered. This paper presents the perspectives of clinicians (n = 64) and senior managers (n = 9) from across three Local Health Districts in New South Wales in Australia. All data were analysed thematically to address the research question: What is needed for Trauma Informed Mental Health Services in Australia? To be trauma‐informed, managers required: leadership at all levels, access to resource, relevant and accessible training, support for staff, resolution of wider systems issues, and clarification of the concept and actions of TIC. Clinicians identified that to be trauma‐informed they required services to: be aware of staff well‐being, support different ways of working, address workplace cultures and provide increased resources. The findings have implications for any service, team or individual seeking to implement TIC within mental health settings.     

Consumers and carers as partners in mental health research: reflections on the experience of two project teams in Victoria, Australia

A successful working partnership in research between a consumer project team from the Victorian Mental Illness Awareness Council and a carer project team from the Victorian Mental Health Carers Network was forged during their collaborative involvement in an innovative 2-year pilot project funded by the Victorian Government of Australia. This project trialled new ways of capturing consumer and carer experiences of mental health services, and that feedback was integrated into service quality improvement. Towards the end of the project, an external facilitator was used to enable the two teams to reflect on their experience of working together so that their joint story could be shared with others and used to promote further use of this approach in the mental health field. Main findings included the importance of having strong support and belief at leadership levels, opportunities to build the relationship and develop mutual trust and respect, a common vision and a clearly articulated set of values, targeted training appropriate to the needs of the team members, independent work bases, and mutual support to overcome challenges encountered during the project. The experience forged a close working relationship between the two teams and has set the scene for further participation of consumers and carers in research and innovative quality-improvement processes in the mental health field.     

Managing increased demand for mental health services in a public hospital emergency department: a trial of 'Hospital-in-the-Home' for mental health consumers

Increasing demand from mental health consumers for crisis assessment and intervention in public Emergency Departments (ED) has placed considerable strain on the resources of the ED and long delays awaiting admission are experienced. At Flinders Medical Centre in South Australia, the Psychiatry Department trialled a 'hospital-in-the-home' service to relieve the pressure on the ED and enhance inpatient capacity. The trial has been successful in diverting mental health consumers directly to intensive home-based services from the ED and freeing up beds in the inpatient unit. Evaluation showed that both consumers and their carers were highly satisfied with the hospital-at-home service.     

Collaboration or chaos: A consumer perspective

Consumer participation in all levels of mental health service provision is now government policy throughout Australia. However, effective participation by consumers requires collaboration between mental health nurses and consumers. Effective collaboration and the partnership between those who provide and receive services requires trust and respect on both sides. Accompanying consumers on their ‘journey’ of wellness and recovery is likely to also provide mental health nurses with opportunities for personal and professional growth.     

Meaningful information or a bureaucratic exercise? Exploring the value of routine outcome measurement in mental health

Routine outcome measures have been introduced into mental health services throughout Australia, with the ultimate aim of developing standards for service delivery, and a means to determine the extent to which these standards are being realised in practice. Criticism that the existing measures are not reflecting the aspects of mental health care and treatment considered important by the consumers of those services is common and widespread. The aim of the current study was to explore the utility, effectiveness, and assumptions underlying routine outcome measures used by Victorian mental health services from the perspective of service users. Two focus group interviews were conducted with consumer members of a group known as Psych. Action and Training (a group of consumers and senior nurses with a commitment to consumer participation). The findings demonstrated criticism of the outcome measures routinely used in Victoria. The three main themes to emerge were: assumptions behind routine outcome measures; consumer concerns with routine outcome measures; and consumer perspective: purpose, process and principles.     

Housing and living with a mental illness: Exploring carers' views

Public policy and an increasing body of literature identify housing as a critical element in recovery. Without suitable housing, people have little chance of maintaining other resources in their lives, such as supportive relationships and meaningful activities. It is also public policy that carers are central to decision making. There is evidence in the literature that carers often make a significant contribution to consumers staying well. Unfortunately, carers often feel ignored and/or excluded from decision making. This study is part two of a two‐part study (see Browne et al. 2008 ). It used focus groups with seven carers to explore their perspectives on recovery, with a particular focus on housing needs. The participants agreed that quality housing is a critical element of recovery. They identified ‘safety and vulnerability’ and ‘stigma’ as the important issues to be considered. They recommended that supported housing be stable, that services come to the consumer, and that the safety of consumers be a priority. This study took place in Australia and the findings have relevance there, but there are also implications for mental health service delivery internationally.     

Meaningful Information or a Bureaucratic Exercise? Exploring the Value of Routine Outcome Measurement in Mental Health

Routine outcome measures have been introduced into mental health services throughout Australia, with the ultimate aim of developing standards for service delivery, and a means to determine the extent to which these standards are being realised in practice. Criticism that the existing measures are not reflecting the aspects of mental health care and treatment considered important by the consumers of those services is common and widespread. The aim of the current study was to explore the utility, effectiveness, and assumptions underlying routine outcome measures used by Victorian mental health services from the perspective of service users. Two focus group interviews were conducted with consumer members of a group known as Psych. Action and Training (a group of consumers and senior nurses with a commitment to consumer participation). The findings demonstrated criticism of the outcome measures routinely used in Victoria. The three main themes to emerge were: assumptions behind routine outcome measures; consumer concerns with routine outcome measures; and consumer perspective: purpose, process and principles.