Recovery of evidence‐based practice

Consumer recovery is now enshrined in the national mental health policy of many countries. If this construct, which stems from the consumer/user/survivor movement, is truly to be the official and formal goal of mental health services, then it must be the yardstick against which evidence‐based practice (EBP) is judged. From a consumer‐recovery perspective, this paper re‐examines aspects of services chosen for study, methodologies, outcomes measures, and standards of evidence associated with EBP, those previously having been identified as deficient and in need of expansion. One of the significant differences between previous investigations and the present study is that the work, writing, perspectives, and advocacy of the consumer movement has developed to such a degree that we now have a much more extensive body of material upon which to critique EBP and inform and support the expansion of EBP. Our examination reinforces previous findings and the ongoing need for expansion. The consumer recovery‐focused direction, resources, frameworks, and approaches identified through the present paper should be used to expand the aspects of services chosen for study, methodologies, outcomes measures, and standards of evidence. This expansion will ultimately enable services to practice in a manner consistent with the key characteristics of supporting personal recovery.     

‘Things you can't learn from books’: Teaching recovery from a lived experience perspective

Mental health policy in Australia is committed to the development of recovery‐focused services and facilitating consumer participation in all aspects of mental health service delivery. Negative attitudes of mental health professionals have been identified as a major barrier to achieving these goals. Although the education of health professionals has been identified as a major strategy, there is limited evidence to suggest that consumers are actively involved in this education process. The aim of this qualitative study was to evaluate students’ views and opinions at having been taught ‘recovery in mental health nursing’ by a person with a lived experience of significant mental health challenges. In‐depth interviews were held with 12 students. Two main themes were identified: (i) ‘looking through fresh eyes’ – what it means to have a mental illness; and (ii) ‘it's all about the teaching’. The experience was perceived positively; students referred to the impact made on their attitudes and self‐awareness, and their ability to appreciate the impact of mental illness on the individual person. Being taught by a person with lived experience was considered integral to the process. This innovative approach could enhance consumer participation and recovery‐focused care.     

‘There's more to a person than what's in front of you’: Nursing students’ experiences of consumer taught mental health education

Holistic and person‐centred nursing care is commonly regarded as fundamental to nursing practice. These approaches are complementary to recovery which is rapidly becoming the preferred mode of practice within mental health. The willingness and ability of nurses to adopt recovery‐oriented practice is essential to services realizing recovery goals. Involving consumers (referred herein as Experts by Experience) in mental health nursing education has demonstrated positive impact on the skills and attitudes of nursing students. A qualitative exploratory research project was undertaken to examine the perspectives of undergraduate nursing students to Expert by Experience‐led teaching as part of a co‐produced learning module developed through an international study. Focus groups were held with students at each site. Data were analysed thematically. Understanding the person behind the diagnosis was a major theme, including subthemes: person‐centred care/seeing the whole person; getting to know the person, understanding, listening; and challenging the medical model, embracing recovery. Participants described recognizing consumers as far more than their psychiatric diagnoses, and the importance of person‐centred care and recovery‐oriented practice. Understanding the individuality of consumers, their needs and goals, is crucial in mental health and all areas of nursing practice. These findings suggest that recovery, taught by Experts by Experience, is effective and impactful on students’ approach to practice. Further research addressing the impact of Experts by Experience is crucial to enhance our understanding of ways to facilitate the development of recovery‐oriented practice in mental health and holistic and person‐centred practice in all areas of health care.     

Perceptions of crisis care in populations who self‐referred to a telephone‐based mental health triage service

Although psychiatric crises are very common in people with mental illness, little is known about consumer perceptions of mental health crisis care. Given the current emphasis on recovery‐oriented approaches, shared decision‐making, and partnering with consumers in planning and delivering care, this knowledge gap is significant. Since the late 1990s, access to Australian mental health services has been facilitated by 24/7 telephone‐based mental health triage systems, which provide initial psychiatric assessment, referral, support, and advice. A significant proportion of consumers access telephone‐based mental health triage services in a state of crisis, but to date, there has been no published studies that specifically report on consumer perceptions on the quality and effectiveness of the care provided by these services. This article reports on a study that investigated consumer perceptions of accessing telephone‐based mental health triage services. Seventy‐five mental health consumers participated in a telephone interview about their triage service use experience. An eight‐item survey designed to measure the responsiveness of mental health services was used for data collection. The findings reported here focus on the qualitative data produced in the study. Consumer participants shared a range of perspectives on telephone‐based mental health triage that provide invaluable insights into the needs, expectations, and service use experiences of consumers seeking assistance with a mental health problem. Consumer perceptions of crisis care have important implications for practice. Approaches and interventions identified as important to quality care can be used to inform educational and practice initiatives that promote person‐centred, collaborative crisis care.     

Handover of patient information from the crisis assessment and treatment team to the inpatient psychiatric unit

Handover, or the communication of patient information between clinicians, is a fundamental component of health care. Psychiatric settings are dynamic environments relying on timely and accurate communication to plan care and manage risk. Crisis assessment and treatment teams are the primary interface between community and mental health services in many Australian and international health services, facilitating access to assessment, treatment, and admission to hospital. No previous research has investigated the handover between crisis assessment and treatment teams and inpatient psychiatric units, despite the importance of handover to care planning. The aim of the present study was to identify the nature and types of information transferred during these handovers, and to explore how these guides initial care planning. An observational, exploratory study design was used. A 20‐item handover observation tool was used to observe 19 occasions of handover. A prospective audit was undertaken on clinical documentation arising from the admission. Clinical information, including psychiatric history and mental state, were handed over consistently; however, information about consumer preferences was reported less consistently. The present study identified a lack of attention to consumer preferences at handover, despite the current focus on recovery‐oriented models for mental health care, and the centrality of respecting consumer preferences within the recovery paradigm.     

Exploring the meaning of recovery‐oriented care: An action‐research study

The present study describes participants' perspectives of the meaning of recovery‐oriented care in developing services for people with psychosocial disability associated with mental illness. Participants were involved in a 12‐month cooperative inquiry action‐research group from August 2012 to July 2013, with six consumers, four clinicians, and a carer. A major finding was the importance of the facilitation of dialogue that acknowledged the asymmetrical power differences between participants. Thematically‐analysed data identified an overarching global theme: ‘I want services to hear me’. The theme reflected a shared view that participation is important in service development. Actions included mapping the integration of consumer participation within a mental health service and developing workshops to support change. Addressing the asymmetrical power relationship inherent in traditional mental health design is important. Using participatory processes, structural discrimination is revealed, and tensions associated with clinical mental health services and psychiatric practice can be discussed. A partnership approach to service development enables the social determinants of health to be addressed more effectively, as well as supporting individual recovery. These approaches create the potential for genuine transformational change. Approaches that support coproduction and codesign have the potential to enable solutions.     

Research and organizational issues for the implementation of family work in community psychiatric services

BACKGROUND: The need for evidence-based practice (EBP) to guide and develop mental health services remains fundamental for modern services. Aim. To discuss issues that impact upon implementation of EBP and practice development using family work (FW) as an example. METHODS: A selection of the FW literature was reviewed drawing on sources including the Cochrane Library, Cinahl and Medline. Keywords used were FW, community mental health team and research design. FINDINGS: Centralized policy initiatives and guidelines that are themselves guided by evidence of randomized controlled trials predominantly risk alienating practitioners and clients/carers. Family work has some demonstrable clinical benefits although models differ and the active therapeutic agent remains unclear. Its adoption into routine care is also hindered by a productivity management outlook that seeks to maximize stretched resources and whose values are likely to be internalized by practitioners. The dichotomous position of previous research and practice development make implementation of EBP difficult and highlights the need for strategic planning that embraces both factors. CONCLUSION: The current drive to increase EBP requires a bi-directional process of influence that allows individual practitioners and clients/carers to become producers of evidence and not simply recipients. The authors support wider adoption of case study research designs to reflect the unpredictable nature of mental health care. Adoption of assertive community treatment models within community services is most likely to promote the excellence management model and accommodate EBP such as FW.     

Changing practice using recovery‐focused care in acute mental health settings to reduce aggression: A qualitative study

Consumer aggression is common in acute mental health settings and can result in direct or vicarious psychological or physical impacts for both consumers and health professionals. Using recovery‐focused care, nurses can implement a range of strategies to reduce aggression and empower consumers to self‐regulate their behaviour, when faced with challenging situations, such as admission to the acute care setting. Currently, there is limited literature to direct nurses in the use of recovery‐focused care and how it can be used to reduce consumer aggression. Twenty‐seven mental health nurses participated in this study. The constructivist grounded theory method guided data collection and analysis to identify categories that accurately described participants’ experiences. Five categories emerged that described how nurses can implement recovery‐focused care clinically to reduce the risk of consumer aggression: (i) identify the reason for the behaviour before responding; (ii) being sensitive to the consumer's trigger for aggression; (iii) focus on the consumer's strengths and support, not risks; (iv) being attentive to the consumer's needs; and (v) reconceptualize aggression as a learning opportunity. As the importance of promoting consumer recovery is now embedded in mental health policies internationally, nurses need to prioritize the application of recovery‐focused care clinically. Further research to provide evidence‐based outcomes supporting the use of recovery‐focused care is needed.     

Towards relational recovery: Nurses’ practices with consumers and families with dependent children in mental health inpatient units

Facilitating parent–child and family connections during parental hospitalization provides important opportunities for mental health services to support individual and family recovery. Nurses are often the primary point of contact for families in the inpatient context. They play an integral role in the care provision of consumers and families and in supporting consumers’ recovery. The aim of the present qualitative study was to explore nurses’ practice with families in inpatient mental health settings in the context of designated family rooms. Three themes were derived from the thematic analysis of semistructured interviews with 20 nurses from four mental health inpatient units. Nurses experienced tensions within their roles in balancing safety and risk, a lack of confidence in family‐focused practices in relation to role expectations, and challenges in juggling nursing care ideals with the contemporary realities of inpatient practice. A family‐centred relational recovery approach is recommended for mental health services, which is underpinned by family‐focused policies and processes, and supported at an organizational, managerial, and local‐unit level. At an individual level, nurses need professional development on the models of care they practice in, explicit role clarity on their practice with families, and education on evidence‐based brief family interventions.     

Exploring the usefulness of a recovery-based approach to dementia care nursing

Exploring new approaches to dementia care nursing is vital to enable services to cope with the expected rise in demand for healthcare due to an ageing population. A comparison between the current person-centred care approach in aged care and recovery-based approach that underpins mental health nursing was reviewed in the literature to determine which is more useful to dementia care nursing. The recovery model is the conceptual framework that underlies the recovery-based approach. It broadens the current person-centred care approach through the fostering of hope, facilitative rather than directive care, and enhances autonomy. This promotes positive outcomes for older people with dementia through empowerment to make choices in the way they wish to live within the community. This essay proposes that the recovery-based approach is more useful to dementia care nursing than person-centred models.     

Promoting the Value of Mental Health Nursing: The Contribution of a Consumer Academic

Mental illness is known to occur frequently in the general population and is more common within the general health care system. High-quality health care requires nurses to have the skills, knowledge and attitudes to provide care for people experiencing mental illness or mental distress. Research suggests health professionals, including nurses, tend to share similar negative attitudes to mental illness as the general population, and consequently, mental health nursing is not a popular career path. These two factors signify a need to influence more positive attitudes toward mental illness and mental health nursing among nursing students. A qualitative exploratory research study was undertaken to examine the experiences, opinions and attitudes of an academic and research team to the introduction of a consumer academic within an undergraduate mental health nursing subject. In-depth interviews were conducted with teaching and research team members. The importance of mental health skills emerged as a major theme and included sub-themes: mental health across the health care system; contribution of consumer academic to nursing skills; addressing fear and stigma, and inspiring passion in mental health nursing. Findings suggest academic input from people with lived experience of recovery from mental illness can influence the development of mental health nursing skills and enhance the popularity of mental health nursing as a career.     

Nursing based evidence: moving beyond evidence-based practice in mental health nursing

Various authors suggest mental health nursing is dominated by knowledge borrowed from psychiatry, pharmacology and the behavioural sciences. These disciplines favour knowledge developed using quantitative methodologies so they and evidence-based practice (EBP) and evidence-based nursing (EBN), increasingly called for in mental health nursing, fit seamlessly together. Nevertheless, as these movements dismiss qualitative approaches to knowledge (evidence) development, I argue against the move toward EBP/EBN in mental health nursing. This is because the specialty's primary interests - human experiences of illness/health care and human relationships, often do not lend themselves to being quantitatively researched. Using nursing examples, I demonstrate how qualitative research, wholly unacceptable in relation to EBP/EBN quality of evidence scales, is indispensable to mental health nursing. The need for evidence arising from qualitative research in no way precludes the need for quantitatively derived evidence. Indeed, the specialty's twofold interest - the work of nurses with clients and the explication of phenomena which inform practice, require diverse knowledge and thus, diverse research approaches. This twofold interest defines the area of mental health nursing practice, and knowledge informing it is referred to as nursing based evidence (NBE). Because it values multiple approaches to knowledge development, NBE provides a way to articulate the specialty's distinct contribution to the health care of people experiencing mental illness and advances mental health nursing.     

Consumer attitudes towards evidence based mental health services among American mental health consumers

The Consumer Attitudes towards Evidence Based Services (CAEBS) scale is a 29‐item questionnaire designed to assess public views on the role of science in helping to guide mental health treatment. The aim of the current study was to assess the Factor structure the CAEBS in an online sample of adults seeking information about mental health services. The CAEBS was administered to a nationwide sample of participants from websites offering classified advertisements for mental health related study participation (n = 312). An Exploratory Factor Analysis (EFA) suggested four factors based on 26 of the items: Beliefs Regarding Therapists' Practices, Attitudes about Mental Health Policy, Negative Personal‐Level Attitudes toward EBPs, and Negative Societal‐Level Attitudes towards EBPs. In order to increase consumer empowerment within the mental health‐care system and develop policies supporting EBP usage, mental health professionals need to increase communication with the public to address these concerns and leverage positive attitudes.     

Critical thinking and contemporary mental health care: Michel Foucault's “history of the present”

In order to be able to provide informed, effective and responsive mental health care and to do so in an evidence‐based, collaborative and recovery‐focused way with those who use mental health services, there is a recognition of the need for mental health professionals to possess sophisticated critical thinking capabilities. This article will therefore propose that such capabilities can be productively situated within the context of the work of the French philosopher Michel Foucault, one of the most challenging, innovative and influential thinkers of the 20th century. However, rather than focusing exclusively upon the content of Foucault's work, it will be suggested that it is possible to discern a general methodological approach across that work, a methodological approach that he refers to as “the history of the present.” In doing so, Foucault's history of the present can be understood as a productive, albeit provisional, framework in which to orientate the purpose and process of critical thinking for mental health professionals by emphasizing the need to both historicize and politicize the theoretical perspectives and therapeutic practices that characterize contemporary mental health care.     

Collaboration as a process and an outcome: Consumer experiences of collaborating with nurses in care planning in an acute inpatient mental health unit

This qualitative study explores inpatient mental health consumer perceptions of how collaborative care planning with mental health nurses impacts personal recovery. Semi‐structured interviews were conducted with consumers close to discharge from one unit in Sydney, Australia. The unit had been undertaking a collaborative care planning project which encouraged nurses to use care plan documentation to promote person‐centred and goal‐focussed interactions and the development of meaningful strategies to aid consumer recovery. The interviews explored consumer understandings of the collaborative care planning process, perceptions of the utility of the care plan document and the process of collaborating with the nurses, and their perception of the impact of collaboration on their recovery. Findings are presented under four organizing themes: the process of collaborating, the purpose of collaborating, the nurse as collaborator and the role of collaboration in wider care and recovery. Consumers highlighted the importance of the process of developing their care plan with a nurse as being as helpful for recovery as the goals and strategies themselves. The findings provide insights into consumers’ experiences of care planning in an acute inpatient unit, the components of care that support recovery and highlight specific areas for mental health nursing practice improvement in collaboration.     

Community mental health nurses' perspectives of recovery-oriented practice

Recovery-oriented practice, an approach aligned towards the service user perspective, has dominated the mental health care arena. Numerous studies have explored service users' accounts of the purpose, meaning and importance of 'recovery'; however, far less is known about healthcare staff confidence in its application to care delivery. A self-efficacy questionnaire and content analysis of nursing course documents were used to investigate a cohort of community mental health nurses' recovery-oriented practice and to determine the extent to which the current continuing professional development curriculum met their educational needs in this regard. Twenty-three community mental health nurses completed a self-efficacy questionnaire and 28 course documents were analysed. The findings revealed high levels of nurses' confidence in their understanding and ability to apply the recovery model and low levels of confidence were found in areas of social inclusion. The content analysis found only one course document that used the whole term 'recovery model'. The findings suggest a gap in the nurses' perceived ability and confidence in recovery-oriented practice with what is taught academically. Hence, nursing education needs to be more explicitly focused on the recovery model and its application to care delivery.     

Mental health nurses’ attitudes towards consumer involvement in nursing handover pre and post an educational implementation

Involving mental health consumers in nursing handover is a recent introduction to practise in acute mental health units. However, implementation must recognize that mental health care is complex and the approach needs to include recovery‐focused philosophies of practice. Evidence shows that nurses and other health professionals consider poor handover practices may be the source of adverse events; however, the views of mental health nurses about involving consumers in nursing handover have not been previously reported. The aim of this study was to identify nurses’ attitudes towards consumer involvement in handover and to measure the effect of a training programme upon these attitudes. A single‐group pre‐post‐test intervention study was undertaken. The study was conducted on the adult acute mental health inpatient unit of a major metropolitan hospital in Victoria, Australia, 2016–2017. Questionnaires were developed to capture the views of the nurses about proposed changes in the afternoon nursing handover process. A questionnaire was administered before and after the training intervention, an innovative, multi‐media education handover package. We found that training had a significant influence on mental health nurses’ attitudes towards involving consumers in the handover. Therapeutic engagement improved following training and miscommunication reduced when all players are informed and have the opportunity to engage with the information. This study has demonstrated that well‐planned education can influence nurses’ attitudes about involving consumers in the nursing handover processes.     

Determining the effectiveness of mental health services from a consumer perspective: part 1: enhancing recovery

The routine use of standardized instruments to measure consumer outcomes is now part of mental health policy throughout Australia. However, it has been broadly criticized for (i) not involving consumer input into the design of instruments; and (ii) not reflecting the aspects of care and treatment considered beneficial for recovery by consumers themselves. The importance of the concept of recovery is increasingly considered in the literature. Despite this, there is a paucity of research describing the effectiveness of services in promoting recovery from the perspective of consumers of mental health services. The aim of this study is to explore consumer perspectives in relation to the factors that promote and impede recovery, and the principles that ideally should underpin the evaluation of 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 Part 1 of the findings, pertaining to aspects of mental health services that enhance recovery. Two main themes arose during the data analysis process: (i) treatment; and (ii) support and social connectedness. Various treatment strategies, including medication and spiritual involvement, were considered helpful. However, support from both staff and peers emerged as a more important and influential factor.     

WEAVING A NEW SAFETY NET OF MENTAL HEALTH CARE IN RURAL AMERICA: A MODEL OF INTEGRATED PRACTICE

Life in rural America is often idealized, yet rural Americans suffer from mental illness in rates comparable to urban America and require similar types of support and services. However, millions of individuals living in rural areas go without needed mental health services. The dominant care model allows the treatment of mental illness to be delivered by non-mental health professionals with little or no education or training in psychiatric care and who have little desire to provide this type of care, resulting most often in ineffective or inappropriate treatment. Lacking access to appropriate and effective care, rural mentally ill individuals are more often symptomatic than their urban counterparts and may never find relief from the disabling symptoms of treatable mental illnesses. This article will focus on the current state of psychiatric-mental health care in the context of these realities and discuss the impact of the current trend of mental illness being treated by non-mental health professionals. The article will conclude by proposing a model of advanced practice nursing that the authors believe will increase both access and efficacy of treatment for the mentally ill living in rural America. This Integrated Model views the current system of care that completely separates location for traditional physical and mental health care as antithetical to integration and to holism and presents a new model for understanding and provided integrated health care to meet the needs of rural mentally ill individuals and families.