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.     

‘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.     

Perception of risk for older people living with a mental illness: Balancing uncertainty

Risk is commonly defined as a negative threat which needs to be controlled and mitigated; as a concept, it takes high priority in contemporary mental health services. Health‐care organizations and clinicians are now required to use levels of risk as a benchmark for clinical decision‐making. However, perceptions of risk change according to the lens through which it is viewed. A qualitative, exploratory research study was undertaken in an aged persons’ mental health programme in Victoria, Australia, to explore the notion of risk from the multiple perspectives of service providers and consumers. Data were obtained through in‐depth interviews, and analysis was based on the framework of Ritchie and Spencer. Balancing uncertainty emerged as a major theme, and comprised two subthemes: (i) complexity of risk from the perspective of providers of services; and (ii) complexity of safety from the perspectives of recipients of services. These differences emphasize a significant disjuncture between perceptions of risk and the potential for the individual needs and concerns of consumers to be subsumed under broader organizational issues. The uncertainty this tension highlights suggests the need to reconceptualize risk, incorporating the views and experiences of all stakeholders, particularly consumers and carers, to enhance recovery‐oriented services and facilitate consumer participation within mental health services.     

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.     

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.     

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.     

Development and evaluation of a training program in peer support for former consumers

While mental health policy in Australia promotes the involvement of mental health consumers in service planning, implementation and evaluation, little has been reported on the training required for the new roles that consumers are being expected to undertake. In this study, 10 former consumers of mental health services participated in a 16-week training program in peer support. The impact of the program on the psychological well-being of the participants was assessed using a battery of self-evaluation questionnaires and focus group interviews. Findings suggest that exposure to people with acute mental health problems (i.e. inpatients), did not, in this instance, adversely impact on the psychological well-being of the participants. Barriers to consumer participation in the mental health field are discussed and recommendations for the content and structure of future consumer peer support training initiatives are proposed.     

Consumer participation in nurse education: A national survey of Australian universities

Consumers of mental health services have an important role to play in the higher education of nursing students, by facilitating understanding of the experience of mental illness and instilling a culture of consumer participation. Yet the level of consumer participation in mental health nursing programmes in Australia is not known. The aim of the present study was to scope the level and nature of involvement of consumers in mental health nursing higher education in Australia. A cross‐sectional study was undertaken involving an internet survey of nurse academics who coordinate mental health nursing programmes in universities across Australia, representing 32 universities. Seventy‐eight percent of preregistration and 75% of post‐registration programmes report involving consumers. Programmes most commonly had one consumer (25%) and up to five. Face‐to‐face teaching, curriculum development, and membership‐to‐programme committees were the most regular types of involvement. The content was generally codeveloped by consumers and nurse academics (67.5%). The frequency of consumer involvement in the education of nursing students in Australia is surprisingly high. However, involvement is noticeably variable across types of activity (e.g. curriculum development, assessment), and tends to be minimal and ad hoc. Future research is required into the drivers of increased consumer involvement.     

Mental health consumers' with medical co‐morbidity experience of the transition through tertiary medical services to primary care

Medical comorbidity in people with long‐term mental illness is common and often undetected; however, these consumers frequently experience problems accessing and receiving appropriate treatment in public health‐care services. The aim of the present study was to understand the lived experience of mental health consumers with medical comorbidity and their carers transitioning through tertiary medical to primary care services. An interpretative, phenomenological analysis approach was used, and semistructured, video‐recorded, qualitative interviews were used with 12 consumers and four primary caregivers. Four main themes and related subthemes were abstracted from the data, highlighting consumer's and carers’ experience of transition through tertiary medical to primary care services: (i) accessing tertiary services is difficult and time consuming; (ii) contrasting experiences of clinician engagement and support; (iii) lack of continuity between tertiary medical and primary care services; and (iv) Mental Health Hospital Admission Reduction Programme (MH HARP) clinicians facilitating transition. Our findings have implications for organisational change, expanding the role of MH HARP clinicians (whose primary role is to provide consumers with intensive support and care coordination to prevent avoidable tertiary medical hospital use), and the employment of consumer and carer consultants in tertiary medical settings, especially emergency departments.     

Changing attitudes: the role of a consumer academic in the education of postgraduate psychiatric nursing students

Consumer participation in health care is increasingly becoming an expectation within mental health services. Consumer involvement in the education of mental health professionals, including nurses is considered crucial to achieving this aim. This article describes the impact of a mental health consumer academic on the attitudes of postgraduate psychiatric nursing students towards consumer participation. A questionnaire was administered to students before (n = 25) and following (n = 19) exposure to the teaching of the consumer academic. Comparison of results suggests that support for consumer participation increases after exposure to the consumer academic reinforcing the value of mental health consumers in psychiatric nursing education.     

Doing what we can,but knowing our place: Being an ally to promote consumer leadership in mental health

Consumer participation in all aspects of mental health services is clearly articulated as an expectation of contemporary mental health policy. Consumer leadership has been demonstrated to be beneficial to mental health services. Barriers to implementation have limited the realization of this goal. In this discursive paper, we argue that non‐consumers who support consumer partnerships and leadership (known as ‘allies’) have an important role to play in facilitating and supporting consumers in leadership roles. Allies currently have more potential to influence resource allocation, and might be viewed more credibly by their peers than consumer leaders themselves. We call for allies to ensure their role is one of support and facilitation (doing what they can), rather than directing the content or speaking on behalf of the consumer movement (knowing their place). In the present study, we address the importance of allies for the consumer movement. It proposes some ‘rules of engagement’ to ensure that allies do not intentionally or otherwise encroach on consumer knowledge and expertise, so that they maintain the important position of supporting consumers and facilitating the valuing and use of consumer knowledge, expertise, and ultimately, leadership.     

Promoting genuine consumer participation in mental health education: a consumer academic role

Mental health policy reform in Australia has led to the expectation of increased consumer participation not only in all aspects of service delivery, but also in the education and training of mental health professionals. The aim of this paper is to explore the development and introduction of a role for a consumer of mental health services within an academic institution, including achievements of the role and the principles contributing to successful implementation. The consumer academic position was successfully implemented and has proved a valuable role. The success of the role was considered to be dependent on the following factors: partnership and commitment, support, scope and autonomy. In conclusion, a consumer can play a valuable role within an academic institution. However, success will depend upon a number of important environmental factors that promote the independence of the consumer voice.     

Consumer involvement in the tertiary‐level education of mental health professionals: A systematic review

A systematic review of the published work on consumer involvement in the education of health professionals was undertaken using the PRISMA guidelines. Searches of the CINAHL, MEDLINE, and PsychINFO electronic databases returned 487 records, and 20 met the inclusion criteria. Further papers were obtained through scanning the reference lists of those articles included from the initial published work search (n = 9) and contacting researchers in the field (n = 1). Thirty papers (representing 28 studies) were included in this review. Findings from three studies indicate that consumer involvement in the education of mental health professionals is limited and variable across professions. Evaluations of consumer involvement in 16 courses suggest that students gain insight into consumers' perspectives of: (i) what life is like for people with mental illness; (ii) mental illness itself; (iii) the experiences of admission to, and treatment within, mental health services; and (iv) how these services could be improved. Some students and educators, however, raised numerous concerns about consumer involvement in education (e.g. whether consumers were pursuing their own agendas, whether consumers' views were representative). Evaluations of consumer involvement in education are limited in that their main focus is on the perceptions of students. The findings of this review suggest that public policy expectations regarding consumer involvement in mental health services appear to be slowly affecting the education of mental health professionals. Future research needs to focus on determining the effect of consumer involvement in education on the behaviours and attitudes of students in healthcare environments.     

Mental health consumers' perceptions of receiving recovery-focused services

Rationale, aims and objectives  This study examines the experiences of mental health service consumers engaged in various recovery-focused support practices as well as examining consumer valuing of these activities.
Method  A self-report questionnaire was developed drawing on key aspects of the Collaborative Recovery Model (CRM) (responsibility, collaboration, autonomy, motivation, needs, goals, homework). Ninety-two adult consumers from metropolitan, regional and rural non-government organizations and public mental health services in eastern Australian states completed the questionnaire.
Results  Consumers using services provided by CRM-trained workers identified significant changes to service delivery in relation to frequency with which they were encouraged to take responsibility for their recovery, degree to which they collaborated with staff and the extent to which they were encouraged to complete homework activities to assist them to achieve their goals, when compared with consumers using traditional services. The key aspects of the CRM were valued by consumers. No differences were found in terms of overall ratings of clinician helpfulness in assisting recovery between the two groups.
Conclusions  Consumers are able to perceive recovery-focused service changes. Although preliminary, this is a significant step towards assessing the operationalization of recovery principles from the consumer's perspective.     

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.     

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.