Fidelity and recovery-orientation in assertive community treatment

Cross-cultural adaptation of the Recovery Self-Assessment RSA-R Family/Brazil: Validity evidence based on test content

In the cross-cultural adaptation of instruments, the qualitative component of adaptation is generally poorly reported, sometimes being superficially addressed. In this study we aimed to describe the qualitative component of the cross-cultural adaptation process and to demonstrate validity evidence based on test content of the Recovery Self-Assessment-RSA-R Family/Brazil. We conducted a qualitative study that included the steps of preparation, translation, back-translation, expert's assessment, workshop with a researcher from Yale University, and two pilot studies involving family members of patients attended at mental health services. Among the results, we found considerable validity evidence based on test content with a percentage of agreement above 80%. Pilot studies contributed to accentuating this evidence, assisting in the cultural adequacy of the statements and in the operational equivalence of the instrument. The adaptation process of the RSA-R Family/Brazil proved to be complex. From this experience, we concluded that presenting validity evidence based on test content is important to ensure the applicability tools to the target culture. The instrument will still be evaluated as for psychometric characteristics through statistical techniques.

Perception of Recovery Orientation as a Predictor of Clinician Turnover in Community Mental Health Clinics

Turnover in community mental health clinics threaten the delivery of quality behavioral health services; recovery orientation has been shown to be associated with lower levels of burnout but its relationship with actual turnover has not yet been examined. This study aimed to examine the relationship between provider perceptions of recovery orientation and 12-month turnover status among community mental health providers. Secondary data analyses were conducted with data collected from 224 community mental health providers from ten organizations across 14 clinic sites participating in a larger effectiveness-implementation trial. Chi square analyses were used to examine between-site variation in 1-year turnover rates among the ten organizations. Logistic regression was used to examine effects of perceptions of recovery orientation along with known predictors of turnover among community mental health providers. Results revealed no between-site variation in organizational turnover rates. The logistic regression model was statistically significant, χ²(17) = 47.64, p < .0001 and explaining 30% (Nagelkerke R²) of within-site variance and correctly classifying 79% of cases. Perceptions of recovery orientation emerged as the sole significant predictor of 12-month turnover status, with higher levels of recovery orientation significantly associated with lower odds of turnover at 12 months [B = .90, p = .008, OR 2.47 (95% CI 1.23, 4.82)]. Perceptions of recovery orientation was protective against 12-month turnover status suggesting that a more person-centered and empowering approach to care may improve the provider experience. More research is needed to further understand how recovery orientation can contribute to workforce stability.

Avaliação de serviços orientados ao recovery no Brasil: potências e desafios nos processos de adaptação transcultural de instrumentos de medida

O presente relato de experiência tem como objetivo refletir sobre à orientação ao recovery nos serviços comunitários de saúde mental, apontando os desafios e potências que surgiram no trabalho com usuários e familiares. As reflexões sobre o tema foram baseadas na pesquisa “Recovery: Instrumentos para sua aferição na realidade brasileira, através da adaptação transcultural do instrumento de avaliação Recovery Self-Assessment (RSA-R). Para o desenvolvimento desse estudo, seguimos a metodologia de Adaptação transcultural de instrumentos que inclui as etapas de tradução, retrotradução, avaliação por especialistas, dois estudos pilotos com usuários e familiares. Os resultados dessa experiência foram: o recovery trata-se de um construto ainda pouco explorado no Brasil, o instrumento objeto da pesquisa trouxe algumas práticas inexistentes no contexto brasileiro e que exigiam níveis altos de alfabetização por parte dos participantes. Em contrapartida, a nossa população tinha baixos níveis de escolarização, tornando a experiência ainda mais desafiante. Também, a partir de nossa incursão no campo, podemos identificar que a relação do familiar com os serviços é muito frágil. Os serviços de saúde mental no país precisam repensar suas práticas, principalmente no que diz respeito à inclusão e participação efetiva do familiar no tratamento. A partir desses resultados, destacamos a importância das avaliações de serviços de saúde mental, com a participação dos usuários e familiares, sendo um desafio na estruturação de avaliações sistemáticas dos serviços públicos.

Cross-cultural adaptation of the recovery self-assessment instrument (RSA–R) person in recovery version to Brazilian Portuguese (Pt/Br)

Purpose

The Recovery Self-Assessment (RSA–R) in Revised Version is an instrument designed to assess the degree to which mental health programs and services implement recovery-oriented practices. The purpose of this paper is to conduct a cross-cultural adaptation of the RSA–R instrument for use in local mental health services in the city of Campinas, State of São Paulo, Brazil.

Design/methodology/approach

This method for cross-cultural adaptation of the instrument included a series of iterative steps including preparation, translation, back translation, harmonization, expert evaluation, focus groups, in-depth interviews, expert opinion and pilot study.

Findings

A multi-rater assessment of the equivalence of content between the original RSA–R and the translated version revealed that each of the 32 items achieved at least 88% agreement in terms of equivalency. A multi-step harmonization process revealed additional suggestions for improvements in readability, comprehension and applicability to Brazilian context. An expert in youth and adult education provided additional stylistic recommendations. Combined, this iterative approach to cross-cultural translation resulted in an adapted version of the instrument that was well understood, culturally appropriate and adequate for further verification of psychometric properties.

Originality/value

The recovery process in Brazil and in the USA has culturally determined differences in terms of the way mental disorders are understood, diagnosed and treated. Moreover, there are different notions of what constitutes desirable results of recovery, health care and welfare. At the present time, there are few, if any, available cross-cultural instruments to assess the recovery-orientation of services between Brazil and the USA.

File audit to assess sustained fidelity to a recovery and wellbeing oriented mental health service model: an Australian case study

Background

Over the past decade there has been increasing attention to implementing recovery-oriented approaches within mental health service practice and enhancing fidelity to such approaches. However, as is often the case with evidence-based practices, less attention has been paid to the sustainability of recovery-oriented approaches over time. This study sought to investigate whether fidelity to a recovery-oriented practice framework – the Collaborative Recovery Model could be sustained over time.

Method

The study setting was an Australian community managed mental health organisation. A file audit of consumer support plans was undertaken using the Goal and Action Plan Instrument for Quality audit tool (GAP-IQ). The audit tool assessed 17 areas for quality. Consumers (n = 116) from a large community managed mental health organisation participated in the study. Sustained fidelity to the Collaborative Recovery Model (CRM) was determined by comparing results from the file audit to a similar audit conducted 3 years earlier.

Results

The file audit revealed a significant increase in fidelity to CRM practices between 2011 and 2014. Fidelity to individual audit items that comprise the GAP-IQ was also found to significantly increase across 16 of the 17 GAP-IQ audit items, with the exception of the ‘Action Plan Review’ audit item.

Conclusions

A comparison of file audit data across different time points within the same setting can provide useful feedback about whether or not a practice is being sustained over time. Although fidelity increased overtime the study design does not allow conclusions that training and coaching practices implemented by the organisation were responsible.

Understanding the mental health and recovery needs of Canadian youth with mental health disorders: a Strategy for Patient-Oriented Research (SPOR) collaboration protocol

BACKGROUND

While considerable progress is being made to understand the health and self-management needs of youth with mental health disorders, little attention has focused on the mental health and recovery needs that the youth themselves identify-this despite a national priority to incorporate patient-oriented research into the development and assessment of mental health services. To address this gap, estimates of the extent to which existing patient-reported outcome measures (PROMs)-originally developed for use amongst adult populations-are clinically meaningful and psychometrically fit for use among youth are needed. In tandem, a recovery profile for youth can be constructed incorporating the youth perspective of the services provided within a community mental health setting.

METHODS/DESIGN

This study will utilize a mixed methods design incorporating qualitative focus group interviews and cross-sectional survey. Our process will begin with the hiring of a youth peer research partner who will provide lived experience expertise through all phases of the study. We will advertise, recruit, and conduct four focus groups with youth who receive services from the Foundry Vancouver Granville located in British Columbia, Canada. In the first two focus groups, we will recruit youth aged 15-18 years (n = 10). In the second two focus groups, we will recruit young adults aged 19-24 years (n = 10). In parallel, we will conduct a cross-sectional survey of the recovery and mental health needs of youth, informed by ten widely used and validated PROM. Thematic analysis techniques will guide the identification of predominant thematic trends in the qualitative focus group data. We will use Classical and Rasch measurement methods to test and analyze the reliability and validity of selected PROM measures for youth populations.

DISCUSSION

The proposed study has the potential to produce a preliminary conceptual and measurement model for understanding the mental health and recovery needs of youth with mental health disorders. This evidence will inform how youth mental health services can grow, support, and sustain the capacity for a collaborative, interdisciplinary and innovative patient-oriented research environment. Findings will also contribute much needed evidence to improve the standard of care for youth who experience mental health disorders in Canada and beyond.

Impact of a Mental Health Nursing Training-Programme on the Perceived Recovery-Orientation of Patients and Nurses on Acute Psychiatric Wards: Results of a Pilot Study

In mental health nursing, recovery-orientation is regarded as a best practice approach for patient care. To assess the effect of an intervention utilising a recovery-oriented approach in acute practice, a controlled pilot trial was conducted. On intervention wards, mental health nurses received special training. Recovery Self-Assessment Scale was used to assess the effects of the training. No statistically significant effects were found, between the experimental conditions. Reasons for this result may be methodological, practical or due an intervention that was not powerful enough. Recovery-oriented intervention studies in mental health nursing should be conducted with caution.

ACT and Recovery: What We Know About Their Compatibility

While assertive community treatment (ACT) is a widely implemented evidence-based practice, the extent of its recovery orientation has been debated. A literature search identified 16 empirical articles studying recovery and ACT. These 16 studies were classified as involving stakeholder perceptions, interventions, or fidelity measurement. Stakeholders generally viewed ACT as being recovery oriented; research on both interventions and fidelity measurement showed promising approaches. Overall the literature yielded encouraging findings regarding ACT and recovery, though there remains a dearth of research on the topic. We discuss future directions for research and practice to ensure that ACT programs skillfully support recovery.

Recovery practice in community mental health teams: national survey

BACKGROUND

There is consensus about the importance of 'recovery' in mental health services, but the link between recovery orientation of mental health teams and personal recovery of individuals has been underresearched.

AIMS

To investigate differences in team leader, clinician and service user perspectives of recovery orientation of community adult mental health teams in England.

METHOD

In six English mental health National Health Service (NHS) trusts, randomly chosen community adult mental health teams were surveyed. A random sample of ten patients, one team leader and a convenience sample of five clinicians were surveyed from each team. All respondents rated the recovery orientation of their team using parallel versions of the Recovery Self Assessment (RSA). In addition, service users also rated their own personal recovery using the Questionnaire about Processes of Recovery (QPR).

RESULTS

Team leaders (n = 22) rated recovery orientation higher than clinicians (n = 109) or patients (n = 120) (Wald(2) = 7.0, P = 0.03), and both NHS trust and team type influenced RSA ratings. Patient-rated recovery orientation was a predictor of personal recovery (b = 0.58, 95% CI 0.31-0.85, P<0.001). Team leaders and clinicians with experience of mental illness (39%) or supporting a family member or friend with mental illness (76%) did not differ in their RSA ratings from other team leaders or clinicians.

CONCLUSIONS

Compared with team leaders, frontline clinicians and service users have less positive views on recovery orientation. Increasing recovery orientation may support personal recovery.

Physical health, community participation and schizophrenia

Our objective is to identify links between physical health and community participation among individuals with schizophrenia or a psychosis mental illness. Semi-structured qualitative and quantitative interviews and community tours were conducted over 10 months ( N = 30). Interviews were transcribed and analyzed using a grounded theory coding strategy. Physical health played an important role in community participation both as a cause and consequence. Key processes included mobility issues impeding physical community involvement; a multi-directional relationship between social relationships, community involvement, and physical health; identity as a mechanism linking physical health problems and community engagement; and the potential for community-based mental health programs.

Person-centered care planning and service engagement: a study protocol for a randomized controlled trial

Background

Service disengagement is a pervasive challenge the mental health care system faces. Mental health services are of little value should persons with mental illnesses continue to opt out of receiving them. Consumers attribute disengagement from care to an absence of choice in their treatment. In response, the mental health system is adopting a person-centered model, based upon recovery principles, to engage consumers more actively in their care. Person-centered care planning is a promising practice involving collaboration to develop and implement an actionable plan to assist the person in achieving personal recovery goals.

Methods/design

This study design combines a parallel-group randomized controlled trial of community mental health organizations with qualitative methods to assess the effectiveness of person-centered care planning. Participants at 14 sites in Delaware and Connecticut will be randomized to treatment as usual or the person-centered care planning intervention. Participants will be in leadership (n = 70) or supervisory or direct care (n = 210) roles. The person-centered care planning intervention involves intensive staff training and 12 months of ongoing technical assistance. Quantitative survey data will be collected at baseline, 6 months and 12 months measuringperson-centered care planning competency and organizational factors. Consumer outcomes (engagement, medication adherence, functioning and consumer satisfaction) will be assessed by Medicaid and state-level data. Qualitative data focused on process factors will include staff and consumer interviews and focus groups. In this intent-to-treat analysis, we will use mixed-effects multivariate regression models to evaluate the differential impact of the person-centered care planning intervention on each consumer and implementation outcome as well as the extent to which clinician assessments of organizational factors are associated with the implementation outcome. Mixed methods will triangulate and strengthen the interpretation of outcomes.

Discussion

The aim of this study is to generate valuable guidance for state systems engaged in scale-up and transformation efforts. Targeted staff selection for training to support sustainability will serve to provide further insight into important intervention implementation strategies. Person-centered care planning has the potential to enhance the impact of all evidence-based and recovery-oriented practices and bring practice into line with the emerging national guidelines in health care reform.

Trial registration

This trial was registered with ClinicalTrials.gov (Identifier: NCT02299492) on 21 November 2014 as New York University Protocol Record PCCP-13-9762, Person-Centered Care Planning and Service Engagement.

Resident and proprietor perspectives on a recovery orientation in community-based housing

OBJECTIVE

Stable housing is a fundamental human right, and an important element for both mental health recovery and social inclusion among people with serious mental illness. This article reports findings from a study on the recovery orientation of structured congregate community housing services using the Recovery Self-Assessment Questionnaire (RSA) adapted for housing (O'Connell, Tondora, Croog, Evans, & Davidson, 2005).

METHODS

The RSA questionnaires were administered to 118 residents and housing providers from 112 congregate housing units located in Montreal, Canada.

RESULTS

Residents rated their homes as significantly less recovery-oriented than did proprietors, which is contrary to previous studies of clinical services or Assertive Community Treatment where RSA scores for service users were significantly higher than service provider scores. Findings for both groups suggest the need for improvement on 5 of 6 RSA factors. While proprietors favored recovery training and education, and valued resident opinion and experience, vestiges of a traditional medical model governing this housing emerged in other findings, as in agreement between the 2 groups that residents have little choice in case management, or in the belief among proprietors that residents are unable to manage their symptoms.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

This study demonstrates that the RSA adapted for housing is a useful tool for creating recovery profiles of housing services. The findings provide practical guidance on how to promote a recovery orientation in structured community housing, as well as a novel approach for reaching a common understanding of what this entails among stakeholders. (PsycINFO Database Record

Mental health reform at a systems level: widening the lens on recovery-oriented care

This paper is an initial attempt to collate the literature on psychiatric inpatient recovery-based care and, more broadly, to situate the inpatient care sector within a mental health reform dialogue that, to date, has focused almost exclusively on outpatient and community practices. We make the argument that until an evidence base is developed for recovery-oriented practices on hospital wards, the effort to advance recovery-oriented systems will stagnate. Our scoping review was conducted in line with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (commonly referred to as PRISMA) guidelines. Among the 27 papers selected for review, most were descriptive or uncontrolled outcome studies. Studies addressing strategies for improving care quality provide some modest evidence for reflective dialogue with former inpatient clients, role play and mentorship, and pairing general training in recovery oriented care with training in specific interventions, such as Illness Management and Recovery. Relative to some other fields of medicine, evidence surrounding the question of recovery-oriented care on psychiatric wards and how it may be implemented is underdeveloped. Attention to mental health reform in hospitals is critical to the emergence of recovery-oriented systems of care and the realization of the mandate set forward in the Mental Health Strategy for Canada.

Measuring the Capacity of Staff Culture to Further Recovery from Psychiatric Disabilities

Three linked instruments for measuring the recovery-orientation of mental health program culture are introduced as the Recovery Centered Measures (RCM). Two scales assess the views of staff and of consumers, respectively, regarding staff–consumer interactions. A third scale measures staff culture. The RCM scales are quick, easy to understand (reading level of grade 5.4), and internally consistent. Test–retest correlations ranged from 0.81 to 0.67. Convergent validity with three related instruments was appropriate. The scales discriminate ACT from residential programs. The RCM scales show strong potential to be useful to program administrators and researchers working to increase the recovery-orientation of programs.

Measuring the recovery orientation of assertive community treatment

BACKGROUND

Approaches to measuring recovery orientation are needed, particularly for programs that may struggle with implementing recovery-oriented treatment.

OBJECTIVE

A mixed-methods comparative study was conducted to explore effective approaches to measuring recovery orientation of assertive community treatment (ACT) teams.

DESIGN

Two ACT teams exhibiting high and low recovery orientation were compared using surveys, treatment plan ratings, diaries of treatment visits, and team leader-reported treatment control mechanisms.

RESULTS

The recovery-oriented team differed on one survey measure (higher expectations for consumer recovery), treatment planning (greater consumer involvement and goal-directed content), and use of control mechanisms (less use of representative payee, agency-held lease, daily medication delivery, and family involvement). Staff and consumer diaries showed the most consistent differences (e.g., conveying hope and choice) and were the least susceptible to observer bias but had the lowest response rates.

CONCLUSIONS

Several practices differentiate recovery orientation on ACT teams, and a mixed-methods assessment approach is feasible.

Recovery-oriented practices of psychiatric-mental health nursing staff in an acute hospital setting

BACKGROUND

There is a national initiative to integrate recovery-oriented practices into the delivery of mental health services. Few empirical studies have been conducted to measure these practices in psychiatric-mental health (PMH) nursing, particularly in short-term acute hospital settings.

OBJECTIVE

This study examined the reliability of the Recovery Self Assessment-Registered Nurse Version (RSA-RN) and explored recovery practices of PMH nurses and nursing staff in an acute treatment setting.

DESIGN

A descriptive one-group design with convenience sampling was employed. One hundred and five participants completed the RSA-RN and the demographic data form.

RESULTS

The RSA-RN full-scale instrument demonstrated excellent internal consistency, and the five subscales demonstrated acceptable internal consistency. Significant, favorable relationships were found between RSA-RN scores and nursing staff who (a) had formal education in mental health recovery, (b) considered themselves knowledgeable about recovery, and (c) considered their place of work to be "recovery-oriented."

CONCLUSION

The RSA-RN is a useful tool in measuring recovery-oriented practice. Formal education should be considered as an intervention to increase recovery-oriented practices in PMH nursing.

Practitioner attributes as predictors of restrictive practices in assertive community treatment

BACKGROUND

Practitioners variably use restrictive practices with assertive community treatment (ACT) consumers. Little is known about practitioner attributes, such as pessimistic attitudes and lack of advanced education, which may predict greater use of restrictive practices.

OBJECTIVES

To describe the frequency of restrictive practices in ACT and examine the relationship between practitioner attributes, particularly pessimistic attitudes and education, and the frequency with which restrictive practices are reportedly used in daily treatment of adults with severe mental illness.

DESIGN

A cross-sectional study of 122 ACT practitioners in one state.

RESULTS

More restrictive practices were rarely reported by practitioners. Pessimistic attitudes and lack of graduate-level training were associated with self-reported higher use of restrictive practices, even when controlling for select consumer caseload variables and ACT program fidelity.

CONCLUSIONS

This study indicates the need to identify practitioner-related factors that may contribute to the high use of restrictive practices, and develop and implement relevant staff training.