Recovery Under Close Observation - Three Decades On

It’s now over three decades since William A. Anthony’s seminal paper (Anthony, 1993) helped redefine our understanding of mental illness recovery and its implications for services. It amplified the voices of people with lived experience, emphasising that recovery isn’t solely about symptom remission, instead, it’s about living a fulfilling, hopeful, and meaningful life.

Recovery has become an important international driver for mental health policy and practice, but there is a lack of evidence on how practices have actually altered towards a recovery orientation in that time. The evidence could not be more critical currently, as we start asking: ‘has recovery worked?’

We have previously reported on large trials that assessed the outcomes for patients where recovery-focused interventions and practices were applied in community settings. While the UK-based REFOCUS trial (Slade et al, 2015) failed to show any effect on patient outcomes, a similar trial in Australia, which tweaked the REFOCUS intervention and methodology, did show a significant improvement in outcomes for patients in receipt of recovery interventions. Both studies were faced with considerable challenges, common to practice-based trials, including high staff turnover. Despite this, the Australian study at least offered evidence that it is possible to train large numbers of community mental health staff in recovery-focused practices, and that this training can benefit the personal recovery of people receiving services.

While trials are essential for robustly assessing the effectiveness of interventions, they can be hard to implement where the interventions are highly complex and relational, as is the case for many recovery oriented practices. Trials also provide a particular snapshot of practices that may not necessarily be representative of routine staff practices and attitudes. We have also previously reported on how the adoption of recovery-oriented tools into routine practice can be frustratingly slow.

All in all, it is important to have better evidence of what is actually happening in routine practice, and the extent to which the aspirations and world view articulated by Anthony 30 years ago are being realised today.

Enter Anju Sreeram, Wendy Cross and Louise Townsin who conducted an observational study of Mental Health Nurses within acute inpatient psychiatric units in Australia, with the aim of establishing what attitudes the nurses had towards mental health conditions and recovery-oriented practice.

Recovery has become an important international driver for mental health policy and practice.

Methods

The researchers conducted a non-participant observation study over three acute psychiatric units within a hospital in Victoria, Australia. Each unit had an Intensive Care Area and a Lower Dependency Unit. The unit was ‘closed’, meaning patients could not leave without staff permission.

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The Mental Illness Clinicians’ Attitude Scale-Version 4 [MICA-v4] (Gabbidon et al., 2013) and The Recovery Attitude Questionnaire-7 [RAQ-7] (Borkin et al.,2000) were used to record observations of interactions with consumers related to the attitudes towards mental-illness and recovery.

Observations were carried out in the morning and afternoon shifts for one hour at a time within the Intensive Care Areas and in the Lower Dependency Units by two observers with extensive experience in mental health nursing within acute inpatient settings. All participants knew they were being observed and written consent was sought from all parties (staff and patients/consumers) following face to face meetings to explain the study.

Observations were carried out in the morning and afternoon shifts for an hour at a time.

Results

Unit 1

The observation found that nurses were knowledgeable and recovery-focused in their interactions, though there were some insufficiencies in meeting consumers physical needs within a busy environment, despite it also being described as ‘settled’. Only five Nurses and four Consumers were observed. The Intensive Care Unit was described as ‘hectic’ with one nurse to every two patients and couldn’t be assessed.

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Unit 2

Nurses within the second observation were described as caring for consumers with dignity and respect despite the challenges of working in a busy environment. The recovery approach was integrated into the ward with visual depictions of hope and peers present on-site. No evidence of negative attitudes towards consumers or recovery were seen and staff facilitated sessions around mindfulness and wellbeing. Only four nurses and six consumers were observed and observation did not take place in the Intensive Care Area as the unit was ‘highly volatile and acute’.

Unit 3

The third observation showed positive attitudes and good recovery-oriented practice, whilst highlighting some deficiencies around documenting consumers physical needs and the fast pace of the environment. Four consumers were observed though it is not clear how many nurses were observed on this unit. The observation began in the ICA, but had to be abandoned when the ward became ‘too acute’ following a fire alarm.

Conclusions

The study concluded that Mental Health Nurses were found to have positive attitudes towards recovery and mental illness overall, with efforts being made to meet consumers individual needs. Some deficiency in the provision of physical care to consumers was observed and this was highlighted as an area of improvement.

It was proposed that deficiency in service could be also be due to lack of experience around looking after people with co-morbid physical health conditions or with diagnostic overshadowing causing clinicians to overlook physical health conditions as an attribute of the mental illness. The authors state that this could be mitigated by further training.

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Nurses had positive attitudes towards recovery, but there were deficiencies in physical health care.

Strengths and limitations

To the authors’ knowledge, this was the first non-participants observational study to understand Mental Health Nurses’ attitudes towards mental illness and recovery-orientated practice within acute inpatient psychiatric units, and as such, provides real world evidence of routine clinical practice.

However, observations could only be conducted for a limited time and all participants were conscious of their surroundings and knew they were being watched, potentially leading to the Hawthorne Effect (where individuals change their behaviour if they know they are being observed). Also, none of the observations in the Intensive Care Areas were successful, with two unable to begin and a third interrupted, meaning that an important are of practice was excluded from the findings.

While using observational methods to assess routine practice has advantages, and these findings are relatively encouraging, it is impossible to generalise the findings to other service settings given the limited number of self-selecting units involved.

Person in silhouette holding a torch or light.

This study is the first to observe Mental Health Nurses’ attitudes towards mental illness and recovery-oriented practice in acute settings.

Implications for practice

The study highlights that:

Good attitudes can potentially lead to job satisfaction for the nursing staff.
Acute inpatient units are busy environments and a review of nurse patient ratios was recommended to prevent staff burnout and to motivate new nurses to take this as a career route.
Effective facilitation of recovery-oriented practices was limited due the challenges of delivering the level of care required with the current consumer to nurse ratio.
Maintaining a recovery-oriented work culture was highlighted as a key focus.
Education and training could address inadequate provision of physical care of people with mental illness.
Future research could focus on the effective preparation of Mental Health Nurses to provide physical care of people with mental illness.

A concern on reviewing this paper was how challenging it is to be a mental health nurse responding to potentially conflicting drivers. Nurses are required to know all the skills, procedures and expectations to work within the medical model and complete ongoing training in clinical skills, mental health and recovery. Three fields of knowledge and continual training all alongside their main work, which is mental health nursing in the units themselves. When doing that high pressure job, they are having to balance both the medical model and recovery considerations including any conflicts in their interactions.

Also telling was that none of the observations within the acute units could be completed, or in two cases started. If these could not be conducted at points where the wards were at the lighter end of busy, fire alarm excluded, then that raises important questions about what environments we expect our most vulnerable to heal in and our professionals to work in. A poor nurse to consumer ratio, an extremely fast pace of work and an environment too unsettled to conduct a relatively small study within cannot equally be ‘settled’.

If we struggle to get recovery practice or small studies into the environments where they are most needed, does it flag up major, potentially insurmountable challenges with the current approaches to supporting some of our most vulnerable? With alternatives to crisis support, such as with the Leeds Survivor-Led Crisis Service, showing their worth, is it time to focus instead on fundamentally reviewing and overhauling how we support people in mental health crisis?

Tweaking existing systems and processes to be more recovery-oriented seems to happen at a frustratingly slow pace. Eight years ago, Dr Sarah Carr described her despair at the pace of getting integrating recovery-focused care planning into the healthcare system in England. This latest study implies that fundamental problems remain when seeking to introduce recovery-approaches into clinical environments, and that there is some way to go before we can make any claims as to recovery having ‘worked’ in service settings. Our patients and the staff who support them deserve better.