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

摘要

BackgroundRecovery-oriented practice: the collaborative recovery model (CRM)The promotion of recovery-oriented approaches and their provision in mental health services has increased during the past decade for consumers experiencing and living with mental illness [1]. Recovery-oriented approaches involve fostering personal growth, encouraging active participation in one’s broader community, and empowering consumers to live a valued and meaningful life [2, 3]. Consumers have identified that desired outcomes are not limited to symptom reduction or “getting better” [1], but are more about learning how to live a personally fulfilling life even if symptoms continue to persist [3]. However, challenges are routinely experienced by services in the mental health sector when they attempt to implement recovery-oriented approaches within service practice [4, 5]. Evidence suggests that barriers are influenced by the extent of orientation at the organisational systems and procedural levels [4, 5].Internationally governments have encouraged or compelled service providers to operate in recovery enhancing ways by linking provision of funding for community-based organisation to this objective [6, 7]. In Australia, the strength of commitment to recovery-oriented practice is easily recognisable in health policy documents [8]. Several Australian National Mental Health Plans have recommended that a recovery orientation should drive service delivery (e.g., Australian Health Ministers, 2009). One of the five priority areas includes addressing “Social Inclusion and Recovery”, and stipulates that mental health providers develop cultures that are founded on and reflective of a recovery orientation [9]. To assist translation at the service and practice level a National Framework for recovery-oriented services was published in 2013 to provide guidance for all people working in the mental health sector for what a recovery-orientation is and how it can be implemented [10]. However, high-level policies and guidance documents are important but not sufficient to ensure recovery-oriented care is delivered. Even when these recovery values are espoused at the level of individual organisations these values may not be translated into practice.The Collaborative Recovery Model (CRM) is a well-established recovery-oriented approach to working with consumers experiencing a severe mental illness (SMI) [11, 12]. It employs the use of a coaching-style relationship that encourages individual growth, hope and supports people to, “move beyond illness towards one’s best possible self” [13]. The CRM empowers consumers to clarify their values, establish goals and complete action plans that provide them with the direction needed to pursue their vision of a valued life. Progress is reviewed collaboratively between the consumer and their mental health practitioner throughout the course of support. Any barriers to completing an action plan or achieving set goals are identified and modified accordingly [11].Past studies examining the efficacy of the CRM approach for consumers experiencing a SMI have identified a range of positive outcomes. The approach has been found to be positively regarded by both consumers and mental health practitioners [13, 14] and perceived as being implemented at a high level [14]. Consumers receiving services from CRM trained workers identify components of the approach being delivered (e.g., action planning) at a higher frequency than consumers whose support workers have not been trained in the model [13]. Workers trained in CRM report significantly more positive recovery-oriented attitudes following training [15]. The action planning (therapeutic homework) components of CRM have been associated with more positive service user outcomes [14, 16]. A number of mental health organisations in Australia have adopted the CRM as their primary service delivery model. However, as is common with the implementation of evidence-based practices (EBP’s) in general, barriers have been encountered when implementing the CRM [17].Studies examining the key factors that facilitate and hinder the implementation of EBP’s have consistently found that staff training is crucial to the successful implementation of EBP [15, 18]. Providing staff with training in the CRM has not only been found to facilitate the implementation of this approach in mental health settings, but also increases the skill and overall confidence of workers in their engagement with consumers [15]. However, staff training in isolation has not resulted in mental health practitioners sustaining their use of recovery-oriented approaches over time [17]. Recent studies indicate that the likelihood of staff transferring newly acquired therapeutic skills, and continuing to use these skills over time, is improved when it is supplemented with regular coaching [11]. Specifically, it has been found that providing staff with training in the CRM that is supplemented by regular supervision or coaching: (i)