It has been over thirty years since William A. Anthony's seminal article (Anthony, 1993) helped redefine our understanding of mental illness recovery and its implications for services. It amplified the voices of people with lived experience and emphasized that recovery is not just about relieving symptoms, but instead about living a full, 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 shifted towards a recovery orientation over that period. The evidence could not be more critical at this point, as we begin to ask: 'did recovery work?'
We have previously reported on large trials evaluating outcomes for patients where recovery-focused interventions and practices were implemented in community settings. Although the UK-based REFOCUS trial (Slade et al, 2015) failed to find any effect on patient outcomes, A similar trial in Australia that modified the REFOCUS intervention and methodology showed a significant improvement in outcomes for patients. when receiving recovery interventions. Both studies faced considerable challenges common to experience-based trials, including high staff turnover. Nevertheless, the Australian study at least provided evidence that training a large number of community mental health workers in recovery-oriented practices is feasible and that training can benefit the personal recovery of people receiving services.
Although trials are important to robustly evaluate the effectiveness of interventions, they can be difficult to implement where interventions are highly complex and interconnected, as is the case with many recovery-oriented practices. Trials also provide a specific snapshot of experiences that are not representative of employees' everyday experiences and attitudes. We've reported before how the adoption of recovery-oriented tools into mainstream practice can be frustratingly slow.
Overall, it is important to have better evidence of what actually happens in everyday practice and to what extent the aspirations and vision expressed by Anthony 30 years ago are being realized today.
Enter Anju Sreeram, Wendy Cross and Louise Townsin, who conducted an observational study of Mental Health Nurses in acute inpatient psychiatric units in Australia to determine nurses' attitudes towards mental health conditions and recovery-oriented practice.
Recovery has become an important international driver for mental health policy and practice.
Methods
Researchers conducted a non-participant observational study of three acute psychiatric units at a hospital in Victoria, Australia. Each unit had an Intensive Care Unit and a Low Dependency Unit. The unit was “locked”, meaning patients could not leave without permission from staff.
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 regarding attitudes toward mental illness and recovery.
Observations were conducted by two observers with extensive experience in mental health nursing in the acute inpatient setting for one-hour morning and afternoon shifts in Intensive Care Units and Low Dependency Units. All participants were aware that they were being observed, and written consent was sought from all parties (staff and patients/consumers) after face-to-face meetings to explain the study.
Observations were made for one hour in the morning and afternoon shifts.
Results
Unit 1
Observation showed that nurses were knowledgeable and focused on recovery in their interactions, although there were some deficiencies in meeting the physical needs of consumers in a crowded environment, although this was described as “settled”. Only five nurses and four Consumers were observed. The Intensive Care Unit attended to both patients with one nurse described as 'confused' and unable to assess.
Unit 2
In the second observation, nurses were described as caring for consumers with dignity and respect despite the challenges of working in a crowded environment. A restorative approach was integrated into the ward with visual representations of hope and peers present on site. There was no evidence of negative attitudes towards consumers or recovery, and staff facilitated sessions around mindfulness and well-being. Only four nurses and six consumers were observed and the Intensive Care Unit was not observed as the unit was “highly variable and acute”.
Unit 3
A third observation showed a positive attitude and good recovery-oriented practice, but also highlighted some shortcomings in documenting the physical needs of consumers and the fast pace of the environment. Although it is unclear how many nurses were observed in this unit, four consumers were observed. Surveillance began at the ICA but had to be abandoned when the ward became “too sharp” after a fire alarm.
Results
The study concluded that Mental Health Nurses have a positive attitude towards recovery and mental illness as a whole, with efforts to meet the individual needs of consumers. Certain deficiencies in the provision of physical assistance to consumers were observed and this was highlighted as an area for improvement.
It has been suggested that the lack of service may also be related to a lack of experience caring for people with physical health conditions or to diagnostic overshadowing, which causes clinicians to overlook physical health conditions as an attribute of mental illness. The authors report that this can be reduced with additional training.
Nurses' attitudes toward recovery were positive, but physical health was lacking.
Strengths and limitations
To the authors' knowledge, this was the first non-participant observational study to understand Mental Health Nurses' attitudes towards mental illness and recovery-oriented practice in acute inpatient psychiatric units, thus providing real-world evidence from everyday clinical practice.
However, observations could only be made for a limited period of time, and all participants were aware of their surroundings and aware that they were being observed, potentially leading to the Hawthorne effect (where individuals change their behavior if they know they are being observed). Also, none of the observations in the Resuscitation areas were successful, two failed to start, and the third was interrupted, meaning that an important experiment was excluded from the findings.
Although there are advantages to using observational methods to assess everyday practice and these findings are relatively encouraging, given the limited number of self-selected units involved, the findings cannot be generalized to other service settings.
This study is the first to observe Mental Health Nurses' attitudes towards mental illness and recovery-oriented practice in an acute setting.
Implications for practice
The research emphasizes that:
- A good attitude can potentially lead to job satisfaction for nurses.
- Acute inpatient units are busy environments and a review of nurse patient ratios has been recommended to prevent staff burnout and encourage new nurses to consider this as a career path.
- Effective facilitation of recovery-oriented practices was limited by challenges in delivering the level of care required by the current consumer-to-nurse ratio.
- Maintaining a recovery-oriented work culture was a key focus.
- Education and training can address the inadequate provision of physical care for people with mental illness.
- Future research could focus on effectively training Mental Health Nurses to provide physical care to people with mental illness.
A concern in reviewing this paper was how difficult 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 to complete ongoing training in clinical skills, mental health and recovery. Three areas of knowledge and continuing education along with their main job as a mental health nurse on the wards. In performing this high-pressure job, they must balance both the medical model and recovery considerations, including any conflicts in their interactions.
It should also be noted that none of the observations within the acute units could be completed or, in two cases, initiated. If these cannot be implemented in busy wards, except in case of a fire alarm, it raises important questions about the environments in which we expect the most vulnerable people to recover and our professionals to work. A poor nurse consumer ratio, an extremely fast pace of work, and an environment too unstable to conduct relatively little research within are equally “unsolvable.”
If we struggle to get recovery experience or small research in the environments most in need, does this mark huge, potentially insurmountable challenges with current approaches to supporting some of our most vulnerable? With alternatives to crisis support such as the Leeds Survivor-Led Crisis Service demonstrating their value, is it time to focus on overhauling and overhauling how we support people in mental health crisis?
The adjustment of existing systems and processes to be more recovery-oriented is happening at a disappointingly slow pace. Eight years ago, Dr. Sarah Carr described Disappointment at the pace of integrating recovery-focused care planning into the health system in England. This recent research suggests that fundamental problems remain when trying to apply recovery approaches to clinical settings, and that we have some way to go in making any claims about recovery that we 'work' in service settings. Our patients and their support staff deserve better.
We have a ways to go before we can make any claims about recovery that “worked” in extreme settings.
Statement of interest
There is no report.
Connections
Primary paper
Sreeram, A., Cross, WM, & Townsin, L. (2023). Mental Health Nurses' attitudes towards mental illness and recovery-oriented practice in acute inpatient psychiatric units: A non-participant observational study. International Journal of Mental Health Nursing, 32(4), 1112-1128
Other references
Anthony W (1993). Recovery from mental illness: A guiding vision of the mental health system in the 1990sJournal of Psychosocial Rehabilitation, 16 (4), 11-23.
Slade, M., Bird, V., Clarke, E., Le Boutillier, C., McCrone, P., Macpherson, R., … Leamy, M. (2015). Supporting recovery in patients with psychosis through care by community-based adult mental health teams (REFOCUS): a multisite, cluster, randomized, controlled trial. Lancet Psychiatry, 0366(15), 1-12.