Developing involvement during a programme of recovery research

Purpose To consider the process of working with a Lived Experience Advisory Group (LEAP) and its outcomes in REFOCUS, a large 5 year programme of recovery research. Design Narrative reflections on the experience of working with LEAP were collected from five members and the Chair of LEAP, two REFOCUS researchers and the Principal Investigator (PI). These were synthesised to show both the process and outcomes of LEAP involvement in REFOCUS, and how involvement evolved organically over time. Findings Individual reflective accounts showed how working with LEAP impacted (to a greater or lesser extent) on each individual involved in the process, providing new insights and influencing, to varying degrees, the way in which they then worked with LEAP. Synthesis of the reflections showed how these changes impacted organically on LEAP's process of involvement, with a shift in LEAP's role from being purely consultative/advisory towards one which was much more about co-production, with LEAP proactively contributing to some aspects of Refocus in the later stages of the study. Practical implications We stress the importance of considering process as well as outcomes in Patient and Public Involvement (PPI), and make practical recommendations for improving both in future programmes of research. Originality/value This is the first empirical evaluation of user and carer involvement and its development during a large recovery research programme

‘We needed to talk about it’: The experience of sharing the emotional impact of health care work as a panellist in Schwartz Center Rounds® in the UK

Objectives Schwartz Center Rounds® (‘Rounds’) are multidisciplinary forums where health care staff come together to reflect upon the emotional impact of their work. In each Round, a small number of staff (panellists) share experiences through stories to trigger reflection in audience members. Previous research has identified impacts associated with Rounds’ attendance, but little is known about the experience and impact of Rounds from panellists’ perspectives. This study is the first to explore the role of disclosure and reflection through storytelling in Rounds, specifically exploring panellists’ motivations, experiences and reported impacts associated with panel participation. Methods Interviews with 50 panellists, from nine case-study sites in the United Kingdom, representing acute, community and mental health National Health Service trusts and hospices. Data were analysed using thematic analysis. Results Most panellists spoke positively about their experience of sharing their stories in Rounds. Reported impacts included: increased emotional resilience and acceptance of experiences; reduced negative assumptions about colleagues and increased approachability and trust increasing tolerance and compassion; the creation of a space to stop and think and to reframe negative patient experiences facilitating greater empathy and emotional disclosure becoming more visible and normative, thereby helping change culture. Impacts on staff were similar regardless of contextual variability, including their professional group or role, with the exception of impact on patient care, which was not mentioned by non-clinical staff. The extent of panel preparation and audience characteristics (e.g. size, composition and response to their stories) influenced panellists’ experiences and outcomes. Conclusions Rounds highlight the important role of disclosure and reflection through storytelling to support panellists with the emotional aspects of their work, providing a space for support with the emotional demands of health care, reducing the need for employees to be stoic. Panel participation also offers an important source of validation in organizations marked by scrutiny

Development and evaluation of an Individualised Outcome Measure (IOM) for randomised controlled trials in mental health

Predefined, researcher-selected outcomes are routinely used as the clinical end-point in randomised controlled trials (RCTs); however, individualised approaches may be an effective way to assess outcome in mental health research. The present study describes the development and evaluation of the Individualised Outcome Measure (IOM), which is a patient-specific outcome measure to be used for RCTs of complex interventions. IOM was developed using a narrative review, expert consultation and piloting with mental health service users (n=20). The final version of IOM comprises two components: Goal Attainment (GA) and Personalised Primary Outcome (PPO). For GA, patients identify one relevant goal at baseline and rate its attainment at follow-up. For PPO, patients choose an outcome domain related to their goal from a predefined list at baseline, and complete a standardised questionnaire assessing the chosen outcome domain at baseline and follow-up. A feasibility study indicated that IOM had adequate completion (89%) and acceptability (96%) rates in a clinical sample (n=84). IOM was then evaluated in an RCT (ISRCTN02507940). GA and PPO components were associated with each other and with the trial primary outcome. The use of the PPO component of IOM as the primary outcome could be considered in future RCTs

Evaluating the feasibility of complex interventions in mental health services: standardised measure and reporting guidelines

Aims: To develop a) an empirically-based standardised measure of the feasibility of complex interventions for use within mental health services and b) reporting guidelines to facilitate feasibility assessment. Method: A focussed narrative review of studies assessing implementation blocks and enablers was conducted with thematic analysis and vote counting used to determine candidate items for the measure. Twenty purposively sampled studies (15 trial reports, 5 protocols) were included in the psychometric evaluation, spanning different interventions types. Cohen’s Kappa was calculated for inter-rater reliability and test-retest reliability. Results: 95 influences on implementation were identified from 299 reviewed references. The final measure - Structured Assessment of Feasibility (SAFE) - comprises 16 items rated on a Likert scale. SAFE demonstrated excellent inter-rater (kappa 0.84, 95% CI 0.79 - 0.89) and test re-test reliability (kappa 0.89, 95% CI 0.85 - 0.93). Cost information and training time were the two influences least likely to be reported in intervention papers. SAFE Reporting Guidelines include 16 items organised into 3 categories (Intervention, Resource consequences, Evaluation). Conclusion: SAFE is a novel approach to evaluating interventions, and supplements efficacy and health economic evidence. SAFE Reporting Guidelines will allow feasibility of an intervention to be systematically assessed

Realist evaluation of Schwartz rounds® for enhancing the delivery of compassionate healthcare:understanding how they work, for whom, and in what contexts

Background Healthcare work is known to be stressful and challenging, and there are recognised links between the psychological health of staff and high-quality patient care. Schwartz Center Rounds® (Rounds) were developed to support healthcare staff to re-connect with their values through peer reflection, and to promote more compassionate patient care. Research to date has focussed on self-report surveys that measure satisfaction with Rounds but provide little analysis of how Rounds ‘work’ to produce their reported outcomes, how differing contexts may impact on this, nor make explicit the underlying theories in the conceptualisation and implementation of Rounds. Methods Realist evaluation methods aimed to identify how Rounds work, for whom and in what contexts to deliver outcomes. We interviewed 97 key informants: mentors, facilitators, panellists and steering group members, using framework analysis to organise and analyse our data using realist logic. We identified mechanisms by which Rounds lead to outcomes, and contextual factors that impacted on this relationship, using formal theory to explain these findings. Results Four stages of Rounds were identified. We describe how, why and for whom Schwartz Rounds work through the relationships between nine partial programme theories. These include: trust safety and containment; group interaction; counter-cultural/3rd space for staff; self-disclosure; story-telling; role modelling vulnerability; contextualising patients and staff; shining a spotlight on hidden stories and roles; and reflection and resonance. There was variability in the way Rounds were run across organisations. Attendance for some staff was difficult. Rounds is likely to be a ‘slow intervention’ the impact of which develops over time. We identified the conditions needed for Rounds to work optimally. These contextual factors influence the intensity and therefore degree to which the key ingredients of Rounds (mechanisms) are activated along a continuum, to produce outcomes. Outcomes included: greater tolerance, empathy and compassion for self and others; increased honesty, openness, and resilience; improved teamwork and organisational change. Conclusions Where optimally implemented, Rounds provide staff with a safe, reflective and confidential space to talk and support one another, the consequences of which include increased empathy and compassion for colleagues and patients, and positive changes to practice

Harnessing mental imagery and enhancing memory specificity: Developing a brief early intervention for depressive symptoms in adolescence

Background Treatment innovation for depressive symptoms in adolescence is urgently needed. Adult research suggests interventions targeting underlying cognitive mechanisms, such as dysfunctional mental imagery and overgeneral memory, are promising. Here, we describe and evaluate in a case series a brief imagery-based intervention for depressive symptoms that targets these cognitive mechanisms. Methods Nine participants completed the four-session intervention, whose principle components were imagery rescripting and memory specificity training. Questionnaires and experimental tasks (assessing symptomatology and cognitive mechanisms) were administered at three time points: pre-intervention, post-intervention and 3-month follow-up. Results The intervention was feasible to deliver and acceptable to participants. There was a large reduction in depression symptom scores from pre to post intervention (d = 1.32; 67% showed reliable improvement, RI) and this was maintained at follow-up (d = 1.46; RI = 75%). There were also reductions in anxiety (post: d = 1.15, RI = 44%; follow-up: d = 1.67, RI = 63%), increases in self-esteem (post: d = − 0.70, RI = 44%; follow-up: d = − 1.20, RI = 50%) and noteworthy changes in memory specificity (post: d = − 1.80, RI = 67%; follow-up: d = − 0.94, RI = 63%). Conclusions This is the first study to use imagery rescripting and memory specificity training in adolescence. Initial evidence is provided that the intervention is acceptable and may have clinical utility. Future randomised controlled trials are needed to further assess the intervention

Effectiveness of a group intervention to reduce the psychological distress of healthcare staff: a pre-post quasi-experimental evaluation.

Background Work stress and compassion fatigue are prevalent among healthcare staff and their negative effects on staff well-being and patient care are well-known. This paper reports on the implementation and evaluation of Schwartz Rounds® (Rounds) in UK healthcare organizations, predominantly part of the National Health Service (NHS). Rounds are one-hour, typically monthly, multidisciplinary forums during which clinical and nonclinical healthcare staff discuss the emotional and social demands of delivering patient care. The purpose of this research was to evaluate the effectiveness of Rounds attendance on the psychological distress, work engagement, compassion and self-reflection of healthcare staff. Methods We used a pre-post control design to assess the effect of Rounds attendance across 10 UK healthcare organizations. This design was most appropriate given the voluntary nature of Rounds and ensured the study had ecological validity. Self-reported data were collected from attenders and non-attenders at baseline and at eight-months follow-up. The outcomes were psychological distress, work engagement, compassion and self-reflection. Results During the 8 months’ study duration, regular attenders (N = 51) attended Rounds on average 4 times (2–8). Attenders showed a significantly greater decrease in psychological distress (as measured with the General Health Questionnaire (GHQ)) than non-attenders (N = 233; odds ratio of 0.197; 95% confidence interval (0.047–0.823)). However, Rounds attendance had no significant effect on work engagement, compassion and self-reflection. Conclusions Rounds attendance was linked to a 19% reduction in psychological distress adjusting for covariates. As an organization-wide intervention, Rounds thus constitute an effective, relatively low-cost intervention to assist staff in dealing with the demands of their work and to improve their well-being

Psychometric evaluation of the Questionnaire about the Process of Recovery (QPR)

Background: Supporting recovery is the aim of national mental health policy in many countries, including England. There is a need for standardised measures of recovery, to assess policy implementation and inform clinical practice. Only one measure of recovery has been developed in England: the Questionnaire about the Process of Recovery (QPR) which measures recovery from the perspective of adult mental health service users with a psychosis diagnosis. Aims: To independently evaluate the psychometric properties of the 15-item and 22-item versions of QPR. Method: Two samples were used: Dataset 1 (n=88) involved assessment of QPR at baseline, two weeks and three months. Dataset 2 (n=399; ISRCTN02507940) involved assessment of QPR at baseline and one year. Results: For the 15-item version, internal consistency was 0.89, convergent validity was 0.73, test-retest reliability was 0.74 and sensitivity to change was 0.40. Confirmatory factor analysis showed the 15-item version offered a good fit. For the 22 item version comprising two sub-scales, the Interpersonal sub-scale was found to under-perform and the Intrapersonal sub-scale overlaps substantially with the 15 item version. Conclusions: Both the 15-item and the Intrapersonal sub-scale of the 22-item versions of the QPR demonstrated satisfactory psychometric properties. The 15-item version is slightly more robust and also less burdensome, so it can be recommended for use in research and clinical practice. Declaration of interest: None

A national survey of recovery practice in community mental health teams

Background There is a policy and professional consensus about the importance of ‘recovery’ in mental health services, but the link between recovery-orientation of mental health teams and personal recovery of service users has been under-researched. Aims To investigate differences in team leader, clinician and service user perspectives of recovery orientation of community adult mental health teams in England. Objectives: (1) To compare variations between NHS Trust, team type and participant ratings of recovery-orientation of mental health teams; (2) To explore the relationship between service user ratings of recovery orientation and personal recovery; (3) To test the hypothesis that clinician-rated recovery orientation differs between clinicians with and without personal experience of mental illness or supporting a family member or friend with mental illness. Method In six English Mental Health NHS Trusts (purposively sampled to maximise geographic and demographic spread), randomly-chosen community adult mental health teams were surveyed. A random sample of ten service users, 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 Questionnaire about Processes of Recovery (QPR). Results Team leaders (n=22) rated recovery orientation higher than clinicians (n=109) or service users (n=120) (Wald(7)=7.0, p=0.03), and both NHS Trust and team type influenced RSA ratings. Service user-rated recovery orientation was a predictor of personal recovery (b=0.52, p <.001; 95%CI: .31 to .74). 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

Service user experiences of REFOCUS: a process evaluation of a pro-recovery complex intervention

Purpose: Policy is increasingly focused on implementing a recovery-orientation within mental health services, yet the subjective experience of individuals receiving a pro-recovery intervention is under-studied. The aim of this study was to explore the service user experience of receiving a complex, pro-recovery intervention (REFOCUS), which aimed to encourage the use of recovery-supporting tools and support recovery-promoting relationships. Methods: Interviews (n=24) and two focus groups (n=13) were conducted as part of a process evaluation and included purposive sample of service users who received the complex, pro-recovery intervention within the REFOCUS randomised controlled trial (ISRCTN02507940). Thematic analysis was used to analyse the data. Results: Participants reported that the intervention supported the development of an open and collaborative relationship with staff, with new conversations around values, strengths and goals. This was experienced as hope-inspiring and empowering. However, others described how the recovery tools were used without context, meaning participants were unclear of their purpose and did not see their benefit. During the interviews, some individuals struggled to report any new tasks or conversations occurring during the intervention. Conclusion: Recovery-supporting tools can support the development of a recovery-promoting relationship, which can contribute to positive outcomes for individuals. The tools should be used, in a collaborative and flexible manner. Information exchanged around values, strengths and goals should be used in care-planning. As some service users struggled to report their experience of the intervention, alternative evaluation approaches need to be considered if the service user experience is to be fully captured