Cross-national mixed-methods comparative case study of recovery-focused mental health care planning and co-ordination in acute inpatient mental health settings (COCAPP-A)

Empowerment Scale

A total ES score for each service user respondent was obtained by summing the scores of individual items. The overall mean score for the sample was above the mid-point for the instrument (Table 6). Out of a possible score of 4, indicating a higher perceived level of empowerment, the mean total score was 2.85 (SD 0.5). This is slightly higher than the reference value, but only marginally. 146 The scores were slightly higher than those of the reference group in all subscales apart from ‘power–powerlessness’, for which the scores were comparable. The Wowra and McCarter146 values relate to data collected in South Carolina, USA; therefore, they are from a different health-care system and also from people in contact with community mental health services.

A final comparison was made between the scores for empowerment across the two COCAPP studies (acute and community mental health services). The total score and subscales for the ES were marginally higher in the COCAPP-A study from respondents currently in acute mental health wards than the COCAPP study from respondents in contact with community mental health services. See Chapter 5 for some exploratory inferential analyses.

Views on Inpatient Care Scale

A total score on the VOICE for each respondent was obtained by summing the scores of the individual items. The higher the total score (range 19–114), the more negative the perception of the quality of care on the ward. The score for respondents in Artois is shown in Table 7.

The total scores for VOICE were marginally lower than the reference value provided by Evans et al. 52 The mean scores were in the lower half of the scale, suggesting that service users leaned towards a more positive perception of the ward. There is, however, a large range of responses for this measure, demonstrating that some of the participants had a more negative perception of the ward.

Scale to Assess the Therapeutic Relationship

The mean total score for service users on the STAR-P was 29.02 (SD 11.30), 14.99 (SD 6.77) for ‘positive collaboration’, 7.32 (SD 3.41) for ‘positive clinician input’ and 6.77 (SD 3.34) for ‘non-supportive clinician input’. These values align well with the reference values provided by Nolan (Camden and Islington NHS Foundation Trust, 9 March 2016, personal communication) shown in Table 8. Nolan’s study was conducted in acute wards in the UK as part of the protected engagement time study. There were differences in the ‘non-supportive clinician input’ subscale on which the service users scores were on average two points lower than the reference value and only marginally past the mid-point for this subscale.

The mean total for staff on the STAR-C was 36.08 (SD 4.18), 17.17 (SD 2.65) for ‘positive collaboration’, 10.34 (SD 1.34) for ‘positive clinician input’ and 8.60 (SD 1.53) for ‘emotional difficulties’. All of the subscale values are lower than the reference values, leading to an overall lower average total of approximately 2 points.

When comparing the mean service user and staff scores it is apparent that staff gave higher scores and therefore rated the therapeutic relationship more positively than service users. The total scores are on average 7 points higher for staff than for service users.

Independent samples t-tests were completed to determine if there were significant differences between the perceptions of the therapeutic relationship from service users and staff in the COCAPP-A study. There was a significant difference in the total STAR scores for service users (mean 29.02, SD 11.30) and staff (mean 36.08, SD 4.18) [t(64.9) = –4.28; p < 0.001; 95% confidence interval (CI) –10.35 to –3.77]. Staff perceived therapeutic relationships more favourably than service users. Furthermore, Cohen’s effect size value (d = 0.83) suggests a large practical significance. There was also a significant difference in the responses from service users and staff for two of the subscale scores: non-supportive clinician input and positive clinician input. For the non-supportive clinician input subscale the score for service users (mean 6.77, SD 3.34) was lower than that for staff (mean 8.60, SD 1.53) (t(70.1) = –3.61; p = 0.001; 95% CI –2.84 to –0.82; Cohen’s d = 0.70). For the positive clinician input subscale the score for service users (mean 7.32, SD 3.41) was lower than that for staff (mean 10.34. SD 1.34) (t(66.6) = –6.04; p < 0.001; 95% CI –4.02 to –2.02; Cohen’s d = 1.17). T-test statistics for the remaining subscale are provided in Chapter 5, Table 52.

A final comparison was made between the scores for the therapeutic relationships across the two COCAPP studies (acute and community mental health services). It is clear from the scores in Table 8 that service users in community mental health services score the therapeutic relationship higher than those in acute mental health services.

Recovery Self-Assessment

Mean scores and SDs for the RSA are provided in Table 9. Mean scores for service users and staff on the subscales fell in the moderate to high range (3.06 to 3.45 and 3.15 to 3.53, respectively). The difference in mean total RSA scores was evident, with staff responding with highest ratings [3.36 (SD 0.59)], followed by service users [3.21 (SD 0.96)]. The lowest scoring subscales for service users were ‘choice’ and ‘involvement’, scoring just above three, which within this subscale demonstrates neither a positive nor a negative response. The lowest scoring subscales for staff were ‘involvement’ and ‘diversity of treatment options’. The highest scoring subscale for both service users and staff was ‘life goals’.

Independent samples t-tests were conducted to compare the perceptions of recovery-oriented services for staff and service users in acute mental health services. There were no significant differences in the total RSA scores for service users (mean 3.21, SD 0.96) and staff (mean 3.36, SD 0.59) [t(74.5) = –0.963; p = 0.339; 95% CI –0.47 to 0.16; Cohen’s d = 0.19) or the subscale scores (t-test parameters for subscales are provided in Chapter 5, Table 52.

A final comparison was made between the scores for the perceptions of recovery-oriented care across the two COCAPP studies (acute and community mental health services). The RSA total score for service users and staff in community and acute mental health services in Artois was almost equivalent. There are some differences at the subscale level with service users, in acute services score ‘involvement’ and the ‘diversity of treatment options’ marginally higher than those in community mental health services. Service users in acute inpatient services do however score ‘choice’ much lower than those in community mental health services. There are some differences at the subscale level for staff. In our acute study staff score ‘life goals’ marginally lower and ‘involvement’ and ‘individually tailored services’ marginally higher than in our community study. The ‘diversity of treatment options’ scale is higher and the ‘choice’ subscale is lower in the acute study. See Chapter 5 for some exploratory inferential analyses.

A recovery profile from the RSA scale is in Appendix 5.

Care planning and co-ordination

Most staff participants felt that care plans were a necessary and useful part of work done on the ward. They have become an increasingly focal point of care as a consequence of the shift towards a more collaborative approach and shorter inpatient stays. Care plan documents were referred to regularly, especially during handovers and ward rounds. It was also suggested that care plans could be a useful means of encouraging good MDT collaboration and input. Effective communication between all parties (staff and service users) was felt to be crucial to care planning and it was suggested that continual efforts must be made to facilitate this:

With the number of professionals, sometimes it’s difficult to get everyone on board at the same time and get things communicated in a timely manner to make sure that their care [and] . . . treatment is provided as quickly as possible.

A-ST-104

Contrasting responses were received from service users. Only two participants provided positive accounts; others described matters more ambivalently, citing a lack of knowledge and understanding. One participant complained of a lack of continuity in his care throughout the admission process, which had taken considerable time to resolve.

Responses from carers were similarly diverse, with participants having a clear understanding of how care was being planned and co-ordinated, feeling well informed about progress and developments and being kept up to date with any changes as they occur. Two participants described at length the problems that they had experienced as a result of service users refusing to give consent for the disclosure of any information regarding their care:

She wouldn’t tell me whether she was taking medication or not, the nurses obviously couldn’t tell me, so I didn’t know and that was very frustrating, extremely frustrating.

A-CA-102

Staff said that all service users received written copies of their care plans. One participant was, however, keen to note that care plan documents must be regularly updated and (re)considered:

It feels like a very didactic process, this is your care plan, please sign it and then it’s forgotten about and then not really referred to or updated or nurtured.

A-ST-10

As with staff, service users were divided in their responses to the issue of written care plan documents. Only two participants had copies of their care plans, and said that they understood them and found them helpful, with care planned ‘brilliantly’ (A-SU-104) and the range of activities praised. One service user maintained that he did not have a written care plan at all, while another was unsure whether or not he had one. Just one participant mentioned actually referring to her care plan, although she did not do so regularly.

Among carers, there were similarly mixed responses about care plan documentation. Just two participants had seen written care plans, and only one actually had a copy of the document and he had had to request this.

All staff participants interviewed maintained that service user involvement in the care planning process was essential, and that this was actively encouraged on the ward:

Always having the patient’s views . . . on board and working with what . . . they want.

A-ST-101

This was felt to be a fundamental element of the working ethos on the ward: staff noted that matters had improved over time in this respect, and emphasised that service users typically became more involved as their stay progressed.

In contrast to staff views, few of the service users interviewed talked in any detail about being involved in their care planning. One interviewee complained that the focus of his care planning had been almost entirely on medication and that he sometimes felt unable to have a say. Similarly, only one of the carers interviewed reported being satisfied with their level of involvement in care planning; some carers noted that opportunities had been limited because service users refused to grant their permission for this. Interestingly, although documentation was drawn up by staff and then signed by service users, ownership was conceptualised as a shared endeavour between service users and staff: a form of agreement. Only one service user addressed the issue of care plan ownership, and did so in critical terms:

Own it? Oh no, I don’t own it, it just happens.

A-SU-106

Two service user participants raised concerns about the lack of continuity and coherence between inpatient and community services, and felt that this was having a detrimental impact on their care:

Each doctor [from accident and emergency admission onwards] has been good on their own but each one starts again rather than taking the notes from the last doctor and moving forward, they go back to square one again.

A-SU-106

This was also a concern for carers; one participant described having considerable problems with the handover of care from hospital to community services via an intensive support team. Carers were unsure whether or not, and to what extent, any existing care plans had informed service users’ care on the ward.

Staff noted that initial discussions about discharge took place in ward round meetings, at which time arrangements could be made for support (e.g. accommodation) in the community. A separate (formal and specific) discharge meeting was then held 1 or 2 weeks before a service user left. Staff emphasised that all relevant parties were encouraged to attend and felt that such meetings were most successful when they allowed for the communication of up-to-date details about post-discharge practicalities, such as crisis team follow-ups.

However, there was considerable ambiguity regarding post-discharge care planning; most staff seemed unsure whether or not service users were given a copy of their written care plan to take home, or about what happened to the documents after that. One interviewee described being involved in a new development aimed at improving discharge planning on the ward, and explained that service users now received an ‘interim discharge summary’ (A-ST-106) when they left hospital, which set out, for example, medication guidance, visit arrangements and key contact numbers in case of crisis.

In contrast, service users interviewed said that they had not been involved in any formal discussions about their discharge. Only two of the carer participants described being closely involved in discharge preparations and had attended meetings on the ward. One had been supported in visiting care homes that her daughter might be able to live in after leaving the ward, while another praised negotiations related to arrangements for home leave.

Care reviews

Staff participants noted that reviews were carried out during weekly ward round meetings. Care plans were subsequently updated and changes were implemented as required. Staff noted that reviews should reflect careful monitoring of service users’ progress, with all relevant MDT staff working closely together to facilitate this. Most staff maintained that service users were involved as much as possible in care reviews:

We’ll let the doctor know that they’d like to be seen and arrange for that to happen.

A-ST-104

The responses from service user participants were more diverse. One service user maintained that he had not been involved in any reviews and that no one had discussed the process with him. Another understood his care to be reviewed on a regular basis, but without his involvement. Two other participants were satisfied with their involvement, said that they felt listened to and supported, and found review meetings helpful. Most service user interviewees understood that review meetings were fixed (one weekly) and not flexible. Some participants’ families attended, whereas others had decided against this.

Carers talked at greater length about care reviews than did either service users or staff, and most described their experiences in positive terms. Most had attended review meetings regularly, and felt that these were well organised and structured, that they were able to contribute and that their views were listened to:

It’s very nice, it’s not too big . . . I know [the staff], it’s easygoing.

A-CA-101

Most carers viewed review meetings as a good opportunity to be updated on service users’ treatment and progress. Two interviewees complained that they had to take the initiative if they wanted to attend.

Support systems

Most staff had not received any formal training specifically on care planning and reported that they had learned either via job shadowing opportunities or by actually doing care planning. A-ST-101 noted that training opportunities were available to staff, but that it was their responsibility to pursue these.

Staff were unanimous that families, friends and carers were encouraged to be involved in care planning and were invited to contribute to ward round meetings. Staff felt that the trust’s approach was comprehensive and efficient, and described a mutually rewarding communicative relationship, although this was not the case for all carers:

It took me a while to work out what the hell was going on . . . nobody explained to me in [name of ward] what the ward round was and I had the right to be there.

A-CA-102

One staff participant noted that carer involvement had improved since the introduction of a ‘carers lead’ (A-ST-105) on the ward, a system to enable carers to spend time with a staff member. The challenges of involving carers and families were noted by staff, who felt that overinvolvement and unrealistic expectations could be problematic.

Most service users interviewed had family members or friends who supported them and were happy with their level of involvement. One participant complained that his parents sometimes received more information than he was given, which he found frustrating.

Staff noted that the disparity between the 24-hour inpatient care and the working hours of other services created difficulties in arranging meetings and appointments.

On the whole, service users described their relationships with staff in positive terms, and felt able to share their fears and concerns. One participant felt that staff could be inconsistent in their interactions and another complained about the unsatisfactory level of personal engagement between service users and staff. Most service user participants felt that staff attitudes were good, and that they were treated with dignity, respect and compassion. One service user provided a wholly negative account, describing how she was refused a key to her own room when first admitted to the ward, and complained that staff were neglectful of physical needs.

Safety and risk

Staff participants described risk assessment as a key component of care planning on the ward. The importance of careful and continual monitoring and observation was highlighted. Most service user participants reported feeling safe on the ward, and drew comparisons (both positive and negative) with previous experiences on inpatient units elsewhere. Only one service user provided a wholly negative account, maintaining that the reasons for her detention were not justified or explained. All of the carers interviewed felt that service users’ safety had been adequately considered and managed on the ward:

[Staff] did all they could to keep [name] safe.

A-CA-102

Staff participants noted that risk assessments involved the consideration of physiological risks and the close examination of relevant historical factors from service users’ existing notes, and also felt that the safety of the self and of others should be given equal attention. The short- and longer-term significance of risk assessment was emphasised. Although most staff felt that risk assessments were effectively conducted, there was acknowledgement of the potentially detrimental consequences to service users of overestimating risk. Staff maintained that formal and informal admissions to the ward were treated in much the same way, although it was acknowledged that particular attention was given to matters of capacity in formal detentions. Service user participants under detention reported that the process had been satisfactorily explained to them and that their rights had been fully clarified.

Four carers of people detained felt that detention had been necessary and beneficial, and reported that matters had been clearly explained to them. Some had long-term experience of previous detentions and were knowledgeable about the process.

Staff noted that formal discussions about risk took place during weekly ward round meetings, but conceded that service users were not always involved in these discussions. Negotiations around medication were described as especially challenging. None of the service users or carers interviewed mentioned being involved in discussions about risk.

Organisational context

Staff participants were unable to identify any formal policies or specific local developments underpinning the provision of care on the ward, but each recognised different sets of values and principles. These ranged from service user safety to person-centred care, recovery-focused work and good communication between staff, MDT members and service users. Most staff felt that things were done well and with the best of intentions. Challenges faced by staff were acknowledged. These included financial pressures, lack of resources and the requirement for a fast ‘turnaround’ of service users on the ward, which was described as disheartening. Most staff participants emphasised the efforts made to manage these challenges in their everyday work on the ward.

Recovery

Staff participants were familiar with the ‘journey’ metaphor, although none used it themselves, even when they acknowledged its usefulness: most definitions focused on service user choice and empowerment. Some staff were concerned that the notion of recovery could create unrealistic goals for service users and felt that officially sanctioned conceptualisations of recovery were sometimes inconsistent with actual lived experiences.

Only two service users offered a definition of recovery, one describing it in terms of personal wellness and another associating the idea with hospital discharge: they indicated that there had been little sustained or detailed discussion around the subject. Staff and service user participants were aware of divergent conceptualisations of recovery, which was seen as a potential hindrance to effective care planning.

Carer participants gave more detailed definitions of recovery than either staff or service users, and some took great care to acknowledge the process of recovery to be a lengthy and complex one, typically involving ongoing care and medication. They also recognised the non-linear quality of the recovery experience, which was understood to be challenging, noting that the journey metaphor was idealistic and of limited relevance to some.

Staff maintained that they worked in a recovery-oriented way on the ward, although the challenges of doing so were emphasised, with changing organisational objectives and limited resources cited as significant factors. Most carers said that they found it difficult to know whether or not service users’ care had been recovery focused.

Service users seemed more ambivalent about the whole concept of recovery and only two expressed strong feelings as to whether or not their hospital stay had been helpful in this respect. One participant felt that it had, whereas another gave a contrasting view that he felt that he was simply left to occupy himself on the ward.

Most service users seemed to consider hospital a preferable option for them at the current time, but were also aware of the disadvantages of the environment in terms of their well-being:

It’s better than being outside with no help but that maybe the atmosphere in here is a little, it gets into your nerves, they jangle a bit.

A-SU-106

In keeping with staff responses, almost all of the carers interviewed felt that service users’ hospital stays had helped with their recovery, especially in terms of the extent to which they had stabilised and settled the person.

Two carers felt quite strongly that better (and greater) provision of psychological therapies would help with recovery and would have liked to have this in addition to the medication as a means of ‘deeply investigating the causes [of the illness] and trying to right that’ (A-CA-102).

Personalisation

Most of the staff, service users and carers interviewed were unfamiliar with the term ‘personalisation’ but understood it to mean person-centred care. Half of the staff felt that care on the ward was personalised and individually tailored to service users’ needs, although some were more sceptical about the relevance of personalisation to inpatient care:

Personalisation is what we know of them as a patient, not as a person. It’s patientisation . . . [it’s] service userisation.

A-ST-105

Most service user participants felt that their care on the ward had not been personalised and observed that individually tailored care was less possible in hospital than in the community.

Carers’ responses on this subject were mixed. One participant felt that care on the ward had been adequately personalised, and gave examples of staff providing his daughter with crossword puzzles and taking her to have her nails painted and her feet massaged. He also felt that her views and wishes were listened to. Others were less certain, and were reluctant to give a firm opinion. As with staff and service users, carers were aware of the extent to which care could be personalised on the ward.

Two staff interviewees described service user empowerment as a key objective on the ward, but most were more ambivalent about this. Staff emphasised some of the tensions in collaborative decision-making, maintaining that a satisfactory compromise was always sought.

Barriers and facilitators

For most staff, good communication between all parties was seen as a key factor in helping to facilitate recovery-focused and personalised care. It was felt that staff could benefit from listening carefully to families and carers, who often had a good understanding of service users’ needs and wishes. Careful handling of issues pertaining to consent and information sharing were also understood to be important in this respect, with resistance from service users identified as an area of contention:

Most of the patients don’t want any medication or don’t think they’re ill, which is of course part of it, part of being ill a lot of the time, or not wanting their medication, part of why they’ve relapsed, so why they’re here in the first place.

A-ST-103

Service user involvement was seen as another facilitator, as was a comprehensive consideration of service users’ personal histories.

Various suggestions were made about how care planning might be improved. These ranged from extending business hours to maintaining contact with service users after discharge. The potential benefits of involving wider support services more effectively were also discussed, particularly encouraging more professionals to attend ward round meetings.

Several hindrances to the delivery of recovery-focused and personalised care were identified. Inadequate communicative relationships were seen as a major factor, and the lack of one-to-one time available for staff to spend with service users was also a concern. The extensive quantity of paperwork was felt to be a hindrance to staff, as were constant organisational changes.

Care plan reviews

Ten care plans were reviewed on the main ward in Artois for six female and four male service users ranging in age from 23 to 63 years, eight of whom had been formally detained at some point during their admission. For three participants this was their first admission to hospital and for others this ranged from one to nine previous admissions. In five care plans it was clear that the service user had signed the plan, although in only two cases was it clear that a copy had been given to the service user. No care plans were signed by the named nurse. Each of the 10 service users had attended their last ward round, but on only two occasions were carers present, and on four rounds care co-ordinators had attended, suggesting some possible issues with continuity of care. The care plans reviewed had been clearly written by staff to the person; for example, ‘you stated that you felt ready to go home’. In six care plans there was evidence of coproduction, four care plans showed a strengths-based approach and six showed evidence of encouragement to develop self-management approaches. Care plans on the whole lacked a focus on personalisation (4 out of 10), although recovery-oriented care planning was evident (7 out of 10). Four care plans included the person’s views on their safety and risk, and three care plans included the person’s views on their risk management plan. The majority of care plans (9 out of 10) included plans for discharge.

Meeting observations

In Artois one observation of a ward round meeting was completed. Eight people were present, including two members of the research team, two psychiatrists, the service user and his father. The meeting was held in a light, open room with a welcoming layout, plenty of space and chairs arranged in a circle. The meeting began on time and was led by the patient from the start. Formal introductions were not required because there was a well-established relationship; the staff, service user and carer were familiar and comfortable with one another. The interpersonal effectiveness and non-verbal communication of the psychiatrist were impressive throughout, creating a relaxed space for the service user to discuss their care while maintaining a good balance of firmness when required. Many of the questions were framed by using tentative enquiry such as ‘would you mind if . . .?’, ‘would it be OK if . . .?’, which provided scope for negotiation. Plenty of time and patience was provided, which offered the service user adequate opportunity to ask questions. Discussions were handled respectfully, with the use of recapping and summarising to ensure that the information was understood. The service user’s existing knowledge about his condition and medication were used well, and the staff built on this nicely. Physical health was addressed and medical records were consulted openly for the service user to see and discuss. Most of the discussion focused on medication and the request for leave; however, some time was used to explore the service user’s understanding of his illness and his recovery and progress in an open and empowering way, with praise and encouragement given for progress already made. When minor disagreements occurred, these were handled positively and collaboratively, with the service user’s views considered throughout. The patient’s father was able to contribute to the discussion when he wanted to; his main role was to provide moral support, as the service user was able to lead the conversation himself. The end of the meeting was handled efficiently and empathically; the content was summarised and arrangements for future meetings were discussed, as were steps to implement the changes talked about during the meeting.

Views on Inpatient Care Scale

A total VOICE score for each respondent was obtained by summing the scores of the individual items. The higher the total score (range 19–114), the more negative the perception of the quality of care. The scores for respondents in Burgundy are shown in Table 12.

The total scores for VOICE were considerably lower than the reference value provided by Evans et al. 52 The mean scores were in the lower half of the scale, suggesting that service users leant towards a more positive perception of the ward. The range of responses for this measure is fairly narrow (19.00–84.00) when taking into account the maximal response score of 114. This demonstrates that the responses from participants were not too extremely weighted towards a negative perception of the ward.

Empowerment Scale

A total empowerment score for each service user respondent was obtained by summing the scores of individual items. The overall mean score for the sample was above the mid-point for the instrument. Out of a possible score of 4, indicating a higher perceived level of empowerment, the mean total score was 2.81 (SD 0.46); this is slightly higher than the reference value. 146 The subscale values were slightly higher than the reference group apart from ‘power–powerlessness’, which was marginally lower (Table 13).

A further comparison was made between the scores for empowerment across the two COCAPP studies (acute and community mental health services). Apart from the ‘power–powerlessness’ subscale, the total score and subscale scores for the ES were higher for responses obtained from service users in acute inpatient services than for responses from those in contact with community mental health services. See Chapter 5 for some exploratory inferential analyses.

Scale to Assess the Therapeutic Relationship

For service users the mean total score for the STAR-P was 30.00 (SD 10.15), 15.28 (SD 6.37) for ‘positive collaboration’, 7.47 (SD 3.17) for ‘positive clinician input’ and 7.19 (SD 2.92) for ‘non-supportive clinician input’. These scores closely align with the reference values provided by Nolan (personal communication) shown in Table 14, apart from the ‘non-supportive clinician input’ subscale, for which the service users scores were, on average, 1.5 points lower than the reference value.

For staff the mean total for the STAR-C was 39.33 (SD 4.31), with scores of 18.86 (SD 2.57) for ‘positive collaboration’, 10.95 (SD 1.15) for ‘positive clinician input’ and 9.50 (SD 1.37) for ‘emotional difficulties’. All the subscale values were marginally higher than the reference values apart from the emotional difficulties subscale, which was marginally lower. Overall, the total score was higher than the reference value.

When comparing the mean total scores for service user and staff, it is apparent that staff give higher scores and therefore rated the therapeutic relationship more positively than service users. It is notable that the total score is at least nine points higher for staff than for service users.

An independent-samples t-test was completed to determine if there were significant differences in the perceptions of the therapeutic relationship between service users and staff. There was a significant difference in the total STAR scores for service users was 30.00 (SD 10.15) and staff was 39.33 (SD 4.31) [t(63.2) = –5.76; p < 0.001; 95% CI –12.57 to –6.10, Cohen’s d = 1.20] and all of the subscale scores (t-test statistics for the remaining subscale are provided in Chapter 5, Table 52).

A final comparison was made of the scores for the therapeutic relationships between the two COCAPP studies (acute and community mental health services). It is clear from the scores in Table 15 that service users in community mental health services scored the therapeutic relationship higher than service users in acute mental health services.

Recovery Self-Assessment

Mean scores and SDs for the RSA are provided in Table 15. Mean scores from service users and staff on the subscales fell in the moderate to high range (3.07 and 3.40, and 3.05 and 3.72, respectively). The difference in mean total RSA scores was only marginal; staff had the highest ratings [3.45 (SD 0.65)], followed by service users [3.32 (SD 0.95)]. The lowest scoring subscale was ‘involvement’, with both participant groups showing negligible differences. The highest scoring subscale were ‘choice’ and ‘life goals’ for both groups. Staff rated both of these subscales higher than did service users.

Independent-samples t-tests were conducted to compare the perceptions of recovery-oriented services for staff and service users. There were no significant differences in the total RSA scores for service users (mean 3.32, SD 0.95) and staff (mean 3.45, SD 0.65) [t(79.4) = –0.773; p = 0.442; 95% CI –0.47 to 0.2, Cohen’s d = 0.16] or the subscale scores (t-test statistics for subscales are provided in Chapter 5, Table 52).

A final comparison was made of the scores for the perceptions of recovery-oriented care between the two COCAPP studies (acute and community mental health services). The RSA total scores for service users and staff in community and acute mental health services in Burgundy were almost equivalent. There were some differences at the subscale level, with service users in acute services scoring the ‘life goals’ and ‘choice’ subscales lower than respondents in community services. Conversely, service users scored ‘involvement’ and diversity of treatment options’ subscales higher than did those in community services.

A similar pattern is seen with the responses from staff. An additional difference is that staff working in acute mental health services scored the ‘individually tailored services’ subscale higher than did those in community mental health services. See Chapter 5 for some exploratory inferential analyses.

A recovery profile from the RSA scale is in Appendix 5.

Care planning and co-ordination

Staff at Burgundy felt strongly that care and treatment planning needed to be sufficiently flexible and ‘dynamic’ to allow for constant and continual adaptation in order to adequately address the scope and complexity of changes in individual service user progress:

I think usually the nurses on the ward try and review the care plans at least weekly, but some people coming in crisis point can change day to day . . . so it’s about working with that patient and working with their changes, which is always different.

B-ST-101

It was noted that care planning documentation was ‘basic’, making it difficult to incorporate the necessary nuances of care. It was suggested that the documentation did not capture any complete sense of a service user’s identity:

The little things which sometimes are the most important [for an individual] don’t get captured in a dialogue in that care and treatment plan. I think it’s still quite still professionalised . . . rather than the words of the person, that it’s coming out of really.

B-ST-102

Staff were keen to emphasise that the CTP format required by legislation in Wales was not well suited to the typically short-term nature of acute inpatient care. They also felt that the short-term nature of admissions could make the CTP process extremely challenging, because it meant that difficulties with, for example, finances or housing are prioritised over cultural or spiritual needs. When asked to define care and treatment planning, staff primarily associated this with ideas about discharge and recovery.

Interestingly, the legislative requirements of the Mental Health (Wales) Measure 2010 were not emphasised in participants’ narratives: only two raised this at all, and those who did focused on the concerns and anxieties that it had created for practitioners.

Concerns were raised about the lack of continuity of care planning between community and hospital contexts, which were felt to limit the relevance and transferability of CTPs on admission and discharge. As a strategy for addressing this, the ward currently used a separate ‘add-on’ or ‘intervention’/’management’ plan, which mirrored (but did not replace) any existing CTP and was used specifically for the duration of the service user’s stay. Staff reported that, using this system, all service users received a care plan on admission. It was also noted that the intricacy and quantity of paperwork of the existing CTP format could make liaisons with other agencies more complicated, and that this could be better adapted to the ward:

I think I struggle with the principles [of CTP] and how that fits perhaps into the ward – the confusion that still exists is very much present in terms of the fundamentals of it.

B-ST-102

Service user participants reported having contact with mental health services before their admission to inpatient services. Many either had been seen by a crisis team previously or had been transferred from another psychiatric hospital, often following an accident and emergency admission. This suggests that they would have had existing care plans at the time of their admission, although they seemed to have limited knowledge of the implications of this.

Service user responses mirrored concerns raised by staff about the priority necessarily given to housing and accommodation issues in relation to care planning. Accordingly, perhaps, these are the elements of the CTP process in which service users seemed to be most involved. Interview data from the study also suggest that problems in these areas often accompany the worsening mental health conditions that necessitate hospital admissions in the first place:

The main priority [of my care plan] is finding me somewhere to go first basically . . . so that’s the main goal.

B-SU-103

Staff felt that service user involvement and collaboration in care and treatment planning was important. Staff claimed that a lot of the time service users were unwilling or unable to engage with the care planning process and therefore had little awareness of its relevance to them. Most service user participants were unaware that they had a written care plan and those who were reported that they have not seen the document. Only two service user participants were aware that they had a written CTP. After further exploration by our research support nurse, it was confirmed that there were no existing care plans for the remaining four research interview participants. These disparities can perhaps be partly explained by staff presenting idealised versions of their practice during interviews, which may not necessarily reflect the day-to-day reality experienced by service users:

[My care] hasn’t really been planned, they keep giving me different tablets all the time and I’m not quite sure what tablets they’re giving me, I’m just taking them because they’re asking me to.

B-SU-101

No, nobody talks to me about that.

B-SU-104

For the most part, service users believed that staff on the ward provided a good and fair quality of care, but they did not feel that they were actively involved in the care planning. Service user responses substantiated the observations of staff in terms of the apparent willingness of some to actively choose non-involvement. Although service users felt that there was at least the potential for them to be more involved in their care planning, they maintained that this was not necessarily actively encouraged or pursued by staff. Staff felt strongly that service users should have ownership of their care plans, although they were not certain whether or not service users themselves felt that they owned the plans. Responses from service users on this point would seem to indicate that they did not:

They don’t tell me nothing in this ward. They don’t do nothing. They just give you your tablets and feed you food and that’s it like.

B-SU-101

Staff participants emphasised that discharge plans were discussed with service users as soon as possible after their admission, and it was noted that the health board had a 7-day follow-up system with their crisis teams. Weekly discharge planning meetings ere held on the ward so that service user progress could be shared among all staff. Service users themselves, however, were not certain of this. Indeed, in contrast to the staff responses outlined here, discharge had been discussed with only two of the six participants interviewed. For them, the primary focus had been on resolving housing and accommodation problems: moreover, their discharge was contingent on such resolutions:

[Patients are asked] if they feel that everything’s been addressed on [their care plan] and then seeing what we can do prior to their discharge.

B-ST-106

Care reviews

Staff reported that care was reviewed in its most formal sense during weekly ward round meetings, although service user progress was monitored continuously. Staff emphasised that, ultimately, the review process itself had to reflect the individual needs of the service users. Involvement was encouraged as much as possible, as was the involvement of family, friends and carers. It was, however, noted that this could be challenging.

Responses from service users to questions in this category indicated that they had a very limited knowledge or awareness of the review process in relation to care and treatment planning on the ward. Interestingly, service users did not draw any connection between reviews and ward round meetings, and seemed not to understand that this was when reviews of their CTP took place. One participant also suggested that there may be advantages to not being involved in the review process:

Maybe it’s better if I’m not fully aware of the plan, because if I am I could be more guarded in the way I participate . . . Whereas if I’m not fully aware until the end of the plan, maybe there’d be more honesty in the plan, you see.

B-SU-102

Support systems

Staff reported that they had not received any specific training in care planning. They had attended only basic introductory courses at most, or learned about CTP as a part of their wider nursing education, focusing mainly on issues such as the legislative responsibilities of the Measure and the technicalities of the CTP documentation. It was suggested that this lack of training may be detrimental to the overall coherence of the CTP process.

Burgundy has no official policy on family or carer involvement, and some staff participants would have preferred this to be more formalised. According to staff, the involvement of family and carers is encouraged, with invitations issued to attend and participate in ward round meetings. Staff gave little consideration to the extent to which service users could find such meetings stressful or frightening, and that they may, therefore, be deterred from attending them. Nevertheless, the challenges and potential problems of family/carer involvement were widely acknowledged by staff, especially in terms of how this could sometimes create unrealistic expectations for the various parties. Participants also emphasised that service users’ wishes must be respected. Nevertheless, the challenges and potential problems of family/carer involvement were widely acknowledged by staff, especially in terms of how this may sometimes create unrealistic expectations for the various parties. Participants also emphasised that service users’ wishes must be respected, with some staff feeling that there was value and importance in involving advocates and help from other source when possible.

Responses from service users suggested that they had carers, families or friends who supported them and were involved, to some extent, in their care. On the whole, most seemed satisfied with this level of involvement, although one participant would have preferred her family to be more fully involved. Another had been helped by staff on the ward to maintain a good relationship with her daughter by organising special visiting arrangements:

[Having my family more involved] would have been better. Because they could help me to understand [things more fully].

B-SU-101

Service users reported having at least one named nurse and seeing that person regularly. Most described having good relationships with staff with whom they had the most contact. Only one service user described having had a negative experience in terms of her relationship with ward staff, which she attributed to the lack of one-on-one time available for staff–service user interactions. She also commented that the constant presence of students in ward round meetings prevented her from feeling comfortable enough to talk freely to her doctor. All participants agreed that staff attitudes were good, that staff were compassionate and that they treated service users with dignity and respect.

Safety and risk

There was unanimous agreement among staff at Burgundy that risk assessment was a key priority and of primary importance in care planning, although no mention was made of involving service users in discussions about this. All staff participants maintained that formal and informal admissions were handled in the same way. The consequences of detention (e.g. being confined to the ward, administering enforced medication and the importance of reading service users their rights) were also acknowledged. Staff emphasised the need for continual and ongoing risk assessment, and acknowledged the difficulty of adequately capturing this in the CTP document. The value and importance of positive risk taking was mentioned by only two participants.

For service users, meanwhile, there was a feeling that their safety had been considered during their hospital stay. None had had any detailed discussions about their safety, and two participants did not seem familiar with the idea of a risk assessment at all. Most seemed to have limited knowledge and awareness of the subject:

[I don’t think anyone spoke to me about it], no. It was, other patients were on section and I could see what they were going through, say.

B-SU-104

Organisational context

Staff at Burgundy did not, on the whole, feel that the introduction of the Mental Health (Wales) Measure had led to any significant organisational change. In terms of key developments, the shift towards recovery-oriented practices was felt to have had a significant impact for staff. Staff acknowledged that the centralising of services may have made visiting more difficult for carers owing to increased travel distances and poor local transport options. Empowerment and service user choice were seen as the key values or principles that underpinned the provision of services.

Recovery

Staff participants did not offer any standard or dominant definition of recovery. Recovery was not felt to be a new concept in mental health, but most participants (staff and service users) acknowledged its scope and complexity, as well as its potentially disparate interpretations. Service users did not use any single, universal definition of recovery. Interestingly, service user participants did not feel that the ‘journey’ metaphor was especially relevant, and most acknowledged the concept’s complexity and subjective, individual nature:

But how long’s that journey? . . . How long is a piece of string?

B-SU-104

Staff felt that working in a recovery-focused way required flexibility and a consideration of individual differences, which are very difficult to capture in the CTP document. Service users, for the most part, felt that their hospital stay had helped with their recovery, and recognised this as being linked to an ongoing process of continuing to make positive progress.

The Recovery Star is used on the ward, although this is usually done in an informal way, and staff saw this as a useful means of establishing and encouraging service user involvement. Service users are also encouraged to attend regular recovery group meetings. Only one service user cited the Recovery Star approach used on the ward but noted that it was left to her to develop coping mechanisms for her symptoms. Recovery plans were not mentioned by any other service user participants.

Staff felt that involvement, empowerment and drawing on service users’ own existing individual experiences and knowledge were key factors in striving for recovery and working in a recovery-focused way.

Personalisation

Personalisation is not a term used by staff, although they were familiar with the concept and understood the ways in which it related to the notion of person-centred care. Service users were not familiar with the term at all, however, and had not heard it used on the ward. Staff felt that care on the ward was personalised, but recognised that there could be major challenges when it came to delivering this. They identified service user capacity/ability and logistical resources, as well the specific characteristics of inpatient care, as being particular hindrances. It was also noted that medical and psychological therapeutic models of care were in constant tension.

Most service users seemed to feel that their care on the ward was individually tailored and that staff were sensitive to and respectful of their personal needs. One participant, however, maintained categorically that her experience had not been person centred at all. Staff felt that CTP processes facilitated personalised care more now than they did previously, and it was suggested that working in a personalised way could also usefully involve service users and staff getting to know one another better as individuals. The overall sense was that matters had improved in terms of delivering personalised care.

Barriers and facilitators

Staff felt strongly that good relationships and communication were crucial factors in effective care and treatment planning, as was ensuring service user empowerment and involvement. The greatest challenges identified by participants related to a lack of staff collaboration on the ward and to poor continuity of care. Participants noted that unequal power relations in the structural organisation of the ward could be problematic, and that working in a collaborative or democratic way can could difficult as a result. Participants felt that shifting the culture on the ward away from older medical models of care had been challenging for both staff and service users.

Care plan reviews

Ten service users, eight female and two male, were selected for care plan reviews on the main ward in Burgundy. They ranged in age from 18 to 51 years. All service users were informal (i.e. they were voluntarily on the ward) at the time of the reviews and all but one had had previous admissions to hospital. Our review showed no evidence of care plans for four service users and no evidence of service users signing care plans that we could locate. There was no clear evidence that copies had been given to the service user. Only three care plans were signed by the named nurse. There was evidence that only three service users had attended their last ward rounds and that no carers, advocates or care co-ordinators had attended, suggesting potential problems in terms of continuity of care. For the 10 participants reviewed, there was evidence in only one care plan of the person being involved in the drafting of the plan, which had clearly been written by staff: ‘he would prefer to focus on paid roles and work’. This same care plan showed evidence of strengths-based and recovery approaches and, as well as one other, also showed that the service user’s views had been included in safety and risk assessments. There was no evidence that other participants’ views had been included in risk assessment or management. Most care plans showed an orientation to system-based goals only (e.g. medication compliance). Discharge planning was referred to in just one care plan.

Meeting observations

In Burgundy three observations of ward round meetings were completed. Eight people were present in all meetings, including the researcher, the primary nurse, a staff nurse, a note-taker, a student nurse and a student doctor. The meeting was held in a spacious room with four people seated around a long table in the centre of the room, and the atmosphere was relaxed and friendly. There was no prior preparation made (e.g. positioning of the chair) for where the service user would sit, which proved troublesome on one occasion when the service user chose a seat and was then asked to move. The relationships were fairly well established in all three of the observations, so no introductions were offered and the meeting commenced swiftly with questions directed by the psychiatrist. Eye contact and non-verbal communication was good and the atmosphere was quite friendly. In one of the meetings the psychiatrist’s attention appeared divided and he pursued conversation with the primary nurse about arranging a section 117 while trying to maintain cursory conversation with the service user (‘Everything OK?’). Questions were either framed around information that the psychiatrist possessed or based around areas of weakness or difficulties rather than strengths. In two of the meetings the person was referred to in the third person with little regard for their involvement in the conversation. At other times the service user was interrupted while speaking about topics they wanted to explore, which was likely to have left them feeling overlooked or with little understanding or resolution of their query. Disagreements or complaints were actively avoided, responded to with criticism or met defensively: ‘don’t blame me, we want to discharge you, but we’ve got to have the family agreement . . .’ In two meetings there was no mention of the care plan, and in another a service user asked if they could have a care plan on discharge but the topic of conversation was swiftly changed. The focus of the meetings was largely on practical arrangements (becoming more independent or procedures for discharge), with less attention given to the patient’s condition or feelings or to encouraging their progress. The meetings did not have formal endings; one service user marked the end of the meeting themselves, saying ‘is that all?’. An open invitation to ask questions was given in some instances but not others.

Views on Inpatient Care Scale

A total VOICE score for each respondent was obtained by summing the scores of the individual items. The higher the total score (range 19–114), the more negative the perception of the quality of care on the ward. The score for respondents in Champagne is shown in Table 18.

The total scores for VOICE were marginally lower than the reference value provided by Evans et al. 52 The mean scores were in the lower half of the scale, suggesting that service users lean towards a more positive perception of the ward. There is, however, a large range of responses for this measure, demonstrating that some of the participants have a more negative perception of the ward.

Empowerment Scale

A total ES score for each service user respondent was obtained by summing the scores of individual items. The overall mean score for the sample was above the mid-point for the instrument. Out of a possible score of 4, indicating a higher perceived level of empowerment, the mean total score was 2.93 (SD 0.36). This is higher than the reference value. 146 The subscale values for ‘righteous anger’ and ‘power-powerless’ were equivalent. For all other subscales, the scores were higher than the reference group; in particular, the score for ‘self-esteem–self-efficacy’ was considerably higher than the reference value (Table 19).

A final comparison was made between the scores for empowerment across the two COCAPP studies (acute and community mental health services). The total score and subscales scores for the ES were higher in the COCAPP-A study than the COCAPP study. Only the ‘righteous anger’ and ‘power-powerless’ subscales were equivalent across services. Scores for ‘self-esteem–self-efficacy’ were considerably higher in acute inpatient care than in community mental health services. See Chapter 5 for some exploratory inferential analyses.

Scale to Assess the Therapeutic Relationship

For service users, the mean total score for the STAR-P was 31.35 (SD 10.15), 15.88 (SD 5.54) for ‘positive collaboration’, 7.85 (SD 3.05) for ‘positive clinician input’ and 7.62 (SD 3.14) for ‘non-supportive relationships’. These scores align well with the reference values provided by Nolan (personal communication) shown in Table 20. There are some marginal differences: service users in the current study scored the ‘positive collaboration’ subscale just over one point higher and the ‘non-supportive clinician input’ subscale just over 1 point lower than the reference value.

For staff, the mean total for the STAR-C was 37.00 (SD 4.84), with scores of 17.63 (SD 2.70) for ‘positive collaboration’, 10.34 (SD 1.36) for ‘positive clinician input’ and 8.95 (SD 1.76) for ‘emotional difficulties’. All of the subscale values and the total score were marginally lower than the reference values.

When comparing the mean service user and staff scores, it is apparent that staff give higher scores and therefore rate the therapeutic relationship more positively than service users. Total STAR scores were just over 5 points higher for staff than for service users.

An independent samples t-test was completed to determine if there were significant differences between the perceptions of the therapeutic relationship from service users and staff. There was a significant difference in the total STAR scores for service users [31.35 (SD 10.15)] and staff [37.00 (SD 4.84)] [t(68.7) = –3.56, p = 0.001; 95% CI –8.82 to –2.49; Cohen’s d = 0.71]. For the positive clinician input subscale, the scores for service users were lower [7.85 (SD 3.12)] than the scores for staff [10.34 (SD 1.36)] [t (62.9) = –5.06; p < 0.001, 95% CI –3.58 to –1.55; Cohen’s d = 1.03]. T-test parameters for the remaining subscale are provided in Chapter 5, Table 52.

A final comparison was made of the scores for the therapeutic relationships between the two COCAPP studies (acute and community mental health services). It is clear from the scores in Table 20 that service users in community mental health services scored the therapeutic relationship higher than did service users in acute mental health services.

Recovery Self-Assessment

The mean scores and SDs for the RSA are provided in Table 21. The mean scores from service users and staff on the subscales fell in the middle to moderate (3.01 and 3.35, and 2.85 and 3.46, respectively). The difference in mean total RSA scores was almost equivalent. The lowest scoring subscale was diversity of treatment options for both participant groups. Within this subscale the score demonstrates neither a positive nor a negative response. The highest scoring subscale in both groups was life goals.

Independent samples t-test were conducted to compare the perceptions of recovery-oriented services for staff and service users. There were no significant differences in the total RSA scores for service users [mean 3.24 (SD 0.84)] and staff [mean 3.21 (SD 0.46)] [t(70.8) = 0.212; p = 0.833; 95% CI –0.26 to 0.32; Cohen’s d = 0.04] or the subscale scores (t-test statistics for subscales are provided in Chapter 5, Table 52).

A final comparison was made of the scores for the perceptions of recovery-oriented care between the two COCAPP studies (acute and community mental health services). The RSA total score for service users in acute mental health services in Champagne is slightly higher than that in community mental health services. Conversely, staff in acute mental health services gave a lower overall RSA total score than did those in community mental health services in Champagne.

There are also some differences at the subscale level. In acute services, service user respondents scored the ‘involvement’ and ‘individually tailored services’ subscale higher than respondents in the community study. Conversely, service users in acute inpatient wards scored the ‘choice’ subscale lower than did those in community mental health services.

There are also some differences at the subscale level for staff. In our acute study, staff scored inpatient services lower on the ‘life goals’, ‘choice’ and individually tailored services’ subscales than did respondents in the community study. To a lesser extent, staff also scored ‘involvement’ lower than in the acute study. Conversely, staff in the acute study scored ‘diversity of treatment options’ higher than did staff in the community study. See Chapter 5 for some exploratory inferential analyses.

A recovery profile from the RSA scale is included in Appendix 5.

Care planning and co-ordination

Most staff offered detailed definitions of care planning and co-ordination. It was felt that the primary objective of the CTP process is to provide ‘appropriate’ care to service users, from diagnosis and medication to consideration of service users’ lifestyle factors, their personal histories and family circumstances.

Despite the significance attributed to care planning by staff, only one of the service users interviewed was aware of their care being planned: others said that they had received little or no information, or had been obliged to ask for this, and felt that their views had not been listened to in meetings. Only one participant felt that their care was being planned in a helpful way: another talked of being ‘contained’, rather than actually receiving treatment.

There isn’t a treatment plan. There’s no treatment, there’s just containment. Walking to the shop to get a newspaper isn’t treatment. There’s no therapy here.

C-SU-103

The value of longer-term planning was mentioned by one staff participant, especially the need to make early contact with care co-ordinators in the community; individual care plans were considered to be helpful in this respect. Lack of staff resources resulting in insufficient time available to spend with service users was understood to be a hindrance to the CTP process. Concerns about the shift to electronic records featured strongly in staff interview narratives: it was suggested that this has changed the content (as well as the form) of what is written in the care plan documents and has created a barrier in terms of service user involvement:

I think it tends to maybe forget that the patient needs to be involved, whereas when we were writing them you would pick up that patient’s file, get the patient and go somewhere with them, more of a physical thing, chat with them and talk to them.

C-ST-101

One staff participant thought that care planning applications (apps) would be helpful in terms of communicating with service users, for example by providing prompts for forthcoming meetings. Nevertheless, care plans were considered to be helpful because they offered continuity and coherence.

Although staff emphasised that service users should be involved with every aspect of planning their care, concerns were voiced about the impact of unequal power relations on the communicative dynamics of (e.g. ward round meetings), especially when enforced medication is involved. These struggles were also reflected in service users’ responses: only one felt adequately involved in their care, while others talked of not being sufficiently involved or not being involved at all. One service user participant described participating in rushed care planning meetings, while another provided a detailed account of poor communication between staff and outside services, such that visits from professionals not working on the ward were not effectively co-ordinated.

Staff felt that discharge was a primary objective from the time of admission. Discharge planning – carried out during ward rounds – was described as a process that facilitates multidisciplinary participation from ward staff and community support service representatives, involving consideration of service users’ social support needs, including housing.

Service users, however, reported varying degrees of involvement in, and information sharing on, discharge planning. Some described having been party to no discussions at all, and others had a keen awareness of the challenges and complexities inherent in their discharge procedures, accommodation difficulties or homelessness.

The routes of admission of hospital recounted by service user participants indicate degrees of crisis and significant distress followed by, for some, lengthy admissions (11.5 months in one case). One service user talked of attempting suicide, another of being assaulted, two of being sectioned and one of being made homeless.

The ward environment was strongly criticised by one participant, who described the ward as dirty and smelly, and felt that the care she had received was limited to brief interactions with staff centring on medication. Another was critical of the primacy given to medication, and a third refuted the legitimacy of their admission describing their difficulties as physical rather than mental.

One staff participant felt that care planning tended to miss out areas of individual importance in people’s lives, particularly matters of spirituality and sexuality, and another drew a distinction between what was written about care planning in policies and the difficulties of mobilising this in practice. Staff at this site emphasised the usefulness for continuity of having community staff attending discharge meetings.

Care reviews

Staff indicated that weekly review meetings take place with informal reviews on a daily basis during shift handovers. It was noted that review meetings incorporated multiple staff members, and that involvement of service users’ family members and friends was actively encouraged. Concerns were raised about the inadequate time available for reviews and that time-consuming care plan administration detracted from the time spent with service users. It was suggested that service user involvement in reviews could be helped by encouraging staff to make advance arrangements to meet with patients during quieter times on the ward. Staff understood review meetings to serve as an opportunity to evaluate the effectiveness of care planning and to monitor and assess risk.

Service user participants, however, provided negative accounts of their review meetings, describing these as being full of jargon and typically leading to an increase in medication. One service user reported finding it difficult to say everything that they wanted to say during ward round meetings, because of the lack of time available, and emphasised that writing things down in preparation would be useful. Another complained that ward rounds were full of people who ‘don’t really need to be in there, they’re just there to gawk’ (C-SU-103). Service users felt that ward round meetings were repetitive, and one participant was uncertain if she was being listened to.

Support systems

Staff held various ideas about the most important aspects of their roles, including observing and ‘reporting back’ (C-ST-102) about service users’ progress, spending quality time with them, and focusing on their physical as well as mental health needs. Lack of time was once again cited as a hindrance in this respect. Staff provided varied accounts of the training that they had received, ranging from structured, compulsory sessions to informal options and supervision.

One staff participant noted that better collaboration with (and greater support from) other agencies would be helpful, especially in terms of securing housing arrangements for patients after discharge. Staff maintained that family and friend involvement is was as much as possible. One described how, in meetings or discussions, family members or friends are encouraged to express their preferences, and another that this is particularly important in relation to planning leave. It was acknowledged that overinvolvement of family/carers can, however, cause problems, especially in terms of discharge decisions. Effective communication with families/carers was recognised as a means of resolving such difficulties.

Service user participants reported varying experiences of and views about the support they received. Two stated that they did not have a named or primary nurse, and one claimed that ‘you’re pretty much left to your own devices’ (C-SU-105). Another described the relationship with their named nurse as good, but maintained that this was challenged by shift patterns on the ward. One service user noted that their care on the ward had been characterised by poor communication, and that having a solicitor had proved helpful in overcoming this.

Most service users praised the attitude of staff on the ward, believing that staff were compassionate and treated service users with respect and dignity. In contrast, one service user complained that staff continually confused her with a fellow patient, and was very critical of the care that she had received. One reported their discomfort at regularly having to approach and ask staff for their time:

I don’t like to drag people away from their work . . . They don’t mind but you just feel a little bit intrusive, you know what I mean?

C-SU-105

Service users had varying levels and kinds of contact with wider support networks. Two said that they had received occasional help from social workers, and one explained that the relationship with her community psychiatric nurse (CPN) had broken down. Another indicated that although she was aware of the support available from other workers, this process was never discussed with or explained to her.

Organisational context

Several developments in inpatient care were observed by staff, including an increased focus on involving families and carers, and the implementation of the Measure’s option to allow service users to self-refer. Cutbacks in services and funding were understood to have hindered the effectiveness of care planning and co-ordination, although the Measure was generally felt to have had a positive impact in terms of clarifying expectations and legislative requirements.

Staff provided various accounts that related to the health board’s principles and values. For the most part, these were general conceptualisations, rather than references to specific policies, although it was acknowledged that guidelines do exist.

Recovery

Doubt was cast on the relevance or usefulness of the term ‘recovery’ for some individuals, depending on the nature of their condition. Access to services was acknowledged to be important, and sending people home well was felt to be a primary goal. Another staff participant recognised the ubiquity of the term ‘recovery’, believing that it invoked and represented the shift from asylum-based/medical models of care to newer and more collaborative ones that encourage patient and family involvement. Recovery-oriented practice was seen to have increased the emphasis on leave and discharge, and connections were drawn between recovery and leaving hospital as quickly as possible.

Some staff mentioned the use of recovery tools, although wellness recovery action plans (WRAPs) were not used. Staff noted that although the Recovery Star was used in rehabilitation services at Champagne, it was not used on this ward. Staff maintained that service users’ skills and strengths were recognised and considered. The importance of involving the wider support team (including OTs) was also mentioned.

Service users defined recovery in a variety of ways, and understood this to be a complex and challenging process that necessarily encompassed many different factors. The detrimental impact of mental illness on personal confidence was noted. One participant associated recovery solely with his physical ill health, and another seemed to question the possibility of recovery, given the nature of her illness. Recovery was also associated with improved communicative abilities and self-awareness.

Service users gave mixed views about the ways in which their hospital stay had had an impact on their recovery. Some reported having received practical support, aimed at encouraging service user independence and empowerment. One participant, however, described the ward environment as detrimental to the recovery process: ‘you can’t recover by being locked up in a derelict place . . . filthy everywhere, the patients smell’ (C-SU-102).

None of the participants interviewed indicated that they had been involved in any helpful discussions with staff about their recovery. One service user said that although no one had talked to him about recovery during his time as an inpatient, strategies had been put in place for continuing his medication following discharge, with which he was satisfied. None of the service user participants had recovery plans.

Personalisation

Most staff participants were unfamiliar with the term ‘personalisation’, but all had an awareness of the concept and its association with person-centred care. Only one provided a detailed definition, and did so in positive terms, contrasting current practices with previous ones. Direct connections were also drawn between personalisation and recovery, although it was acknowledged that the term was not used in discussions about care planning.

Most of the service users interviewed were not familiar with the term either, and were unsure about what it might mean, although one participant did associate the term with person-centred/individually tailored care.

Most staff felt that care planning was personalised to a degree; this was linked to the format and structure of written care plan documents, and staff also acknowledged that the successful delivery of a personalised approach depended greatly on the available resources. One member of staff emphasised the extent to which these concerns were related to ethnicity, culture and dignity in terms of behaviours on the ward.

Service users were ambivalent about the personalisation of care planning, although one was very positive about their experiences: ‘without this place it would be the end of me’ (C-SU-105). It was noted that there is, generally, scope for personalisation, although one participant voiced contrasting views and reported that his care had not been personalised or individually tailored in any way at all.

Barriers and facilitators

Factors to help ensure personalised/recovery-focused care included focusing on and regularly reviewing individual needs. Two participants spoke of a lack of resources – especially a lack of nursing staff – and the restrictions that this placed on the time available to spend with service users. Effective communication was seen by staff as important, and an empathic attitude and manner was considered helpful: ‘[to] . . . bear in mind what would you be like in that situation’ (C-ST-102). Integrated care and family involvement were also seen as facilitators.

In terms of barriers, one participant emphasised the problems of delayed discharge caused by the lack of suitable accommodation. The challenge of administering medication for some service users was also seen as a hindrance. It was suggested that delayed discharge is linked to a reduction in the quality of care given to service users. Staff had various suggestions on general improvements to care planning, including investment in service delivery through the provision of more staff. It was noted that, currently, care plans are not comprehensively discussed in ward rounds, and staff felt that this would improve things, especially in relation to risk assessments.

Services users also saw better communication as a means of improving care planning, and some participants felt that an increase in structured ward activities could usefully be made:

. . . have a look around this room, there’s nothing in here, and there’s bits of rubbish everywhere, and it’s like there’s nothing to do.

C-ST-103

Lack of resources was also acknowledged to be having a direct impact on service users; one participant noted that activity/art rooms can only be used as long as there is sufficient staff presence on the ward, which is rarely the case, meaning that activity timetables are rendered redundant.

Care plan reviews

Four participants, three female and one male, were selected for care plans on the main ward in Champagne. They ranged in age from 35 to 49 years. All participants had previous admissions and, although the information provided was unclear, it was determined that one participant had been detained formally. Our review was unable to locate the care plan for one service user. There was no evidence that the remaining care plans had been signed by the service user or that the service user had been given a copy. There was no evidence that the named nurse had signed the care plan. Only one service user had attended the last ward round and no carers attended. The care co-ordinator had attended in only one case and again this suggests potential issues with continuity of care. The care plans had clearly been written by staff and although they demonstrated inclusion of the service users’ views (e.g. ‘patient is happy at present with her current treatment plan although was unsure as to the reason she is prescribed her depot’), there was no clear evidence of coproduction. No care plans demonstrated a strengths-based approach or a focus on personalisation. Two care plans showed some emphasis on person-centred recovery-focused goals, for example supporting a service user to attend church and maintain social activities. Care plans tended to emphasise system-based goals such as medication monitoring and compliance. There was no evidence in the care plans of service user involvement in assessments of safety and risk or in the risk management plans. Discharge planning was evident in care plans, although this seemed somewhat limited (e.g. ‘Integration of the appropriate health and social care services that can support patient to move to [local area] whilst meeting her mental health needs’).

Meeting observations

In Champagne, one observation of a ward round meeting was completed. Eight people were present at the meeting: the researcher, a psychiatrist, the named nurse, two student observers, a note-taker, a doctor and the service user. The meeting was held in an extremely small room. The service user was collected from the ward by the psychiatrist and greeted warmly with a smile and led into the room. Initially, the service user appeared anxious but was reassured by the psychiatrist, with gentle humour, ‘you’re not on trial here, OK?’. The review started with an open enquiry to the service user as to how the week had been. The rest of the meeting focused on exploring the service user’s progress to assess if they were ready for discharge. Focus was placed on self-awareness of relapse indicators and in exploring understanding of potential future problems. There was no evidence of the use of summarising or clarification of what the service user said but sensitive and empathic responses were provided. Emphasis was placed on behavioural patterns and practical strategies rather than feelings and emotions. The service user was knowledgeable about his medication and provided suggestions for changes, which were accepted and adjusted. The psychiatrist and the service user appeared very familiar and comfortable with one another with a well established relationship. This was exemplified by the psychiatrist’s effective use of non-verbal and verbal communication to engage with the service user, who appeared to understand what was being discussed. There was no mention of the care plan in the discussions. Risk and safety were not explicitly mentioned; however, conversations relating to responsibility in decisions around health, in particular the use of substances, were discussed and revisited, with several points reiterated (‘what do you feel is in your control?’). The service user’s relationship with his family was explored, with emphasis placed on concerns about the family’s distress during the last home visit. The service user was asked about updates on his accommodation status, and, interestingly, staff appeared unaware of the progress with this. Discharge was discussed and a date was agreed, and the service user was given the option to invite his parents to the next meeting.

Views on Inpatient Care Scale

A total VOICE score for each respondent was obtained by summing the scores of the individual items. The higher the total score (range 19–114), the more negative the perception of the quality of care on the ward. The score for respondents in Dauphine is shown in Table 24.

The total scores for VOICE were marginally lower than the reference value provided by Evans et al. 52 The mean scores were in the lower half of the scale, suggesting that service users lean towards a more positive perception of the ward. There is, however, a moderate range of responses for this measure, demonstrating that some of the participants have a more negative perception of the ward.

Empowerment Scale

A total ES score for each service user respondent was obtained by summing the scores of individual items. The overall mean score for the sample was above the mid-point for the instrument. Out of a possible score of 4, indicating a higher perceived level of empowerment, the mean total score was 2.80 (SD 0.38), which is slightly higher than the reference value. 146 The subscale values were also slightly higher than the reference group, apart from righteous anger, which was comparable, and power–powerlessness, which was lower (Table 25).

A further comparison was made of the scores for empowerment between the two COCAPP studies (acute and community mental health services). The total score and subscales for the ES were higher for the responses obtained from service users in acute inpatient services than for the responses from those in contact with community mental health services, apart from power–powerlessness, which was lower. See Chapter 5 for some exploratory inferential analyses.

Scale to Assess the Therapeutic Relationship

For service users the mean total score for the STAR-P was 29.17 (SD 10.00), with scores of 14.98 (SD 6.99) for ‘positive collaboration’, 7.16 (SD 3.15) for ‘positive clinician input’, and 7.04 (SD 3.29) for ‘non-supportive relationships’. These scores align well with the reference values provided by Nolan (personal communication) shown below in Table 26, apart from the non-supportive clinician input subscale, for which the service user scores were just over 1.5 points lower than the reference value.

For staff the mean total for the STAR-C was 37.45 (SD 3.73), with scores of 18.20 (SD 2.35) for ‘positive collaboration’, 10.38 (SD 1.07) for ‘positive clinician input’ and 8.86 (SD 1.65) for ‘emotional difficulties’. The subscale values and total scores were aligned well with the reference values, with negligible differences.

When comparing the mean service user and staff scores, it is apparent that staff give higher scores and therefore rated the therapeutic relationship more positively than service users. The total STAR scores are on average eight points higher for staff than for service users.

An independent samples t-test was completed to determine if there were significant differences in the perceptions of the therapeutic relationship between service users and staff. There was a significant difference in the total STAR scores for service users [29.17 (SD 10.00)] and staff [37.45 (SD 3.73)] [t(65.1) = –5.58; p < 0.001; 95% CI –11.23 to –5.32; Cohen’s d = 1.10] and the subscales. T-test statistics for the subscales are provided in Chapter 5, Table 52.

A final comparison was made of the scores for the therapeutic relationships between the two COCAPP studies (acute and community mental health services). It is clear from the scores in Table 26 that service users score this approximately four points higher in the total STAR-P score for community mental health services than for acute mental health services.

Recovery Self-Assessment

The mean scores and SDs for the RSA are provided in Table 27. The mean scores from service users and staff on the subscales fell in the moderate to high range (3.11–3.49 and 3.47–3.93). The mean total RSA scores for staff were higher [3.74 (SD 0.53)] than those for service users [3.30 (SD 0.89)]. The lowest scoring subscale for both participant groups was involvement. The life goals subscale was the highest scoring subscale for both groups.

Independent samples t-tests were conducted to compare the perceptions of recovery-oriented services for staff and service users. There were significant differences in the total RSA scores for service users [3.30 (SD 0.89)] and staff [3.74 (SD 0.53)] [t(85.5) = –3.05; p = 0.003; 95% CI –0.72 to –0.15; Cohen’s d = 0.60]. There were also significant differences in two of the subscale scores, ‘choice’ and ‘individually tailored treatment’ [the rest of the t-test statistics for subscales are provided in Chapter 5 (see Table 52)].

A final comparison was made of the scores for the perceptions of recovery-oriented care between the two COCAPP studies (acute and community mental health services). The RSA total score given by service users in acute mental health services in Dauphine is equivalent to that given by service users in our community study. Conversely, staff in the acute study score the overall RSA total higher than respondents in the community study.

There are also some differences at the subscale level, with service users in acute services scoring the ‘involvement’ and ‘individually tailored services’ higher than did service user respondents in the community study. Conversely, service users in the acute study scored the ‘choice’ subscale lower than those in the community study but scored the ‘life goals’ and ‘diversity of treatment options’ subscale comparably.

There are also some differences at the subscale level for staff. In our acute study, the staff members scored all of the subscales higher than did respondents in the community study. See Chapter 5 for some exploratory inferential analyses.

A recovery profile from the RSA Scale is included in Appendix 5.

Care planning and co-ordination

Staff spoke of the CPA being a ‘framework’ in which people’s care and needs can be planned, as well as of care plans needing to be holistic and focused on service users’ individual needs and to be informed by knowledge of the person’s background and history. It also required good collaboration within the MDT.

I guess it’s about . . . co-ordinating all the different aspects of their care . . . I’m not saying it always does, but I think it should include things like housing and financial support and family support and psychology support and support from psychiatry and medication if that’s what’s useful.

D-ST-102

Some recognised the care plan as part of a wider dynamic and active approach, and that the written document was only one small aspect, designed to ‘make sure all those things happen’ (D-ST-102). It was important to acknowledge that service user and staff perspectives and interpretations may be very different, and to document these. The care plan must be meaningful to the person and must be regularly updated.

Several staff mentioned that they felt under pressure to reach targets (e.g. owing to cuts), and this did not always allow time for individualised care:

The [NHS] culture is becoming target driven . . . and I think sometimes the CPA just becomes one of the targets.

D-ST-106

Three service users were not aware of their care being planned. One said that they would like the care plan to include physical care. Another said that it was important to have a plan that incorporated continuity of care after discharge:

I have no one out there . . . if there is no network then I’ll fall straight away, which is exactly what happened . . . I think it’s really important to have a care plan.

D-SU-105

One service user who was aware of his care plan said that, based on 15 years of experience using services, it was largely a matter of ‘common sense’ (D-SU-104).

Two carers interviewed were both aware that the care of service users was being planned and co-ordinated. Both also felt that their relatives were well supported and that they had received clear information about their care.

The trust had made attempts to simplify and reduce the complexity of care plans, but many staff still struggled with the logistics of completing various forms and uploading them onto the electronic system. The trust had also introduced the ‘This Is Me’ care plan, which was more personal to the service user; it was described as a ‘golden opportunity . . . to find out what the person is about’ (D-ST-104). Staff described care planning as useful to a degree but that they needed to get the service user to ‘talk about themselves and what they hope for the future’ (D-ST-102) and to obtain a holistic view; the care plan became useless if it was just seen as a ‘tick-box’ exercise. Although care plans were not essential, they did have benefits:

. . . without it stuff would get lost and [then] people won’t get support from the relevant agencies that are needed.

D-ST-102

Several staff mentioned that the care plan was a useful aide memoire, although one staff member said that the plans were not done very well on wards. Care plans were used by the MDT and consultants during ward rounds, and many staff referred to the documents on a regular basis, as they provided structure. One staff member mentioned that the plan was used for controlling and monitoring the team. Several staff thought that an app would be a good idea, but data confidentiality issues remained.

Several service users reported having a care plan in the hospital, but not in the community. A couple had found their care plans useful; others did not have one, could not remember it or said that it had been provided weeks after their admission. Several found the plan unhelpful and not important to their health: ‘it doesn’t really help me because it doesn’t influence . . . me’ (D-SU-104). One felt that she had ownership of her care plan, but she could not find it. Another had refused to sign the care plan as the planned one-to-one meetings had not taken place. One carer was very knowledgeable about the care plan, the other less so. Both said that they would welcome a digital care plan or app, as their relatives were computer literate, used their mobile phones constantly and were responsive to messages received by mobile phone.

All staff spoke about a commitment to involving service users in the writing of care plans, but some also acknowledged that this was not always done and that some staff did not see the care plan as a two-way process. Others barriers to involvement included the structure of and jargon in care plans, a lack of spoken English, severity of illness in the early stages of admission, sensitivity around some issues and a refusal by some service users to become involved. There was also some recognition of the involvement of relational power issues and inequalities:

. . . the power thing, how much do people feel able to say no that shouldn’t be in my care plan or to challenge, you know if someone says oh I need you to sign this care plan.

D-ST-102

Overall, service users spoke of having little or no involvement in the writing of their care plan. Some saw the plan as something produced primarily by the ‘the doctors and his team of professionals’ (D-SU-103) and being much the same for everyone. Although some did not seem concerned about their lack of involvement, others would have liked more:

I would know what was going on. I can give my opinions, I get my rights, I get my choices and preferences.

D-SU-101

Both carers said that they had been satisfactorily involved in discussing and planning care, although one complained that they had been given very short notice about ward rounds. The benefits of carer involvement were clearly articulated:

I’ve felt that my voice has been acknowledged, my presence has been acknowledged, and I’ve been able to share with them what [name] would normally hide. And because of sharing that they’ve, they have a better understanding of how to provide that support for [name], whereas if it was [name] on her own she would minimise a lot of things, which a lot of individuals do because of shame.

D-CA-101

Staff spoke of discharge planning being a phased process over time and taking place in ward rounds, care plan reviews and ad hoc meetings with the involvement of MDT, community teams, the service user and, often, carers. There was some recognition that things did not always go to plan, with pressure on beds and community staff creating tensions.

Services users had generally been involved in discussions about plans for their discharge but the details they gave were often sketchy. Some expressed anxieties about their pending discharge:

I’d like to feel like there’s actually someone there fighting my corner for me. And I’m not feeling any of that, I feel like a statistic, I don’t feel like my consultant has, and I’m being really blunt now, I don’t feel like my consultant has any care about me, I don’t feel secure with my discharge. It’s something I worry about, really regular, and it brings me down quite a lot.

D-SU-105

Both carers said that discharge plans had been discussed with them and with service users from an early stage, but this was not necessarily documented in the care plans.

Care reviews

Staff were consistently clear: care plans were reviewed weekly in psychiatrist-led ward rounds with strong MDT involvement. There was recognition that they tried to involve service users in the meetings but these meetings were often too busy or too long, and people felt that they had too little time or felt too intimidated to contribute. Preparing people for reviews helped but this happened too seldom.

Occasionally, staff were held to account by service users requesting the implementation of care plans.

Half of the service users found the meetings quite useful to determine what was required to be discharged and to be able to plan. Others described them as ‘horrid’ and ‘tedious’. One spoke of being overwhelmed, having no control and feeling scared to say what she felt: ‘I don’t feel welcomed, maybe that’s the word, into my own ward round’ (D-SU-105). Carers said that it was difficult to attend because of the fixed time and short notice, and they had mixed experiences of being heard.

Support systems

Staff members articulated their roles with the MDT, with the consultant clearly seeing the role as providing clear clinical leadership and decision-making and the ward manager trying to provide structure and calm, following and guiding staff to address the service users’ needs. Other staff focused more on their direct clinical and social work with service users. Training was a mix of standard mandatory and discipline specific, with little or no focus on care planning and co-ordination.

Service users and carers spoke very positively about their interactions with most staff and often praised named individuals. Some were aware of having a named nurse but even if they did not they found staff responsive and easy to talk to. Staff were described as ‘fantastic’, ‘cool’, ‘caring’ and ‘respectful’:

They’ll always say please and thank you, and call you by your name, and they’re polite and got manners. So, yeah, but they don’t talk down to you.

D-SU-105

There was some suggestion that dealing with conflict was a challenge for some staff.

The ward team was supported by a mix of external agencies and people, all helping to improve services, with MIND, advocates and even researchers mentioned, and housing advisors being especially praised. One staff member emphasised that efforts were always made to ensure good collaboration and communication between the various parties and organisations involved:

. . . people are proactive at getting them involved, and they’re proactive in coming . . . there’s loads of different things . . . loads of support is available.

D-ST-102

Additional support was also recognised by most service users who described helpful input from social workers, psychologists and family workers. This was echoed by both of the carers, who described widespread collaborative support from professional workers involved in the service users’ care that had been effective and valuable, and that it had had a hugely positive impact on the service users’ progress:

I think they think of everything . . . What do I need to do . . . Do I need to settle her in? Do I need to phone her? Do I need to check in on her? And I think that is something that [name of service user] needs all the time, she needs constant reassurance and I think she gets that.

D-CA-101

Staff also spoke of efforts to involve families/carers on the ward and to a great extent this was reflected in the comments of the carers and most of the service users.

Safety and risk

Staff described various processes and structures to ensure that the safety of patients was paramount, while some also spoke of trying to achieve a balance and said that positive risk-taking was important and valuable:

I think that’s important to not let risk impede care or things that can make a difference.

D-ST-102

Although risk was central to care planning and seen as an important feature of working with service users and families, there was also a recognition that documenting risk issues could be stigmatising and had to be balanced by strengths, positivity and the service user taking responsibility. One staff member emphasised that ‘managing risk should be collaborative’ and that having open and sustained conversations with service users could be helpful in terms of risk assessment and management:

. . . sharing the risk plan and saying, well, what do we need to do to keep you safe? . . . Giving people ownership over, over what they would like to happen.

D-ST-102

Service users had little say on this subject, although most were aware of measures taken to manage risk, such as removing certain items on admission. One service user spoke of staff actively keeping her safe when she had been threatened by another patient and two said that their safety was addressed in their care plans. Two also said that more could be done to address issues of physical health and the environment (e.g. dirty patients, lack of clean air) in relation to safety. When mentioned, service users thought that detained patients were treated similarly to informal patients. Carers thought that the safety of patients was addressed.

Organisational context

Staff said that the trust’s focus on quality improvement had led to significant improvements, including reductions in the levels of violence on wards, improved physical health care and the increased involvement of carers. The introduction of a befriending service, peer support workers and a strong service user organisation within the trust were all important.

There was a strong and consistent view that strong trust values and support from senior staff, which included some people with lived experience of mental illness, was creating a much more positive culture with a focus on dignity, privacy, confidentiality, and feedback from service users to improve services:

I guess stuff to do with respect and that people should be respected . . . people’s needs and people’s culture . . . should be respected, and people should be offered things that are relevant to them.

D-ST-102

The aim, described by D-ST-106, was to provide collaborative, recovery-focused, patient-centred care, and a clear relationship between these values and care delivery on the ward was articulated:

. . . [service users’] wishes and their hopes, and dreams and their beliefs about what is really helpful is for them and what is important to them, it should be valued and encouraged, and acknowledged, and actively included in the care plan.

D-ST-102

Recovery

All staff embraced the idea of recovery, although some were not keen on the name. All described recovery as being very personal and also about helping people come to terms with, make sense of and incorporate their experience of mental illness/distress:

. . . it will never be as such recovery, it’s them living with what is part of them and managing it to the best of their ability and what we’re doing is providing them with the skills and the understanding in order to live with what is part of who they are.

D-ST-101

Some spoke of healing, understanding, resilience, well-being and taking control. One described recovery as perhaps a measured response to a trauma or an episode, whereby the individual is able to understand it and be better equipped to deal with a recurrence. Holistic care needed to be tailored to the person. Another said that some of the recovery journey takes place in mental health services, while some takes place at home and in the community at large:

It’s being able to think with the patient about that, I think, and trying to provide good-quality care where it’s necessary but also being able to withdraw and give ownership back to patients and allowing them to continue that.

D-ST-106

All staff said that a recovery-focused approach informed their practice and care planning that was centred on being person-centred, instilling hope and supporting the person to go back into the community and society. Service users described different levels of recovery, from being able to be discharged to a life free of medication and not needing support, or being able to successfully manage or cope with their mental distress. Another service user described recovery as being more balanced and about being able to think clearer.

All felt that hospital admission had helped in their recovery; they found it difficult to explain how, although for some this was about medication. One said that a greater focus on her strengths would have been more helpful. One carer said:

Recovery is about an individual being given the correct support so that they’re able to deal with situations and deal with them appropriately.

D-CA-101

The carer agreed to an extent with the journey metaphor, but emphasised that service users’ recovery is very much a gradual and non-linear process, and that this dynamic needs to be properly understood and respected:

I think [name of service user]’s at that dip where she’s testing her own control of things, so we allow her to have that dip, because if we don’t . . . she will not be able to reinforce, well you know what? I achieved that, I’ve had a dip, I can go back and try it again.

D-CA-101

The other carer saw recovery as more about the service user returning to a previous state of better mental health. Both carers felt that the care was recovery focused but that this was also shaped by the perspective at different points of the service user. One said that the service user’s care planning had been helping with her recovery by recognising trigger points and particularly stressful issues, and also by providing her with a secure base:

[T]hat is something that has been missing in [her] past. She’s fought battles and nobody’s actually stood behind her, and I think this is the first time that she’s actually experienced it, and she is holding on to that, somebody’s there for me.

D-CA-101

Most staff spoke of the ‘This is Me’ care plans and about encouraging service users to develop them as soon as possible following their admission. These were found to be helpful and were reviewed regularly: ‘I think people really value it because . . . it really helps understand what is going on for that individual’ (D-ST-102). A few staff mentioned the recovery star but did not use it, and some spoke of time pressures limiting just how much they could embrace such tools on the ward. Some service users had used the ‘This is Me’ plans; others had not or were not aware of them. None had been aware of other recovery tools. Carers were unsure. Both of the carers and some service users thought that strengths and achievements were recognised, although the traditional care plan did not reflect this.

Personalisation

Staff thought that personalisation was largely about ensuring that care was personalised and focused on the individual. A couple were aware of personal budgets but all had little involvement in these working on the ward. Staff felt that great efforts were taken to be person-centred but that this was sometimes more challenging when someone had been detained and there was disagreement about why they were there.

Few service users understood or recognised the term personalisation; some thought that it was about their care being personal to them or helping in their recovery or about writing their care plan. One detained service user said that their care was not personalised at all. Another gave an example of how, after another service user had stolen her brand-new pyjamas from her room, staff made sure that her room was locked and that her personal space was protected.

The carers were a little unsure about the term but thought that personalisation meant personal care, or ‘not processed’ (D-CA-101). Both thought that care had been personalised and gave examples of this, including arranging visits from and access to the service user’s children.

Barriers and facilitators

Staff spoke of needing more time to spend with service users, to develop therapeutic relationships, to find out more about them and to develop more collaborative approaches. Some wanted more training and staff who had the right approach. One also wanted education for patients and families ‘to help people become the masters of their own illness and their families to identify and support patients with their specific symptoms’ (D-ST-106).

Limited resources in terms of staff, time and facilities impaired attempts to work on recovery, as did responding to emergencies and people being subject to compulsory detention and safeguarding issues. Service reorganisations and loss of key staff had not helped. Some families did not help recovery-focused work. More time for nurses and other staff to spend with service users was seen as the most important factor that would improve care and care planning.

Care plan reviews

Nine care plans were reviewed on the main ward in Dauphine site for four female and five male service users who ranged in age from 18 to 58 years and of whom two were formally detained. For four participants this was their first admission to hospital and for others the number of previous admissions ranged from one to six. No service users had signed their care plans and only two named nurses had done so. It was not clear whether or not copies of care plans had been given to service users. In only two cases was it clear that the service user had attended the last ward round and there was no evidence that carers or care co-ordinators (seven out of nine service users had allocated care co-ordinators) had attended the previous ward round, indicating possible issues with continuity of care. Care plans were written by staff about patient care, although in most cases (seven out of nine) these did reflect the person’s views to certain extent (e.g. ‘he describes his mood as pleasant’, ‘he denies any hallucinations’). There were limited attempts at co-produced care planning (two out of nine) and strengths-based approaches (three out of nine), although the latter were mostly descriptive. There was limited focus on personalisation (four out of nine), use of personal budgets (two out of nine) and recovery-focused work (two out of nine). There was evidence in one case only of the person’s views of safety and risk planning, and in three care plans there was evidence of the person being aware of their risk indicators as a means to manage risk. Most care plans showed orientation to system-based medical goals such as medication compliance, with rare attention paid to social goals (two out of nine). There was no evidence of encouragement towards self-management in care plans. Discharge planning was addressed in six out of nine care plans.

Meeting observations

Two observations of ward round meetings were conducted in Dauphine. Six people were present in both meetings, including a researcher, the nurse in charge, a junior doctor, a student nurse, a psychiatrist and the service user. Two members of staff from a rehabilitation team attended one of the meetings. The room was spacious, with furniture arranged in a circle helping to create what felt to be a relaxed atmosphere. Both meetings were short, one lasting 7 minutes and the other lasting approximately 12 minutes. The psychiatrist led both meetings and gave no opportunity for other staff to speak, apart from the members of the rehabilitation team. Introductions were not provided because both service users had spent a long period of time on the ward and their relationship with the staff present was well established. For one meeting the service user was asked an open question to start: ‘how are you feeling in your mood, how have things been?’ The psychiatrist gave the service user time to speak but was quite firm at times (‘I’ve already told you we’re going to sort it out’) and interrupted (sometimes quite abruptly) to steer the conversation back on track.

The main focus of the meeting was medication and leave in preparation for discharge. Particular care was taken when considering the person’s safety and mobility issues and explaining the importance of taking medication at certain times in the day to reduce the risk of a fall. Enquiries were also made about practicalities of home life (accessibility and general state of the home) in preparation for discharge. Interestingly, the doctor emphasised the importance of the person’s behaviour on the ward in the next few days, warning them that they ‘need to be good in terms of behaviour’ and not to jeopardise the discharge. The meeting ended informally when the service user requested a cigarette break. For the second observation the psychiatrist initially directed the questions to members of the rehabilitation team and they spoke about the person’s ‘inappropriate behaviour tapering down’ alongside plans for the person’s discharge. The doctor addressed the service user sensitively, asking questions which were met with monosyllabic responses. These questions started quite open and then became more specifically about computer games (‘are you a soldier in the game, do you shoot people?’); it was unclear if the questions were directed out of interest or because they related to risk. The doctor demonstrated what appeared to be genuine interest in the well-being of the service user post discharge, enquiring about friendships and the support that could be put in place for their move to the rehabilitation unit. Praise and encouragement was given in reference to the person abstaining from using drugs. This was reinforced by emphasising the importance of this in relation to the person’s clinical history. A reward, of another computer game, was suggested to mark positive progress. Medication was not discussed in this meeting. During the meeting the doctor reviewed a behaviour contract that had been drawn up by the workers at the rehabilitation unit, but did not seem to engage fully with this and did not ask questions. The service user was given the opportunity to ask questions, reassured when needed and given information about future arrangements.

Views on Inpatient Care scale

A total VOICE score for each respondent was obtained by summing the scores of the individual items. The higher the total score (range 19–114), the more negative the perception of the quality of care on the ward. The score for respondents in Languedoc is shown in Table 30.

The total scores for VOICE were marginally lower than the reference value provided by Evans et al. 52 The mean scores were in the lower half of the scale, suggesting that service users leant towards a more positive perception of the ward. There is, however, a large range of responses for this measure, demonstrating that some of the participants had a more negative perception of the ward.

Empowerment Scale

A total ES score for each service user respondent was obtained by summing the scores of individual items. The overall mean score for the sample was above the mid-point for the instrument. Out of a possible score of 4, indicating a higher perceived level of empowerment, the mean total score was 2.92 (SD 0.34), which is slightly higher than the reference value. 146 The subscale values were all higher than the reference group, apart from righteous anger, which was comparable (Table 31).

A further comparison was made of the scores for empowerment between the COCAPP studies (acute and community mental health services). The total score and subscales for the ES were higher in responses obtained from service users in acute inpatient services that in responses from those in contact with community mental health services. See Chapter 5 for some exploratory inferential analyses.

Scale to Assess the Therapeutic Relationship

For service users, the total score for the STAR-P was 27.93 (SD 12.57), 13.85 (SD 7.77) for ‘positive collaboration’, 6.38 (SD 3.85) for ‘positive clinician input’ and 7.71 (SD 3.50) for ‘non-supportive relationships’. These scores align well with the reference values provided by Nolan (personal communication) shown in Table 32. All the values for this study are, however, marginally lower than the reference values for this site.

For staff, the mean total for the STAR-C was 37.98 (SD 4.24), with scores of 18.20 (SD 2.35) for ‘positive collaboration’, 10.55 (SD 1.38) for ‘positive clinician input’ and 9.15 (SD 1.46) for ‘emotional difficulties’. All of the subscale values and the total score were approximately equivalent for the staff in this study and those in the reference study.

When comparing the mean service user and staff scores it is apparent that staff give higher scores therefore rating the therapeutic relationship more positively than service users. Total scores are on average seven points higher for staff than service users.

An independent samples t-test was completed to determine if there were significant differences in the perceptions of the therapeutic relationship between service users and staff. There was a significant difference in the total STAR scores for service users (mean 27.93, SD 12.57) and staff (mean 37.98, SD 4.24) [t(56.3) = –5.19; p < 0.001; 95% CI –13.9 to –6.17; Cohen’s d = 1.07] and two of the subscales (positive collaboration and positive clinician input). T-test statistics for the subscales are provided in Chapter 5, Table 52.

A final comparison was made between the scores for the therapeutic relationships across the two COCAPP studies (acute and community mental health services). It is clear from the scores in Table 32 that service users scored approximately eight points higher in the total STAR-P score for community mental health services than in the total for acute mental health services.

Recovery Self-Assessment Scale

The mean scores and SDs for the RSA scale are provided in Table 33. Mean scores from service users and staff on the subscales fell in the moderate range (3.12–3.38 and 3.25–3.84, respectively). For the mean RSA total score, the staff scores were marginally higher (mean 3.52, SD 0.63) than those of the service users (mean 3.23, SD 1.10). There is some variability between responses for the service users and the staff. For the service users the lowest scoring subscales were individually tailored services, diversity of treatment options and involvement. For staff the lowest scoring subscale was involvement followed closely by individually tailored services. The highest-rated subscale for service users was life goals and for staff it was choice subscale. The staff scored highly on this subscale, indicating that clinician see this as an area of priority.

Independent samples t-test was conducted to compare the perceptions of recovery-oriented services for staff and service users. There were no significant differences in the total RSA scores for service users (mean 3.23, SD 1.10) and staff (mean 3.52, SD 0.63) [t(72.6) = –1.61; p = 0.113; 95% CI –0.73 to 0.08; Cohen’s d = 0.32] or many of the subscale scores (t-test statistics for subscales are provided in Chapter 5, Table 52), apart from the ‘choice’ subscale, where staff (mean 3.84, SD 0.66) scored significantly higher than service users (mean 3.20, SD 1.23) [t(67.8) = –3.15; p = 0.002; 95% CI –1.05 to –0.23; Cohen’s d = 0.65].

A final comparison was made of the scores for the perceptions of recovery-oriented care between the COCAPP studies (acute and community mental health services). The RSA total score for service users in acute mental health services in Languedoc was slightly higher than for those in community mental health services. Conversely, staff gave a marginally lower total RSA score in the acute study than respondents in the community study.

There are some differences at the subscale level, with service users in acute services scoring marginally higher on the ‘life goals’ and ‘individually tailored services’ subscales and considerably higher on the ‘involvement’ and ‘diversity of treatment options’ subscales. Conversely, service users in the acute study scored the ‘choice’ subscale considerably lower than did respondents in the community study.

There are some differences at the subscale level for staff. In our acute study staff scored ‘life goals’, ‘choice’ and individually tailored services’ lower than did respondents in the community study. In contrast, staff scored ‘diversity of treatment options higher’ in the acute study, and scores for ‘involvement’ are comparable across studies. See Chapter 5 for some exploratory inferential analyses.

A recovery profile from the RSA scale is included in Appendix 5.

Care planning and co-ordination

Staff expressed contradictory views on care planning processes. Both the ward manager and the OT saw care planning as central to ensuring that all aspects of care were brought together and centred on the patient:

[B]ringing a person’s care all together really, so it’s like a standard to work around, that it’s all centred around the patient’s care, so everything works for them in the best way, I think.

L-ST-103

Care planning supported multidisciplinary working within the ward team but failed to ensure the involvement of the community teams whose members rarely attended planning meetings or CPA reviews. In contrast, the psychiatrist felt that care planning and reviews were no longer significant or helpful and had simply become another tool for measuring achievement of targets against restricted resources.

All but one of the six service users had no idea if their care was planned or co-ordinated, or, if it was, who might be involved in that. Some spoke of ‘trusting’ staff to do what was best to ‘get them better’ (L-SU-101):

I don’t know if there’s anybody, we’re meant to have a named nurse and associate or something, I only found out my named nurse last week and I couldn’t even tell you who the associate is, so I just assume it’s the doctor.

L-SU-105

The one carer interviewed had attended meetings led by the doctor who directed questions at the patient in what seemed a ‘brusque, unhelpful manner’ (L-CA-101), although the parents were asked for their views. The carer would have appreciated if staff had explained what their son was going through, and given them better understanding of how to respond.

Views on documentation differed. The ward manager and the OT spoke of the care plan as an electronic ‘well-being plan’, which was service user focused, built up over time and involved all team members. This was described as a ‘whole document all in one, so it’s a lot better’ (L-ST-103) and was referred to regularly to guide care. All new inpatients have an ‘admission care plan’ for up to 72 hours, addressing safety, medication, observation levels and leave arrangements before the well-being plan is developed. The psychiatrist distinguished between ‘a management plan’ for psychiatrists and a nursing ‘care plan’ for nurses and saw these as separate, but thought that patients liked to see who is doing what with them. The OT wanted to see a mobile phone app introduced and the psychiatrist would welcome being able to e-mail care plans to service users.

All but one of the six service users had not seen or were very uncertain about their care plans, what was in them, what they meant or whether or not they had one. Two had copies of plans that appeared out of date. Some were more aware of care being planned and co-ordinated in the community but did not feel that these plans had influenced their inpatient care. When service users did have sight of care plans, the difficulty appeared to be in how these were worded, as they did not make much sense to the individual:

It’s mad. All these abbreviations, I ain’t got a clue.

L-SU-105

The carer interviewed said their son did have a care plan, and he had given them a copy. It detailed his medication and that he would be assigned a CPN care co-ordinator. However, the carer felt that it would have been more helpful to have something that ‘describes how he’s going to feel’, with personalised targets and things that were going to help.

Routes of admission to hospital recounted by service users indicated degrees of crisis and significant distress. Most had contact with crisis services, police and accident and emergency. Only half were under existing community care, and they reported minimal support. One spoke of a CPN giving him a depot injection every 2 weeks in the community, but ‘she didn’t used to come and talk.’ (L-SU-104).

All staff said that there was a high level of service user involvement in developing care plans, although less so among those admitted compulsorily or in disagreement about treatment. Current use of technology removes staff from the service user as they have to use computers in offices. Service users reported various experiences of care plans. Some seemed aware of them but felt that they were poorly explained and poorly worded. Care plans seemed to be a source of antagonism for some who did not recognise themselves in the descriptions. One suggested the need for an external independent person or advocate to ensure that the care plan reflected the individual’s understanding and that care plans would more directly refer to therapy rather than prioritising medication.

. . . that would have helped me because it would give us somebody to talk to that wasn’t connected to the hospital or ward.

L-SU-106

Workers indicated that discharge planning was something to be considered immediately and reviewed throughout a stay. Giving a provisional discharge date to aim for an early stage worked to motivate some but created anxiety in others. Inpatients tended to be offered periods of graduated leave and sometimes needed to be referred to other services (e.g. drug/alcohol). Multidisciplinary discharge planning included care co-ordinators if possible, with summaries faxed to general practitioners, 48-hour reviews with the crisis team, and 7-day follow-up with community teams if they have one.

Service users described a mix of very detailed planning for discharge, from plans with good multiagency involvement and discussions with service users, to more limited plans for CPN support on discharge, to little discussion at the time of interview. One person spoke of his anxiety about leaving with day leave lined up and little or no preparation for dealing with anxieties and fears. He reported that he was due for discharge but did not feel ready just yet, and advice to contact a crisis team and enrol at recovery college was challenged as he lived one and a half hours away and feared prohibitive travel costs. None of the service users reported actually completing advanced directives, and one carer spoke of their relative having graduated leave days at home but no discussion or planning with the family.

Care reviews

A general view among staff was that review meetings were quite sensitive to service users’ needs, with sufficient time (30–60 minutes) given for discussion per patient. Prompt sheets had been introduced by the consultant to help service users prepare what they wanted to say but they were rarely used ‘partially because they don’t find me too difficult to talk to’ (L-ST-103). Service users’ views were definitely listened to, although there were ‘red lines’, such as refusing all medication when they were clearly very unwell (L-ST-103). A range of staff attended the meetings, which were usually chaired by the consultant, although she occasionally handed over that role to other staff or even the service user.

Service users described ward rounds with doctors, nurses, students and psychologists present and some mentioned that they had the opportunity to invite a carer/family member with some flexibility given to allow attendance. They were given a chance to speak at meetings but did not mention being prepared for these. Most found ward rounds helpful – ‘very, incredibly helpful, yes’ (L-SU-103) – although these were described as largely a chance to ‘catch up’ with the psychiatrist about medication, etc. ‘Sometimes you feel it’s all been decided before you go in, you get that impression . . .’ (L-SU-106).

Some service users spoke of difficulty in addressing things with doctors or raising things in review meetings, and some variation in style of doctors was mentioned. The one carer interviewed spoke of minimal involvement and described one meeting with a psychiatrist as ‘confrontational’ as the service user was ‘accused’ (L-CA-101) in front of family members of frightening staff.

Support systems

Staff reported being a strong supportive MDT but struggled with external agencies at times. Some staff claimed to bring specific skills to care planning. The OT, for example, suggested that they were one of the few people who brought a social dimension to the process, while the psychiatrist brought leadership. All staff said that they had received the basic trust training in the CPA but that they had developed their skills and approaches through practice and by learning from others.

Named nurses were expected to have twice-weekly meetings with service users and all service users were to meet daily with another staff member. Service users either did not know their primary nurse or reported mixed views of the relationship with them. Few service users appeared to have planned times to meet but some spoke of nurses being caring and helpful when approached. One carer described how, when their relationship with the doctor had broken down, they sought out a nurse to speak with who seemed nice.

Service users gave mixed views on staff attitudes; some were sure that staff listened and were respectful and compassionate, and others were less so. Some of this appeared to relate to the use of bank staff and unqualified people who service users worried did not have the training to understand what was going on with them. There was, however, little support for the idea that the caring and compassionate responses actually translated into care plans, and there was a reported mismatch between positive experiences with staff and care plans that were seen as overly negative, which may have led to service users re-evaluating their experiences of staff in a less favourable light.

The family of one service user was concerned that medical staff had been confrontational with their son from the outset after a very serious incident. However, they highlighted that some nursing staff had stood out and ‘went the extra mile’ so that a close bond between them and their son was formed. The family of one service user was concerned that medical staff had been confrontational from the beginning with their son, after a very serious incident. They highlighted, however, that some nursing staff stood out and went the extra mile so that a close bond between them and their son was formed. There was a concern that for some staff it may only be a job, with insufficient time being taken to listen to parents experiencing distress as their relatives were admitted to hospital for the first time.

For the most part, support from staff external to the ward seemed problematic for service users; it appeared that the ward had not been able to build sustainable connections with external agencies or even with CMHT workers. Workers claimed that family involvement was widely encouraged, and about one-third of service users had a relative present at their reviews, although it was recognised that the timing of ward rounds was not always conducive to this. Issues of family difficulties and overinvolvement were raised, which were seen as reasons not to involve the family rather than being recognised as a potential opportunity to engage the person and their family members in some family work. Service users readily identified support from (often several) family members but all either appeared aware that the involvement of family or carers may not be helpful for them or were concerned that this may be a burden to their family members who often had their own difficulties.

Safety and risk

Risk assessments are conducted, which inform the care plan and are regularly updated by nursing staff and reviewed in review meetings. There was no mention of service user involvement. The OT gave examples of concerns about lone working, carrying out cooking assessments with people who might hide knives and helping people with poor personal hygiene to go out in public.

A number of service users said that they did not feel safe on the ward and would have liked more staff to be available. Some said that their concerns about safety from other patients had not been addressed. The carer spoke of the safety of their son being paramount for staff, except when he had left the ward and drank alcohol with staff unaware of his whereabouts.

The psychiatrist viewed care planning as directed by risk concerns and always weighing up the risk against the benefits, such as benefits of medication against possible side effects, or potential benefits and risks of taking leave. The ward manager clearly saw risk as the dominating issue. The OT suggested that psychiatrists tended to be risk adverse but that balancing risks with responsibilities and taking positive risks were necessary to make progress:

. . . if you let the risk rule over the actual care plan then you’re never going to get anywhere.

L-ST-102

Service users had mixed views on whether or not risk was discussed; some service users knew that this was in their care plan but others were uncertain. Some acknowledged that discussions about safety had occurred and staff were open to discussing this, with one person recognising the role of individual agency in the process:

At the end of the day it’s only what I’m willing to tell them isn’t it, so that, yeah, yeah, that was discussed enough.

L-SU-105

Some staff suggested that service users under a section of the MHA3 were less likely to engage in care plan discussions. At least three of the service users had been compulsorily detained; one thought that this meant staff gave more thought to their care, while another thought that he was being ridiculed through the process. They remained uncertain about their rights.

Organisational context

Staff spoke of various initiatives [e.g. productive ward, 6Cs, Accreditation of Inpatient Mental Health Services (AIMS), CQC inspections] and hoped that they helped to raise standards and remind staff of the importance of care planning. However, too often wards had the ‘worst patients, highest intensity of workload caseloads and were fire-fighting’ (L-ST-101). Personal values of caring, respect, honesty and compassion led people into mental health work: a belief that they were essentially good people trying to do good things for others. Some of this was reflected in the ‘vision statement’ of the trust, giving a sense that it was recognised across the organisation.

Recovery

The psychiatrist declared some scepticism about recovery and suggested that policy-makers ‘just come up with different terminology to try and make it sound like we’re doing a better job’ (L-ST-101). She thought that recovery was not appropriate for everyone: that for some it was about symptom management or lifestyle management. She suggested that it was applied differentially – ‘I’ve got hope for you but I’ve not got hope for you’ – and constructed this as ‘elite versus gutter’, suggesting a serious misunderstanding of recovery philosophy. The other staff were more aligned in their thinking and saw recovery as a process:

To me the term recovery is about that person getting back to maybe what they were or to some sort of level where they can have a life and get by and do things that they want to do.

L-ST-102

The contrast between colleagues here is striking and suggests that the ward does not have a unified and agreed approach to promoting recovery-focused care.

Notions of recovery among services users were mixed but most saw it as getting better and regaining a form of their previous life or coming to terms with the impact of their difficulties. Some did not believe that this was possible, while others saw it as a process concurrent with their condition and that they needed to take an active role in making it happen.

Getting better . . . Just like to get yourself back to your daily routines and being normal again I suppose . . . recovery is not always possible but if you think like that you just, I don’t know, you’re just not going to get better are you if you just keep thinking that.

L-SU-101

The carer saw recovery as referring to the service user getting back to their old self, but they also expressed fears that mental illness would have an irreversible impact on the person’s personality and abilities.

Staff felt that service users could be helped to take initial steps towards recovery and that care planning, including the use of Recovery College, could contribute to setting people on a recovery pathway. Most service users felt that hospital had contributed to their recovery, although one person did not feel that anything had helped.

Staff mentioned WRAPs and the Recovery Star but these tools were seen as more suitable for community support and support in the Recovery College. No service users thought that they had been asked to develop a recovery plan or use any recovery-focused tools. Some said that their achievements and strengths were recognised, although specific examples were not provided. Carers felt that some recovery-focused work had occurred but that more specific goal-related support might have been beneficial.

Personalisation

In general, staff spoke fairly vaguely about putting the patient at the centre of their care, and service users often had no idea what ‘personalisation’ referred to:

It doesn’t mean anything, it just sounds like a made-up word.

L-SU-102

Others thought that it was about tailoring the care plan to their individual needs as each person is different, with one likening it to the personal settings on their mobile phone. All staff felt that they worked with service users in a personalised way and gave examples of this.

Overall, service users felt that there were some attempts to provide personalised care and to respond to individual needs, although it was often difficult to elicit examples of these. The carer felt that good attempts had been made and that their son’s individual character had been recognised after some time. Staff highlighted system and structural issues that could work against personalisation (e.g. MHA status and risk behaviours) but also gave examples of when they had been able to provide more personalised care.

Barriers and facilitators

Staff identified factors that would help recovery and personalised care. These included having more medical and nursing staff on the ward, more input from community teams and more time to develop therapeutic relationships:

How much more would I get from them . . . if they didn’t see me as the medic that you just go and see once a week and get your meds signed off.

L-ST-101

The physical environment of the wards was often not conducive to undertaking the work required, and limited ability to work in the community was also a barrier. Poor Wi-Fi access, inflexible information technology and inadequate documentation were all mentioned, as was the amount of time required to complete documentation to the required standard, as major barriers to spending more time on face-to-face work with service users. A lack of stability in accommodation and the failure of community teams to contain concerns about risk were also seen to put added pressures on ward staff.

Some service users asked for more personalised care and more (better paid) nurses, as well as a focus on autonomy and less concern with rules seen as unimportant. More information was also requested, as was more access to care plans so that people could make some sense of what was going on with their care. The carer would have liked to have been introduced to the CPN while their child was still in hospital and had their information needs addressed, such as being told who was in charge at weekends when they needed advice on medications.

Care plan reviews

Ten participants were selected for care plan reviews on the main ward in Languedoc. All of the service users were male and they ranged in age from 26 to 61 years. Seven service users were formally detained during their admission and 3 of 10 had been admitted to hospital previously. In only two cases was it possible to verify that the service user had signed their care plan, whereas five care plans had been signed by the named nurse. All 10 service users had been given copies of their care plans. All service users had attended their last ward round and in four cases carers had also attended; no advocates attended for any of these participants. Care co-ordinators were present for six of the service user participants who had one allocated, suggesting potential issues with continuity of care. One care plan could not be located for the review. In all of the remaining care plans there was evidence that the service user’s views had been included. The ways in which care plans were written varied from those written to the person (e.g. ‘you have voiced an interest in joining the gym’) to those written as if by the person but in formal language (e.g. ‘I will try and build up a therapeutic relationship with my named nurse’). Although there was evidence of attempts at coproduction and a focus on strengths and recovery ideas, for the most part the care plans simply reported discussions and did not show evidence of, for example, using strengths to orient care. There was some evidence of involvement in discussions about safety, risk and risk management. Some reference to discharge planning, usually involving onward referral rather than specific plans for the individual, was evident in all care plans reviewed.

Meeting observations

In Languedoc, two observations of ward round meetings were conducted. Five people were present in both meetings: a researcher, the nurse in charge, a junior doctor, a psychiatrist and the service user. In one of the meetings a crisis team manager attended. The room was quite small, with sofas and a table dominating the room. Some of the staff sat behind the table; the chair that the service user was directed to was close to the psychiatrist with no barrier between the two. One of the meetings focused on discharge and was quite short (5–7 minutes), while another meeting was substantially longer (20–25 minutes) owing to the discussion of complex needs. For both meetings the charge nurse collected the service user from the ward and led them into the room, where they were warmly welcomed. There was little need for introduction in one of the meetings, as the relationship was well established. In the other meeting the doctor was familiar with the service user and used some small talk to remind the person of their previous contact. The meetings were led by the psychiatrist, the atmosphere was relaxed and the other staff were able to ask questions freely. The doctor led the first part of the meeting and then handed over the chairing role to a nurse. Staff showed interest in what the service user had to say, enquired about future plans and worked collaboratively to arrange follow-up meetings. One service user mentioned struggling with some thoughts, which was not really acknowledged and attended to, and it was unclear if this had been spoken about before. It did appear that this service user expected some further support; it was acknowledged that he was trying and that he had support around him, but the doctor voiced ‘I think now, there’s nothing more the ward can offer you’. In one meeting it was mentioned that a discharge care plan would be given to the person but it was unclear if the person had any involvement in the development of this. Staff spoke for a considerable amount of time before one of the meetings, as they were particularly concerned about risk (‘risk is not obvious but subtle until it boils over and he kills someone’). During the meeting, risk was explored openly and quite sensitively (‘How do you feel about certain risks around you? Sometimes you can be impulsive’). Staff clarified what the person thought, details of medication, triggers and what the person’s understanding was of their admission and how the ward could be supporting them at this time. Enquiries were made about the person’s previous episodes of illness and positive encouragement was provided. Medication was discussed and the option of changes to this was given. Activities were also discussed and suggestions were made for coping with triggers. After the meetings, time was given for brief discussions about what to include in the notes.

Views on Inpatient Care Scale

A total VOICE score for each respondent was obtained by summing the scores of the individual items. The higher the total score (range 19–114), the more negative the perception of the quality of care on the ward. The score for respondents in Provence is shown in Table 36.

The total scores for VOICE were marginally lower than the reference value provided by Evans et al. 52 The mean scores were in the lower half of the scale, suggesting that service users leant towards a more positive perception of the ward. There is, however, a large range of responses for this measure, demonstrating that some of the participants had a more negative perception of the ward.

Empowerment Scale

A total ES score for each service user respondent was obtained by summing the scores of individual items. The overall mean score for the sample was above the mid-point for the instrument. Out of a possible score of 4, indicating a higher perceived level of empowerment, the mean ± SD score was 2.85 ± 0.40 this is slightly higher than the reference value. 146 The subscale values were all higher than the reference values, apart from the righteous anger and power–powerlessness subscales, which were comparable (Table 37).

A further comparison was made of the scores for empowerment between the two COCAPP studies (acute and community mental health services). The total score and subscales for the ES were higher for responses obtained from service users in acute inpatient services that for those in contact with community mental health services, apart from power–powerlessness and righteous anger, which were comparable. See Chapter 5 for some exploratory inferential analyses.

Scale to Assess the Therapeutic Relationship

For service users, the mean total score for the STAR-P was 29.58 (12.20), with scores of 14.72 (7.22) for positive collaboration, 7.41 (3.38) for positive clinician input, and 7.75 (3.42) for non-supportive relationships. These scores align well with the reference values provided by Nolan (personal communication) shown in Table 38. The score for non-supportive clinician input is, however, marginally lower than the reference score.

For staff the mean total for the STAR-C was 37.56 (4.82), with scores of 18.21 (3.01) for positive collaboration, 10.67 (1.20) for positive clinician input and 8.59 (2.33) for emotional difficulties. The subscale scores and total score for this study and the reference values are equivalent, apart from the emotional difficulties subscale, which is approximately 1 point higher in the reference value.

When comparing the service user and staff data, it is apparent that staff give higher scores and therefore rate the therapeutic relationship more positively than service users. Total scores are, on average, 8 points higher for staff than for service users. This reflects the pattern seen in the reference values.

An independent samples t-test was completed to determine if there were significant differences in the perceptions of the therapeutic relationship between service users and staff. There was a significant difference in the total STAR scores for service users (mean 29.58, SD 12.20) and staff (mean 37.56, SD 4.82) [t(67.1) = –4.22; p < 0.001, 95% CI –11.4 to –4.20; Cohen’s d = 0.86]. For the positive clinician input subscale, the scores for service users were lower (mean 7.41, SD 3.38) than those for staff (mean 10.67, SD 1.20) [t(63.9) = –6.32; p < 0.001; 95% CI –4.29 to –2.23; Cohen’s d = 1.28]. T-test statistics for the remaining subscales are provided in Chapter 5, Table 52.

A final comparison was made of the scores for the therapeutic relationships between the two COCAPP studies (acute and community mental health services). It is clear from the scores in Table 38 that service users in community mental health services score the therapeutic relationship marginally higher than those in acute mental health services.

Recovery Self-Assessment

Mean scores and SDs for the RSA are provided in Table 39. The mean scores from service users and staff on the subscales fell in the medium to moderate range (2.99–3.36 and 3.46–3.97, respectively). The difference in mean total RSA scores was higher for staff (mean 3.76, SD 0.56) than for service users (mean 3.20, SD 1.00). The lowest scoring subscales were individually tailored services and involvement for service users and involvement for staff. Both participant groups scored highly on the life goals and choice subscales.

Independent-samples t-tests were conducted to compare the perceptions of recovery-oriented services for staff and service users. There was a significant difference in the total RSA scores between service users (mean 3.20, SD1.00) and staff (mean 3.76, SD 0.56) [t(77.6) = –3.33; p = 0.001; 95% CI –0.89 to –0.22; Cohen’s d = 0.70], highlighting that staff rate recovery higher than do service users. A similar trend was found with most of the subscale scores (t-test statistics for subscales are provided in Chapter 5, Table 52), apart from the involvement subscale, on which there is no difference between the scores that staff (mean 3.46, SD 0.70) and service users (mean 3.06, SD 1.20) provided [t(69.8) = –1.89; p = 0.062; 95% CI –0.82 to 0.02; Cohen’s d = 0.41].

A final comparison was made of the scores for the perceptions of recovery-oriented care between the COCAPP studies (acute and community mental health services). The RSA total scores for service users in community and acute mental health services in Provence were almost equivalent. Conversely, staff respondents from acute wards gave an overall higher RSA total score than those from community teams.

There are also some differences at the subscale level, with service users in acute wards scoring the involvement, diversity of treatment options subscales and, to a lesser extent, the life goals and individually tailored services subscales higher than respondents in community services. Similar to the other research sites, service user respondents in acute wards scored lower on the choice subscale than those in the community study.

There were also differences at the subscale level for staff. In our acute study, staff scored all of the subscales considerably higher than respondents in the community study. Interestingly, staff working in the acute wards scored the diversity of treatment options over 1 point higher than respondents in the community study. See Chapter 5 for some exploratory inferential analyses.

A recovery profile from the RSA scale is in Appendix 5.

Care planning and co-ordination

While some staff described actively involving service users in producing plans, most talked of too little time, few resources and the lack of individualised care plans. One said the CPA was about crisis and risk management with care plans serving only to protect staff against litigation. Communication with and involvement of CMHTs and care co-ordinators was problematic, often delaying discharge. Planning care was the same for detained and informal inpatients but staff thought the status of sectioned service users could be a barrier to engagement.

One service user was not aware of their care being planned and said that planning care meant giving medication and seeing what happened. A second said that staff were trying to get her a social worker and were giving her one-to-one time, but ‘apart from that I don’t really know what they’re up to’ (P-SU-103). Another service user felt relieved that they did not have to co-ordinate their own care, while another spoke of the challenge of moving to another location and not having a care plan with the new care co-ordinator. One carer was aware of co-ordination happening through the community team, while the other was not aware of care being planned.

Staff expressed contradictory views about care plan documentation: some said that digital storage had allowed for wider sharing of information, whereas others spoke of paper plans, failing to complete all of the documentation and community staff not seeing everything. Community care plans did not inform inpatient care. The CQC had criticised a lack of personalised care planning, so more individualised recovery-focused plans were now used, but there were two types of forms, some duplication and insufficient time to complete both.

All service users spoke of their experiences of care planning, with three confirming that they had a care plan. Two were not aware of what was written in the plan and did ‘not feel ownership’; for one this was in part because they did not want to share information about their past illness. One spoke of understanding the care plan’s content. A second service user talked of being well cared-for in hospital and said that their care plan was focused on meeting longer-term accommodation and support needs. A third service user described a regularly updated care plan focusing on safety and risk, and contrasted hospital care experiences with more rapport-based care received in the community. Three service users perceived that staff did little in the way of planning care.

One carer spoke approvingly of distraction techniques being included in the care plan, which the carer saw via the service user. A second carer had never seen a care plan, but thought that it would be helpful for informing them of any progress.

All service users spoke about admissions taking place in the context of self-referral or of family, friend or staff having concerns about their safety. Connections were made between community care and care in the ward, with one service user explaining how hospital staff had been given information about them and others reporting visits by their care co-ordinator. One of the two service users who spoke about their legal status felt that this was not communicated to them clearly.

Staff reported a mix of experiences regarding involvement and collaboration in the production of care plans. Two talked of service users owning their care plans and being involved in reviews and ward rounds. Service users sometimes withheld information or refused copies of their care plans. Care plans could cause upset if the language used was too ‘professional’ and it was important to record information when opinions differed. One described using verbatim quotes in care plans and ensuring that service users were aware when a conversation with a nurse was focused on their care rather than a general chat.

One service user was aware that the care plan had been drawn up and who their named nurse was. Two were troubled by the format of care planning; one wanted the plan to consider her future, her faith and her goals, and she wanted to be more directly involved:

I don’t know if there’s some sort of way if they could sort of write it out on paper while you’re there rather than, because at the moment they type it out and say if you want to make any changes just let me know. And usually you don’t want to just sit there highlighting everything, saying change this. But if they actually sort of created it with you [. . .].

P-SU-106

One service user felt that she had ownership of her care plan, yet she had not written it with staff and did not refer to it much. One carer talked of receiving a care plan that they were not involved in writing, despite being ‘in it together’ (P-CA-101).

Staff said that they placed great emphasis on planning and communicating with community-based colleagues and carers when speaking about discharge planning. The expectation was that they would talk about plans for discharge within 72 hours of a person’s admission, but this was not always possible.

Three service users spoke of being discharged with very little planning or notice, and of being invited into unscheduled meetings with staff to be informed of their imminent departures. One said that discussions about discharge and support with her carer took place only on the day she went home. The eleventh-hour arrangements for discharge were echoed by another service user, who recalled being ‘pulled in out of the blue’ to be told ‘right, you can go’ (P-SU-102). Four service users reported being involved in longer-term discharge planning. One said that discharge was discussed with his wife and with community staff. Carers did not feel informed about discharge arrangements and felt that these were hastily brought forward at short notice. When asked about preparations, one said ‘there wasn’t any’ (P-CA-101).

Care reviews

Weekly reviews for each service user involved members of the MDT, including care co-ordinators where possible, and carers. In the meetings, a clinical review took place for each service user followed by a record of actions to be taken. Care plans could be reviewed following ward rounds and in handovers. One nurse commented that the use of different sets of records by different professional groups was not helpful. Ward rounds could be rushed, with as many as 9–10 people being reviewed within 2.5 hours.

Staff talked of how they involved and listened to service users in reviews, but also of the challenges. Advocacy was mentioned but also that this could antagonise doctors. It was observed how ward rounds could be scary for service users, who might feel judged by the assembled staff.

Service users and carers talked of their experiences of care plan reviews that took place during ward rounds. None had any choice over timing, venue or who was invited other than carers. Their experiences of review meetings in wards rounds were mixed. One service user talked about her care co-ordinator sometimes helping her to prepare, and that ward rounds were sometimes helpful despite the number of people present:

Sometimes you’ve got a load of people in there and you sort of feel a bit like you’re on stage, you know like the spotlight’s on you, sort of thing. But yeah. I’ve had problems with ward rounds but more recently things have been OK, I’ve been able to sort of express myself more.

P-SU-104

Another spoke of being ‘totally involved’, finding ward rounds very helpful and that their ‘wishes and preferences are taken on board’ (P-SU-105) and decisions immediately acted on. A couple of service users, however, described ward rounds as sometimes being organised hastily and ‘quite rushed’, and not helpful: ‘I voice my opinion but they don’t listen’ (P-SU-103). Most talked of not feeling prepared for ward rounds. Two spoke of the ‘power’ in ward rounds and the anxiety they felt at having to ‘sit and wait anxiously’.

[You] shouldn’t really dread ward rounds in a way, but there’s some elements of they don’t really know you, like they just see you once a week and they dictate your life.

P-SU-106

One carer talked of having attended a hastily convened review meeting leading to a discharge that, in the carer’s view, had occurred too early.

Support systems

Staff talked about training for planning care, highlighting both their disciplinary backgrounds and in-service training including classroom sessions, e-learning and mandatory updates. Some also mentioned regular supervision and appraisals and becoming a mentor for student nurses.

Six service users talked of their relationships with named nurses. Five were aware that they had a primary nurse. Most described seeing their primary nurses regularly and having good relationships, and of them being available and good listeners. Most described ward staff as being helpful and said that they trusted them. One-to-one meetings happened, although these were not always pre-arranged. One carer spoke of the person they cared for having good relationships with staff and of being supported, and was aware of the key people on the ward:

They knew how to talk to her and how to get stuff out of her. I mean I found out stuff while she was in there that I didn’t know, because she’d spoken to someone so.

P-CA-101

All service users said that staff treated service users with dignity and respect, although one said that some members of staff were nicer and more compassionate than others. Two spoke of how staff had acted with compassion, care and concern for dignity when helping a distressed woman who had been walking naked through the ward.

Service users also described support from professional and other workers both in hospital and the community. One mentioned he would like to see the community staff visit when the service user is in hospital to build relationships.

Staff talked of working with colleagues to plan care and said that they welcomed links with peer support workers, advocates and others. Helping service users maintain their connections to the community, such as working with families and friends, and welcoming involvement, also brought challenges and frustrations. One spoke of a family member becoming ‘too involved’:

. . . to the point we were asking her not to come in because she wasn’t actually helping in any way and just making things worse.

P-ST-101

Service users spoke of support from family members and other informal carers such as friends and neighbours, but the extent of the help varied. Three described the support they had received from other service users.

The carers felt supported and listened to by staff and knew that community staff were also involved. Carers spoke positively about staff, who they said treated service users with respect, care and compassion. One said, ‘I think they need a medal to be honest with you’ (P-CA-101).

Safety and risk

Ensuring patient safety and managing risk were described by staff as central to their work, with risk assessments ‘coming out of your eyeballs’ (P-ST-101) alongside routine work including observations, ligature audits and clinical reviews. One nurse mentioned reviews at daily handovers and risk assessments shaping what service users could and could not do. One staff member spoke about how difficult it could be to directly address risk during a ward round when the service user was present.

Service users gave examples of when care plans took issues of risk into account, such as recording the use of observations, noting when people have been accompanied off the ward and checking regularly on those who self-harm. One service user talked of safety being considered, saying how ‘they’re there to look after you’ (P-SU-102), but also said that they had not had conversations with staff about safety or risk. Another service user felt that her safety had ‘absolutely’ been considered in her care planning, and gave the examples of her previous risk history being shared with the hospital staff and her observation level being changed when needed. Carers talked about staff taking action to keep people safe, such as removing dangerous objects and conducting frequent observations.

Organisational context

Staff talked about positive developments, including working with only one consultant, the introduction of a housing worker and peer support workers, and greater service user involvement and recovery focus in care planning. A recent duty of candour policy and the introduction of advanced directives were also mentioned. However, changes in shift patterns meant that morning shifts that included ward rounds left little time for anything else. The introduction of a Section 136 room had placed additional demands on staff, as had the introduction of Modified Early Warning Scores, a process for the assessment of physical health.

Recovery

One staff member defined recovery as returning to a ‘normal’ state of functioning. Others spoke of people on a journey to become what they wanted to be, and gave a holistic view of their potential:

[. . .] being able to make improvements in all aspects of their life really. Ensuring stability of their mental health but helping them recover in all aspects of their life as well.

P-ST-104

It was also acknowledged that recovery was an individual process, drawing on personal values and aims, that involved both progress and setbacks. Staff noted the differences in orientation to recovery between hospital and community, including the short-term, sometimes crisis-oriented, nature of the hospital experience.

One service linked recovery to symptoms: ‘getting rid of the voices and what I see. That’s my recovery’ (P-SU-101). Three spoke of returning to a previous state; for example:

[G]etting back to your even normal state that you were a year ago or a few months ago or however long it was, and just feeling healthy and happy and joyful or whatever you want to, and something like that.

[P-SU-102]

Another identified recovery being able:

To do what you want to in your life, as in I want to go to college, I want to finish my degree, I’ve got 2 more years and while I might not be dancing round and everything is wonderful, it’s a slow process but just getting my normal life back really.

P-SU-104

One carer used ‘recovery’ in its clinical sense to indicate that they thought the person would never fully recover, while a second carer embraced a more holistic view of recovery as a process of moving on and learning.

All service users said that hospital had helped their recovery in various ways: by stopping them from hurting themselves; by helping them to feel strong and positive on discharge; by assisting with stabilising mood and feeling safe; and by providing medication and stabilisation. One mentioned that having greater involvement in the planning of her care would have helped with her recovery.

Staff gave divergent responses to questions on the relationships between care, care planning and recovery. One said that recovery had no influence over the way care was planned, but another described how recovery ideas had exerted an impact on his approach to care planning.

Personal recovery plans did not feature strongly in service users’ talk. One said that her care plan focused on helpful distraction techniques, but not on strengths. Another service user talked about achievements being recognised.

Staff gave divergent views on the implementation of recovery-focused care in hospital. For example, a ward manager talked of care plans being very medically driven with almost no focus on strengths and abilities. WRAPs were not used.

Personalisation

Staff were unsure what personalisation meant but offered suggestions, including tailoring care, ensuring that people felt like individuals and care being patient-centred. Only one linked it to personal payments. Service users were also unsure of what was meant by personalisation, although again several felt that it was about tailoring care to the individual. One said:

I don’t know, maybe helping yourself or making your own personal goals maybe? I don’t really know to be honest.

P-SU-103

One carer suggested the idea of personal goals and achievements, while another said:

I guess personalisation means the way her treatment was personalised for her and I guess it was, because everyone is different and everyone needs different help, but I don’t really know what you mean.

P-CA-101

One ward manager said that care was not personalised, as turnover was rapid and the emphasis was on medical treatment. One psychiatrist said that care was not tailored. Others spoke of building rapport and taking account of individual needs. Most service users and carers felt that their care had been personalised to a degree.

Barriers and facilitators

All staff explicitly spoke of the importance of having time to spend with service users, and of talking and listening. This was linked to therapeutic relationships:

I would say that it’s probably being able to build a rapport with a patient, and a therapeutic relationship, that would, I think is the most important thing or tool that I could use as a nurse to, yeah.

P-ST-104

Having more of a recovery-focused approach in the ward was mentioned, as was the importance of instilling hope. Practical help with housing and benefits was seen as important by one staff member, and staff training was seen as important by another.

One carer said that a key challenge was to get more staff. For staff, lack of time and resources featured prominently, encompassing the challenge of staff being deflected by administrative tasks, a reliance on paper (rather than electronic) records, incompatible computer systems, poor communication, and unhelpful separations between hospital and community care.

Closer collaboration between staff and service users in care plan construction was discussed, along with the suggestion that technology might support this (e.g. using tablet computers).

A service user and a carer both spoke of the need for more involvement in care planning and the limited activities available on the ward causing problems for sectioned inpatients who were unable to leave. Carers spoke of the importance of discharge planning, the problem of sudden discharge and lack of accessibility of care plans for visitors in terms of the language used.

Care plan reviews

Eight participants were selected for care plan reviews on the main ward in Provence. These were three female and five male service users who ranged in age from 26 to 43 years; five were formally detained. For three service users this was their first admission to hospital. Three service users had signed their care plans and all care plans had named-nurse signatures. It was clear that only one service user had been given a copy of the care plan and one other had declined the offer. In one case was it clear that a carer had attended a ward round. It was not possible to determine if any service users, advocates or care co-ordinators had attended previous ward rounds, indicating a potential issue of continuity of care. Only four care plans showed evidence of the person’s views being included. The language used varied between describing the service user’s problems in the third person (e.g. ‘describes feeling in his head as ‘chaotic’) and, occasionally, in the first person using quotations in the service user views sections of the plan (e.g. ‘I’m fed up of this’). Most care plans (four out of eight at best for the following categories) did not show evidence of strengths-based approaches, coproduction, personalisation or recovery-focused approaches. When this was evident, the attempt was only partial, suggesting a need for a more sustained focus to achieve these requirements. Seven out of eight care plans showed an orientation towards system-based or medical goals, usually focusing on medication compliance and managing risk, with only one care plan showing person-centred goals and two showing encouragement towards self-management (although these attempts were only partial). Seven out of eight care plans addressed discharge plans. The plans usually showed evidence of a concern about accommodation issues and, in one case, continuity in the form of a request that the care co-ordinator be invited to attend a ward round.

Meeting observations

In Provence, three observations of ward round meetings were conducted. Five people attended all three meetings: two researchers, a senior nurse, a psychiatrist and the service user. In some meetings other clinicians (an OT, a psychologist, a link pathway nurse and a pharmacist) were also in attendance. A carer was present at one of the meetings. For all meetings the nurse collected the service user from the ward, greeting them with warmth and apologising for the delays (20–50 minutes). The meeting was held in a light, spacious room in which chairs were arranged in a circle. The nurse took notes behind a computer, while the doctor, who led the meeting, sat in a large wing-backed chair opposite a seat reserved for the service user. In all meetings, it appeared that the relationship between the doctor, nurse and service user was well established. Introductions were provided for those who had not met. In two of the meetings the service users began speaking without being prompted. One did, however, walk in the room and state ‘I’m terrified’, to which no response was given. Time was provided for the person to speak. The doctor displayed varying levels of interest in what colleagues, the service user and carer had to say. He made good use of clarifying questions when exploring behavioural patterns, but little empathy was displayed. One service user explained that he found it hard to articulate his views; the nurse reassured him that he was coming across fine but the doctor did not respond to this and continued to ask more questions. There were periods of silence during which feelings were not addressed; however, some staff members did interject to empathise but often the conversation was swiftly moved on. At times the doctor appeared disinterested, sitting with his arms crossed, refraining from using eye contact and showing minimal facial expressions throughout. When the doctor mentioned medication he spoke very assertively, stating ‘I will change . . .’ rather than working in collaboration with the person.

The carer was given time to speak and was reassured by the nurse, OT and psychologist about concerns, and it was acknowledged that the process was daunting. The care plan was not discussed during any of the meetings; physical health was, however, explored in one meeting. One meeting was terminated early by the service user because of conflict. In this meeting the doctor began by stating definitively that ‘I spoke to you on Friday; since Friday you have been quite hostile’. The service user agreed that he was angry; however, the ensuing stunted dialogue was matched by the participants’ defensive body language and failed to develop. The conversation was swiftly moved on to medication. Disagreement ensued, which led to the service user storming out of the room (after only a few minutes) saying ‘I want interaction with you; I don’t get one’. The doctor was quite defensive but did try to reassure the service user about the safety of medication; however, his personal questions were not given direct responses. After this meeting the doctor decided that the person did not have capacity and spoke about this in quite a derogatory way. The main focus of the meetings was for medication review, although social outcomes were attended to in one instance. After all of the meetings, the nurse and doctor briefly discussed and agreed what to include in the notes using predefined sections (e.g. Modified Early Warning Score, risk and activities).

Comparison of recovery profiles: Recovery Self-Assessment

Recovery Self-Assessment questionnaire

Recovery Self-Assessment total

When using Artois and Champagne as reference sites (the sites with the lowest scores), it is apparent that Provence and Dauphine are scored significantly higher for the mean RSA total score (Figure 4). This scale measures some important perceptions that may have a significant effect on patient outcomes and concordance to care and collaboration with service users. Subsequent Tukey’s post hoc tests revealed that staff in Artois (3.36, SD 0.59) scored significantly lower on the subscale than staff in Provence (3.76, SD 0.56; p = 0.009; 95% CI –0.73 to –0.07; Cohen’s d = 0.69) and Dauphine (3.74, SD 0.53; p = 0.009; 95% CI –0.70 to –0.06; Cohen’s d = 0.68). Staff in Champagne (3.21, SD 0.46) scored significantly lower on the subscale than staff in Provence (p < 0.001; 95% CI –0.92 to –0.19; Cohen’s d = 1.07) and Dauphine (p < 0.001; 95% CI –0.88 to –0.19; Cohen’s d = 1.07). There were no significant differences between Artois and Champagne and the other sites on this subscale.

FIGURE 4.

Mean total RSA score for staff (95% CI). Scoring range for the mean is from 0 to 5. *p = 0.05; **p = 0.01. Note that * identifies a significant difference compared with Artois and # identifies a significant difference compared with Champagne. The response range for the items is from 1 to 5.

Recovery Self-Assessment life goals

When using Artois and Champagne as reference sites (the sites with the lowest scores), it is apparent that Provence and Dauphine sites are scored significantly higher by staff for the mean life goals subscale score (Figure 5). This scale measures some important perceptions encompassing the extent that staff support the development and pursuit of individually defined life goals such as employment and education. 48 Subsequent Tukey’s post hoc tests revealed that staff in Artois (3.53, SD 0.61) scored significantly lower on the subscale than staff in Provence (3.97, SD 0.56; p = 0.009; 95% CI –0.81 to –0.07; Cohen’s d = 0.75) and Dauphine (3.93, SD 0.53; p = 0.013; 95% CI –0.75 to –0.05; Cohen’s d = 0.70). Staff in Champagne (3.52, SD 0.52) scored significantly lower on the subscale than staff in Provence (p = 0.016; 95% CI –0.84 to –0.05; Cohen’s d = 0.80) and Dauphine (p = 0.023; 95% CI –0.78 to –0.03; Cohen’s d = 0.78). There were no significant differences between Artois and Champagne and the other sites on this subscale.

FIGURE 5.

Mean life goals subscale score for staff (95% CI). Scoring range for the mean is from 0 to 5. *p = 0.05; **p = 0.01. Note that * identifies a significant difference compared with Artois and # identifies a significant difference compared with Champagne. The response range for the items is from 1 to 5.

Recovery Self-Assessment involvement

When using Champagne as a reference site (the site with the lowest score), it is apparent that Provence and Dauphine perform significantly better on the RSA involvement subscale (Figure 6). This scale measures some important perceptions encompassing service user involvement, such as the extent to which service users are involved in the development and provision of services, staff training and advisory board meetings. 48 Subsequent Tukey’s post hoc tests revealed that staff in Champagne (2.85, SD 0.62) scored significantly lower on the subscale than staff in Provence (3.46, SD 0.70; p = 0.002; 95% CI –1.07 to –0.16; Cohen’s d = 0.92) and Dauphine (3.47, SD 0.68; p = 0.001; 95% CI –1.05 to –0.18; Cohen’s d = 0.95). There were no significant differences between Champagne and the other sites on this subscale.

FIGURE 6.

Mean involvement subscale score for staff (95% CI). Scoring range for the mean is from 0 to 5. *p = 0.05. Note that * identifies a significant difference compared with Champagne. The response range for the items is from 1 to 5.

Recovery Self-Assessment diversity of treatment options

When using Artois and Champagne as reference sites (the sites with the lowest scores), it is apparent that Provence and Dauphine sites were performing significantly better for the mean diversity of treatment options subscale score (Figure 7). This scale measures some important perceptions relating to the extent to which the trust/board provides links to peer mentors and support, variety of treatment options and assistance with becoming involved in non-mental health related activities. 48

FIGURE 7.

Mean diversity subscale score for staff (95% CI). Scoring range for the mean is from 0 to 5. **p = 0.01. Note that * identifies a significant difference compared with Artois and # identifies a significant difference compared with Champagne. The response range for the items is from 1 to 5.

Subsequent Tukey’s post hoc tests revealed that staff in Artois (3.21, SD 0.77) scored significantly lower on the subscale than staff in Provence (3.81, SD 0.66; p = 0.001; 95% CI –1.02 to –0.19; Cohen’s d = 0.84) and Dauphine (3.72, SD 0.69; p = 0.003; 95% CI –1.02 to –0.19; Cohen’s d = 0.70). Staff in Champagne (3.06, SD 0.65) also score significantly lower on the subscale than staff in Provence (p < 0.001; 95% CI –1.20 to –0.30; Cohen’s d = 1.15) and Dauphine (p < 0.001; 95% CI –1.09 to –0.23; Cohen’s d = 0.98). There were no significant differences between Artois and Champagne and the other sites on this subscale.

Recovery Self-Assessment choice

It is apparent that Languedoc performed significantly better for the mean Choice subscale score than Artois (Figure 8). This scale measures some important perceptions of the extent to which service users have access to their medical records, that the choices of service users are respected and that measures which are considered coercive in nature are not employed. Subsequent Tukey’s post hoc tests revealed that staff in Artois (3.47, SD 0.67) scored significantly lower on the subscale than staff in Languedoc (3.84, SD 0.66; p = 0.033; 95% CI –0.72 to –0.18; Cohen’s d = 0.56). There were no significant differences between Artois and the other sites on this subscale.

FIGURE 8.

Mean choice subscale score for staff (95% CI). Scoring range for the mean is from 0 to 5. *p = 0.05. The response range for the items is from 1 to 5.

Recovery Self-Assessment individually tailored services

When using Provence and Dauphine as reference sites (the sites with the highest scores), it is apparent that these sites perform significantly better than the other four sites for the mean individually tailored subscale score (Figure 9). This scale measures some important perceptions about the extent to which services are tailored to the individual needs of the service user, their culture and interests and focuses on building community connections. Subsequent Tukey’s post hoc tests revealed that staff in Provence (3.75, SD 0.58) scored significantly higher on the subscale than staff in Languedoc (3.32, SD 0.74; p = 0.028; 95% CI 0.03 to 0.83; Cohen’s d = 0.65), Artois (3.29, SD 0.72; p = 0.009; 95% CI 0.08 to 0.84; Cohen’s d = 0.70) and Champagne (2.92, SD 0.49; p < 0.001; 95% CI 0.41 to 1.25; Cohen’s d = 1.55). Scores between staff in Provence and staff in Burgundy were also approaching significance (p = 0.059; 95% CI –0.01 to 0.82; Cohen’s d = 0.63). Staff in Dauphine (3.81, SD 0.66) also scored significantly higher than staff in Languedoc (p = 0.003; 95% CI 0.11 to 0.87; Cohen’s d = 0.70), Artois (p = 0.001; 95% CI 0.16 to 0.88; Cohen’s d = 0.75), Burgundy (p = 0.009; 95% CI 0.07 to 0.86; Cohen’s d = 0.69) and Champagne (p < 0.001; 95% CI 0.49 to 1.29; Cohen’s d = 0.98). There were no significant differences between Artois, Burgundy, Champagne and Languedoc on this subscale. Scores between staff in Languedoc and Champagne were, however, approaching significance (p = 0.055; 95% CI –0.01 to 0.80; Cohen’s d = 0.64).

FIGURE 9.

Mean individually tailored services subscale score for staff (95% CI). Scoring range for the mean is from 0 to 5. *p = 0.05; **p = 0.01. Note that * identifies a significant difference compared with Provence, # identifies a significant difference compared with Dauphine and ^ identifies a significant difference between Burgundy and Champagne. The response range for the items is from 1 to 5.

Scale to Assess the Therapeutic Relationship – clinician version positive collaboration

It is apparent that Burgundy performs significantly better than Artois for the mean positive collaboration subscale score (Figure 10). This scale measures some important perceptions about rapport and shared understanding of goals focused on mutual openness and trust. Subsequent Tukey’s post hoc tests revealed that staff in Artois (17.17, SD 2.65) score significantly lower on the subscale than staff in Burgundy (18.86, SD 2.57; p = 0.019; 95% CI –3.20 to –0.18; Cohen’s d = 0.65). There were no significant differences between any of the other sites on this subscale.

FIGURE 10.

Mean STAR-C positive collaboration subscale score for staff (95% CI). Scoring range for the scale is from 0 to 24. *p = 0.05. The response range is from 0 to 48.

Scale to Assess the Therapeutic Relationship – clinician version total

It is apparent that Burgundy performs significantly better than Artois for the mean positive collaboration subscale score (Figure 11). This scale measures some important perceptions that may have a significant effect on patient outcomes and concordance to care and collaboration with service users. Subsequent Tukey’s post hoc tests revealed that staff in Artois (36.08, SD 4.18) scored significantly lower on the subscale than staff in Burgundy (39.33, SD 4.31; p = 0.011; 95% CI –5.76 to –0.75; Cohen’s d = 0.77). There were no significant differences between any of the other sites on this subscale.

FIGURE 11.

Mean STAR-C total score for staff (95% CI). Scoring range for the scale is from 0 to 48. **p < 0.01. The response range is from 0 to 48.

Correlation between the Recovery Self-Assessment and the Scale to Assess the Therapeutic Relationship – patient version

There were positive associations found between the positive collaboration subscale, the positive clinician input subscale and the five RSA subscales (Table 49). There were either small or medium correlations between the non-supportive clinician input and the five subscales of the RSA. This is expected, as this subscale is a negatively framed subscale and, therefore, less likely to correlate with the RSA.

Although it appears that these questionnaire scales have a strong positive correlation, the results should be taken with caution. There is the possibility that a ceiling effect in the data negatively skewed them. When assessing the correlations by trust/health board, it is apparent that there is some variability (Table 50).