The Rehabilitation Effectiveness for Activities for Life (REAL) study: a national programme of research into NHS inpatient mental health rehabilitation services across England

Suitability of service users and preadmission assessment

Generally, staff felt that, for them to be able to assist people in their recovery, it was essential that the service user was prepared or ‘suitable’ for rehabilitation.

One of the things that was established before I started, was that was quite a clear referral pathway into us, so people have to meet criteria to be deemed suitable for the placement.

Unit 0503, female, unit manager, 49

We like to make sure that people are in a position to benefit from the service, if people aren’t ready we will happily wait and reassess them at a later date when they might be in a slightly better position to engage with the services that we can provide.

Unit 1803, female, qualified nurse, 26

People have got to feel that coming here is going to be of benefit to them and that they are going to get something out of it.

Unit 1802, female, OT, 36

Readiness or ‘suitability’ for rehabilitation was predicated on the provision of multidisciplinary pre-admission assessments, as highlighted by the following staff comment:

We have a referral form that we send out that we feel covers most of the areas that we are interested in and that gives us a taster of the person. We then go and see the person, read through their notes, meet with the staff that they work with, look at any assessment work that’s been done, meet the person, have a chat with them, find out what they want, what their expectations are, what, what they want from us, we will tell them about us, what we can do for them, what we can offer them realistically and we go from there.

Unit 1703, female, qualified nurse, 43

In some cases the preadmission assessment would be further discussed within the multidisciplinary team (MDT) to ensure the appropriateness of the placement.

That information then comes back to the ward, where we have a MDT referrals meeting, where we will discuss that person in depth and then that may lead to a further assessment.

Unit 1703, female, qualified nurse, 43

Staff also indicated that it was important to allow time for referred service users to have pre-admission visits or periods of trial leave to the unit so that their suitability could be further assessed.

A visit helps to kind of ease anxieties, from both sides [staff and service user] and get an idea partly of what we’ve been referred is true and for them [service user] to get an idea of what we’re like.

Unit 1803, female, qualified nurse, 26

However, some staff reported that assessment processes were, on occasion, compromised because of pressure on acute admission beds. Thus, some service users were transferred to the rehabilitation unit prematurely and/or inappropriately.

We have a small number of clients, that really, ideally, are not ready for rehab[ilitation] and maybe need an alternative placement, but unfortunately there was a period when we were having to fill the beds.

Unit 0901, female, manager, 40

[T]he only reservations that people [staff] have are of whether people coming here are suitable for rehabilitation. And that’s a concern, ‘cause it’s always a concern that people are being pushed out of acute units.

Unit 1501, male, qualified nurse, 46

I think it’s become more acute as there’s less acute beds, there’s more pressure to kind of get people out quicker, so some people who are a little more acutely ill when they first come here.

Unit 0701, male, qualified nurse, 42

. . . sometimes we do favours for the acute services and take people who are perhaps are still a little bit too acutely ill for us . . .

Unit 2503, female, OT, 37

The inappropriateness of these placements, and the resulting problems, quickly become obvious. One of the biggest issues for staff was a lack of motivation among service users.

If clients don’t feel that there is going to be any benefit in coming here, and they can’t see that there is anything that we can provide that’s going to help them in any way, then they probably don’t really have that motivation to work with us.

Unit 1802, female, OT, 36

Despite these difficulties, staff still seemed to be willing to work with all of those who were admitted to their service, even if the specific aims of their treatment were not clear:

I think there is always something that they can benefit from, something that we can offer them. Whether it’s the full rehab[ilitation] package or um, or just something little that they can then, but even just a bit of education on their medication or you know, or social skills or something like that.

Unit 1802, female, OT, 36

I think some patients will get more out of it than others, but that greatly depends on their motivation and their wanting to change.

Unit 1801, male, qualified nurse, 32

However, although staff emphasised the importance of a thorough initial assessment, service users were often vague when questioned about the referral and admission process. In an apparent contradiction of staff’s assertions of service user preparation, service users generally appeared passive and rather uninvolved in the assessment and decision-making process related to their admission into rehabilitation. Often, their only source of information was fellow service users who were currently in, or had previously used, the rehabilitation unit.

I didn’t know anything. I was told just like a basic house where you have rooms in the house with other patients.

Unit 1803, male, service user, 42

I thought it would be more or less the same sort of set up, as [name of previous unit] and, erm, and really I didn’t have any idea really apart from, erm, it was, erm, it wasn’t a secure unit.

Unit 1802, male, service user, 45

All I knew was from people that had been in here in this house [rehabilitation unit].

Unit 1803, male, service user, 42

Although service users were generally positive about the idea of rehabilitation, most had little understanding of its specific purpose:

I suppose . . . somewhere to fix my problems . . .

Unit 1401, male, service user, 23

Only one service user seemed to have a better understanding, describing it as somewhere:

. . . to help me get back into the community and settle and start doing normal things, like start getting a job and my own place and stuff like that.

Unit 1502, female, service user, 26

Ethos and approach

When asked about the ethos and approach of the service, many staff spoke about the need for the team to be motivated to work with service users with longer-term needs. Many felt that both staff and service users should be clear about the aims of treatment. Several staff emphasised the importance of the service providing a flexible and individually tailored approach that was sensitive to the changing needs of service users.

I think you need a really good level of enthusiasm in the staff.

Unit 0901, female, support worker, 22

I think the approach should be one that is definitely based on evidence-based interventions um and that there is a clear pathway so that when people come they know what’s expected of them and that there will be a beginning, middle and an end.

Unit 0503, female, manager, 49

I think ideally a rehab[ilitation] unit, I mean it’s, it would evolve with the person.

Unit 0701, male, qualified nurse, 42

It would be an environment that was supportive, um, proactive, I would say a nurturing environment that was sort of going to help – help and support the individual.

Unit 1501, male, qualified nurse, 27

I suppose it’s patient-led so that patients are actually telling me, oh I’d like to do this or I’d like to try this, and that we can be responsive to what they’d like us to do.

Unit 0503, female, manager, 49

Service users reported that the rehabilitation units provided more individual freedom and autonomy than did acute admission wards.

. . . well you get more freedom, and you’re not with people who have just become ill . . .

Unit 1703, female, service user, 55

They don’t push you, they don’t push you do this or push you to do that, they just leave you to your own devices, let you do your own thing, sort of thing.

Unit 1703, male, service user, 51

However, service users’ perspectives on structure and autonomy tended to be based on personal tastes. Thus, other service users felt that the ‘regime’ in the rehabilitation unit was too inflexible, particularly in relation to getting up in the morning. Other complaints were made regarding the inflexibility of medication times and meal choices (although these were no different from the institutional routine of any hospital unit).

There are set times for medication, so, well, patients are aware of the times of medication, and therefore it’s just sort of routine you know?

Unit 1802, male, service user, 45

You have to decide what you want your meal to be in 2 days in advance and I guess that’s not really what you have to do in the real world.

Unit 0701, male, service user, 21

A number of service users spoke positively about the opportunity that they had in the rehabilitation unit to try things out, and valued the staff’s support and willingness to help them engage in activities.

I have come from being, wrapped in cotton wool, right to, you know, this life centre, of go and enjoy it, do what you want you want to do, and the staff will say, they will support you.

Unit 1802, male, service user, 45

Built environment

The 12 units visited varied greatly in terms of their built environment. Only one had been purpose built to provide rehabilitative care. Of the remaining 11, two were hospital wards, two were in buildings that had been designed and previously used for another purpose and the remaining seven had been converted from mainstream community-based residences. Changing the use of the building from its original purpose had led to some compromises with regard to what the service was able to provide, but the buildings were generally in a good state of repair, both structurally and decoratively. However, some were more ‘homely’ in style than others.

Some staff identified and described how the building had a positive effect on the rehabilitative process. However, there were a number of concerns voiced by staff about inadequacies related to the built environment that detracted from service users’ rehabilitation, including overcrowding, shared bathrooms, a lack of male- or female-only spaces and a lack of dedicated space for occupational therapy activities.

I think it is a fairly modern, well-equipped, comfortable environment.

Unit 1401, male, manager, 39

Here we have a series of practice flats and I think they’re quite good and they offer an opportunity to self-cater and um, also so that they can socialise they are equipped with lounge, a bedroom, a kitchen, washroom, bath and they are separate from the unit but they’re not, they have, they can come to us at any time.

Unit 1501, male, qualified nurse, 46

. . . it would be nice for people to have en-suite facilities . . .

Unit 1802, female, OT, 36

. . . all of the stuff, I have to do like that is in the communal kitchen areas, which is quite tricky, well it can be sometimes, quite tricky, about managing that, because if you’re teaching people skills or getting them to relearn skills that they haven’t used for a long time, particularly people that might have anxieties, or very low confidence . . .

Unit 1802, female, OT, 36

The staff working in units based in hospitals questioned the suitability of rehabilitation being provided in these settings. More directly, staff were concerned that the concept of rehabilitation was contradicted and undermined by situating this work in an institutional environment.

I personally think that the hospital setting isn’t necessarily ideal for the client group.

Unit 1703, female, qualified nurse, 43

. . . and just the setting we’re in, the buildings really, it’s a really old hospital and it looks like a really old hospital, here which doesn’t foster feelings of you know, people want to look after themselves, it fosters kind of institutional/institutionalisation.

Unit 0701, male, qualified nurse, 42

. . . because we are in a hospital, we have to fit into the hospital situation, in terms of appointments, and pharmacy and people coming and going and that does obviously put limitations on things [sic: the ‘things’ referred to here are activities].

Unit 1703, female, nurse, 43

Service users were generally positive about the quality of their accommodation. When these facilities were available, having access to a private bathroom and kitchen facilities was regarded as particularly important.

You have your own room, your shower is in your own room, and you can make coffee and that when you want it.

Unit 0901, male, service user, 29

You have your own room with a cooker in and microwave and things in [studio flats for pre-discharge use].

Unit 1803, male, service user, 21

However, regardless of the environment and the geographic location (suburbs, inner city or a rural area), emphasis was placed on the importance of being close to community facilities and/or having good transport links to facilitate service users’ access to the community. Indeed, it was felt that proximity to local services helped to attenuate the sense of institutionalisation that some units created.

It’s really, really important, that were not so much in the middle of nowhere, so you can use trains, buses, and things like that, so that’s pretty useful for an ideal setting. I don’t think a rehab[ilitation] unit is going to be very effective in the middle of nowhere really because, we are supposed to be encouraging people to, access the community, and planning for when they go home, or go elsewhere, that they can support themselves.

Unit 2503, female, activity worker, 33

A lot of it is about, being able to access community services and start doing the things that people are going to be doing when they leave here and get them in to routines around that, and I think I have to say we are very lucky, where we are based, we are so near the town, and so near all the services.

Unit 1802, female, OT, 36

Facilitating activities

In 11 of the 12 units, the researchers noted that activities appeared to be taking place both on and off the unit. Activity programmes were often clearly displayed on noticeboards, and individualised programmes were filed in service users’ case notes. A variety of activity equipment was also observed in the units and there were often photographs on display of outings and activities that service users had participated in. However, in one unit, although an activity programme was on display, staff reported that the activities listed were not actually being delivered.

Many staff highlighted the need for rehabilitation services to provide service users with opportunities to develop or relearn skills, not just through providing activities on the unit but also through facilitating and supporting them to access community activities. This bridging function of their work is illustrated in the following comments:

To me this [rehabilitation] is all about building, you know, daily living skills, instilling confidence in people that perhaps has been shattered or perhaps they never had it at all.

Unit 1803, male, support worker, 48

It’s about helping people being able to function when they leave here, so whether it’s about learning cooking skills, so they can do that when they leave here, or whether it’s about accessing community services, so that when they leave here they are, going out and having that social contact, they are going to access things of interest, whether it’s vocational stuff, like setting up with work, you know, developing peoples routines, erm, it should all relate to, how that’s going to benefit people to move forward, to become more independent.

Unit 1802, female, OT, 36

I think, part of, one of the main parts of our, our role is to re-engage people with the community. You know and the only way you’re going to do that is to get them out of this unit to experience that.

Unit 1401, male, unit manager, 39

Definitely, that’s really important, really important, say, you know, if people want to go back to education, you would do that, to facilitate it . . . if they want voluntary work, or paid work.

Unit 2503, female, activity worker, 33

We do have links with the local college and we have several people that do courses at one of the local centres . . . they do basic literacy, community skills and creative writing.

Unit 1703, female, qualified nurse, 43

I meet up with a community walking group, and the reason I do that is because I couldn’t run a walking group myself here, but the reason I take people there is because that’s again something that people can follow through in the community when they have left.

Unit 1802, female, OT, 36

. . . well yes, I mean we go, there are local college do offer a number of courses for example we had a chap who’s been doing art, we have a chap who is doing horticultural college . . .

Unit 1501, male, qualified nurse, 46

Staff in some units had found ways to maximise service users’ access to activities by holding the activities in the evenings when service users were more likely to be up and about and when the units were less busy. Staff also noted that offering a variety of activities was important for engaging different service users. However, the purpose of these activities was not always that clear.

We do evening activities on a regular basis for the patients, but they’re quite social and diversionally orientated.

Unit 0503, female, manager, 49

On Thursday we have an activity which we arrange for all service users. Now that tends to be very socially oriented, so that would either be a place of interest . . . a sporting/leisure activity . . . or we’ll go out to, somewhere for an extended period, so we’ll you know, either go, maybe to do a walk for example in the lakes.

Unit 1401, male, unit manager, 39

I think it’s just a case of organising something and then seeing if you rope in as many patients as you can, going out, whether that be a pool group, or going out for a meal, and stuff like that, and . . . sometimes you can persuade the patients, talk them round into going out.

Unit 1801, male, qualified nurse, 32

However, simply motivating services users to leave the unit was a considerable challenge.

It’s all about trying to get them off the unit in the day time, get them out, that’s where we tend to have problems, ‘cause they don’t want to go out. So it’s trying to get them off, and get them motivated.

Unit 1401, female, qualified nurse, 56

Staff also recognised and reported working with service users to provide an individualised programme of activities: a plan that was guided by the service user’s interests and at a pace they could manage.

You know rather than us saying you know this is what you need to do, it’s very much more now working with the residents here and seeing what they want to do and working at a pace where they feel comfortable with.

Unit 1502, male, qualified nurse, 42

We do change things and personalise things, for individual people, you know, what their interests are, what their aims are, what their goals are.

Unit 1802, female, OT, 36

Although the staff’s interviews suggested that providing a variety of activities was a major focus of their work, this was contradicted by a commonly held perception of service users that the units were dull and devoid of stimulation, that they spent much of their time watching television or smoking.

I don’t really do anything. I just go out to the shop and come back. Some days you’ve got some OT but it’s not every day. I mean you don’t have a lot to do.

Unit 0901, male, service user, 28

It’s so easy to be lazy, you know, just get, get you med[ication]s, and sit around smoking, drinking tea and coffee.

Unit 1802, male, service user, 45

For other service users, the experience was more positive, and some particularly valued having the autonomy to choose what they wanted to do.

. . . and here, they don’t push you, they don’t push you do this or push you to do that, they just leave you to your own devices, let you do your own thing, sort of thing.

Unit 1703, male, service user, 51

You have got a bit of freedom, you know, you can go out and go for a walk or something like that.

Unit 1803, male, service user, 21

The majority of service users reported that they attended to basic activities of daily living to different degrees and with different levels of support.

Everyone has to tidy their rooms once a week and um everyone has to do their laundry.

Unit 1803, male, service user, 21

Budgeting, cooking, washing your clothes, certain chores . . .

Unit 1501, male, service user, 51

Well basically, I done the shopping, I do cooking and stuff like that so it gives me something to do.

Unit 1803, male, service user, 42

Self-catering which is cooking, and buying some food from the shop.

Unit 0701, male, service user, 26

In addition, many service users also reported having taken part in a wide range of other activities:

. . . like quad biking, walking ponies, horse riding, segways, martial arts in the forest, loads of things.

Unit 0701, male, service user, 22

Playing the computer, we got guitars and things, we got a drum set, a set a keyboard, a guitar room and all that here.

Unit 0901, male, service user, 29

However, some service users felt that they were made to participate in activities despite not finding them appropriate or likely to be beneficial.

I didn’t feel like I needed, needed that group at all, I mean I went along to one, and I mean, I couldn’t get anything out of it.

Unit 1803, male, service user, 21

I just don’t like it [activity groups] – I haven’t really got a choice you know.

Unit 0701, male, service user, 26

Benefits of a good therapeutic relationship

Staff felt that forming a good relationship with service users over time was a very important part of the work that they were doing, and that it reduced the barriers between them and helped the service user feel more able to discuss specific issues.

. . . you could build a really good therapeutic relationship with the person and essentially you get far more information, because they’re far more relaxed.

Unit 0901, female, manager, 40

. . . people aren’t going to engage unless they want to and it’s about kind of I guess finding something they enjoy and developing rapport with that individual um so much as you know what they enjoy you might not know how to get them involved in that unless you have a good relationship with them and you know other things about them and they trust you to help them get involved in things.

Unit 1803, female, qualified nurse, 26

I enjoy the fact that there’s no quick fixes, that people are complex and this, you can’t say there’s this thing wrong with them – do this and it will all get better – you have to really understand somebody and really get to know them.

Unit 2503, female, OT, 37

Time needed to build therapeutic relationships

Staff often reflected that it took a considerable amount of time to build up therapeutic rapport with service users, and they seemed to particularly value the fact that working in the rehabilitation service, where service users tended to stay for longer periods of time, gave them this opportunity, whereas other mental health services did not.

I really enjoy it, yeah I really enjoy it, I find I get far more interaction with service users than I have done in my short nursing practice.

Unit 1501, male, qualified nurse, 27

I find it much more satisfying than in acute services where it’s a very quick turnover, it’s, it’s down to medication, it’s very quickly out of the door and you have a sad feeling that people will be back because you have only really scratched the surface, where here you can get a much more in-depth knowledge of people.

Unit 2504, female, qualified nurse, 49

However, service users reported more mixed experiences of their relationships with staff. Although the majority reported that they found staff to be supportive, some had negative views.

Actually the majority of nurses I think are great and I really like them and yeah I do get on well with most of the nurses here, yeah.

1803, male, service user, 21

When I first came here I didn’t feel like new I just fitted in like straight away, and the staff were really helpful.

Unit 1502, female, service user, 26

The staff are very good here, they are very supportive.

Unit 1801, female, service user, 55

I get on with them alright but they can be a bit of a pain, to be honest.

Unit 1401, male, service user, 32

I would say that the staff can be very over bossy and unkind.

Unit 1501, male, service user, 32

Pathways into working in mental health rehabilitation

Staff in rehabilitation services fell into two main categories with regard to how they came to be working in rehabilitation services: those who had chosen to work in rehabilitation and those who had been redeployed there, seeing it as an easier option than other services.

I’ve chosen to work primarily in rehabilitation for most of my professional life.

Unit 1501, male, qualified nurse, 46

I come here, because I’d been on acute previously to that, so I’d been on acute for 10 years and it was getting too much, it was getting too stressful, and it was making me ill to be quite honest, so I had to move really, so I’ve been here since last May.

Unit 1401, female, qualified nurse, 56

Staffing levels and skill-mix

Staff frequently reported that the unit did not have enough staff to work with service users one to one in the way they would like to. Many units had only two staff per shift available outside core office hours.

I think we could do with more numbers [staff] to be honest, we could do more one to one, in fact we could do a lot more one-to-one work.

Unit 0503, male, qualified nurse, 52

I think it’s adequately staffed . . . we meet our, our minimums, our basics. But a lot more staff means that we would be able to do a lot more things. More rehab[ilitation]-focused work, so you could actually allocate someone to, you know, on a daily basis to cook for someone, to shop with someone. Sometimes you just can’t do that, you know, with your resources.

Unit 1401, male, unit manager, 39

Up until 2 weeks ago we got two OTs on the ward, myself and another occupational therapist, it meant we could concentrate both on the in-ward activities and the psychoeducational groups and diversional activities, the on-ward services and also that we can focus on one-to-one on getting back out to the locality. I am now having to cover two people’s jobs.

Unit 1703, male, OT, 42

Despite this, most staff felt that their team had an adequate range of skills; however, this seemed to be interpreted with regard to the interests of staff members rather than the multidisciplinarity of the team and specific skills they had been trained in:

. . . a mixture of old and young and a mixture of kind of skills and experiences across the board from people who have got excellent cooking skills, to others who have far more in the way of kind of life experiences, which has got its benefits.

Unit 1803, female, qualified nurse, 26

I think it’s a very good mix actually. Um, if you look at the staff nurses, you’ve got myself, another staff nurse, who qualified the same time, so we’re newly qualified, you know just over a year. Then you got a couple of other staff nurses that have been qualified, well one for about 6 years, and then another like 20 years and then you’ve got the Sister, 20 odd years. So it’s a good mix.

Unit 1501, male, qualified nurse, 27

Staff training

Staff recognised the benefits of attending training for their continuing professional development. However, staff often reported that resources were not always available to fund their place on courses, that courses were often full and that providing adequate cover to release staff for training was problematic.

I think training is hugely important for everybody.

Unit 1703, female, qualified nurse, 43

I think over time even little bits of training can make a significant difference in, not just in how you do your work, but in kind of how you feel about your work and every year you go to the same manual handling course, it’s a bit dull really, it’s not very mind expanding.

Unit 1501, male, qualified nurse, 46

I’m trying to get on the mentor’s course, it’s run through the university, I did get a place, but I had to kind of wait a year and it then happened that I couldn’t attend, but there’s no kind of professional, forward-looking development really.

Unit 1502, male, qualified nurse, 42

That [access to training] is getting more and more limited I would say, I mean, I just had a support worker knocked back for the OT training because there was only two places funded this year. I think there’s always more you can offer and I think um, I’d like to see more people accessing the psychosocial interventions degree that there is.

Unit 2503, female, OT, 37

[T]o be honest, one of the bigger problems is actually the backfill to people, is if you send someone off on a course, if there is no funding to cover them when they’re absent, that’s probably a bigger problem than the cost of a course.

Unit 2503, female, OT, 37

Owing to the recognised difficulties in accessing training, senior members of the unit staff (managers/psychologists/senior OTs) sometimes provided in-house training.

It tends to be in-house stuff that we do ourselves, within the current professionals either the [unit psychologist], or other psychologists would run.

Unit 0701, male, qualified nurse, 42

The previous consultant did training in rehab[ilitation] and around the recovery model, and a psychologist would also bring things to the table like CBT, um maybe incorporate, you know, interview techniques, and stuff like that, so if what we can get from each other.

Unit 0901, female, manager, 40

We’ve got an OT that works here, and does onsite training as well, you know, about how to engage with people.

Unit 1401, male, manager, 39

Support workers were particularly aware of their lack of training:

. . . we weren’t really given any help in what to do, sort of just go talk to people. I suppose it’s the best way to get experience is just to go out and do it, but yeah didn’t have any training.

Unit 0901, female, support worker, 22

This was also noted by some service users.

If you’ve got a problem they can’t help you, you know, they’re support staff, they don’t get no training.

Unit 1703, male, service user, 53

People are not trained, you know, the care workers and support staff, I mean.

Unit 1801, female, service user, 34

Staff roles

Nursing staff seemed less able than other members of the MDT to define their role. Generally, they described their role as one of co-ordinating other staff and functions within the unit rather than delivering these themselves.

I’m just, I’m an overseer really. I just kind of make sure things are getting done. You know so it would be nice to be involved more in there.

Unit 1501, male, qualified nurse, 46

The role of unqualified staff and support workers seemed much clearer both to the support workers themselves and to other staff. Most described it as providing ‘hands-on’ and practical support to service users, working in collaboration with other staff under the supervision of the qualified nurses.

It’s usually the support workers that have to go out for appointments, hospital appointments and stuff, they’re also the ones that are expected to do most of the, kind of, tasks on the unit, like lunch and activities and stuff.

Unit 0901, female, support worker, 22

They’ve come very much as health support workers, but they support people in their rehabilitation. They have got really good skills, I mean some of them have never worked in mental health or even the health service before, they have actually come with a real range of life skills and abilities.

Unit 2503, female, OT, 37

I believe that on the one hand that the backbone of the NHS, be it general or psychiatric, are support workers, who are often not necessarily qualified but people of a certain age who are prepared to just get in and muck in and do stuff.

Unit 1703, male, OT, 42

The OTs were also clear about their role and remit within the service.

We are trying to help someone achieve the maximum amount of independence and autonomy whilst you know getting whatever support they might require.

Unit 1703, male, OT, 42

It’s about supporting people to become as independent as they can, supporting people, to be able to go and do the things that they, partly need to do but want to do, and that’s all about fulfilling dreams and hopes, and is very goal orientated, strength based, that’s what OT is.

Unit 1802, female, OT, 36

We can concentrate both on the in-ward activities, and the psycho-educational groups and diversional activities, kind of getting people up and doing arts and crafts and computers, to kind of involve all the patients in the in-ward services and also that we can focus on one to one on getting back out to the locality where they came from and want to go back to.

Unit 1703, male, OT, 42

However, although most OTs had a good understanding of their role, they often felt that other staff did not fully understand it, seeing OTs as people who could run groups and organise outings.

. . . the staff have seen it [occupational therapy services] as – oh the OT’s here, they are going to do a cinema trip, they are going to do, a this trip, a that trip, and I don’t do that here . . .

Unit 1802, female, OT, 36

One member of the nursing team, a unit manager, echoed this view:

It’s not just for say example, OT doing just shopping stuff um, maybe they need to be involved in other things because they have to have time for assessments, one to one with clients and stuff, and they’re fantastic when it comes to running groups and they facilitate groups, they also you know, implement new groups as well.

Unit 0901, female, unit manager, 40

A number of service users were able to identify the specific tasks and responsibilities of staff from different disciplines who had assisted them in their rehabilitation.

The nurses help you with things, erm, do care plans and things like that to help you improve, and improve on my mental health as well.

Unit 1502, female, service user, 26

They [the nurses] make you better with tablets.

Unit 0503, female, service user, 25

I use a technique, one technique is to keep a diary, the occupational therapist has, erm, been showing me how to use a diary, how to make entries, to check it every day, and you know it’s important.

Unit 1802, male, service user, 45

However, commonly, service users tend to describe the role of the staff group collectively rather than the respective roles of individual disciplines:

The staff, they help you keep positive, they tell you don’t think about it, try to think positive.

Unit 1801, female, service user, 34

The staff are very friendly and they get you motivated, they’re on your case . . .

Unit 1803, female, service user, 26

Staff satisfaction

Overall, staff appeared satisfied with their work and appeared to gain great satisfaction from seeing people progress in their recovery.

I enjoy rehab[ilitation] very much, I’ve worked in rehab for a while and worked in rehab in other places, and um, it is, it’s kind of where I find my skills fit.

Unit 2503, female, OT, 37

I enjoy the interaction with the residents, um, I enjoy the different characters, I enjoy seeing the people make progress.

Unit 1803, male, support worker, 48

I enjoy having the time to develop um working relationship with the people I’m supporting, I enjoy supporting them and seeing them do well.

Unit 0701, female, qualified nurse, 45

. . . that’s one of the reasons that I enjoy rehab[ilitation] so much, you can see them go through their journey, and then they leave, and you then you think ‘oh’, but you know they have to move on and you think, well it’s a positive step because now they’ve moved on it means they’re doing really well.

Unit 0901, female, unit manager, 40

Staff shortages

A recurrent problem reported by staff of all disciplines was that the unit was understaffed and they did not have enough time to spend with service users as a result of competing priorities.

I think that’s a big thing there, be patient, trying to do different things, but most of all having the time to spend with them, that is the very important thing because we don’t, as the qualified nurses, we don’t.

Unit 1401, female, qualified nurse, 56

Sometimes when you’re busy doing bits, you don’t really get the sense that you are getting anything done, and sometimes you want to sort out things with your client but you’re not able to do that because you’re too busy dashing around doing a little bit of this and a bit of that, and managing small bits to keep the unit running.

Unit 1801, male, qualified nurse, 32

I got quite a few staff off on long-term sick at the moment, when we’ve got our full establishment operating we’re able to do a lot more social inclusion work.

Unit 0503, female, unit manager, 49

I personally could see work for another qualified OT. I don’t enjoy, is the amount of work that there is and there just being me, so it goes back to the staffing thing. It can be frustrating at times.

Unit 1802, female, OT, 36

I am now having to cover two people’s jobs and it means that stuff is falling by.

Unit 1703, male, OT, 42

It can be understaffed a lot though, um, when I first got here, in the first month, it probably was understaffed most shifts.

Unit 0901, female, support worker, 22

Increased administrative duties

Many nursing staff noted that the amount of administrative work had increased in recent years and that this meant they did not have adequate time to work directly with service users, which was a source of dissatisfaction.

The trouble is being kind of one of the senior staff nurses here, is that you often get stuck in the office and you have to do all of the paperwork and you don’t . . . it’s the support workers who get out and about and take them out to different places and ahh, they probably see more of the benefits of the work than I do.

Unit 1501, male, qualified nurse, 46

It’s the admin[istration] and the paperwork side of things that since we’ve become a foundation trust we just seem to have a lot of audits. We audit the audits!

Unit 1502, male, qualified nurse, 42

Some service users were also acutely aware of how much time nurses spent in the office:

I’m a patient, remember writing is finished, who comes first the writing or the patient. You know I’m ill, I’m saying I’m ill and they have to go and write it down you know.

Unit 1703, male, service user, 53

Lack of supported accommodation for service users to move on to

Unit managers often reported that they were under pressure from their seniors to discharge people owing to a lack of beds in the system, but there was often not enough suitably supported accommodation for service users to move on to.

We’ve often got people here who don’t really need to be here but they’re waiting for 24-hour supported accommodation.

Unit 0503, female, unit manager, 49

Institutional practices

Some nurses reported that they found some of their colleagues’ practices to be rather rigidly outdated and that these colleagues lacked the motivation to update their practice through training opportunities.

There are nursing staff here that have been here for a very, very long time, and they don’t like change, and it causes a lot of – it causes a lot of friction among staff.

Unit 1401, female, qualified nurse, 56

However, yes there is always going to be some people that will get set in one way of doing things, right and that may affect the way they work with people.

Unit 0701, female, qualified nurse, 45

I think if, this service, does stay open, and we get [. . .], the newer type client group that we have started to get, there may be some members of staff, that may need a little bit more sort of training, because we are used to caring for people, who . . . who have needed long-term care.

Unit 1801, female, qualified nurse, 40

It’s the old school I think that drag their heels a bit regarding taking up of additional training.

Unit 0503, female, unit manager, 49

Community resources

As well noting the inadequacies of suitable facilities within the unit (such as appropriately equipped kitchens for assessing and working with service users, as noted previously), OTs also reported that they found it difficult to maintain up-to-date information about community resources that service users could engage with.

It can be quite tricky, knowing about what’s out there, what’s available, it’s very time-consuming, it is hard work, because a lot of these things do change every year, so trying to keep up with it, [laugh] it does take up quite a lot of your time.

Unit 1802, female, OT, 36

The opportunity for reflective practice as a team

A sense of defeatism or of being ‘stuck’ in the rehabilitation units permeated the focus group discussions, whereby staff conveyed the perception that service users were often unable to progress and they, the staff, felt trapped and ineffective. The work of the GetREAL teams appeared to lead to staff members reflecting on the way they provided, and engaged service users in, activities. Staff also valued the opportunity that the intervention provided them for thinking together as a team about their approach.

It had an enormous benefit in that it were joint working and collaborative working and that it was going to bring everyone together, as one team, working in one direction.

Occupational therapy instructor, unit 2902

We all met as a team then and we discussed a plan as to how we’re going to achieve that in the short term and long term . . . to discuss the strategy, how we are going to get there, how we are going to achieve it, so I think that was a good opportunity for all of us to exchange ideas and think how can we improve the service. I think that was good . . . to think about it and reflect what we’ve done at work and what we could have improved on or do better.

Staff nurse, unit 0102

. . . it’s probably the first time that we’ve been able to get together totally as a team since, well after 2 years, so it was really helpful that that was included as part of the study.

Clinical psychologist, unit 0102

Questioning existing structures and processes

The chance to plan and reflect on areas of need also provided the opportunity for staff to put structures in place that could facilitate meeting these needs. For instance:

. . . after that [the intervention], we came up with a kind of protocol for therapeutic outings, so that it was clear, how much money could be afforded for therapeutic outings and in fact, we incorporated the option to have a therapeutic outing that was completely of a client’s own choice, it didn’t have to fall into a certain sort of category of you know and they can say well I would like to do this and we had an allowance that the client could claim to do an activity. And that still stands really, and that was a new, that came out of REAL. And obviously we had to limit it to a couple of times a week maximum. But most clients haven’t take much advantage of it, but some have, you know, have used it to very great effect to do their own thing.

Unit manager, unit 3704

As well as promoting the importance of reviewing structures and processes that could enable service user activities, the GetREAL intervention also seemed to allow staff to become more flexible in their approach. For instance, staff reported that they no longer necessarily provided groups or activities at certain times, but were better able to respond to service users’ needs and wishes for specific activities.

We are more flexible now, whereas before we were kind of more rigid you know so rather than thinking oh no we have to wait until this time and that day to do [activities]. So we use our time a lot better now.

Staff nurse, unit 0102

Some aspects of working arrangements were not open to renegotiation with staff. For instance, a ward manager described staff members’ reluctance to work flexible shift times that would allow more meaningful activities for service users, such as going to the cinema:

They get into the groove and they kind of build their life around the shift system. They don’t want to do a 9 to 5 or a 12 to 8 so they could go to the pictures or something.

Unit manager, unit 3704

Providing a more person-centred service

The GetREAL teams seemed to bring an objective, outside perspective that helped staff to see the potential to deliver their service differently. Staff cited specific examples of how practices such as cooking and laundry had been modernised as a direct result of the intervention:

The morning shift had to get everybody’s laundry done in that shift . . . sort of at our convenience. Why does it have to be like that? Why can’t we be a bit more flexible? And it was just having some fresh eyes coming in and seeing.

OT, unit 2902

This external perspective provided by the GetREAL teams, and the process of reviewing practice, allowed staff to reflect on whether or not they were really meeting service users’ individual needs.

[The unit] was bad at looking at people as individuals. It was like well this is how we’ve done it and we’ve done this for years and yeah we ain’t gonna change.

OT, unit 2902

Some patients are harder to engage, but . . . now I just try harder to find something that they like, that will kind of motivate them, personally, like more individually rather than as a whole, trying the same thing for everybody, but now I try to really pick something that will get them like ah, OK!

Support worker, unit 3704

They [the GetREAL team] also showed us ways of talking one on one to see what they actually like. It’s alright us putting groups on, but if they don’t like them . . .

Nursing assistant, unit 4204

Giving permission to change working practice

The GetREAL team appeared to play an important role in providing permission for staff, particularly support staff, to move beyond the perceived confines of their role.

I’m coming as a band 2, band 3 – it felt like we weren’t allowed to do anything . . . ‘cause it was their job role to do all that, but whereas now it feels we’re able to do it.

Health-care assistant, unit 2902

It’s given the nursing assistants sort of carte blanche to do more and to get involved more to make a difference.

Staff nurse, unit 2902

Staff also referred to the hierarchy within the service that acted as an important constraint on what they felt permitted to do.

For a lot of health-care assistants, there’s issues of power and who actually gives permission . . . and I think, depending on how the structure works, the hierarchy works, it perhaps is hard for some people to feel like actually I think it would be really good to do swimming, to do whatever. But am I? Is that alright on this shift?

Staff nurse, unit 2902

Activity workers particularly benefited from the developing role and greater sense of confidence and I think with that has also come much greater initiative in terms of setting up certain activities and ways of working with our patients.

Consultant psychiatrist, unit 0804

It’s given us more confidence to know we can take them out, where personally I didn’t feel that I could beforehand.

Health-care assistant, unit 2902

Building staff confidence

One senior member of staff noted a sense of increased confidence and agency among the team in relation to activities.

I think they did help with structuring and how to go about it, but I think with some people they gave them the confidence and the encouragement as well to go ahead with it rather than, just an idea, they kind of helped them put it into action. Staff feel, not that they couldn’t before, but I think there’s a renewed confidence in saying – I’d like to do this kind of group, how do I go about it? – and then before you know it, within 3 or 4 weeks, the posters are up, the group’s sort of set up and away it goes.

Staff nurse, unit 3106

It’s been a process that has enabled a number of key people within the team to be confident in terms of developing an innovative, professional repertoire of behaviours and activities within the unit actually and for the team to feel comfortable with that. It’s a big difference.

Consultant psychiatrist, unit 0804

Broadening staff responsibilities to include service user activities

A number of staff reported that the intervention reminded them that the promotion of service user activities was an important task for the whole team:

Yeah it just reminds everybody that it’s an MDT responsibility, not just the OT’s.

Charge nurse, unit 4203

Prior to the GetREAL team coming, the occupational therapy staff tended to run those groups and I think there was perhaps a view from the nursing staff that if they were doing a group it was almost seen as an add-on extra. And I think what the GetREAL team was trying to say was ‘no, it’s not an add-on extra, this is part of everybody’s role’.

Occupational therapy instructor, unit 2902

Staff also spoke of the benefit of having an ‘identified lead for an activity’, which represented an important change in accountability for the provision of activities:

I think now that we have also identified who is leading on a particular activity so that they will be answerable if it takes place or not. Rather than before we used to just diarise ‘today is bingo’ but nobody is really taking [it].

Staff nurse, unit, 0902

Motivating change in staff and service users

Staff reported an increased sense of motivation among the team during the period in which the GetREAL teams were working with them:

There was a renewed enthusiasm . . . it did make people think I could do something and I could start it and did.

Staff nurse, unit, 3106

Staff felt that the GetREAL intervention empowered and motivated not only them, but also their service users. This, in turn, had a positive effect on staff morale:

We see them happy as well, makes us happy if we see them engaged, yes it gives us satisfaction.

Health-care assistant, unit 0902

Competing priorities

Many staff reported that they had to spend a lot of their time completing paperwork and other tasks, and did not have sufficient time to engage in face-to-face activities with service users.

Well I don’t particularly enjoy it, I’d sooner be with patients than sat filling forms in myself, but it just justifies a moment in time, with all the cutbacks in all this country, you’ve got to justify what you’re doing, and it just makes you feel better that it’s another job you’re doing.

Staff nurse, unit 0502

We can only afford something like 10 minutes per shift, because there are other tasks to do, so . . . we have limited time in order to give them that quality time . . . they can approach a staff anytime and say sit down while you have a chat, and that’s fine but then you have to go back and do other things.

Staff nurse, unit 0902

Many staff saw paperwork as a priority because they knew that their performance would be questioned if it was not completed.

You wouldn’t get pulled up on what activities you’re not doing, you get pulled up on your paperwork that’s not filled in, or you haven’t ticked these boxes.

Staff nurse, unit 3106

Activities were often viewed as less important than other tasks (such as medication administration) and were likely to be abandoned when the unit was short of staff.

The needs of the ward, with staffing we’ve got, comes before activities.

Unit manager, unit 3301

I think we still lack a good strong skill base for that very, very basic motivating work with clients . . . there are staff on the team that are very, very, very good at that and others who just don’t seem to . . . and unfortunately I think it’s a slightly attitudinal thing. That it’s not the most important part of their job really.

Unit manager, unit 3704

Roles and responsibilities

Despite the enthusiasm for the changes in practice while the GetREAL team were working in the unit, some nursing staff appeared to revert to a previous position about their remit once the team left, whereby they did not consider engaging service users in activities to be their responsibility.

We’ve got to do our own job and then try to fit other people’s jobs in.

Staff nurse, unit 3301

If we nurses do all this, what would be the role of the OT . . . If my role just covered activities like an OT, then that would be easy.

Charge nurse, unit 4203

Even one unit manager felt that there was no capacity in the team to focus on service user activities:

Nobody’s actually took over where they [the GetREAL team] left off. Because I mean, each and every one of us, have got enough on our job role as it is.

Unit manager, unit 3301

Service user factors

Similarly, some of the previous defeatism centring on the severity of service users’ symptoms and the difficulty in engaging them in activities seemed to have re-emerged once the GetREAL teams left.

I think a lot of it depended on their mental status, the clients you’re working with. You could work with those who are interested to do that particular activity, you know you could find two or three people interested, but I think mental state . . . is probably the reason why some of the activities failed in the first place.

Staff nurse, unit 0902

You need that consistency with the clients wanting to engage in it really. And getting something out of it . . .

Staff nurse, unit 3106

Staff also felt that their relationships with their service users were impeded by the power imbalance inherent in inpatient mental health settings:

As the primary nurse or care co-ordinator of your clients, they mostly sometimes try to choose what they say to you or how they engage with you because they think this might affect them . . . I used to have a more close relationship when I was like a support worker with clients, because they think of, ‘I can say anything to him, it can’t affect me’, but as a qualified nurse now they’re a bit distanced, they can’t say anything to me, he’s going to document that, it’s going to affect me and he’s going to say that in ward round.

Staff nurse, unit 0902

It was also suggested that the service users who had been present on the units while the GetREAL teams had worked there were unrepresentative of the unit’s usual patients, who were not as easy to engage:

When they [the GetREAL team] came, they were dropped into a golden opportunity when we did have a fair few clients that you could motivate.

Unit manager, unit 0502

Misunderstanding of the aims of the intervention

We noted that the aims of the enabling stage of the intervention may not have been fully communicated to or understood by all staff. Some staff appeared not to have understood that it aimed to increase their confidence and skills in engaging service users in activities and to embed these new skills into their future routine practice.

So probably since they last came here, we’ve had eight new people in, who have not had that involvement from the GetREAL service and started off on that kind of train of thought really.

Staff nurse, unit 3106

Some staff felt that the enabling stage was too short to have been able to change practice, and did not appear to realise that they needed to continue to invest in the process to ensure that change was sustained:

There was the stumbling block of getting ideas achieved in 5 weeks.

Unit manager, unit 0102

There was also some evidence of misunderstanding of one of the key concepts of the intervention, that of using a personalised approach to engaging service users in activities that are meaningful to them, rather than a ‘one size fits all’ approach.

Loads of people say, I’m not doing jigsaws, I’m too old to be doing jigsaws, I’m a man . . . I don’t want to draw. Some clientele love to do activities, and love to participate, whereas you’ve got a patient like [name removed] who’s my patient, lord knows I’ve tried with him, and he thinks he’s not ill. I’m not doing jigsaws! I’m not painting! So I think you know, no matter how much you try sometimes, it’s very, very . . .

Staff nurse, unit 0502

Unit 1: largest mean change in primary outcome (unit code 4203)

This unit had the highest mean change in primary outcome (service user activity as assessed using the time-use diary74) between baseline and 12-month follow-up. This unit had opened within the past 5 years. It was based in a suburban hospital setting and had 15 beds. All of the beds were occupied at baseline and at 12-month follow-up in phase 3 of the REAL programme. The staff working on the unit included a psychiatrist, a clinical psychologist and an OT, as well as nursing and support worker staff (QuIRC). Those involved in the ‘sign-up’ meeting (the pre-disposing stage of the GetREAL intervention) were the unit manager, an activity worker and two staff nurses (fidelity sheet unit 1). The initial GetREAL staff training workshop was attended by 18 out of 24 (75%) staff, and the final workshop was attended by 9 out of 24 (36%) staff (fidelity sheet unit 1).

Unit 2: mid-range change in primary outcome (unit code 3301)

This unit had opened > 5 years ago. It was based in an urban area in the community and had 25 beds. All of the beds were occupied at baseline and at 12-month follow-up in phase 3 of the REAL programme. The staff working on the unit included a psychiatrist, a clinical psychologist and an OT, as well as nurses and support workers (QuIRC). Those involved in the ‘sign-up’ meeting (the pre-disposing stage of the GetREAL intervention) were the unit manager and clinical psychologist (fidelity sheet unit 2). The initial GetREAL staff training workshop was attended by 24 out of 36 (67%) staff, and the final workshop was attended by 12 out of 36 (33%) staff (fidelity sheet unit 2).

Unit 3: smallest change in primary outcome (unit code 2902)

This unit was community based. It had 31 beds and was located in a rural area. At baseline, 81% of the beds were occupied and at the 12-month follow-up 94% of the beds were occupied. The unit staff included nurses, support workers and an OT. A psychiatrist and a clinical psychologist provided input to the unit but were not considered part of the unit staff numbers (QuIRC). Those involved in the ‘sign-up’ meeting (the pre-disposing stage of the GetREAL intervention) were the unit manager, an OT, an activity worker, a senior service manager, the psychiatrist and clinical psychologist (fidelity sheet unit 2). The initial GetREAL staff training workshop was attended by 28 out of 36 (78%) staff, and the final workshop was attended by 8 out of 36 (22%) staff (fidelity sheet unit 3).

Receptiveness of unit staff to the GetREAL teams

From the data we identified differences in the general receptiveness of staff to the GetREAL teams. Across the three units, some staff members reported that they had heard that the GetREAL team was coming and some reported that they had not. Some staff indicated that they were unsure about the purpose, whereas those who had attended the pre-disposing meeting had a clearer idea. Staff often reported that their unit manager had not given then much information about the intervention prior to the GetREAL team’s arrival. (Note: the research team asked the unit managers to avoid telling staff about the intervention until after the researchers had collected baseline data in phase 3 in order to keep the researchers masked as to whether or not the unit had been randomly selected to receive the intervention. As there was often very little time between baseline data collection and the GetREAL team arriving, it was not possible for unit managers to inform the whole staff team in advance.)

The findings from three staff focus groups (one in each unit) and the GetREAL team reflective diary notes did not provide a consistent picture of the information staff had about the GetREAL intervention before the team arrived on the units. The focus group participants were able to state quite precisely the level of information they had received before the start of the intervention. This varied between knowing that the team was coming and knowing what they would be doing. For instance:

The OT didn’t know we [GetREAL team] were coming until last Thursday but expects her peers to be interested and wants better briefing. Many of the staff didn’t know much about the REAL programme and phase 3.

RD, unit 1

We weren’t aware of what it [GetREAL] was about . . . it was do it with activities and their [patients’] mental health and stuff, but, actually sort of what people are going to, what the intervention was.

SFG, unit 2

We just had a few days’ notice that they [GetREAL team] were coming, but we didn’t actually know what they were about.

SFG, unit 3

In the staff focus groups, participants were able to share their concerns. For instance, a charge nurse (CN) in unit 1 was concerned about the presence of the GetREAL team on the ward:

I was worried it might be a bit unrealistic because the GetREAL team were extra people on the ward, so of course the engagement and the activities were going to be more.

SFG CN, unit 1

Similarly, OTs in unit 3 appeared confused about whether the GetREAL team would be working just with the nurses on the unit or with them (SFG OT, unit 3). However, this was quickly clarified by the team, who explained that they worked with all staff on the unit.

Unit staff reported both positive and critical views about the GetREAL teams. For example, the unit manager of unit 1 said:

It was a good thing to have intensive involvement for a few weeks from REAL and thought this was valuable and helpfully was keen to embed with staff members who are closely involved.

RD, unit 1

However, in the same unit the OT had different views:

I was very apprehensive about them [GetREAL team] coming and thinking, oh XXXX, someone is going to be coming watching over us, more watching over us rather than giving, ah working with us . . . ooh is she going to be watching me and judging what I’m doing?

SFG OT, unit 1

The OT in unit 2 was of the view that those in the GetREAL team could be useful allies and would assist with their work (RD and SFG, unit 2). However, the GetREAL OT had some concerns about this:

The unit OT seems to take on a lot – when activities do not happen because some staff members make excuses she took this on herself and this seemed unsustainable.

RD, unit 2

The unit 3 staff members were quite positive about the GetREAL intervention:

I was totally positive about the GetREAL because as an OT, I believe in occupation as being therapeutic.

SFG OT1, unit 3

Similarly, a staff nurse said:

I viewed it [GetREAL] positively and thought it was good idea because we’re here for the patients, for them to express themselves, to work out activities and to enthuse us. It brought some good perspectives.

SFG SN1, unit 3

However, another staff nurse in the same unit felt that there had been inadequate planning for the intervention:

It [GetREAL] just started, stopped and then no one mentioned anything until I saw it in the diary.

SFG SN2, unit 3

Furthermore, the OT in unit 3 felt that the GetREAL team focused on working with the nurses and suggested that they should have done more work with the therapists (SFG OT3, unit 3).

Impact of the GetREAL teams

Staff and service users’ views varied as to the extent and type of impact the GetREAL teams had. From the data we identified many examples of how it had had a positive impact on the unit team, including improving the collaboration between unit staff, increasing their confidence in certain skills and motivating them. There was also recognition that it had led to an increase in the range of activities offered to service users and encouraged service users’ involvement in planning activities.

GetREAL has promoted staff and service users’ involvement in activities, which is valuable.

SFG CN, unit 1

After GetREAL the unit staff have better understanding of complexities of the unit.

SFG, unit 2

It [GetREAL] had an enormous benefit in that it was joint working and collaborative working and that it was going to bring everyone together, as one team, working in one direction, and offering the service users here a greater range of meaningful activities, not necessarily just groups but meaningful activity, in the widest sense.

SFG OTi, unit 3

In unit 1, although a great deal of work had already gone into promoting service users’ access to the community before the GetREAL team arrived, the service users were not involved in planning their days and nor were they regularly consulted about activities. The GetREAL team helped the unit’s OT to change the unit’s community meetings to a more participative style, and to plan activities on the unit with service users (RD and SFG, unit 1). This change was well received by service users, which pleased staff.

Across all three units, the service user experts who cofacilitated the staff training days in the first and last weeks of the GetREAL enabling stage seemed to inspire staff to give more thought to how they could develop their approach to service user involvement. The staff focus group participants felt that, during the enabling stage, the unit team were energised and motivated, more confident and more engaged in thinking about how best to support service users (SFG, units 1, 2 and 3). The GetREAL teams had also had a directly positive effect on service users, empowering them to suggest activities that they wanted to do (SFG, unit 3).

The data also suggest that the GetREAL teams gave the unit OTs support and helped them develop their skills in actively engaging other members of the MDT in planning and leading activities with service users. This was achieved through modelling collaborative action planning, sharing occupational therapy concepts and skills with all staff, and encouraging them to try out the activities suggested by service users. There seemed to be a general shift in attitude, whereby, at the start of the enabling stage, many unit staff had viewed activities as the job of the OT, but the stage it progressed more staff seemed to acknowledge the importance of activities for service users’ recovery, and to see this as something that the whole team should enable (RD and SFG, unit 1).

In unit 3, the OT was very enthusiastic about the GetREAL intervention, especially about its potential to improve multidisciplinary collaboration and disseminate the message that engaging service users in meaningful activity was a role for all staff on the unit. However, the therapist felt that the intervention was a little too focused on the nurses, and that more time should have been given to working alongside OTs. However, at the staff focus group 6 months later, some nursing staff complained that they felt they were expected to do the OT’s job as well as their own (RD and SFG, unit 3).

Maintaining initial enthusiasm

The ‘maintaining initial enthusiasm’ theme refers to the longer-term sustainability of the changes introduced during the enabling stage of the GetREAL intervention. The data from the three units revealed that once the enabling stage had started, staff members and service users were enthusiastic about the intervention. For example, in their focus group, the unit 3 staff reflected on how the team had motivated them to start different activities with service users (e.g. dancing or attending the local gym). They found the training interesting, and felt listened to and supported. Staff indicated that the changes they made during the intervention were successfully sustained and further developed over the following few months. However, we did not have specific data available to assess if this momentum was maintained over the longer term.

Staff across the three units seemed to appreciate outsiders (the GetREAL teams) stimulating them to look at things afresh. They also appeared to gain satisfaction from seeing service users responding positively to the changes that were facilitated by the GetREAL teams, and reported feeling more confident in engaging service users in activities (SFG, units 1, 2 and 3). However, the service user interviews revealed how some activities introduced during the enabling stage (photography, visiting the aquatic centre) did not continue owing to a lack of equipment (camera) or insufficient numbers of available staff to accompany them (SUI, unit 3).

The GetREAL legacy

In unit 1, some of the activities initiated in the enabling stage, involving all staff members, were sustained, such as working on a local allotment. This appeared to have been helped by positive feedback to staff from service users about how much they enjoyed it. In unit 1 there was also evidence that staff members, mainly nurses and the OT, were continuing to refer to the action plan and review the actions they had agreed to continue after the GetREAL team left (SFG unit 1). The staff focus group in unit 3 also suggested a lasting benefit from the enabling stage, in that service users were reported to be accessing the community more for activities, to the point where:

Sometimes there is nobody left in the building to take part in the activities in the unit.

SFG, unit 3

However, the unit 2 staff members were less positive, admitting:

Nobody actually took over where the GetREAL team left off because each and every one of us staff members has got enough on their job roles.

SFG, unit 2

Mechanism: RS

The literature suggests that staff groups will be receptive to making long-term changes and increasing their engagement with recovery-based practice if they feel involved, valued, enthusiastic and engaged in the training/change programme. Contextual factors that might promote, or inhibit, this sense of enthusiasm, engagement, involvement and feeling valued include characteristics of the training/change programme, organisational structures and systems, and the local culture and climate (see Table 34).

The case study data and evidence from the literature review for each of the three priority candidate theories within the RS mechanism are presented below. A summary of the main characteristics of the papers reporting on primary studies referred to below is provided in Table 33.

Priority mechanism: SC

The literature suggests that staff groups will make long-term changes in practice if they feel supported, both by management and colleagues, to do so; this is one of our postulated mechanisms of long-term change. Contextual factors that might promote, or inhibit, this sense of support, encouragement and motivation include characteristics of the training/change programme, organisational structures and systems, and the local culture and climate (see Table 33).

The corroborative evidence that emerged from our literature review and case studies for each of the four priority candidate theories included under the SC mechanism is presented below. A summary of the main characteristics of the primary study papers referred to below is provided in Table 32.

Mechanism: RER

When staff groups of a mental health inpatient rehabilitation unit have taken part in a training programme aimed at increasing their engagement with recovery-based practice, they will make long-term changes if they, and the service users, feel that recovery is everyone’s responsibility – all staff, all service users.

There was some support for this theory arising from the qualitative data from all three case study units. The more successful unit (unit 1) appeared to have a more open and supportive staff culture that facilitated the aims of the GetREAL intervention, to enhance shared responsibility for engaging service users in activity. For instance, the GetREAL OT observed that:

The Unit 1 multidisciplinary team is democratic by the consultative style and humility of the consultant and other professionals . . . but that the nursing staff may remain quite hierarchical and didactic in their planning of work.

RD, unit 1

The GetREAL intervention was seen to encourage team reflection and decision-making, as it was reported that:

[T]he turning point has been the team meeting, where the Action Plan was reviewed – this prompted staff to think about how the patients can be more involved in their treatment by planning their own week.

RD, unit 1

Furthermore, the GetREAL team observed that the unit 1 OT was skilful at encouraging nursing staff to support and share responsibility for activities.

The data from unit 2 suggested that at the start of the enabling stage there were barriers to staff taking on shared responsibility, but over time and through shared discussions the GetREAL team facilitated staff in improving their communication and collaboration:

The team planned away days for discussion and collaborative planning . . . In which the OT will input information about MOHOST [an occupational therapy assessment tool] to one of these away days and other topics are included: how do we talk to each other? How do we keep each other informed?

RD, unit 2

Furthermore, the GetREAL team’s OT noted in their reflective diary that the unit 2 staff members:

[D]iscussed communication ideas for activity planning and agreed to put activities in to the diary and add a column in the allocation sheet to support staffing and prioritising of activities. Also discussed visual prompt and manager has ordered an extra white board for the office following the discussion.

RD, unit 2

The data from unit 3’s staff focus group suggest that during their group supervision meetings the staff usually reflected on the work they had done and how to improve it. They mentioned that they found it useful to reflect on their work as a team. In addition, staff members found the noticeboard very useful as an indicator of how well they were doing in focusing on service user activities, and this also aided handover between shifts because:

[I]t was listed on the noticeboard what all service users are doing on daily basis.

SFG, unit 3

Mechanism: RR

When staff of a mental health inpatient rehabilitation unit have taken part in a training programme aimed at increasing their engagement with recovery-based practice, they will make long-term changes and increase their engagement with recovery-based practice if they, and the service users, feel that working collaboratively with service users towards recovery is realistic.

Service users were involved in both the design and delivery of the GetREAL intervention from the start of its development. Disappointingly, the GetREAL teams found that the case study units did not involve service users in planning and providing activities on their units to any great extent. The GetREAL teams attempted to rectify this by inviting staff to work with them to involve service users in making choices and run community meetings, thus demonstrating service users’ potential. This had some positive responses from staff, adding tentative support to this theory.

The staff nurse of unit 1 identified that:

The underlying issue is the lack of service user involvement in their own care let alone the running of the unit. It is very disempowering. Staff don’t even ensure that service users discuss and sign their care plans.

SFG SN, unit 1

Similarly, the GetREAL team’s OT noted that:

[T]he care planning does not involve the patients directly and when explored it is left to the nursing staff to discuss and seek collaboration.

RD, unit 1

Later, the GetREAL team involved service users in planning the week’s activities by sitting with them one to one, encouraging them to plan their own week and use the weekly timetable sheets (RD, unit 1).

The team identified that service users in unit 2 were underengaged. Although the team found this challenging to address, after organising a service user forum meeting they felt that service user involvement was progressing (RD, unit 2).

In unit 3, staff focus group participants felt that the GetREAL service user consultant had been an important contributor to the intervention. This encouraged the staff to put forward plans for more service user involvement in the unit and to invite in ex-service users (SFG, unit 3). The GetREAL team’s OT observed that the unit’s activity worker had started collecting ideas about what service users would like to do through running ‘taster sessions’, although the response was limited and the service users identified things that were already happening on the unit, rather than suggesting new activities (RD, unit 3).

There was support for ‘quick wins’ having a positive impact on staff changes. For instance, in unit 1:

[S]ome of the nursing staff mentioned that they had found the weekly timetable useful and seen the benefits of promoting service user involvement.

TN, unit 1

The unit 2 data showed that staff members gradually started to talk more about activities, introducing one-to-one activities with service users and responding to individual service users’ suggestions for specific activities (RD, unit 2). The GetREAL team’s OT observed that the staff members in unit 2 who had previously not been involved in the activities or shown some reluctance started putting themselves forward to cover the groups. For example:

[A] member of the team who previously spent the majority of his shift in the office was making a concerted effort to be out of the office with service users today.

RD, unit 2

Furthermore, it was reported by the unit 2 staff that:

[T]hey feel as a result of the GetREAL input staff are spending more one to one time with service users.

SFG, unit 2

Unit 3 staff focus group participants stated that ‘the GetREAL OT has set up a new white board with the programme of activities and groups for the week that was owned by the nurses and will be updated each Sunday’ (SFG, unit 3). This was done to encourage the staff members to look at the board and organise appointments around the activities, so that these were prioritised, and to manage shifts around activities (SFG, unit 3).

Mechanism: RFR

Staff will increase their engagement with recovery-oriented practice if they feel that they have the resources to do so and/or if barriers (individual, group or organisational) have been removed.

The qualitative data identified the importance of flexibility of shift and working patterns and problems when shift working is inflexible. For instance, the GetREAL team’s OT observed that many of the nursing staff members in unit 1 were supportive of service user activity but did not always know what was planned until the day they came into work. It became clear from the activity planning meeting that the unit’s OT did not plan the activities with the rest of the team (RD, unit 1).

They also noted in their reflective diary that ‘there are some people on the ward who say “that’s not a nursing job, I’m not doing it” but they have taken part in the GetREAL training workshops’ (RD, unit 1).

Data from unit 2 suggested that greater role flexibility led to positive outcomes. For example, nursing assistants became increasingly engaged in established activities and in suggesting new ones, and nurses became increasingly supportive of this by managing shifts to better accommodate these. It was noted in the GetREAL team’s reflective diary that the unit staff appeared keen to get involved with activities and, over time, this was true even of those staff members who had earlier stated that they felt activities to be the OT’s job (RD, unit 2).

The unit 3 staff were split into two teams and worked across two floors of the unit. This avoided the need for bank staff to cover staff absence, but it was observed by the GetREAL team’s OT that ‘Staff members go off for a week or two between shifts on both floors. This breaks continuity in getting activities up and running all following through what service users want’ (RD, unit 3).

Research design

A quantitative rating instrument was developed to measure the uptake and receptiveness of each unit to the GetREAL intervention. A quantitative data analysis using random-effects modelling was then carried out using these ratings to investigate associations with service user outcome data collected at the 12-month follow-up in phase 3 of the REAL programme (service user activity as assessed by the time-use diary74 and social function as assessed by the LSP). 75

Quantitative rating instrument

A categorical variable was developed from a combination of the GetREAL fidelity rating used in phase 3 of the REAL programme and the qualitative data used in the realistic evaluation, to rate each unit that received the GetREAL intervention dichotomously as ‘good’ or ‘poor’ in terms of their uptake and receptiveness of the intervention. Uptake was defined as the acceptance or adoption of a new product or idea, or the number of people wanting to do something, such as use a service or study a particular subject. Receptiveness was defined as having the quality of receiving, taking in or admitting, or being ready and willing to accept something such as a new idea. These definitions were operationalised and incorporated into a draft instrument by SC. ‘Uptake’ was rated using the following items from the GetREAL fidelity rating sheets: attendance of staff at the two training events, and whether or not the units had spontaneously corresponded with the intervention teams during the 12-month reinforcing stage. The ‘receptiveness’ of each unit was rated using items identified from the realist review of context and mechanisms associated with sustainable change in recovery-based practice within rehabilitation mental health units: ‘receptive staff’, ‘recovery is realistic’ and ‘resourced for recovery’. The draft instrument, consisting of 26 items, was piloted by SC with the data from the three case study units used in the realistic evaluation. The researchers carrying out the case study analyses (SB and HB) and the reviewer of the literature (MG) were consulted on the validity of the ratings and the items in the ratings instrument. The scores reflected both the qualitative and quantitative data for these three units (higher for unit 1, lower for unit 3). Amendments were made to the instrument, which included deleting some items considered of less direct relevance to the study aims.

The final rating instrument comprised 23 items, as shown in Table 38. This was used to rate all 19 units. Data were extracted from the GetREAL intervention fidelity rating sheets, the daily reflective practice diaries completed by the OT of each GetREAL intervention team during the first week of the enabling stage, the staff initial training day evaluations, supervision notes and initial action plans. For each unit, each item was given a score of 1 (good) or 0 (poor) when supporting data existed for that unit, and marked as ‘not known’ if there were no supporting data. A rating for each unit was calculated as the mean of all of the scored items.

Quantitative data analysis: random-effects modelling

LM analysed the data using Stata version 13 for Windows (StataCorp LP, College Station, TX, USA). Summary statistics were calculated for the uptake and receptiveness instrument total score, the uptake and receptiveness subscale scores and the individual instrument items. The three ratings (uptake, receptiveness and total score) were used as continuous measures and also dichotomised at their means and medians.

The outcomes entered into the model were the 12-month follow-up assessments of service user activities74 and social function75 gathered in phase 3 of the REAL programme (time-use diary and LSP scores, respectively). Individual-level data were modelled using linear mixed models to take into account the clustering by unit to see if the uptake and receptiveness rating scores, or items selected in line with the theories generated from the realistic evaluation, were associated with the outcomes. 148 These were explored first in an unadjusted model and then in three adjusted models, as follows:

• adjusted model 1 – adjusted for unit mean baseline score of the outcome (time-use diary or LSP)

• adjusted model 2 – adjusted for unit mean baseline score of the outcome and GetREAL team

• adjusted model 3 – adjusted for unit mean baseline score of the outcome and interaction between uptake and receptiveness rating score or dichotomous good/poor rating as appropriate and GetREAL team.

Strengths and limitations

The choice of realist methodology to evaluate the GetREAL intervention has been vindicated through a demonstration of the complexity of the system. The use of a rapid realist review to generate candidate programme theories proposing the relationships between context and mechanism leading to long-term change has been instrumental to the evaluation process, particularly as we were dealing with a scarcity of programme data for evaluation. Without the rapid realist review to generate the candidate programme theories, there would have been a danger of ‘overfitting’ the data,151 and our findings would have limited generalisability even to other units within the study.

Owing to time limitations, the rapid realist review was constrained by the scope (and quantity) of the documents feeding into the candidate programme theories. Thus, for pragmatic reasons, the bibliographic database searches were tightly defined; however, this was tempered by taking a more inclusive approach to papers put forward by the stakeholder (LRG and EP) groups and discovered through grey literature, reference and citation searches. As was appropriate for maximum utility to the realistic evaluation, the candidate programme theories were rooted in the context of recovery-based training for multidisciplinary staff working in inpatient mental health rehabilitation services. Further work would be needed to make our theories generalisable outside this context. The triangulation of our theories with other published mid-range theories of individual and organisational behavioural change is also desirable: again, an activity that was not performed for this evaluation owing to time constraints. However, transparently recorded processes throughout the rapid realist review have ensured a robust platform on which to build this future work.

The LRG/EP consultation and involvement was a strength of our approach; although time constraints prevented us from performing a Delphi consensus-forming exercise, we did obtain validation of our candidate programme theories and a steer on prioritising them for further exploration. However, in some instances the papers that were originally suggested by the LRG and EP members were not of immediate relevance to the review, possibly representing a shortfall in our efforts to explain the methodology in layman’s terms.

Although the priority programme theories have been consolidated using evidence from the literature, and tested as far as possible using data gathered during the evaluation of the GetREAL intervention, more thorough theory testing from case studies drawn from wider bodies of literature is ongoing work. Additionally, we acknowledge that theoretical saturation may well not yet have been reached; there may yet be further mechanisms and/or contexts that are undiscovered. For instance, in the treatment of theory RS3 (incorporation of recovery to existing change programme) (see Priority theory RS3), we have proposed that one way of moderating the effect of staff ‘change fatigue’ might be to incorporate a new training programme into an existing change initiative. However, other strategies may also be effective.

Although acknowledging the complexity of the interactions between contexts and mechanisms, our findings suggest that the following modifications could strengthen the GetREAL intervention:

1. Pre-intervention site assessment to identify potential problems and the service’s readiness for change.

2. Initial buy-in needed by all disciplines, at all levels.

3. Attendance at training workshops should be promoted by senior staff to demonstrate managerial sign-up and to engage reluctant staff.

4. Services should ensure that they have structures and processes to facilitate and maintain service user involvement in the planning and delivery of the service (e.g. service user-led meetings and posts such as peer support workers).

5. There needs to be sufficient staff and greater flexibility in working patterns to allow staff time to engage in activities with service users.

6. The recording of service user activities needs to reflect all aspects of activity, not just those on the unit, and data need to be collated and fed back to staff and service users in a way that is meaningful and useful for them and for service managers.

7. Roles such as change agent or champion need to be integrated within the team, rather than this function being associated with an individual staff member (who may leave).

8. Existing practice improvement programmes (such as ‘Productive Ward’) need to be integrated with GetREAL to embed a combined long-term change process.

9. The OT on the unit needs to have the skills and support to engage the MDT in activities as part of everyone’s role.

10. Staff supervision needs to incorporate regular review of how the team and individual staff are working to prioritise and engage service users in activities.