Original Article
Recovery-Oriented Care in a Secure Mental Health Setting: ‘‘Striving for a Good Life’’ Brian McKenna, RN, BA, MHSc, PhD1,2, Trentham Furness, PhD1,2, Deepa Dhital, PhD1,2, Malcolm Park, RN, GradDipPN2, and Fiona Connally, RN, GradDipPN2
ABSTRACT Recovery-oriented care acknowledges the unique journey of the consumer to regain control of his or her life in order to live a good life. Recovery has become a dominant policy-directed model of mental health service delivery. Even services that have traditionally been institutional and custodial have been challenged to embrace a recovery-oriented model. The aim of this qualitative study was to provide a description of service delivery in a secure in-patient mental health service, which has developed a self-professed recovery-oriented model of service delivery. An in-depth case study of the secure in-patient service using an exploratory research design was undertaken to meet the aim of this study. Qualitative data was gathered from interviews with consumers and staff (n = 15) and a focus group with carers (n = 5). Data were analyzed using a content analysis approach. Ethical approval for the study was obtained. The stakeholders readily described the secure service within recovery domains. They described a common vision; ways to promote hope and autonomy; examples of collaborative partnership which enhanced the goal of community integration; a focus on strength-based, holistic care; and the management of risk by taking calculated risks. Discrepancies in the perceptions of stakeholders were determined. This case study research provides a demonstrable example of recovery-in-action in one secure mental health service in Australia. It is intended to assist mental health services and clinicians seeking guidance in developing strategies for building and maintaining partnerships with consumers and carers in order for secure services to become truly recovery-oriented. KEY WORDS: Mental health; recovery; recovery-oriented care; secure services
he “person-centered care” movement powerfully demonstrates that fully including the individual consumer as a person, at all stages of their involvement with healthcare services, leads to more efficacious and satisfying outcomes (Australian Commission on Safety and Quality in Health Care, 2011). This approach acknowledges the unique needs, concerns, and preferences of the individual and is inclusive of the family and other
T
Author Affiliations: 1School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Fitzroy, Australia. 2NorthWestern Mental Health, The Royal Melbourne Hospital, Parkville, Australia. The authors declare no conflict of interest. Correspondence: Brian McKenna, RN, BA, MHSc, PhD, NorthWestern Mental Health, Level 1 North, City Campus, The Royal Melbourne Hospital, Grattan Street, Parkville, Victoria, Australia 3050. E-mail: [email protected] Received March 23, 2014; accepted for publication March 31, 2014. Copyright © 2014 International Association of Forensic Nurses DOI: 10.1097/JFN.0000000000000027
Journal of Forensic Nursing
carers of the person concerned. Although there is wide agreement about the need for person-centered care (Barker, 2001; Beckett, Field, Molloy, Yu, Holmes & Pile, 2013), healthcare organizations often have difficulty implementing the type of change necessary to commence (Davidson, Tondora, Lawless, & Rowe, 2008; Shepherd, Boardman, & Burns, 2010) and sustain this approach (Australian Commission on Safety and Quality in Health Care, 2011). Furthermore, as a theme of person-centered care, “recovery” (Anthony, 1993) has emerged to become a preferred stand-alone model of mental health service provision (Drennan, Law, & Alred, 2012; McLoughlin, Du Wick, Collazzi, & Wick, 2013). Recovery-oriented care focuses on the lived experience and unique growth of the individual consumer, with the aim of the person living a satisfying life alongside the limitations imposed by mental health needs (Drake & Latimer, 2012; Oades & Anderson, 2012). Recovery is conceptualized as a unique consumer journey, which is traversed through wellness and illness (Leamy, Bird, Le Boutillier, Williams, & Slade, 2011). Recovery involves www.journalforensicnursing.com
Copyright © 2014 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
63
Original Article
the consumer connecting with those who are able to support, having a sense of hope and optimism for a life worth living, building and defining a sense of identity, developing a meaning in life that is spiritually and socially integrated, and having a sense of empowerment in controlling one’s own destiny (Borg & Davidson, 2007; Leamy et al., 2011). However, among forensic mental health services, where consumers are under restriction through condition of legal detainment, “imposed recovery” (Young, 2011, p. 397) can compromise major themes of recovery-oriented care. Imposed recovery has the potential to compromise choice and autonomy. It can impose lengths of stay that stifle hope. Those detained may present with behaviors that require challenging and confronting approaches, rather than the usual affirming styles of communication associated with fostering engagement. Finally, those detained under “imposed recovery” may experience the double stigma of serious mental illness and criminality, which make reintegration and inclusion into society difficult (Dorkins & Adshead, 2011; Mezey, Kavuma, Turton, Demetriou & Wright, 2010; Young, 2011). Mental health policies in many countries, including Australia, have endorsed the need for mental health services and the mental health workforce to be recovery-oriented (i.e., supportive of the recovery journey of consumers). The momentum for change to recovery-oriented service delivery has led to the development of service frameworks (Department of Health, 2011; Department of Health and Aging, 2013) and practice guidelines (Davidson et al., 2008). Even services that have traditionally been institutional, custodial, and involved in compulsory treatment under mental health legislation have been challenged to embrace the transformation to recovery-oriented care (Corlett & Miles, 2010; Hillband, Young & Griffith, 2010; McLoughlin, 2011; Simpson & Penney, 2011). Despite the administrative momentum for recovery, many mental health services are seeking guidance on appropriate strategies for building and maintaining partnerships among clinicians, consumers, and carers in order to become recovery oriented. There is a paucity of evidencebased literature focusing on what recovery-in-action looks like in a secure settings. It is imperative that successes in the transformation to recovery-oriented care are captured. Such evidence may be used as a practical guide to assist services and individual clinicians, such as nurses, as they grapple with this change. Therefore, the aim of this qualitative study was to provide a description of service delivery in a secure in-patient mental health service, which has developed a self-professed recovery orientation as its model of care. The intent was to determine the extent to which elements of service delivery resemble the domains of recovery-oriented care specific to the demands of the Australian jurisdiction (Department of Health, 2011; Department of Health and Aging, 2013). 64
www.journalforensicnursing.com
▪
Methods Research Design This research was conducted as an illustrative case study of the description of the recovery-oriented approach to service delivery in a secure in-patient mental health setting. Case studies are primarily aimed at investigating a complex intervention or approach within the real-life context in which it occurs (Davey, 1991; Yin, 2003). This research was approved by the Melbourne Health Office for Research.
Secure Setting One in-depth case study was the focus of this research. The adult unit is a 26-bed secure, extended-care facility in a large metropolitan mental health service provider for a catchment of 1.3 million people in Melbourne. The unit employs 40 staff across the multidisciplinary spectrum. The secure setting is accessible as an external wing of a metropolitan hospital. The unit is equipped with a communal kitchen, a designated space with gym equipment, separate male and female living areas, a sensory modulation room, and various communal living areas. The unit has several court yards for outdoor recreation and quiet spaces. The unit provides medium to long-term in-patient treatment and support for adult consumers who have unremitting and severe symptoms of mental illness. This illness can often be complicated by a history of the use of drugs and alcohol, nonadherence with medication, poor response to medication, lack of social supports, nonengagement with community services, involvement in crime, and homelessness. The secure service provides treatment, supervision, and support for those whose needs cannot be met adequately by other available programs and services. In 2006, the workforce/administrators of the unit developed a self-professed recovery-oriented model of service delivery. Despite the legal status as a locked facility, the service supports consumers to live well in the presence and/or absence of their mental illness, with the goal of a “good life” once discharged.
Data Collection Qualitative methods of data collection were used (i.e. 60-minute one-on-one interviews with current and past consumers and current staff and a 60-minute focus group with carers). A consumer researcher conducted the interviews with consumer participants. The consumer researcher has been in the role of a consumer consultant for 12 years. The consumer researcher was provided with the interview schedule and prompts to assist responses. The schedule consisted of questions about (a) the consumers’ experience of participation in the secure service, (b) what it is about the service framework that is recovery-oriented, (c) how involvement in the service has affected their recovery, and (d) the relationship of the Volume 10 • Number 2 • April-June 2014
Copyright © 2014 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
Original Article
recovery-oriented service delivery with the consumer’s sense of overall recovery. One researcher (B.M.) undertook all one-on-one interviews with staff and asked what it is about the service framework that was recovery oriented. The same researcher (B.M.) conducted a single focus group with carers using the same interview schedule as staff. He was assisted by another member of the research team (D.D.) who took field notes, which were integrated into the data analysis. The interview schedule was based on the domains of recoveryoriented care in the Victorian context (Department of Health, 2011) and asked how current service delivery (a) promotes a culture of hope, autonomy, self-determination through holistic and personalized care; (b) establishes collaborative partnerships and meaningful engagement; (c) focuses on strengths; (d) includes families and carers; and (e) encourages community participation and citizenship. All interviews were recorded on an audio-digital recorder (Sony ICD-PX333M). Data were collected from July to September 2013.
Data Analysis A general inductive approach was used to analyze the qualitative data (Thomas, 2006). Data were transcribed and organized with the use of NVivo (QSR International Pty Ltd. Version 10, 2012). The coding for both consumer and other key stakeholder data were developed through continuous reading and agreement among the researchers (B.M., T.F., and D.D.) and then aligned with the preexisting domains of recovery (Department of Health, 2011). As necessary during analysis, content and codes were either collapsed or split into preexisting or different categories, until central relationships began to emerge (Patton, 2002). Each pattern was examined for supporting quotes from the data. Rigor was further enhanced by collective agreement among the research team on the categorical analytic framework, emergent patterns, and supporting evidence (Guba & Lincoln, 2005; Mays & Pope, 1995).
▪
Results Sample Description A total of 20 key stakeholders provided informed voluntary consent to participate in this research. One-on-one interviews were held with a purposive sample of consumers (n = 4), a consumer consultant, a manager, a lead nurse, registered nurses (n = 3), an enrolled nurse, a consultant psychiatrist, a social worker, an occupational therapist, and a psychologist. The carer focus group was conducted with five participants.
Content Domains The participants in this study readily discussed aspects of service delivery, which they thought integrated into the recovery domains, upon which the interview schedule was Journal of Forensic Nursing
based. The seven content domains were (a) a common vision: a journey toward “a life worth living”; (b) promoting hope; (c) promoting autonomy and self-determination; (d) meaningful engagement; (e) focusing on strengths; (f) holistic and personalized care; (g) community participation and citizenship; and (h) managing risks by taking calculated risks.
A Common Vision: A Journey Toward “a Life Worth Living” A common vision of recovery was expressed by all stakeholders, which is captured in the belief that consumers are on a journey to achieve “a life worth living.” This was eloquently expressed by one consumer participant as a desire to: …keep out of jail, keep off the street, keep out of hospitals, and not relapse. Next move at summer time is to get supported accommodation. Then get a part time job…get a double bed in a one bedroom flat, then get married and have kids. I want to try a normal life, like everybody else. (Consumer) Yet a sense of the challenge of the journey was also conveyed, especially when the journey was conceptualized within the reality of enduring mental illness: …sickness lasts forever, the [consumer] is sick… they take medications, some will always be like that. We will always need help towards life…. (Consumer)
Promoting Hope Developing a culture of hope was viewed as a fundamental clinical need in supporting the challenge of the journey. Clinicians expressed the need to commence building hope from admission, and the development of hope was seen as providing the “scaffolding” necessary to achieve sustained change. Consumers were viewed as integral in fashioning this scaffolding. Central to supporting hope was developing collaboration through a “step-by-step” care plan. This clinical process commenced through narrative discussions with the consumer, which focused on goal setting. Consumers were encouraged to set goals. If long-term goals were projected, such as the desire to leave the service, then the consumer was refocused on developing a small number of short-term goals, toward these ends. The achievement of short-term goals was viewed as developing a sense of hope and providing a launching pad to embark on more adventurous goals: The step-by-step plan…they [the consumer] formulate it. [For the clinicians], it’s about understanding the [consumers]; what they do day to day…. (Nurse) www.journalforensicnursing.com
Copyright © 2014 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
65
Original Article A milestone in establishing hope was the granting of day or overnight leave from the secure service. Leave enabled a gradual transition to reconnecting with those who could assist in reestablishing everyday life back in the community. This reconnection enhanced the strengthening of relationships to sustain consumers on their recovery journey: I pick him up and it’s a bit of a long drive, so you get a bit of time and he did start to talk a little bit about being here, which he never used to do when he was in other places…there is some spark somewhere…a touch of hope at the moment, I think. (Carer) The development of hope appeared to be gradual, systematic, and methodical. Yet flexibility in this approach was evident, and situations were highlighted when the only way forward in achieving hope for “a life worth living” appeared to lie in going directly to the long-term goal: [The consumer]…was a very difficult person to deal with. As soon as he arrived he kept on saying he wanted to ride in a helicopter. So we finally said “if you save your money, we will take you to the show (with the helicopter).” Sure enough it did happen maybe six or eight months later…. His face just lit up like you wouldn’t believe. No one had ever taken him seriously before. So from that day on he just improved. Otherwise he was never going to improve. Twenty years admitted and then he went to [supported living] and now he is living with his mother. (Manager)
Promoting Autonomy and Self-determination Promoting autonomy and self-determination may appear paradoxical when consumers enter this secure service involuntarily under conditions of legal coercion. The clinical staff were aware of this paradox: We work here in a recovery model and we are all about autonomy and individual choice, and we sit here and say at the end of the day it’s up to you. If you want to change or not. But on the other hand we kind of say to them, “You are not well, that’s why you are locked in here.” (Psychiatrist) Mental health legislation in this jurisdiction allows containment, compulsory treatment, the use of force, and restriction on leave. Within the boundaries of the legislative constraint, clinical staff indicated an attempt to encourage and foster choice, even though choice might be limited to the extent that it almost offered the “illusion of choice.” Although the degree of choice was constrained, flexibility was explored, as limited as that might be. The most common examples provided by clinicians related to medication 66
www.journalforensicnursing.com
administration, where there was the attempt to offer choice about the type of medication, the dose, and the route: …being on an involuntary treatment order, that restricts the choice…but if they are willing to take one medication but not another, then we are happy to negotiate. And same with dosage, if someone experiencing side effects…then we might negotiate for a lower dose. (Nurse) The clinical review was the most cited clinical process in which there was a clinical perception of promoting autonomy and self-determination by negotiating a pathway forward in the planned care of the individual. Clinicians believed that consumer participation in the clinical review allowed consumers to engage in dialogue and assist in orchestrating their recovery plan, rather than being passive recipients of mandated treatment. However, despite this attempt to foster choice and autonomy, consumers did not necessarily perceive the process as empowering. As stated by one consumer, They outnumbered me in the clinical review and give me the medications that I don’t need at all… they effect and paralyse your brain. (Consumer)
Meaningful Engagement A long length of stay is a reality for consumers of secure services. Clinicians and carers saw positive advantage in this time, which enabled continuity of care and the time necessary to strengthen collaborative partnerships and meaningful engagement. Engagement was typically described as occurring through informal conversations between consumers and staff during the mundane activities of everyday life, such as sharing a cup of tea, walking around the block, or doing tasks such as shopping or cooking. The process allowed rapport building and founded trust. Clinicians also discussed “presencing” or being with the consumer at times that were important to them as a key pragmatic process. The process, for example, could involve facilitating and participating in group activities for leisure purposes: We printed out some of the exercise groups in the community. And she kind of picked one that she would like and we facilitated that. There are times when I actually did zumba [aerobic exercise] with her. (Social Worker)
Focusing on Strengths Clinical staff prioritized focusing on the strengths of consumers. Once strengths were identified, constructive feedback, guidance, and encouragement were seen by clinical staff as strengthening the confidence and self-worth of consumers: Volume 10 • Number 2 • April-June 2014
Copyright © 2014 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
Original Article
You start to see those more intangible strengths that people have like their leadership. We’ve had [consumers] who have organised groups, got people there on time…. (Manager) However, the ability to develop strengths was constrained by legislative requirements or structural impediments, such as staff difficulties balancing individual need with the management of the whole in-patient community. Consumers viewed such constraints as frustrating: …they said I am fit enough to work and when I found work they said I have got four hours for the whole week and four hours consist of travel time as well. So I said it takes me half an hour to get there and forty five minutes back. Restrictions make it impossible. (Consumer)
Holistic and Personalized Care Holistic care was also viewed by clinical staff as central to the recovery approach in the secure service. The length of stay of consumers in the service allowed a holistic approach to both mental health and physical health to be gradually embedded through systematic planning. Change was not forced on people from a position of staff authority: [Consumers] don’t want to change what they eat or to stop smoking. We never stop trying to encourage that, we look at everything from family dynamics through to their own physical and mental health. Those things are in their step-by-step plans about exercise, diet, and social engagement. (Manager) Evidence of holistic and personalized care was also cited in responsiveness to diversity, in meeting social, cultural, and religious needs. To accommodate specific gender requests, the staff talked about the development of a designated area for female consumers: The women’s lounge has a few couches with rugs and cushions, and a big telly and purple walls with different decorative words hanging on the walls (like, “hope” and “love”). And there is pampering stuff, if you want to do pampering sessions and foot spas. (Occupational Therapist) Religious practices were supported through enabling religious food observances and visits by religious leaders. For example, during the fasting requirements of Ramadan, clinicians were flexible with medication schedules to accommodate the fasting requirements of Islamic consumers. It is in the commitment to partnerships with carers that the Journal of Forensic Nursing
holistic vision of the service was best personified. Carers were viewed as the repositories of the in-depth understanding of consumers, which was pivotal in the delivery of holistic care. Yet the vulnerability of carers was also acknowledged: We have realised it’s the same amount of work that we do with our families that we have to do with consumers. They have lost hope, are burnt out, been abused, assaulted…. (Manager) Family meetings and regular family peer-support sessions were arranged. Visiting hours were flexible and modified to suit the circumstances of carers in an effort to support the holistic and personalized care of the consumer. However, potential tensions were expressed in the relationship between staff, consumers, and carers, which required careful negotiation. Consumers have choice regarding carer involvement in their treatment plan. Clinical staff acknowledged confidentiality and the right of consumers to determine the involvement of carers. Yet when tension arose, support to all involved remained evident: I had a client in the past who did not want anything to do with the family…so again we have to respect the client’s opinion. He requested that he did not want to see his mother at all, but Mum still attended our carer’s group as a way of support, which worked really well for her. (Social Worker)
Community Participation and Citizenship A stay in the secure service may be lengthy but only constitutes one phase of the recovery journey. The goal of “a good life” involves community reintegration. There was a commitment to commence engagement even if reintegration into the community was not imminent: We’ve got one Vietnamese man here at the moment who is extremely unwell, constantly psychotic, and also cognitively impaired. He can’t live anywhere else. With the agreement of the Vietnamese men’s group in the community, he goes there, with a staff member. (Manager) Staff in the secure service were proactive in negotiating contracts with external agencies to expose consumers to experiences that better equip them for future life in the community. In some cases, this involved consumers establishing a sense of belonging to the community. This was well demonstrated in a contract negotiated to complete mosaics to beautify the surrounds of a new motorway: …it was around the idea that you were doing something for the community. It was to beautify the community. But it was also something that is going www.journalforensicnursing.com
Copyright © 2014 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
67
Original Article
to last and something that [the consumers] could say “I have done that, look what I did” and have some pride, plus learn some new skills. (Manager)
Managing Risks by Taking Calculated Risks Recovery in a secure environment is complicated by the degree of risk consumers may pose to self or others. There is a responsibility to maintain the safety of the consumer, their peers, staff, family, and in some cases the wider community. From the interviews with staff, it was clear that the management of risk was facilitated by knowing the person and the response to risk was individualized: When he is escalating, the best thing is not to confront him. The best thing is to open the front door and say to him go out and have a cigarette or go out and you know take ten deep breaths. With someone else we might offer them PRN or sensory modulation. But for this particular client, we know that other things do not work with him. (Team Leader) An emphasis was placed on dynamic risk factors that could be managed, such as the reduction of symptoms that linked to aggression through the use of medication. There was also a focus on the person’s strengths and attributes that were protective of risk manifesting. Calculated risk management decisions were supported within the context of knowing the person, which might initially appear radical within the confines of a secure service. Such decisions rested with the whole clinical team and involved the consumer and carers: We have a man who is very antisocial in the community. He won’t stay here either. We assessed the risks and gave him leave as long as he came back and took his clozapine, had his blood test, and didn’t get into trouble or doesn’t come back intoxicated or on drugs…. He’s got a girlfriend out there, friends, things to do. He can occupy his day. He hasn’t assaulted anyone because from the start we have worked on ways to treat him, address the risks, but let him feel that he is being heard. (Manager)
▪
Discussion
The findings of this case study show the ability of stakeholders of a secure mental health service to embrace the challenges of imposed recovery and a commitment to maintain a recovery-oriented focus. All stakeholders had a common vision of a “life worth living” despite legal detainment, long length of stay, challenging behavior, and degrees of social exclusion. Good risk assessment and management is crucial within the secure context and is a therapeutic task involving a 68
www.journalforensicnursing.com
complex clinical understanding of the impact of both static and dynamic risk factors on the individual (Maden, 2005; Mullen, 2000; Young, 2011). Such understanding comes from knowing the person (Department of Health, 2011) but also requires collaboration with consumers and carers in the transition toward a pathway to safety and eventual prosocial community living. From the point of admission, staff showed the ability to engage with the consumer in order for trust to be developed. Calculated collaborative decisions were made regarding risk management to enhance the consumer’s journey, rather than reverting to a riskadverse approach traditionally aligned to secure services, which potentially stalls progress (Eidhammer, Flutteret & Bjørkly, 2014). Staff attempted to bridge the gulf of engagement with a potentially discriminating community by brokering opportunity. This opportunity was focused on the wider community learning about the capabilities of consumers and consumers developing a sense of belonging to the wider community they felt divorced from.
▪
Implications for Clinical Forensic Nursing Practice
This case study assists clinical practice by describing a service that purports to be recovery-oriented. It adds to our understanding about what recovery-oriented services can look like within environments that traditionally prioritize psychiatric treatment, safety, and risk minimization. However, discrepancies between stakeholders on the progress of the service toward recovery as the stand-alone model of care indicate “work in progress.” As such, practical suggestions are only just beginning to emerge. However, the pragmatic processes highlighted in the results of this case study may be used as an exemplar to support future clinical practice and refinement toward a recovery-oriented model of care in secure in-patient and forensic mental health services.
▪
Limitations
This case study does not claim to establish the effectiveness of this recovery-oriented secure service delivery, as it is difficult to determine this based on the reflections of stakeholders. The case study is limited to a pragmatic description of a single secure service through the perceptions of a small number of purposively selected key stakeholders who interface with the service. As such, data may not represent the descriptions of recovery in similar services internationally. Furthermore, this case study focuses on a secure service situated in general mental health services, with a population detained under mental health legislation, as opposed to consumers disposed under criminal justice legislation to forensic mental health services. Volume 10 • Number 2 • April-June 2014
Copyright © 2014 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
Original Article
▪
Conclusions
This case study is an attempt to show the transformation of the rhetoric of recovery into an example of recovery-inaction in a secure mental health service. The intent of this outcome is to assist mental health services and clinicians seeking guidance in developing appropriate strategies for building and maintaining partnerships with consumers, families, and carers in order for services to become truly recovery oriented (i.e., supportive of the recovery journey of consumers).
▪
References
Anthony, W. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16(4), 11. Australian Commission on Safety and Quality in Health Care. (2011). Patient-centred care: Improving quality and safety through partnerships with patients and consumers. Sydney, Australia: ACSQHC. Barker, P. (2001). The tidal model: Developing an empowering, person-centred approach to recovery within psychiatric and mental health nursing. Journal of Psychiatric and Mental Health Nursing, 8(3), 233–240. Beckett, P., Field, J., Molloy, L., Yu, N., Holmes, D., & Pile, E. (2013). Practice what you preach: Developing personcentred culture in inpatient mental health settings through strengths-based transformational leadership. Issues in Mental Health Nursing, 34(8), 595–601. Borg, M., & Davidson, L. (2007). The nature of recovery as lived in everyday experience. Journal of Mental Health, 17(2), 129–140. Corlett, H., & Miles, H. (2010). An evaluation of the implementation of the recovery philosophy in a secure forensic service. The British Journal of Forensic Practice, 12(4), 14–25. Davey, L. (1991). The application of case study evaluations. Practical Assessment, Research & Evaluation, 2(9). Retrieved from http://PAREonline.net/getvn.asp?v=2&n=9 Davidson, L., Tondora, J., Lawless, M., O’Connell, M., & Rowe, M. (2008). A practical guide to recovery-oriented practice tools for transforming mental health care. New York, NY: Oxford University Press. Department of Health. (2011). Framework for recoveryoriented practice. Melbourne, Australia: Mental Health, Drug and Regions Division, Victorian Government. Department of Health and Aging. (2013). A national framework for recovery-oriented mental health services: Policy and theory. Retrieved from http://www.ahmac.gov.au/cms_ documents/National%20Mental%20Health%20Recovery% 20Framework%202013-Policy&theory.PDF Dorkins, E., & Adshead, G. (2011). Working with offenders: Challenges to the recovery agenda. Advances in Psychiatric Treatment, 17(3), 178–187. Drake, R., & Latimer, E. (2012). Lessons learned in developing community mental health care in North America. World Psychiatry, 11(1), 47–51.
Journal of Forensic Nursing
Drennan, G., Law, K., & Alred, D. (2012). Recovery in the forensic organization. In Drennan, G. & Alred, D. (Eds.), Secure recovery (pp. 55–72). Oxon, UK: Routledge. Eidhammer, G., Flutteret, F., & Bjørkly, S. (2014). User involvement in structured violence risk management within forensic mental health facilities—A systematic literature review. Journal of Clinical Nursing. doi: 10.1111/jocn.12571. Guba, E., & Lincoln, Y. (2005). Paradigmatic controversies, contradictions, and emerging confluences. In Denzin, N. & Lincoln, Y. (Eds.), The Sage handbook of qualitative research (pp. 191–216). Thousand Oaks, CA: Sage. Hillband, M., Young, J., & Griffith, E. (2010). Managing risk and recovery: Redefining miscibility of oil and water. Journal of the American Academy of Psychiatry and Law, 38(4), 452–456. Leamy, M., Bird, V., Le Boutillier, C., Williams, J., & Slade, M. (2011). Conceptual framework for personal recovery in mental health: systematic review and narrative synthesis. The British Journal of Psychiatry, 199, 445–452. Maden, A. (2005). Violence risk assessment: The question is not whether but how. Psychiatric Bulletin, 29(4), 121–122. Mays, N., & Pope, C. (1995). Rigour and qualitative research. British Medical Journal, 311, 109–112. McLoughlin, K. (2011). Is recovery possible in forensic hospital settings? Archives of Psychiatric Nursing, 25(5), 390–391. McLoughlin, K., Du Wick, A., Collazzi, C., & Puntil, C. (2013). Recovery-oriented practices of psychiatric-mental health nursing staff in an acute hospital setting. Journal of the American Psychiatric Nurses Association, 19(3), 152–159. Mezey, G., Kavuma, M., Turton, P., Demetriou, A., & Wright, C. (2010). Perceptions, experiences and meanings of recovery in forensic psychiatric patients. The Journal of Forensic Psychiatry & Psychology, 21(5), 683–696. Mullen, P. (2000). Forensic mental health. British Journal of Psychiatry, 176(4), 312–319. Oades, L., & Anderson, J. (2012). Recovery in Australia: Marshalling strength and living values. International Review of Psychiatry, 24(3), 5–10. Patton, M. (2002). Qualitative research and evaluation methods (3rd ed.). Thousand Oaks, CA: Sage. Shepherd, G., Boardman, J., & Burns, M. (2010). Implementing recovery. London, UK: Sainsbury Centre for Mental Health. Simpson, A., & Penney, S. (2011). The recovery paradigm in forensic mental health services. Criminal Behaviour and Mental Health, 21(5), 299–306. Thomas, D. (2006). A general inductive approach for analysing qualitative evaluation data. American Journal of Evaluation, 27(2), 237–246. Yin, R. (2003). Applications of case study research (2nd ed.). Thousand Oaks, CA: Sage. Young, A. (2011). Deconstructing imposed recovery—Clinical perceptions of the legal and administrative framework for managing restricted mental health patients—The experience of one hospital in the independent sector. Journal of Nursing and Healthcare of Chronic Illness, 3(4), 397–406.
www.journalforensicnursing.com
Copyright © 2014 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
69
Recovery-Oriented Care in a Secure Mental Health Setting: ‘‘Striving for a Good Life’’ Brian McKenna, RN, BA, MHSc, PhD1,2, Trentham Furness, PhD1,2, Deepa Dhital, PhD1,2, Malcolm Park, RN, GradDipPN2, and Fiona Connally, RN, GradDipPN2
ABSTRACT Recovery-oriented care acknowledges the unique journey of the consumer to regain control of his or her life in order to live a good life. Recovery has become a dominant policy-directed model of mental health service delivery. Even services that have traditionally been institutional and custodial have been challenged to embrace a recovery-oriented model. The aim of this qualitative study was to provide a description of service delivery in a secure in-patient mental health service, which has developed a self-professed recovery-oriented model of service delivery. An in-depth case study of the secure in-patient service using an exploratory research design was undertaken to meet the aim of this study. Qualitative data was gathered from interviews with consumers and staff (n = 15) and a focus group with carers (n = 5). Data were analyzed using a content analysis approach. Ethical approval for the study was obtained. The stakeholders readily described the secure service within recovery domains. They described a common vision; ways to promote hope and autonomy; examples of collaborative partnership which enhanced the goal of community integration; a focus on strength-based, holistic care; and the management of risk by taking calculated risks. Discrepancies in the perceptions of stakeholders were determined. This case study research provides a demonstrable example of recovery-in-action in one secure mental health service in Australia. It is intended to assist mental health services and clinicians seeking guidance in developing strategies for building and maintaining partnerships with consumers and carers in order for secure services to become truly recovery-oriented. KEY WORDS: Mental health; recovery; recovery-oriented care; secure services
he “person-centered care” movement powerfully demonstrates that fully including the individual consumer as a person, at all stages of their involvement with healthcare services, leads to more efficacious and satisfying outcomes (Australian Commission on Safety and Quality in Health Care, 2011). This approach acknowledges the unique needs, concerns, and preferences of the individual and is inclusive of the family and other
T
Author Affiliations: 1School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Fitzroy, Australia. 2NorthWestern Mental Health, The Royal Melbourne Hospital, Parkville, Australia. The authors declare no conflict of interest. Correspondence: Brian McKenna, RN, BA, MHSc, PhD, NorthWestern Mental Health, Level 1 North, City Campus, The Royal Melbourne Hospital, Grattan Street, Parkville, Victoria, Australia 3050. E-mail: [email protected] Received March 23, 2014; accepted for publication March 31, 2014. Copyright © 2014 International Association of Forensic Nurses DOI: 10.1097/JFN.0000000000000027
Journal of Forensic Nursing
carers of the person concerned. Although there is wide agreement about the need for person-centered care (Barker, 2001; Beckett, Field, Molloy, Yu, Holmes & Pile, 2013), healthcare organizations often have difficulty implementing the type of change necessary to commence (Davidson, Tondora, Lawless, & Rowe, 2008; Shepherd, Boardman, & Burns, 2010) and sustain this approach (Australian Commission on Safety and Quality in Health Care, 2011). Furthermore, as a theme of person-centered care, “recovery” (Anthony, 1993) has emerged to become a preferred stand-alone model of mental health service provision (Drennan, Law, & Alred, 2012; McLoughlin, Du Wick, Collazzi, & Wick, 2013). Recovery-oriented care focuses on the lived experience and unique growth of the individual consumer, with the aim of the person living a satisfying life alongside the limitations imposed by mental health needs (Drake & Latimer, 2012; Oades & Anderson, 2012). Recovery is conceptualized as a unique consumer journey, which is traversed through wellness and illness (Leamy, Bird, Le Boutillier, Williams, & Slade, 2011). Recovery involves www.journalforensicnursing.com
Copyright © 2014 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
63
Original Article
the consumer connecting with those who are able to support, having a sense of hope and optimism for a life worth living, building and defining a sense of identity, developing a meaning in life that is spiritually and socially integrated, and having a sense of empowerment in controlling one’s own destiny (Borg & Davidson, 2007; Leamy et al., 2011). However, among forensic mental health services, where consumers are under restriction through condition of legal detainment, “imposed recovery” (Young, 2011, p. 397) can compromise major themes of recovery-oriented care. Imposed recovery has the potential to compromise choice and autonomy. It can impose lengths of stay that stifle hope. Those detained may present with behaviors that require challenging and confronting approaches, rather than the usual affirming styles of communication associated with fostering engagement. Finally, those detained under “imposed recovery” may experience the double stigma of serious mental illness and criminality, which make reintegration and inclusion into society difficult (Dorkins & Adshead, 2011; Mezey, Kavuma, Turton, Demetriou & Wright, 2010; Young, 2011). Mental health policies in many countries, including Australia, have endorsed the need for mental health services and the mental health workforce to be recovery-oriented (i.e., supportive of the recovery journey of consumers). The momentum for change to recovery-oriented service delivery has led to the development of service frameworks (Department of Health, 2011; Department of Health and Aging, 2013) and practice guidelines (Davidson et al., 2008). Even services that have traditionally been institutional, custodial, and involved in compulsory treatment under mental health legislation have been challenged to embrace the transformation to recovery-oriented care (Corlett & Miles, 2010; Hillband, Young & Griffith, 2010; McLoughlin, 2011; Simpson & Penney, 2011). Despite the administrative momentum for recovery, many mental health services are seeking guidance on appropriate strategies for building and maintaining partnerships among clinicians, consumers, and carers in order to become recovery oriented. There is a paucity of evidencebased literature focusing on what recovery-in-action looks like in a secure settings. It is imperative that successes in the transformation to recovery-oriented care are captured. Such evidence may be used as a practical guide to assist services and individual clinicians, such as nurses, as they grapple with this change. Therefore, the aim of this qualitative study was to provide a description of service delivery in a secure in-patient mental health service, which has developed a self-professed recovery orientation as its model of care. The intent was to determine the extent to which elements of service delivery resemble the domains of recovery-oriented care specific to the demands of the Australian jurisdiction (Department of Health, 2011; Department of Health and Aging, 2013). 64
www.journalforensicnursing.com
▪
Methods Research Design This research was conducted as an illustrative case study of the description of the recovery-oriented approach to service delivery in a secure in-patient mental health setting. Case studies are primarily aimed at investigating a complex intervention or approach within the real-life context in which it occurs (Davey, 1991; Yin, 2003). This research was approved by the Melbourne Health Office for Research.
Secure Setting One in-depth case study was the focus of this research. The adult unit is a 26-bed secure, extended-care facility in a large metropolitan mental health service provider for a catchment of 1.3 million people in Melbourne. The unit employs 40 staff across the multidisciplinary spectrum. The secure setting is accessible as an external wing of a metropolitan hospital. The unit is equipped with a communal kitchen, a designated space with gym equipment, separate male and female living areas, a sensory modulation room, and various communal living areas. The unit has several court yards for outdoor recreation and quiet spaces. The unit provides medium to long-term in-patient treatment and support for adult consumers who have unremitting and severe symptoms of mental illness. This illness can often be complicated by a history of the use of drugs and alcohol, nonadherence with medication, poor response to medication, lack of social supports, nonengagement with community services, involvement in crime, and homelessness. The secure service provides treatment, supervision, and support for those whose needs cannot be met adequately by other available programs and services. In 2006, the workforce/administrators of the unit developed a self-professed recovery-oriented model of service delivery. Despite the legal status as a locked facility, the service supports consumers to live well in the presence and/or absence of their mental illness, with the goal of a “good life” once discharged.
Data Collection Qualitative methods of data collection were used (i.e. 60-minute one-on-one interviews with current and past consumers and current staff and a 60-minute focus group with carers). A consumer researcher conducted the interviews with consumer participants. The consumer researcher has been in the role of a consumer consultant for 12 years. The consumer researcher was provided with the interview schedule and prompts to assist responses. The schedule consisted of questions about (a) the consumers’ experience of participation in the secure service, (b) what it is about the service framework that is recovery-oriented, (c) how involvement in the service has affected their recovery, and (d) the relationship of the Volume 10 • Number 2 • April-June 2014
Copyright © 2014 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
Original Article
recovery-oriented service delivery with the consumer’s sense of overall recovery. One researcher (B.M.) undertook all one-on-one interviews with staff and asked what it is about the service framework that was recovery oriented. The same researcher (B.M.) conducted a single focus group with carers using the same interview schedule as staff. He was assisted by another member of the research team (D.D.) who took field notes, which were integrated into the data analysis. The interview schedule was based on the domains of recoveryoriented care in the Victorian context (Department of Health, 2011) and asked how current service delivery (a) promotes a culture of hope, autonomy, self-determination through holistic and personalized care; (b) establishes collaborative partnerships and meaningful engagement; (c) focuses on strengths; (d) includes families and carers; and (e) encourages community participation and citizenship. All interviews were recorded on an audio-digital recorder (Sony ICD-PX333M). Data were collected from July to September 2013.
Data Analysis A general inductive approach was used to analyze the qualitative data (Thomas, 2006). Data were transcribed and organized with the use of NVivo (QSR International Pty Ltd. Version 10, 2012). The coding for both consumer and other key stakeholder data were developed through continuous reading and agreement among the researchers (B.M., T.F., and D.D.) and then aligned with the preexisting domains of recovery (Department of Health, 2011). As necessary during analysis, content and codes were either collapsed or split into preexisting or different categories, until central relationships began to emerge (Patton, 2002). Each pattern was examined for supporting quotes from the data. Rigor was further enhanced by collective agreement among the research team on the categorical analytic framework, emergent patterns, and supporting evidence (Guba & Lincoln, 2005; Mays & Pope, 1995).
▪
Results Sample Description A total of 20 key stakeholders provided informed voluntary consent to participate in this research. One-on-one interviews were held with a purposive sample of consumers (n = 4), a consumer consultant, a manager, a lead nurse, registered nurses (n = 3), an enrolled nurse, a consultant psychiatrist, a social worker, an occupational therapist, and a psychologist. The carer focus group was conducted with five participants.
Content Domains The participants in this study readily discussed aspects of service delivery, which they thought integrated into the recovery domains, upon which the interview schedule was Journal of Forensic Nursing
based. The seven content domains were (a) a common vision: a journey toward “a life worth living”; (b) promoting hope; (c) promoting autonomy and self-determination; (d) meaningful engagement; (e) focusing on strengths; (f) holistic and personalized care; (g) community participation and citizenship; and (h) managing risks by taking calculated risks.
A Common Vision: A Journey Toward “a Life Worth Living” A common vision of recovery was expressed by all stakeholders, which is captured in the belief that consumers are on a journey to achieve “a life worth living.” This was eloquently expressed by one consumer participant as a desire to: …keep out of jail, keep off the street, keep out of hospitals, and not relapse. Next move at summer time is to get supported accommodation. Then get a part time job…get a double bed in a one bedroom flat, then get married and have kids. I want to try a normal life, like everybody else. (Consumer) Yet a sense of the challenge of the journey was also conveyed, especially when the journey was conceptualized within the reality of enduring mental illness: …sickness lasts forever, the [consumer] is sick… they take medications, some will always be like that. We will always need help towards life…. (Consumer)
Promoting Hope Developing a culture of hope was viewed as a fundamental clinical need in supporting the challenge of the journey. Clinicians expressed the need to commence building hope from admission, and the development of hope was seen as providing the “scaffolding” necessary to achieve sustained change. Consumers were viewed as integral in fashioning this scaffolding. Central to supporting hope was developing collaboration through a “step-by-step” care plan. This clinical process commenced through narrative discussions with the consumer, which focused on goal setting. Consumers were encouraged to set goals. If long-term goals were projected, such as the desire to leave the service, then the consumer was refocused on developing a small number of short-term goals, toward these ends. The achievement of short-term goals was viewed as developing a sense of hope and providing a launching pad to embark on more adventurous goals: The step-by-step plan…they [the consumer] formulate it. [For the clinicians], it’s about understanding the [consumers]; what they do day to day…. (Nurse) www.journalforensicnursing.com
Copyright © 2014 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
65
Original Article A milestone in establishing hope was the granting of day or overnight leave from the secure service. Leave enabled a gradual transition to reconnecting with those who could assist in reestablishing everyday life back in the community. This reconnection enhanced the strengthening of relationships to sustain consumers on their recovery journey: I pick him up and it’s a bit of a long drive, so you get a bit of time and he did start to talk a little bit about being here, which he never used to do when he was in other places…there is some spark somewhere…a touch of hope at the moment, I think. (Carer) The development of hope appeared to be gradual, systematic, and methodical. Yet flexibility in this approach was evident, and situations were highlighted when the only way forward in achieving hope for “a life worth living” appeared to lie in going directly to the long-term goal: [The consumer]…was a very difficult person to deal with. As soon as he arrived he kept on saying he wanted to ride in a helicopter. So we finally said “if you save your money, we will take you to the show (with the helicopter).” Sure enough it did happen maybe six or eight months later…. His face just lit up like you wouldn’t believe. No one had ever taken him seriously before. So from that day on he just improved. Otherwise he was never going to improve. Twenty years admitted and then he went to [supported living] and now he is living with his mother. (Manager)
Promoting Autonomy and Self-determination Promoting autonomy and self-determination may appear paradoxical when consumers enter this secure service involuntarily under conditions of legal coercion. The clinical staff were aware of this paradox: We work here in a recovery model and we are all about autonomy and individual choice, and we sit here and say at the end of the day it’s up to you. If you want to change or not. But on the other hand we kind of say to them, “You are not well, that’s why you are locked in here.” (Psychiatrist) Mental health legislation in this jurisdiction allows containment, compulsory treatment, the use of force, and restriction on leave. Within the boundaries of the legislative constraint, clinical staff indicated an attempt to encourage and foster choice, even though choice might be limited to the extent that it almost offered the “illusion of choice.” Although the degree of choice was constrained, flexibility was explored, as limited as that might be. The most common examples provided by clinicians related to medication 66
www.journalforensicnursing.com
administration, where there was the attempt to offer choice about the type of medication, the dose, and the route: …being on an involuntary treatment order, that restricts the choice…but if they are willing to take one medication but not another, then we are happy to negotiate. And same with dosage, if someone experiencing side effects…then we might negotiate for a lower dose. (Nurse) The clinical review was the most cited clinical process in which there was a clinical perception of promoting autonomy and self-determination by negotiating a pathway forward in the planned care of the individual. Clinicians believed that consumer participation in the clinical review allowed consumers to engage in dialogue and assist in orchestrating their recovery plan, rather than being passive recipients of mandated treatment. However, despite this attempt to foster choice and autonomy, consumers did not necessarily perceive the process as empowering. As stated by one consumer, They outnumbered me in the clinical review and give me the medications that I don’t need at all… they effect and paralyse your brain. (Consumer)
Meaningful Engagement A long length of stay is a reality for consumers of secure services. Clinicians and carers saw positive advantage in this time, which enabled continuity of care and the time necessary to strengthen collaborative partnerships and meaningful engagement. Engagement was typically described as occurring through informal conversations between consumers and staff during the mundane activities of everyday life, such as sharing a cup of tea, walking around the block, or doing tasks such as shopping or cooking. The process allowed rapport building and founded trust. Clinicians also discussed “presencing” or being with the consumer at times that were important to them as a key pragmatic process. The process, for example, could involve facilitating and participating in group activities for leisure purposes: We printed out some of the exercise groups in the community. And she kind of picked one that she would like and we facilitated that. There are times when I actually did zumba [aerobic exercise] with her. (Social Worker)
Focusing on Strengths Clinical staff prioritized focusing on the strengths of consumers. Once strengths were identified, constructive feedback, guidance, and encouragement were seen by clinical staff as strengthening the confidence and self-worth of consumers: Volume 10 • Number 2 • April-June 2014
Copyright © 2014 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
Original Article
You start to see those more intangible strengths that people have like their leadership. We’ve had [consumers] who have organised groups, got people there on time…. (Manager) However, the ability to develop strengths was constrained by legislative requirements or structural impediments, such as staff difficulties balancing individual need with the management of the whole in-patient community. Consumers viewed such constraints as frustrating: …they said I am fit enough to work and when I found work they said I have got four hours for the whole week and four hours consist of travel time as well. So I said it takes me half an hour to get there and forty five minutes back. Restrictions make it impossible. (Consumer)
Holistic and Personalized Care Holistic care was also viewed by clinical staff as central to the recovery approach in the secure service. The length of stay of consumers in the service allowed a holistic approach to both mental health and physical health to be gradually embedded through systematic planning. Change was not forced on people from a position of staff authority: [Consumers] don’t want to change what they eat or to stop smoking. We never stop trying to encourage that, we look at everything from family dynamics through to their own physical and mental health. Those things are in their step-by-step plans about exercise, diet, and social engagement. (Manager) Evidence of holistic and personalized care was also cited in responsiveness to diversity, in meeting social, cultural, and religious needs. To accommodate specific gender requests, the staff talked about the development of a designated area for female consumers: The women’s lounge has a few couches with rugs and cushions, and a big telly and purple walls with different decorative words hanging on the walls (like, “hope” and “love”). And there is pampering stuff, if you want to do pampering sessions and foot spas. (Occupational Therapist) Religious practices were supported through enabling religious food observances and visits by religious leaders. For example, during the fasting requirements of Ramadan, clinicians were flexible with medication schedules to accommodate the fasting requirements of Islamic consumers. It is in the commitment to partnerships with carers that the Journal of Forensic Nursing
holistic vision of the service was best personified. Carers were viewed as the repositories of the in-depth understanding of consumers, which was pivotal in the delivery of holistic care. Yet the vulnerability of carers was also acknowledged: We have realised it’s the same amount of work that we do with our families that we have to do with consumers. They have lost hope, are burnt out, been abused, assaulted…. (Manager) Family meetings and regular family peer-support sessions were arranged. Visiting hours were flexible and modified to suit the circumstances of carers in an effort to support the holistic and personalized care of the consumer. However, potential tensions were expressed in the relationship between staff, consumers, and carers, which required careful negotiation. Consumers have choice regarding carer involvement in their treatment plan. Clinical staff acknowledged confidentiality and the right of consumers to determine the involvement of carers. Yet when tension arose, support to all involved remained evident: I had a client in the past who did not want anything to do with the family…so again we have to respect the client’s opinion. He requested that he did not want to see his mother at all, but Mum still attended our carer’s group as a way of support, which worked really well for her. (Social Worker)
Community Participation and Citizenship A stay in the secure service may be lengthy but only constitutes one phase of the recovery journey. The goal of “a good life” involves community reintegration. There was a commitment to commence engagement even if reintegration into the community was not imminent: We’ve got one Vietnamese man here at the moment who is extremely unwell, constantly psychotic, and also cognitively impaired. He can’t live anywhere else. With the agreement of the Vietnamese men’s group in the community, he goes there, with a staff member. (Manager) Staff in the secure service were proactive in negotiating contracts with external agencies to expose consumers to experiences that better equip them for future life in the community. In some cases, this involved consumers establishing a sense of belonging to the community. This was well demonstrated in a contract negotiated to complete mosaics to beautify the surrounds of a new motorway: …it was around the idea that you were doing something for the community. It was to beautify the community. But it was also something that is going www.journalforensicnursing.com
Copyright © 2014 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
67
Original Article
to last and something that [the consumers] could say “I have done that, look what I did” and have some pride, plus learn some new skills. (Manager)
Managing Risks by Taking Calculated Risks Recovery in a secure environment is complicated by the degree of risk consumers may pose to self or others. There is a responsibility to maintain the safety of the consumer, their peers, staff, family, and in some cases the wider community. From the interviews with staff, it was clear that the management of risk was facilitated by knowing the person and the response to risk was individualized: When he is escalating, the best thing is not to confront him. The best thing is to open the front door and say to him go out and have a cigarette or go out and you know take ten deep breaths. With someone else we might offer them PRN or sensory modulation. But for this particular client, we know that other things do not work with him. (Team Leader) An emphasis was placed on dynamic risk factors that could be managed, such as the reduction of symptoms that linked to aggression through the use of medication. There was also a focus on the person’s strengths and attributes that were protective of risk manifesting. Calculated risk management decisions were supported within the context of knowing the person, which might initially appear radical within the confines of a secure service. Such decisions rested with the whole clinical team and involved the consumer and carers: We have a man who is very antisocial in the community. He won’t stay here either. We assessed the risks and gave him leave as long as he came back and took his clozapine, had his blood test, and didn’t get into trouble or doesn’t come back intoxicated or on drugs…. He’s got a girlfriend out there, friends, things to do. He can occupy his day. He hasn’t assaulted anyone because from the start we have worked on ways to treat him, address the risks, but let him feel that he is being heard. (Manager)
▪
Discussion
The findings of this case study show the ability of stakeholders of a secure mental health service to embrace the challenges of imposed recovery and a commitment to maintain a recovery-oriented focus. All stakeholders had a common vision of a “life worth living” despite legal detainment, long length of stay, challenging behavior, and degrees of social exclusion. Good risk assessment and management is crucial within the secure context and is a therapeutic task involving a 68
www.journalforensicnursing.com
complex clinical understanding of the impact of both static and dynamic risk factors on the individual (Maden, 2005; Mullen, 2000; Young, 2011). Such understanding comes from knowing the person (Department of Health, 2011) but also requires collaboration with consumers and carers in the transition toward a pathway to safety and eventual prosocial community living. From the point of admission, staff showed the ability to engage with the consumer in order for trust to be developed. Calculated collaborative decisions were made regarding risk management to enhance the consumer’s journey, rather than reverting to a riskadverse approach traditionally aligned to secure services, which potentially stalls progress (Eidhammer, Flutteret & Bjørkly, 2014). Staff attempted to bridge the gulf of engagement with a potentially discriminating community by brokering opportunity. This opportunity was focused on the wider community learning about the capabilities of consumers and consumers developing a sense of belonging to the wider community they felt divorced from.
▪
Implications for Clinical Forensic Nursing Practice
This case study assists clinical practice by describing a service that purports to be recovery-oriented. It adds to our understanding about what recovery-oriented services can look like within environments that traditionally prioritize psychiatric treatment, safety, and risk minimization. However, discrepancies between stakeholders on the progress of the service toward recovery as the stand-alone model of care indicate “work in progress.” As such, practical suggestions are only just beginning to emerge. However, the pragmatic processes highlighted in the results of this case study may be used as an exemplar to support future clinical practice and refinement toward a recovery-oriented model of care in secure in-patient and forensic mental health services.
▪
Limitations
This case study does not claim to establish the effectiveness of this recovery-oriented secure service delivery, as it is difficult to determine this based on the reflections of stakeholders. The case study is limited to a pragmatic description of a single secure service through the perceptions of a small number of purposively selected key stakeholders who interface with the service. As such, data may not represent the descriptions of recovery in similar services internationally. Furthermore, this case study focuses on a secure service situated in general mental health services, with a population detained under mental health legislation, as opposed to consumers disposed under criminal justice legislation to forensic mental health services. Volume 10 • Number 2 • April-June 2014
Copyright © 2014 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
Original Article
▪
Conclusions
This case study is an attempt to show the transformation of the rhetoric of recovery into an example of recovery-inaction in a secure mental health service. The intent of this outcome is to assist mental health services and clinicians seeking guidance in developing appropriate strategies for building and maintaining partnerships with consumers, families, and carers in order for services to become truly recovery oriented (i.e., supportive of the recovery journey of consumers).
▪
References
Anthony, W. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16(4), 11. Australian Commission on Safety and Quality in Health Care. (2011). Patient-centred care: Improving quality and safety through partnerships with patients and consumers. Sydney, Australia: ACSQHC. Barker, P. (2001). The tidal model: Developing an empowering, person-centred approach to recovery within psychiatric and mental health nursing. Journal of Psychiatric and Mental Health Nursing, 8(3), 233–240. Beckett, P., Field, J., Molloy, L., Yu, N., Holmes, D., & Pile, E. (2013). Practice what you preach: Developing personcentred culture in inpatient mental health settings through strengths-based transformational leadership. Issues in Mental Health Nursing, 34(8), 595–601. Borg, M., & Davidson, L. (2007). The nature of recovery as lived in everyday experience. Journal of Mental Health, 17(2), 129–140. Corlett, H., & Miles, H. (2010). An evaluation of the implementation of the recovery philosophy in a secure forensic service. The British Journal of Forensic Practice, 12(4), 14–25. Davey, L. (1991). The application of case study evaluations. Practical Assessment, Research & Evaluation, 2(9). Retrieved from http://PAREonline.net/getvn.asp?v=2&n=9 Davidson, L., Tondora, J., Lawless, M., O’Connell, M., & Rowe, M. (2008). A practical guide to recovery-oriented practice tools for transforming mental health care. New York, NY: Oxford University Press. Department of Health. (2011). Framework for recoveryoriented practice. Melbourne, Australia: Mental Health, Drug and Regions Division, Victorian Government. Department of Health and Aging. (2013). A national framework for recovery-oriented mental health services: Policy and theory. Retrieved from http://www.ahmac.gov.au/cms_ documents/National%20Mental%20Health%20Recovery% 20Framework%202013-Policy&theory.PDF Dorkins, E., & Adshead, G. (2011). Working with offenders: Challenges to the recovery agenda. Advances in Psychiatric Treatment, 17(3), 178–187. Drake, R., & Latimer, E. (2012). Lessons learned in developing community mental health care in North America. World Psychiatry, 11(1), 47–51.
Journal of Forensic Nursing
Drennan, G., Law, K., & Alred, D. (2012). Recovery in the forensic organization. In Drennan, G. & Alred, D. (Eds.), Secure recovery (pp. 55–72). Oxon, UK: Routledge. Eidhammer, G., Flutteret, F., & Bjørkly, S. (2014). User involvement in structured violence risk management within forensic mental health facilities—A systematic literature review. Journal of Clinical Nursing. doi: 10.1111/jocn.12571. Guba, E., & Lincoln, Y. (2005). Paradigmatic controversies, contradictions, and emerging confluences. In Denzin, N. & Lincoln, Y. (Eds.), The Sage handbook of qualitative research (pp. 191–216). Thousand Oaks, CA: Sage. Hillband, M., Young, J., & Griffith, E. (2010). Managing risk and recovery: Redefining miscibility of oil and water. Journal of the American Academy of Psychiatry and Law, 38(4), 452–456. Leamy, M., Bird, V., Le Boutillier, C., Williams, J., & Slade, M. (2011). Conceptual framework for personal recovery in mental health: systematic review and narrative synthesis. The British Journal of Psychiatry, 199, 445–452. Maden, A. (2005). Violence risk assessment: The question is not whether but how. Psychiatric Bulletin, 29(4), 121–122. Mays, N., & Pope, C. (1995). Rigour and qualitative research. British Medical Journal, 311, 109–112. McLoughlin, K. (2011). Is recovery possible in forensic hospital settings? Archives of Psychiatric Nursing, 25(5), 390–391. McLoughlin, K., Du Wick, A., Collazzi, C., & Puntil, C. (2013). Recovery-oriented practices of psychiatric-mental health nursing staff in an acute hospital setting. Journal of the American Psychiatric Nurses Association, 19(3), 152–159. Mezey, G., Kavuma, M., Turton, P., Demetriou, A., & Wright, C. (2010). Perceptions, experiences and meanings of recovery in forensic psychiatric patients. The Journal of Forensic Psychiatry & Psychology, 21(5), 683–696. Mullen, P. (2000). Forensic mental health. British Journal of Psychiatry, 176(4), 312–319. Oades, L., & Anderson, J. (2012). Recovery in Australia: Marshalling strength and living values. International Review of Psychiatry, 24(3), 5–10. Patton, M. (2002). Qualitative research and evaluation methods (3rd ed.). Thousand Oaks, CA: Sage. Shepherd, G., Boardman, J., & Burns, M. (2010). Implementing recovery. London, UK: Sainsbury Centre for Mental Health. Simpson, A., & Penney, S. (2011). The recovery paradigm in forensic mental health services. Criminal Behaviour and Mental Health, 21(5), 299–306. Thomas, D. (2006). A general inductive approach for analysing qualitative evaluation data. American Journal of Evaluation, 27(2), 237–246. Yin, R. (2003). Applications of case study research (2nd ed.). Thousand Oaks, CA: Sage. Young, A. (2011). Deconstructing imposed recovery—Clinical perceptions of the legal and administrative framework for managing restricted mental health patients—The experience of one hospital in the independent sector. Journal of Nursing and Healthcare of Chronic Illness, 3(4), 397–406.
www.journalforensicnursing.com
Copyright © 2014 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
69
