NURSING
Recovery-Oriented Care in Older-Adult Acute Inpatient Mental Health Settings in Australia: An Exploratory Study Brian McKenna, PhD,*† Trentham Furness, PhD,*† Deepa Dhital, PhD,*† and Susan Ireland, Grad Dip MH†
Recovery-oriented care acknowledges the unique journey that consumers lead with the aim of regaining control of their lives in order to live a good life. Recovery has become a dominant policy-directed model of many mental health care organizations, but in older-adult acute mental health inpatient settings, nurses do not have a clear description of how to be recovery-oriented. The aims of this study were to determine the extent to which elements of existing nursing practice resemble the domains of recovery-oriented care and provide a baseline understanding of practice in preparation for transformation to recovery-oriented mental health care provision. An exploratory, qualitative research design was used to meet the research aims. A purposive sample of mental health nurses (N = 12) participated in focus groups in three older-adult inpatient settings in Australia. A general inductive approach was used to analyze the qualitative data. The mental health nurses in this study readily discussed aspects of their current practice within the recovery domains. They described pragmatic ways to promote a culture of hope, collaborative partnerships, meaningful engagement, autonomy and self-determination, and community participation and citizenship. Nurses also discussed challenges and barriers to recovery-oriented care in older-adult acute mental health settings. This study identified a reasonable baseline understanding of practice in preparation for transformation to recovery-oriented older-adult mental healthcare provision. A concerted drive focused on recovery education is required to effectively embed a recovery-orientated paradigm into older-adult mental health settings. J Am Geriatr Soc 62:1938–1942, 2014.
Key words: recovery-oriented care; older adults; acute inpatient; mental health From the *School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Fitzroy, Vic., Australia; and †NorthWestern Mental Health, Royal Melbourne Hospital, Parkville, Vic., Australia. Address correspondence to Professor Brian McKenna, NorthWestern Mental Health, Level 1 North, City Campus, The Royal Melbourne Hospital, Grattan Street, Parkville, Victoria, Australia 3050. E-mail: [email protected] DOI: 10.1111/jgs.13028
JAGS 62:1938–1942, 2014 © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society
T
he common “person-centered care” approach in general health settings acknowledges the unique needs, concerns, and preferences of the individual and is inclusive of the family and other caregivers.1 In mental health organizations, care delivery based on “recovery” is related to person-centered care.2 Recovery-oriented care is a preferred policy-directed model of mental health care provision in many countries in the developed world.3–5 Recovery is described as a unique journey that consumers lead with the aim of regaining control of their lives6 in order to live a good life.7–9 Thus, Australian older-adult inpatient mental health organizations must strive to address the holistic needs of each consumer to assist with his or her unique recovery journey.9 The aging population in the developed world is projected to contribute to an increased demand for care from health systems,10,11 in part because of advances in medical treatment.12 An aging population may have mental health disorders such as dementia, depression, and anxiety,10,11,13 and physical health conditions such as organ dysfunction14 and cardiovascular,15 osteoporotic,16 and oncological diseases17 often coexist in older adults. Nurses working in older-adult acute inpatient mental health units are cognizant of the unique combination of mental illness, cognitive changes, and coexisting physical health conditions,18 but methods to provide recovery-oriented care have not been thoroughly described at this time. Specifically, the pragmatic processes to promote a culture of hope, autonomy, and self-determination through holistic and personalized care; establish collaborative partnerships and meaningful engagement; focus on consumers’ strengths; include families and caregivers; and encourage community participation and citizenship19 are not well articulated for older-adult acute inpatient mental health settings. The intent of this qualitative study, therefore, was to allow mental health nurses the opportunity to reflect on and describe current nursing practice in older-adult acute inpatient mental health settings that are not overtly recovery oriented. The aims were to determine the extent to which elements of existing nursing practice resemble the
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domains of recovery-oriented care and to provide a baseline understanding of practice in preparation for transformation to recovery-oriented settings as reflected in policy directives in Australia.9,19
METHODS
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framework, emergent patterns, and supporting evidence enhanced rigor.25
RESULTS Description of Focus Group Participants
An exploratory research design incorporating qualitative in-depth focus group interviews20 was used to meet the research aims. Exploratory research is undertaken when a problem has not been clearly defined.21 The Melbourne Health Office for Research approved this research.
Twelve mental health nurses (mean of mental health nursing experience 20 years) participated in the three focus groups. All nurses were qualified registered nurses. The range of experience in an older-adult inpatient mental health setting was 1 to 18 years (mean 10 years). The majority of nurses were female (n = 11). The nurses were trained in Australia (n = 10) and the United Kingdom (n = 2).
Participants
Content Domains
Using a hospital-based information flyer, a purposive sample of mental health nurses was recruited to participate in a focus group at each of three older-adult acute inpatient settings in a large mental health organization. Four mental health nurses and one researcher (BM) attended a 60- to 90-minute focus group conducted at each older-adult acute inpatient setting. A total of 12 mental health nurses provided voluntary informed consent and participated in this study. At each of the three settings, the focus group was conducted on location in a locked, private meeting room. Participants were not provided with incentives to participate.
Participants in this study discussed five content domains specific to recovery: a culture of hope, collaborative partnerships, meaningful engagement, autonomy and self-determination, and community participation and citizenship. A sixth overarching theme that related to the challenge to recovery-oriented care in older-adult acute inpatient mental health settings was pertinent to the discussions of each domain.
Research Design
Procedures The focus group interview schedule enquired about current practice based on the domains of recovery-oriented care in the Australian context19,22 to promote a culture of hope; autonomy and self-determination; holistic and personalized care; collaborative partnerships and meaningful engagement; a focus on strengths; involvement of family, caregivers, support people, and significant others; responsiveness to diversity; and encouragement of community participation and citizenship. For example, mental health nurses were asked whether their “care focuses on promoting hope,” with prompts to describe how their clinical practice may focus on promoting hope and to provide specific pragmatic examples. The focus group interview schedule was identical for all three focus groups. The same researcher (BM) conducted all focus groups. Responses were recorded using an audio-digital recorder. Two researchers (DD, TF) transcribed all interviews.
A Culture of Hope The cohort of nurses acknowledged that consumers admitted to the older-adult inpatient mental health units often felt worthless. To support hope, nurses would allocate therapeutic time with each consumer to moderate negative attitudes and reassure consumers by reinforcing that the consumer is not a burden, admission is a short-term stage of the recovery journey, admission can enhance understanding of their mental illness, and consumers are capable and can live meaningful lives. Nurses expressed the need to avoid overwhelming the consumer while gradually instilling hope: “I think when they come in here, they have mental health issues, they think there is no recovery, or there is no hope for them. So it’s that reassurance and telling them that they are not going to be here forever, no one stays here forever.” The nurses discussed that the eventual goal was to reestablish the preadmission routines that bring meaning to peoples’ lives. Communicating with the family enhanced an understanding of such routines: “Get the family to bring the pet dog in, or go for a coffee, to the hairdresser —the little things that the [consumer] does to feel better about themselves.”
Data Analysis A general inductive approach was used to analyze the qualitative data23 (NVivo version 10; QSR International Pty Ltd., Burlington, MA). Through continuous reading and agreement of the researchers, the coding was aligned with the preexisting domains of recovery.19 As necessary during analysis, the initial content domains were collapsed or split into preexisting categories, until central relationships began to emerge.24 Each pattern was examined for supporting quotations from the data. Collective agreement of the research team on the categorical analytical
Collaborative Partnerships A collaborative focus with the consumer was directed at the small steps of the recovery journey, achievable within the short time frame of the person’s stay in the acute inpatient setting: “[Consumers] need to feel like people are taking them seriously, let them settle in, not bombard them with recovery from the first day, as it can be too overwhelming.” Collaboration also occurred through promoting a holistic response to care. The physical health of older-adult
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mental health consumers within a holistic overview was a constant consideration: “. . .you can’t get away from those issues, especially in the elderly when they are here and [their physical health] is the very thing that is causing their stress and mental illness.” Sociocultural and spiritual needs were also considered in collaboration with consumers and caregivers: “We have to be aware of beliefs. It’s hard but it’s the little things, like phoning up the family and asking the questions.” Collaboration with the family and guardians was a major partnership initiative, because consumers’ were often unsure or unable (too cognitively impaired) to articulate with clarity how their recovery journey should be structured before, during, and after discharge. Nurses conveyed a sense of knowing what consumers were capable of becoming but needed the assistance of the family to gather the specific knowledge and details that facilitated a recovery-oriented model of care: “. . .they [the family] know what works and what doesn’t, rather than us through using trial and error.”
Meaningful Engagement Establishing meaningful engagement and rapport with consumers was viewed as being central to current mental health nursing practice. A vital component of establishing rapport was to initially assess the consumer’s level of cognitive ability and coexisting physical health needs to modify the approach to assist meaningful engagement. Meaningful engagement often occurred through exploring the person’s everyday life, whereby consumers’ were encouraged to “tell their story”: “I ask about what was your occupation? What do you do during your retirement?” The nurses listened to consumers, allowed them to “vent their stuff,” to describe personal issues, and to elaborate on interests that fostered happiness (e.g., pets, family, getting a haircut, coffee at a preferred cafe): “The more they feel better about themselves, the better the recovery is when they go home.” Nurses reframed situations in which consumer behavior, on the face of things, could be misinterpreted as bizarre, inconvenient, or indicative of deteriorating mental health status as opportunities for meaningful engagement. There was an attempt to explain behavior within past routines. For instance, one consumer would lie on his back every day staring at the ceiling, which is explainable behavior within the context of his lifetime occupation as a vehicle mechanic. Another consumer would walk about the unit checking all the door and window locks, again explainable within his past role as a security guard. Finally, one consumer repeatedly placed all the chairs from the dining room in a neat line in a corridor, acceptable within the context of being a bus driver before retirement. Understanding such behavior enhanced engagement. Nurses were then able to support and focus on meaningful engagement by modifying the environment of the unit to maintain safety and to support individual consumer behavior.
Autonomy and Self-Determination The pragmatic process of involving the consumer in goal setting at the time of admission supported autonomy:
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“Asking them what they want first off, not what we want for them. What do they want to achieve? What is their outcome from being in a place like this?” The nurses discussed some tension when the views of their family or guardian challenged notions of self-determi nation that consumers experiencing cognitive impairment expressed: “We have to put ourselves in [the family’s] shoes. There is always a lot of issues over many years. . .they are also getting older and maybe a little burnt out.” At such times, the nurses took a reconciliatory position seeking compromise by determining what was functionally possible for the consumer in the mental health unit, what was a realistic level of autonomy (e.g., selfbathing and dressing), and what self-determined and autonomous activities of daily living needed to be supported to maintain independence after discharge.
Community Participation and Citizenship The nurses mentioned facilitating community reintegration by supporting day and weekend leave, encouraging consumers to reengage with daily activities, and creating activity groups such as a breakfast club and social outdoor eating occasions. High acuity and the reality that some consumers may require a supportive living environment after discharge limited consumer participation. Other factors, such as time allocation and management and administrative workload, were cited as sometimes limiting preparation for community participation and citizenship to levels that resembled preadmission. Continuity of care with external support agencies was encouraged. This was most successful in relation to community mental health settings whereby some case managers would visit consumers during admission at the inpatient unit: “So case managers come to our team meetings, so they know what’s happening with the [consumer]. Then they also see the [consumer] while they are here.”
Challenges to Recovery in Older-Adult Acute Inpatient Mental Health Settings In discussing each of the recovery domains, a series of challenges emerged. The nurses expressed difficulties in framing recovery as a journey when dementia and physical illness signaled irreversible deterioration: “For our people who are here with depression, their recovery may be getting back home and living their life independently. People with dementia, their recovery might be not being distressed, aggressive, or upset, because they are never going to get better. Recovery means different things for different people.” “. . .if they have terminal cancer, you are not going to offer them hope to the point that they will be better soon and be going home.” Organizational structures also challenged perceptions of the consumer’s recovery journey. The pressures of a busy ward with low nursing staff numbers and high consumer numbers and the reliance on temporary staff who were unfamiliar with the inpatient unit were examples of the organizational challenges to recovery. A perceived incompatibility of the clinical profiles of consumers admit-
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ted to the mental health organization was also seen as a challenge to recovery: “I think having a mixture of [consumers] with an organic illness and a functional illness is very difficult . . .we’ve got depressed ladies, and six guys wandering around with behavioral and psychological symptoms of dementia and they are intrusive to everyone.” Furthermore, a lack of knowledge about recoveryoriented care among staff was commonly stated: “We need a lot more education on it.”
DISCUSSION The results of this study describe the extent to which mental health nurses pragmatically apply a recovery-oriented model of care in older-adult acute inpatient mental health units that are not overtly organized to be recovery oriented. Nurses in this study described positive effects of collaborative care, which enhances community care after discharge from inpatient units.26 Because it has been suggested that self-management improves community participation and citizenship of older adults with mental illness and cognitive deterioration,10,27 the pragmatic processes to support and strengthen autonomy and self-determination, described by nurses in this study, may enhance recovery after discharge. For community-dwelling older adults with enduring mental health needs, identifying existing social networks, roles, and activities supports recovery.6 Nurses in the current study used collaboration with consumers, caregivers, and colleagues, with similar effect. The integration of family and caregivers across the duration of stay in the acute inpatient unit was clear in the results of the current study, as engaging with them was highlighted when participants were discussing every domain of recovery. This highlights the significance of family and caregivers in recoveryoriented care for older adults.19 Older-adult acute inpatient mental health units also house some consumers who experience coexisting physical and mental health needs, including cognitive impairment, and who depend on mental health professionals and caregivers. Nurses in this study expressed difficulty in framing recovery as a journey in such situations. Further consideration should be focused on nurses understanding the concept of recovery as it applies to such complexity. It is not as important for older adults with mental illnesses to be educated about and encouraged to seek “recovery” as it is to be supported effectively in leading the kinds of lives they wish to lead. The role of caregivers, therefore, becomes pivotal in understanding what this “life worth living” actually is. Flexibility of organizational structures is required to address such diversity,28,29 as is flexibility in the application of the recovery principles to complicated consumer presentations. Nurses in this study highlighted a willingness to gain understanding through professional development about practice modes of recovery-oriented care to address such complexity. That sentiment is matched in mental health colleagues3 and consumers.30,31 Because recovery is a relatively recent preferred policy-directed mode of care in Australian mental health organizations, it is likely that older-adult consumers with a
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history of serious mental illness have not been exposed to recovery-oriented care. As such, the notion of “starting” consumers on a recovery journey at this stage of their lives posed a conundrum for nurses in this study. Because recovery-oriented settings develop across the life span, it is important that future research be longitudinal and crosssectional to adequately reflect the effect of models of care on the totality of the journey experienced. Furthermore, the policy-driven model of recovery reflecting a “one model fits all” approach needs to be considered in the context specific to older adults with mental health and coexisting physical health conditions. Descriptions of the practice of recovery-oriented care were collected from a small number of nurses in one of Australia’s largest mental health organizations. As such, data may not represent descriptions of mental health nursing practice in other settings or mental health nurses in general. Nurses who were ill-informed about recovery-oriented care or were resistant to the concept may not have consented to the focus groups, leading to a potential selection bias. Because recovery-oriented care enables consumers to be proactive about their journey, the results of this study are limited without the opinions of consumers within the multidisciplinary setting. Therefore, generalizations about the effect of care that resembles recovery-oriented domains may not be externally valid without consumer, caregiver, and multidisciplinary input. Conceptual frameworks of recovery specific to the characteristics of the older-adult acute inpatient mental health settings are being developed, and older-adult mental health care system change is predicted.6 The results of this study show nursing practice strengths and areas of uncertainty about recovery-oriented care. As mental health organizations across Australia begin the systemic transformation to a recovery-oriented model of care, results of this study show that a cohort of mental health nurses can identify recovery in older-adult acute mental health inpatient settings that are not overtly recovery oriented and articulate with pragmatic clarity how to care within a recovery-oriented paradigm. A concerted drive focused on education regarding recovery, including an exploration of the challenges to recovery-oriented care in older-adult acute inpatient settings, is required to effectively embed a recovery-oriented paradigm.
ACKNOWLEDGMENTS This study was undertaken at NorthWestern Mental Health and received no financial support. Conflict of Interest: Brian McKenna, Trentham Furness, and Deepa Dhital are affiliated with NorthWestern Mental Health. Susan Ireland is employed by NorthWestern Mental Health. None of the authors have any financial interest, patents, company holdings, or stock to disclose related to this unfunded study. Author Contributions: All authors contributed to concept and design. BM conducted all focus groups. SI arranged all focus groups. BM, DD, and TF were involved with data processing and analysis. All authors contributed to drafting and review of the manuscript. Sponsor’s Role: None.
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REFERENCES 1. Australian Commission on Safety and Quality in Health Care. Patient-Centred Care: Improving Quality and Safety through Partnerships with Patients and Consumers. Sydney: ACSQHC, 2011. 2. Anthony W. Recovery from mental illness: The guiding vision of the mental health system in the 1990s. Psychiatr Rehabil J 1993;16:11–23. 3. McLoughlin K, Du Wick A, Collazzi C et al. Recovery-oriented practices of psychiatric-mental health nursing staff in an acute hospital setting. J Am Psychiatr Nurses Assoc 2013;19:152–159. 4. Drennan G, Law K, Alred D. Recovery in the forensic organization. In: Drennan G, Alred D, eds. Secure Recovery. Abingdon, UK: Routledge, 2012, pp 55–72. 5. Whitley R, Gingerich S, Lutz W et al. Implementing the illness management and recovery program in community mental health settings: Facilitators and barriers. Psychiatr Serv 2009;60:202–209. 6. Daley S, Newton D, Slade M et al. Development of a framework for recovery in older people with mental disorder. Int J Geriatr Psychiatry 2013;28:522–529. 7. Oads L, Anderson J. Recovery in Australia: Marshalling strength and living values. Int Rev Psychiatry 2012;24:5–10. 8. Turton P, Demetriou A, Boland W et al. One size fits all: Or horses for courses? Recovery-based care in specialist mental health services. Soc Psychiatry Psychiatr Epidemiol 2011;46:127–136. 9. Department of Health and Aging. A National Framework for RecoveryOriented Mental Health Services: Policy and Theory. Commonwealth of Australia [on-line]. Available at www.ahmac.gov.au/cms_documents/ National%20Mental%20Health%20Recovery%20Framework%202013Policy&theory.PDF Accessed August 1, 2013. 10. Cheffey J, Hill L, Roberts G et al. Supporting self-management in early dementia: A contribution towards ‘living well’? Adv Psychiatr Treat 2013;19:344–350. 11. Christensen K, Doblhammer G, Rau R et al. Ageing populations: The challenges ahead. Lancet 2009;374:1196–1208. 12. Mariotto A, Yabroff K, Shao Y et al. Projections of the cost of cancer care in the United States: 2010–2020. J Natl Cancer Inst 2011;103:117– 128. 13. Han B, Gfroerer J, Colpe L et al. Serious psychological distress and metal health service use among community-dwelling older U.S. adults. Psychiatr Serv 2011;62:291–298. 14. Adhikari N, Fowler R, Bhagwanjee S et al. Critical care and the global burden of critical illness in adults. Lancet 2010;376:1339–1346.
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15. Heidenreich P, Trogdon J, Khavjou O et al. Forecasting the future of cardiovascular disease in the United States: A policy statement from the American Heart Association. Circulation 2011;123:933–944. 16. Harvey N, Denninson E, Cooper C. Osteoporosis: Impact on health and economics. Nat Rev Rheumatol 2010;6:99–105. 17. Jemal A, Bray F, Centre M et al. Global cancer statistics. CA Cancer J Clin 2011;61:69–90. 18. McCabe M, Davison T, Mellor D et al. Depression among older people with cognitive impairment: Prevalence and detection. Int J Geriatr Psychiatry 2006;21:633–644. 19. Department of Health. Framework for Recovery-Oriented Practice. Melbourne: Mental Health, Drug and Regions Division, Victorian Government, 2011. 20. Kitzinger J. Qualitative research: Introducing focus groups. BMJ 1995; 311:299–302. 21. Stebbins R. Exploratory Research in the Social Sciences. Sage University Paper Series on Qualitative Research Methods, Vol. 48. Thousand Oaks, CA: Sage, 2001. 22. McKenna B, Furness T, Dhital D et al. Recovery-oriented care in acute inpatient mental health settings: An exploratory study. Issues Ment Health Nurs 2014;35:526–532. 23. Thomas D. A general inductive approach for analysing qualitative evaluation data. Am J Eval 2006;27:237–246. 24. Patton M. Qualitative Research and Evaluation Methods, 3rd ed. Thousand Oaks, CA: Sage, 2002. 25. Mays N, Pope C. Rigour and qualitative research. BMJ 1995;311:109–112. 26. Thota A, Sipe T, Byard G et al. Collaborative care to improve the management of depressive disorders. Am J Prev Med 2012;42:525–538. 27. Kartalova-O’Doherty Y, Stevenson C, Higgins A. Reconnecting with life: A grounded theory study of mental health recovery in Ireland. J Ment Health 2012;21:136–144. 28. Franz C, Barker J, Kim K et al. When help becomes a hindrance: Mental health referral systems as barriers to care for primary care physicians treating patients with Alzheimer’s disease. Am J Geriatr Psychiatry 2010;18:576–585. 29. Toward JI, Ostwald SK. Exploring mental health services needs for the elderly: Results of a modified Delphi study. Community Ment Health J 2002;38:141–149. 30. Schroeder R. The seriously mentally ill older adult: Perceptions of the patient-provider relationship. Perspect Psychiatr Care 2012;49:30–40. 31. Borg M, Kristainsen K. Recovery-oriented professionals: Helping relationships in mental health services. J Ment Health 2004;13:493–505.
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Recovery-Oriented Care in Older-Adult Acute Inpatient Mental Health Settings in Australia: An Exploratory Study Brian McKenna, PhD,*† Trentham Furness, PhD,*† Deepa Dhital, PhD,*† and Susan Ireland, Grad Dip MH†
Recovery-oriented care acknowledges the unique journey that consumers lead with the aim of regaining control of their lives in order to live a good life. Recovery has become a dominant policy-directed model of many mental health care organizations, but in older-adult acute mental health inpatient settings, nurses do not have a clear description of how to be recovery-oriented. The aims of this study were to determine the extent to which elements of existing nursing practice resemble the domains of recovery-oriented care and provide a baseline understanding of practice in preparation for transformation to recovery-oriented mental health care provision. An exploratory, qualitative research design was used to meet the research aims. A purposive sample of mental health nurses (N = 12) participated in focus groups in three older-adult inpatient settings in Australia. A general inductive approach was used to analyze the qualitative data. The mental health nurses in this study readily discussed aspects of their current practice within the recovery domains. They described pragmatic ways to promote a culture of hope, collaborative partnerships, meaningful engagement, autonomy and self-determination, and community participation and citizenship. Nurses also discussed challenges and barriers to recovery-oriented care in older-adult acute mental health settings. This study identified a reasonable baseline understanding of practice in preparation for transformation to recovery-oriented older-adult mental healthcare provision. A concerted drive focused on recovery education is required to effectively embed a recovery-orientated paradigm into older-adult mental health settings. J Am Geriatr Soc 62:1938–1942, 2014.
Key words: recovery-oriented care; older adults; acute inpatient; mental health From the *School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Fitzroy, Vic., Australia; and †NorthWestern Mental Health, Royal Melbourne Hospital, Parkville, Vic., Australia. Address correspondence to Professor Brian McKenna, NorthWestern Mental Health, Level 1 North, City Campus, The Royal Melbourne Hospital, Grattan Street, Parkville, Victoria, Australia 3050. E-mail: [email protected] DOI: 10.1111/jgs.13028
JAGS 62:1938–1942, 2014 © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society
T
he common “person-centered care” approach in general health settings acknowledges the unique needs, concerns, and preferences of the individual and is inclusive of the family and other caregivers.1 In mental health organizations, care delivery based on “recovery” is related to person-centered care.2 Recovery-oriented care is a preferred policy-directed model of mental health care provision in many countries in the developed world.3–5 Recovery is described as a unique journey that consumers lead with the aim of regaining control of their lives6 in order to live a good life.7–9 Thus, Australian older-adult inpatient mental health organizations must strive to address the holistic needs of each consumer to assist with his or her unique recovery journey.9 The aging population in the developed world is projected to contribute to an increased demand for care from health systems,10,11 in part because of advances in medical treatment.12 An aging population may have mental health disorders such as dementia, depression, and anxiety,10,11,13 and physical health conditions such as organ dysfunction14 and cardiovascular,15 osteoporotic,16 and oncological diseases17 often coexist in older adults. Nurses working in older-adult acute inpatient mental health units are cognizant of the unique combination of mental illness, cognitive changes, and coexisting physical health conditions,18 but methods to provide recovery-oriented care have not been thoroughly described at this time. Specifically, the pragmatic processes to promote a culture of hope, autonomy, and self-determination through holistic and personalized care; establish collaborative partnerships and meaningful engagement; focus on consumers’ strengths; include families and caregivers; and encourage community participation and citizenship19 are not well articulated for older-adult acute inpatient mental health settings. The intent of this qualitative study, therefore, was to allow mental health nurses the opportunity to reflect on and describe current nursing practice in older-adult acute inpatient mental health settings that are not overtly recovery oriented. The aims were to determine the extent to which elements of existing nursing practice resemble the
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domains of recovery-oriented care and to provide a baseline understanding of practice in preparation for transformation to recovery-oriented settings as reflected in policy directives in Australia.9,19
METHODS
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framework, emergent patterns, and supporting evidence enhanced rigor.25
RESULTS Description of Focus Group Participants
An exploratory research design incorporating qualitative in-depth focus group interviews20 was used to meet the research aims. Exploratory research is undertaken when a problem has not been clearly defined.21 The Melbourne Health Office for Research approved this research.
Twelve mental health nurses (mean of mental health nursing experience 20 years) participated in the three focus groups. All nurses were qualified registered nurses. The range of experience in an older-adult inpatient mental health setting was 1 to 18 years (mean 10 years). The majority of nurses were female (n = 11). The nurses were trained in Australia (n = 10) and the United Kingdom (n = 2).
Participants
Content Domains
Using a hospital-based information flyer, a purposive sample of mental health nurses was recruited to participate in a focus group at each of three older-adult acute inpatient settings in a large mental health organization. Four mental health nurses and one researcher (BM) attended a 60- to 90-minute focus group conducted at each older-adult acute inpatient setting. A total of 12 mental health nurses provided voluntary informed consent and participated in this study. At each of the three settings, the focus group was conducted on location in a locked, private meeting room. Participants were not provided with incentives to participate.
Participants in this study discussed five content domains specific to recovery: a culture of hope, collaborative partnerships, meaningful engagement, autonomy and self-determination, and community participation and citizenship. A sixth overarching theme that related to the challenge to recovery-oriented care in older-adult acute inpatient mental health settings was pertinent to the discussions of each domain.
Research Design
Procedures The focus group interview schedule enquired about current practice based on the domains of recovery-oriented care in the Australian context19,22 to promote a culture of hope; autonomy and self-determination; holistic and personalized care; collaborative partnerships and meaningful engagement; a focus on strengths; involvement of family, caregivers, support people, and significant others; responsiveness to diversity; and encouragement of community participation and citizenship. For example, mental health nurses were asked whether their “care focuses on promoting hope,” with prompts to describe how their clinical practice may focus on promoting hope and to provide specific pragmatic examples. The focus group interview schedule was identical for all three focus groups. The same researcher (BM) conducted all focus groups. Responses were recorded using an audio-digital recorder. Two researchers (DD, TF) transcribed all interviews.
A Culture of Hope The cohort of nurses acknowledged that consumers admitted to the older-adult inpatient mental health units often felt worthless. To support hope, nurses would allocate therapeutic time with each consumer to moderate negative attitudes and reassure consumers by reinforcing that the consumer is not a burden, admission is a short-term stage of the recovery journey, admission can enhance understanding of their mental illness, and consumers are capable and can live meaningful lives. Nurses expressed the need to avoid overwhelming the consumer while gradually instilling hope: “I think when they come in here, they have mental health issues, they think there is no recovery, or there is no hope for them. So it’s that reassurance and telling them that they are not going to be here forever, no one stays here forever.” The nurses discussed that the eventual goal was to reestablish the preadmission routines that bring meaning to peoples’ lives. Communicating with the family enhanced an understanding of such routines: “Get the family to bring the pet dog in, or go for a coffee, to the hairdresser —the little things that the [consumer] does to feel better about themselves.”
Data Analysis A general inductive approach was used to analyze the qualitative data23 (NVivo version 10; QSR International Pty Ltd., Burlington, MA). Through continuous reading and agreement of the researchers, the coding was aligned with the preexisting domains of recovery.19 As necessary during analysis, the initial content domains were collapsed or split into preexisting categories, until central relationships began to emerge.24 Each pattern was examined for supporting quotations from the data. Collective agreement of the research team on the categorical analytical
Collaborative Partnerships A collaborative focus with the consumer was directed at the small steps of the recovery journey, achievable within the short time frame of the person’s stay in the acute inpatient setting: “[Consumers] need to feel like people are taking them seriously, let them settle in, not bombard them with recovery from the first day, as it can be too overwhelming.” Collaboration also occurred through promoting a holistic response to care. The physical health of older-adult
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mental health consumers within a holistic overview was a constant consideration: “. . .you can’t get away from those issues, especially in the elderly when they are here and [their physical health] is the very thing that is causing their stress and mental illness.” Sociocultural and spiritual needs were also considered in collaboration with consumers and caregivers: “We have to be aware of beliefs. It’s hard but it’s the little things, like phoning up the family and asking the questions.” Collaboration with the family and guardians was a major partnership initiative, because consumers’ were often unsure or unable (too cognitively impaired) to articulate with clarity how their recovery journey should be structured before, during, and after discharge. Nurses conveyed a sense of knowing what consumers were capable of becoming but needed the assistance of the family to gather the specific knowledge and details that facilitated a recovery-oriented model of care: “. . .they [the family] know what works and what doesn’t, rather than us through using trial and error.”
Meaningful Engagement Establishing meaningful engagement and rapport with consumers was viewed as being central to current mental health nursing practice. A vital component of establishing rapport was to initially assess the consumer’s level of cognitive ability and coexisting physical health needs to modify the approach to assist meaningful engagement. Meaningful engagement often occurred through exploring the person’s everyday life, whereby consumers’ were encouraged to “tell their story”: “I ask about what was your occupation? What do you do during your retirement?” The nurses listened to consumers, allowed them to “vent their stuff,” to describe personal issues, and to elaborate on interests that fostered happiness (e.g., pets, family, getting a haircut, coffee at a preferred cafe): “The more they feel better about themselves, the better the recovery is when they go home.” Nurses reframed situations in which consumer behavior, on the face of things, could be misinterpreted as bizarre, inconvenient, or indicative of deteriorating mental health status as opportunities for meaningful engagement. There was an attempt to explain behavior within past routines. For instance, one consumer would lie on his back every day staring at the ceiling, which is explainable behavior within the context of his lifetime occupation as a vehicle mechanic. Another consumer would walk about the unit checking all the door and window locks, again explainable within his past role as a security guard. Finally, one consumer repeatedly placed all the chairs from the dining room in a neat line in a corridor, acceptable within the context of being a bus driver before retirement. Understanding such behavior enhanced engagement. Nurses were then able to support and focus on meaningful engagement by modifying the environment of the unit to maintain safety and to support individual consumer behavior.
Autonomy and Self-Determination The pragmatic process of involving the consumer in goal setting at the time of admission supported autonomy:
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“Asking them what they want first off, not what we want for them. What do they want to achieve? What is their outcome from being in a place like this?” The nurses discussed some tension when the views of their family or guardian challenged notions of self-determi nation that consumers experiencing cognitive impairment expressed: “We have to put ourselves in [the family’s] shoes. There is always a lot of issues over many years. . .they are also getting older and maybe a little burnt out.” At such times, the nurses took a reconciliatory position seeking compromise by determining what was functionally possible for the consumer in the mental health unit, what was a realistic level of autonomy (e.g., selfbathing and dressing), and what self-determined and autonomous activities of daily living needed to be supported to maintain independence after discharge.
Community Participation and Citizenship The nurses mentioned facilitating community reintegration by supporting day and weekend leave, encouraging consumers to reengage with daily activities, and creating activity groups such as a breakfast club and social outdoor eating occasions. High acuity and the reality that some consumers may require a supportive living environment after discharge limited consumer participation. Other factors, such as time allocation and management and administrative workload, were cited as sometimes limiting preparation for community participation and citizenship to levels that resembled preadmission. Continuity of care with external support agencies was encouraged. This was most successful in relation to community mental health settings whereby some case managers would visit consumers during admission at the inpatient unit: “So case managers come to our team meetings, so they know what’s happening with the [consumer]. Then they also see the [consumer] while they are here.”
Challenges to Recovery in Older-Adult Acute Inpatient Mental Health Settings In discussing each of the recovery domains, a series of challenges emerged. The nurses expressed difficulties in framing recovery as a journey when dementia and physical illness signaled irreversible deterioration: “For our people who are here with depression, their recovery may be getting back home and living their life independently. People with dementia, their recovery might be not being distressed, aggressive, or upset, because they are never going to get better. Recovery means different things for different people.” “. . .if they have terminal cancer, you are not going to offer them hope to the point that they will be better soon and be going home.” Organizational structures also challenged perceptions of the consumer’s recovery journey. The pressures of a busy ward with low nursing staff numbers and high consumer numbers and the reliance on temporary staff who were unfamiliar with the inpatient unit were examples of the organizational challenges to recovery. A perceived incompatibility of the clinical profiles of consumers admit-
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ted to the mental health organization was also seen as a challenge to recovery: “I think having a mixture of [consumers] with an organic illness and a functional illness is very difficult . . .we’ve got depressed ladies, and six guys wandering around with behavioral and psychological symptoms of dementia and they are intrusive to everyone.” Furthermore, a lack of knowledge about recoveryoriented care among staff was commonly stated: “We need a lot more education on it.”
DISCUSSION The results of this study describe the extent to which mental health nurses pragmatically apply a recovery-oriented model of care in older-adult acute inpatient mental health units that are not overtly organized to be recovery oriented. Nurses in this study described positive effects of collaborative care, which enhances community care after discharge from inpatient units.26 Because it has been suggested that self-management improves community participation and citizenship of older adults with mental illness and cognitive deterioration,10,27 the pragmatic processes to support and strengthen autonomy and self-determination, described by nurses in this study, may enhance recovery after discharge. For community-dwelling older adults with enduring mental health needs, identifying existing social networks, roles, and activities supports recovery.6 Nurses in the current study used collaboration with consumers, caregivers, and colleagues, with similar effect. The integration of family and caregivers across the duration of stay in the acute inpatient unit was clear in the results of the current study, as engaging with them was highlighted when participants were discussing every domain of recovery. This highlights the significance of family and caregivers in recoveryoriented care for older adults.19 Older-adult acute inpatient mental health units also house some consumers who experience coexisting physical and mental health needs, including cognitive impairment, and who depend on mental health professionals and caregivers. Nurses in this study expressed difficulty in framing recovery as a journey in such situations. Further consideration should be focused on nurses understanding the concept of recovery as it applies to such complexity. It is not as important for older adults with mental illnesses to be educated about and encouraged to seek “recovery” as it is to be supported effectively in leading the kinds of lives they wish to lead. The role of caregivers, therefore, becomes pivotal in understanding what this “life worth living” actually is. Flexibility of organizational structures is required to address such diversity,28,29 as is flexibility in the application of the recovery principles to complicated consumer presentations. Nurses in this study highlighted a willingness to gain understanding through professional development about practice modes of recovery-oriented care to address such complexity. That sentiment is matched in mental health colleagues3 and consumers.30,31 Because recovery is a relatively recent preferred policy-directed mode of care in Australian mental health organizations, it is likely that older-adult consumers with a
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history of serious mental illness have not been exposed to recovery-oriented care. As such, the notion of “starting” consumers on a recovery journey at this stage of their lives posed a conundrum for nurses in this study. Because recovery-oriented settings develop across the life span, it is important that future research be longitudinal and crosssectional to adequately reflect the effect of models of care on the totality of the journey experienced. Furthermore, the policy-driven model of recovery reflecting a “one model fits all” approach needs to be considered in the context specific to older adults with mental health and coexisting physical health conditions. Descriptions of the practice of recovery-oriented care were collected from a small number of nurses in one of Australia’s largest mental health organizations. As such, data may not represent descriptions of mental health nursing practice in other settings or mental health nurses in general. Nurses who were ill-informed about recovery-oriented care or were resistant to the concept may not have consented to the focus groups, leading to a potential selection bias. Because recovery-oriented care enables consumers to be proactive about their journey, the results of this study are limited without the opinions of consumers within the multidisciplinary setting. Therefore, generalizations about the effect of care that resembles recovery-oriented domains may not be externally valid without consumer, caregiver, and multidisciplinary input. Conceptual frameworks of recovery specific to the characteristics of the older-adult acute inpatient mental health settings are being developed, and older-adult mental health care system change is predicted.6 The results of this study show nursing practice strengths and areas of uncertainty about recovery-oriented care. As mental health organizations across Australia begin the systemic transformation to a recovery-oriented model of care, results of this study show that a cohort of mental health nurses can identify recovery in older-adult acute mental health inpatient settings that are not overtly recovery oriented and articulate with pragmatic clarity how to care within a recovery-oriented paradigm. A concerted drive focused on education regarding recovery, including an exploration of the challenges to recovery-oriented care in older-adult acute inpatient settings, is required to effectively embed a recovery-oriented paradigm.
ACKNOWLEDGMENTS This study was undertaken at NorthWestern Mental Health and received no financial support. Conflict of Interest: Brian McKenna, Trentham Furness, and Deepa Dhital are affiliated with NorthWestern Mental Health. Susan Ireland is employed by NorthWestern Mental Health. None of the authors have any financial interest, patents, company holdings, or stock to disclose related to this unfunded study. Author Contributions: All authors contributed to concept and design. BM conducted all focus groups. SI arranged all focus groups. BM, DD, and TF were involved with data processing and analysis. All authors contributed to drafting and review of the manuscript. Sponsor’s Role: None.
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