Michael Coffey

Recovery: what mental health nurses and service users say about the concept of recovery

Accessible summary • This qualitative study investigated the subjective experiences of recovery in mental health with service users and mental health nurses. • Data from two focus groups were analysed and found differing perceptions of how mental health services are delivered and the barriers that are seen to hinder the implementation of a recovery philosophy. • The main findings of the study are that recovery is a difficult-to-define concept and remains a challenge for both this group of service users and nurses. Abstract This study presents a thematic analysis of focus group talk to examine what recovery in mental health means to service users and nurses. Data were collected from two focus groups, one group of service users and one group of nurses. The service user group (n= 6) were adults with previous or recent experience of inpatient mental health services. The nursing group were registered nurses (n= 5) of various grades and experience currently working in inpatient mental health services in one region of the UK. Thematic analysis using Krueger and Caseys framework led to four themes being developed. These were ‘understandings of recovery’, ‘semantics’, ‘therapeutics’ and ‘a journey’. While the recovery concept was not new to either group, understandings of recovery were vague and contradictory.

‘You don't talk about the voices’: voice hearers and community mental health nurses talk about responding to voice hearing experiences

AIMS AND OBJECTIVES To explore service user and community mental health nurses views on responses to voice hearing experiences. BACKGROUND People who hear distressing auditory hallucinations (voices) are often in contact with mental health services. Nursing responses to this experience have been limited, although emerging evidence suggests some utilitarian alternative interventions, such as discussing the content and meaning of the voices. DESIGN Using exploratory interviews, this study investigated the response to voice hearing, with a purposive sample of community mental health nurses (n = 20) and service users (n = 20). This paper reports on a thematic content analysis of transcribed interviews, which highlighted differences in perspectives of voice hearers and the nurses supporting them. RESULTS Voice hearers reported that interventions from community mental health nurses were limited to reviews of medication, access to the psychiatrist and non-directive counselling. They identified alternative needs, which involved talking more about the content and meaning of their voices. Conversely, community mental health nurses regarded their responses to voice hearing as being considered, titrated and demonstrating an awareness of the personal contexts of service users. These responses were however restricted by their perception of skill limitations. CONCLUSIONS The contrasting views of nurses and users of services demonstrated in this study, reveal multiple social realities that represent a challenge to accepted professional responses in the provision of mental health care. RELEVANCE TO PRACTICE People who hear voices express an interest in more helpful responses from community mental health nurses. The findings of this study indicate that nurses must begin to orientate themselves towards a more critical practice stance that encompasses available knowledge on the voice hearing experience.

A risk worth taking? Value differences and alternative risk constructions in accounts given by patients and their community workers following conditional discharge from forensic mental health services

Patients leaving forensic psychiatric settings on conditional discharge face the challenge of achieving successful community integration, which involves not re-offending, adjusting to the local community and building support networks. Aftercare and monitoring of patients by workers ostensibly assists with integration, but is often dominated by concerns about risks to the public. Risk is seen to emanate from individuals, with steps taken to ensure intensive monitoring and, if necessary, swift return to hospital. This article shows that workers and conditionally discharged patients have distinct views about risk in community living which are driven by contrasting values and priorities; and that some of these differences are associated with the provision of care itself. A discursive analysis of accounts, drawn from 59 interviews with patients and workers, demonstrates that fears about deviant status weigh most heavily for the individual leaving hospital. Aftercare, with its focus on intensive regular visits by nurses, social workers, police and voluntary agencies, works to ‘unmask’ the person to the wider community, setting them apart as needing supervision. Discharged patients express unease that this unmasking undermines their attempts to begin new lives. Their concern suggests that significant iatrogenic risk arises from aftercare. Workers are not indifferent to this issue, but are themselves subject to public safety imperatives which require surveillance and control of individuals deemed risky. Community integration has the potential to be an important mediator in future risk behaviours. However, managing intensive aftercare without allowing for its wider visibility may jeopardise its achievement.

Recovery-focused care planning and coordination in England and Wales: a cross-national mixed methods comparative case study

BackgroundIn the UK, concerns about safety and fragmented community mental health care led to the development of the care programme approach in England and care and treatment planning in Wales. These systems require service users to have a care coordinator, written care plan and regular reviews of their care. Processes are required to be collaborative, recovery-focused and personalised but have rarely been researched. We aimed to obtain the views and experiences of stakeholders involved in community mental health care and identify factors that facilitate or act as barriers to personalised, collaborative, recovery-focused care.MethodsWe conducted a cross-national comparative study employing a concurrent transformative mixed-methods approach with embedded case studies across six service provider sites in England and Wales. The study included a survey of views on recovery, empowerment and therapeutic relationships in service users (n = 448) and recovery in care coordinators (n = 201); embedded case studies involving interviews with service providers, service users and carers (n = 117) and a review of care plans (n = 33). Quantitative and qualitative data were analysed within and across sites using inferential statistics, correlations and framework method.ResultsSignificant differences were found across sites for scores on therapeutic relationships. Variation within sites and participant groups was reported in experiences of care planning and understandings of recovery and personalisation. Care plans were described as administratively burdensome and were rarely consulted. Carers reported varying levels of involvement. Risk assessments were central to clinical concerns but were rarely discussed with service users. Service users valued therapeutic relationships with care coordinators and others, and saw these as central to recovery.ConclusionsAdministrative elements of care coordination reduce opportunities for recovery-focused and personalised work. There were few common understandings of recovery which may limit shared goals. Conversations on risk appeared to be neglected and assessments kept from service users. A reluctance to engage in dialogue about risk management may work against opportunities for positive risk-taking as part of recovery-focused work. Research to investigate innovative approaches to maximise staff contact time with service users and carers, shared decision-making in risk assessments, and training designed to enable personalised, recovery-focused care coordination is indicated.

Validation of mid-infrared spectrometry in milk for predicting body energy status in Holstein-Friesian cows

Cow energy balance is known to be associated with cow health and fertility; therefore, routine access to data on energy balance can be useful in both management and breeding decisions to improve cow performance. The objective of this study was to determine if individual cow milk mid-infrared spectra (MIR) could be useful to predict cow energy balance across contrasting production systems. Direct energy balance was calculated as the differential between energy intake and energy output in milk and maintenance (maintenance was predicted using body weight). Body energy content was calculated from (change in) body weight and body condition score. Following editing, 2,992 morning, 2,742 midday, and 2,989 evening milk MIR records from 564 lactations on 337 Scottish cows, managed in a confinement system on 1 of 2 diets, were available. An additional 844 morning and 820 evening milk spectral records from 338 lactations on 244 Irish cows offered a predominantly grazed grass diet were also available. Equations were developed to predict body energy status using the milk spectral data and milk yield as predictor variables. Several different approaches were used to test the robustness of the equations calibrated in one data set and validated in another. The analyses clearly showed that the variation in the validation data set must be represented in the calibration data set. The accuracy (i.e., square root of the coefficient of multiple determinations) of predicting, from MIR, direct energy balance, body energy content, and energy intake was 0.47 to 0.69, 0.51 to 0.56, and 0.76 to 0.80, respectively. This highlights the ability of milk MIR to predict body energy balance, energy content, and energy intake with reasonable accuracy. Very high accuracy, however, was not expected, given the likely random errors in the calculation of these energy status traits using field data.

Ordinary risks and accepted fictions: how contrasting and competing priorities work in risk assessment and mental health care planning

Communication and information sharing are considered crucial to recovery‐focused mental health services. Effective mental health care planning and coordination includes assessment and management of risk and safety.

Negotiating identity transition when leaving forensic hospitals

The transition from hospital patient to community resident is something which is far from straightforward. For those with multiple labels of disability, chronicity and criminal offending behaviours this transition is particularly complicated. This article reports on a study of accounts provided by a hard-to-reach group of patients and their workers in one region of the UK. Through the use of 59 in-depth interviews with conditionally discharged persons, community mental health nurses and social workers, everyday understandings of the process of discharge and reintegration were investigated. The primary focus was on how identity was handled in the talk of discharged persons and what workers said about this. Analysis focused upon the action-oriented nature of accounts related to discharge, community return and attempts to construct viable identities in the outside world. This study found that stories did the work of loosening previous labels. Illness as mitigation was deployed as an important resource for this purpose. Deviant labels signifying mental illness and criminality presented enduring identity-threats. It was found that as they adjust to return to the community, individuals deploy particular types of identity talk to neutralize ascriptions of continuing deviance and make claims to normality. Workers for their part supported illness as mitigation but continued to orient towards risk as an enduring identity label. In their day-to-day lives the accomplishment of ‘ordinary’ identities was a continuing task of discharged persons in maintaining community return.

New roles for nurses as approved mental health professionals in England and Wales

This paper critically discusses the challenges mental health nurses face in trying to achieve a balance between fulfilling biomedical and social roles. We suggest that dilemmas exist for nurses in attempting to combine both approaches in their practice. We present a specific example of these as occasioned by the advent of the approved mental health professional role in England and Wales. This statutory role requires the adoption of an independent social perspective as a counterbalance to the biomedical perspective brought by psychiatrists. Using the idea of occupational jurisdictions we discuss how nurses embarking on this new role are effectively crossing into territories previously occupied by the profession of social work. We also reveal the tensions for nurses who fulfil the approved mental health professional role whilst simultaneously carrying out work in other areas which demands a more overtly biomedical approach. We review critical accounts of the validity of bio-psycho-social models and concerns about maintaining positive therapeutic alliances alongside making applications for compulsory detention, assessment and treatment. We argue that the new role may become part of the professional project of mental health nursing, but also present challenges in helping redefine nursings identity and practice.

Stress and coping in forensic community mental health nurses: Demographic information and qualitative findings

Occupational stress and burnout in nurses is now well documented. Community mental health nursing has been shown to be particularly stressful. The field of forensic psychiatry has in recent years seen the emergence of the role of the forensic community mental health nurse (FCMHN). There is little documented evidence about these nurses or their experience and perceptions of the work they do. This study forms part of a larger study investigating the levels and sources of stress and burnout among this group of nurses. Preliminary findings suggest that, as a group, FCMHNs are an experienced group of nurses with an average 15 years or more in psychiatric nursing. They tend to occupy higher grades and are almost equally made up of men (53.8%) and women (46.2%). The majority are happy with life in general, do not use maladaptive coping strategies, have good job security (67.1%), feel supported by their manager (87.2%) and carry an average caseload of 13.15 patients. Caseload issues and organisational issues were reported as the most stressful elements of work. Peer support and good supervision were the main coping strategies reported. Consideration for training and reducing the isolation of FCMHNs as they expand into new areas with increased risk of role ambiguity is indicated.

Study protocol: cross-national comparative case study of recovery-focused mental health care planning and coordination (COCAPP)

BackgroundThe collaborative care planning study (COCAPP) is a cross-national comparative study of care planning and coordination in community mental healthcare settings. The context and delivery of mental health care is diverging between the countries of England and Wales whilst retaining points of common interest, hence providing a rich geographical comparison for research. Across England the key vehicle for the provision of recovery-focused, personalised, collaborative mental health care is the care programme approach (CPA). The CPA is a form of case management introduced in England in 1991, then revised in 2008. In Wales the CPA was introduced in 2003 but has now been superseded by The Mental Health (Care Co-ordination and Care and Treatment Planning) (CTP) Regulations (Mental Health Measure), a new statutory framework. In both countries, the CPA/CTP requires providers to: comprehensively assess health/social care needs and risks; develop a written care plan (which may incorporate risk assessments, crisis and contingency plans, advanced directives, relapse prevention plans, etc.) in collaboration with the service user and carer(s); allocate a care coordinator; and regularly review care. The overarching aim of this study is to identify and describe the factors that ensure CPA/CTP care planning and coordination is personalised, recovery-focused and conducted collaboratively.Methods/designCOCAPP will employ a concurrent transformative mixed methods approach with embedded case studies. Phase 1 (Macro-level) will consider the national context through a meta-narrative mapping (MNM) review of national policies and the relevant research literature. Phase 2 (Meso-level and Micro-level) will include in-depth micro-level case studies of everyday ‘frontline’ practice and experience with detailed qualitative data from interviews and reviews of individual care plans. This will be nested within larger meso-level survey datasets, senior-level interviews and policy reviews in order to provide potential explanations and understanding.DiscussionCOCAPP will help identify the key components that support and hinder the provision of personalised, recovery-focused care planning and provide an informed rationale for a future planned intervention and evaluation.