Sarah Cook

Can the impact of public involvement on research be evaluated? A mixed methods study

Background  Public involvement is central to health and social research policies, yet few systematic evaluations of its impact have been carried out, raising questions about the feasibility of evaluating the impact of public involvement.

Valuing Occupational Therapy as a Complex Intervention

This opinion piece introduces a framework for understanding and valuing occupational therapy as a complex intervention. The nature of complexity, particularly non-linearity and unpredictability, is summarised. The factors that characterise occupational therapy as a complex intervention are then presented. These include the visible actions that constitute the occupational therapy process; the centrality of activities and occupation in the therapists thinking and actions; the shifts of perspectives in occupational therapy intervention; the client-centred nature of practice; and the importance of the therapists thinking skills. All these factors elucidate why we should be proud of the complexity of occupational therapy and why a simple definition is unattainable.

Defining an Occupational Therapy Intervention for People with Psychosis

The purpose of the study was to define occupational therapy in its entirety for people with psychotic conditions in community settings, in order to produce an intervention schedule for piloting in a randomised controlled trial. Initially, a draft schedule was designed using Creeks (2003) definition of occupational therapy as a complex intervention and other literature regarding psychosis. Consensus methods provided a systematic and transparent process for refining the schedule: the Delphi method was used with 20 local mental health occupational therapists followed by a modified nominal group technique with occupational therapists attending a national conference. This paper focuses on the process of gaining consensus and the practice-related issues that arose. The results identified 82 components that detailed occupational therapy actions under 11 stages. The preferred approach was client centred, with models of practice, goals and actions chosen collaboratively with the individual client. Occupational therapy was defined as separate to care management but incorporated some generic tasks. The discussion of this studys implications includes setting a finite length of intervention; barriers to practice; the importance of activity analysis and doing activities together with clients; and how defining practice may help to clarify the role of the occupational therapist in multidisciplinary team work.

What helps and hinders people with psychotic conditions doing what they want in their daily lives

It is important for people to do what they want in their daily lives and this is embedded in concepts of recovery, rehabilitation, social inclusion and quality of life. To research what helps and hinders people with psychotic conditions to do what they want, 24 people already engaged in a trial of occupational therapy were interviewed by a service user researcher. The qualitative methods used framework analysis. The findings described what the participants appreciated about occupational therapy and how other workers sometimes delivered occupational therapy type interventions. As well as therapy, multifarious factors appeared to have an impact on peoples choices and actions and these reiterated the findings from prior studies. These internal and external factors combined in complex relationships. People felt particularly vulnerable when staff behaved uncaringly and with disrespect because this replicated past traumas, stigmatisation and rejection. The participants revealed how important it was for staff to pitch their interventions right for them at the time. The study led to suggestions that occupational therapists refine their artistry in order to hone their interventions to suit the individual, follow guidance on developing therapeutic relationships and recovery-focused capabilities, enhance caring by getting support themselves and employ critical thinking to challenge organisational barriers and their professions rhetoric.

Lifestyle Matters for maintenance of health and wellbeing in people aged 65 years and over: study protocol for a randomised controlled trial

BackgroundHealthy, active ageing is strongly associated with good mental wellbeing which in turn helps to prevent mental illness. However, more investment has been made into research into interventions to prevent mental illness than into those designed to improve mental wellbeing. This applied research programme will provide high quality evidence for an intervention designed to improve and sustain mental wellbeing in older adults.Methods/DesignThis study was a multi-centre, pragmatic, two-arm, parallel group, individually randomised controlled trial to determine the population benefit of an occupational therapy based intervention for community living people aged 65 years or older. Participants (n = 268) will be identified in one city in the North of England and in North Wales through GP mail-outs, signposting by local authority, primary care staff and voluntary sector organisations and through community engagement. Participants will be randomised to one of two treatment arms: an intervention (Lifestyle Matters programme); or control (routine access to health and social care). All participants will be assessed at baseline, 6 and 24 months post-randomisation. The primary outcome, which is a person reported outcome, is the SF-36 Mental Health dimension at six months post randomisation. Secondary outcome measures have been selected to measure psychosocial, physical and mental health outcomes. They include other dimensions of the SF36, EQ-5D-3L, Brief Resilience Scale, General Perceived Self Efficacy Scale, PHQ-9, de Jong Gierveld Loneliness Scale, Health and Social Care Resource Use and the wellbeing question of the Integrated Household Survey 2011. A cost effectiveness analysis will investigate the incremental cost per Quality Adjusted Life Years (QALYs) of the Lifestyle Matters intervention compared with treatment as usual.DiscussionThe questions being posed through this research are important given the increasing numbers of older people, pressure on the public purse and the associated need to support good health in the extended lifespan. The proposed trial will determine the clinical and cost effectiveness of the intervention delivered in a UK context. The results will support commissioners and providers with decisions about implementation.Trial registrationCurrent Controlled Trials ISRCTN67209155

Barriers to the sustainability of an intervention designed to improve patient engagement within NHS mental health rehabilitation units: a qualitative study nested within a randomised controlled trial

BackgroundWe undertook a cluster randomised controlled trial to assess the effectiveness of a staff training intervention to improve patient engagement in activities in inpatient mental health rehabilitation units. Concurrently, we undertook a qualitative study to investigate the experiences of staff within the intervention units and the contextual issues that may have influenced the effectiveness of the intervention.MethodWe conducted focus groups with staff working in the inpatient units that received the intervention, sampled using a maximum variation strategy.ResultsThe intervention was accepted by staff. However, the skills gained, and changes to the unit’s processes and structures that were agreed with the intervention team were not sustained after they left. The main reasons for this were a) external factors (economic recession, resource limitations); b) organisation level factors (lack of senior staff support; competing priorities); c) limitations of the intervention itself (length of intensive training period; reinforcement of skills).ConclusionThis study illustrates some of the inter-related factors which operate at different levels within and outside of NHS organisations that may impact on the success of complex interventions. These factors need to be considered when designing interventions to ensure adequate buy-in from senior staff.Trial registrationCurrent Controlled Trials ISRCTN25898179 (Registered 23 April 2010)

A preventative lifestyle intervention for older adults (Lifestyle Matters): a randomised controlled trial

Abstract Objectives to test whether an occupation-based lifestyle intervention can sustain and improve the mental well-being of adults aged 65 years or over compared to usual care, using an individually randomised controlled trial. Participants 288 independently living adults aged 65 years or over, with normal cognition, were recruited from two UK sites between December 2011 and November 2015. Interventions lifestyle Matters is a National Institute for Health and Care Excellence recommended multi-component preventive intervention designed to improve the mental well-being of community living older people at risk of decline. It involves weekly group sessions over 4 months and one to one sessions. Main outcome measures the primary outcome was mental well-being at 6 months (mental health (MH) dimension of the SF-36). Secondary outcomes included physical health dimensions of the SF-36, extent of depression (PHQ-9), quality of life (EQ-5D) and loneliness (de Jong Gierveld Loneliness Scale), assessed at 6 and 24 months. Results data on 262 (intervention = 136; usual care = 126) participants were analysed using intention to treat analysis. Mean SF-36 MH scores at 6 months differed by 2.3 points (95 CI: −1.3 to 5.9; P = 0.209) after adjustments. Conclusions analysis shows little evidence of clinical or cost-effectiveness in the recruited population with analysis of the primary outcome revealing that the study participants were mentally well at baseline. The results pose questions regarding how preventive interventions to promote well-being in older adults can be effectively targeted in the absence of proactive mechanisms to identify those who at risk of decline. Trial Registration ISRCTN67209155.

Development of a staff training intervention for inpatient mental health rehabilitation units to increase service users' engagement in activities

Introduction This study developed a training intervention (‘GetREAL’) to change the practice of staff working in National Health Service inpatient mental health rehabilitation units in order to increase service users’ engagement in activities. Method The intervention was developed through eight consultation events and piloting in two settings, drawing on the expertise of occupational therapists, psychiatrists, organisational change specialists and service users, together with multi-disciplinary teams. Results A manual for the intervention, a fidelity checklist, an induction programme and training materials were produced. The intervention applied a three-stage change model (predisposing, enabling and reinforcing) and was informed by theories from occupational therapy and organisational development. It was delivered by psychiatrists, occupational therapists, activity workers and service users. Staff were encouraged to change their ward structures and routines as well as their practice. Clinical supervision and reflective practice were integral to the trainers’ regime. Conclusion The intervention was theoretically coherent, allied to practice and shown to be feasible to deliver. It offered tailored work-based training to the whole multi-disciplinary team, including support staff. Making activity central to rehabilitation could improve patients’ use of time and their consequent function and wellbeing. However, questions were raised about long-term sustainability of change processes.

Recovery-based staff training intervention within mental health rehabilitation units: a two-stage analysis using realistic evaluation principles and framework approach.

BackgroundLong-term change in recovery-based practice in mental health rehabilitation is a research priority.MethodsWe used a qualitative case study analysis using a blend of traditional ‘framework’ analysis and ‘realist’ approaches to carry out an evaluation of a recovery-focused staff training intervention within three purposively selected mental health rehabilitation units. We maximised the validity of the data by triangulating multiple data sources.ResultsWe found that organisational culture and embedding of a change management programme in routine practice were reported as key influences in sustaining change in practice. The qualitative study generated 10 recommendations on how to achieve long-term change in practice including addressing pre-existing organisational issues and synergising concurrent change programmes.ConclusionsWe propose that a recovery-focused staff training intervention requires clear leadership and integration with any existing change management programmes to facilitate sustained improvements in routine practice.

Occupational therapists as change agents in multidisciplinary teams

Introduction This qualitative study explored the experiences of occupational therapists attempting to implement change within multidisciplinary teams via a 5-week training intervention. This encouraged ward staff in inpatient mental health rehabilitation units to facilitate service user engagement in activities. This study is supplementary to a randomised control trial (RCT). Method Daily diaries and training reflections completed by two therapists (P1 and P2) during the training were subjected to Framework analysis. The indexing stage of this process was completed in collaboration with the participants. Findings When implementing change, the occupational therapists encountered a number of barriers such as emotional responses and attitudes towards service users. Facilitators of change included openness, sharing knowledge and skills, and reported change. The analysis revealed a change process moving from ‘assessing the context’, to ‘building relationships’ and ‘addressing issues’ that was aided by the therapists’ high-level skills and capacity for social and self-awareness. Conclusion The process of change aligned well with the chosen three-stage model of change as well as occupational therapy philosophy. When acting as change agents, the therapists adapted and applied their clinical skills to the organisational context in accord with their core values and capacity for social and self-awareness.