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The Development of Recovery Competencies for In-patient Mental Health Providers Working with People with Serious Mental Illness. Shu-Ping Chen , Ph. D. Candidate, School of Rehabilitation Therapy, Queen’s University

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slide1

The Development of Recovery Competencies for In-patient Mental Health Providers Working with People with Serious Mental Illness

Shu-Ping Chen, Ph. D. Candidate, School of Rehabilitation Therapy, Queen’s University

Terry Krupa, PhD, OT Reg (Ont), Professor, School of Rehabilitation Therapy, Queen’s University

i the in patient context
I. The In-patient context

The downsizing and/or closures of psychiatric hospitals and the increase of community-based services

  • Acute units: People admitted to acute in-patient units can be vulnerable and in extreme distress.
  • Long-term units: Althoughthe number of long-stay patients in tertiary psychiatric hospitalsdeclined during the past three decades,a group of patients are still served in these hospitals.
characteristics of the in patient context
Characteristics of the in-patient context
  • Restrictions
  • Unpredictability
  • Control
      • maintaining stabilization by means of rules and routines
  • Medical model
      • symptom reduction
      • problem-oriented interventions
ii recovery
II. Recovery
  • The vision of recovery has become the foundation for mental health services worldwide.
      • Many countries have adopted recovery as a basic principle for mental health policy making and service providing system at a national level.
        • Canada
        • The United States
        • New Zealand
        • Australia
        • The United Kingdom
        • Ireland
        • ……
recovery concepts
Recovery Concepts
  • Definition of recovery: Recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential”(SAMHSA, 2006)
  • Recovery is a continuous and non-linear process, occurring even when an individual experiences intense forms of health services, such as hospitalization.
recovery concepts8
Recovery Concepts
  • Recovery means that a person can live a satisfying, hopeful, and productive life no matter what limitations are caused by illness.
  • Recovery is about personal awareness and individual ways of coping.
  • Recovery doesn’tmean:
      • There is a cure.
      • People will never have to take medication again.
recovery oriented mental health system
Recovery-oriented Mental Health System
  • A recovery-oriented mental health system is characterized by program structures such as mission, policies, procedures, record keeping, and quality assurance that are consistent with fundamental recovery value. Farkas, et al, 2005
  • Mental health providers’ understanding, beliefs, values, and attitudes about recovery are one of the key elements in the system transformation towards recovery orientation
iii providers competency
III. Providers’ competency
  • Some hospital-based providers demonstrated fewer recovery attitudes, because
      • fewer opportunities to observe successful consumers in the community
      • the population they served tended to be more severely ill
  • There are numerous competency documents that exist in the mental health field. However, only a few of them are recovery-focused.
existing recovery competency frameworks
Existing recovery competency frameworks

Generic Recovery Competency Frameworks

  • Coursey et al (2000)
  • Young et al (2000)
  • Ohio Department of Mental health (1999)
  • O'Hagan, 2001 (New Zealand)
  • NHS Education for Scotland, 2007
existing recovery competency frameworks13
Existing recovery competency frameworks

Specific Recovery Competency Framework

  • NHS Education for Scotland: “A capability framework for working in acute mental health care”
      • Acute mental health care in Scotland: resolution teams, crisis centers, and intensive home care mostly in the community settings
        • 1) rights, values and recovery focused practice;
        • 2) supporting recovery from acute crisis;
        • 3) making a difference in acute care;
        • 4) sharing positive risk taking
problem statement cont
Problem Statement (Cont.)
  • No recovery competency frameworks addressed the competencies specifically for in-patient providers has been developed.
problem statement cont16
Problem Statement (Cont.)
  • There are still some gaps in in-patient providers’ competencies in a recovery-oriented practice.
  • Therefore, an increase of competencies among in-patient service providers is imperative to working within a recovery-orientated system.
definition
Definition
  • Recovery competency
      • the mental health providers’ attitudes, knowledge, skills, and behaviours required for effective performance in a recovery-oriented service.
  • Mental health providers
      • mental health professionals who provide clinical services and include occupational therapists, psychologists, nurses, social workers, psychiatrists, and managers.
  • In-patient context
      • Ontario tertiary mental health hospitals
purpose
Purpose

The purpose of this study was to:

1. identify the most salient recovery competencies required of in-patient providers to inform the development of an educational program

2. develop a shared understanding of recovery by providers

slide21
Phase One:

The Development of

Recovery Competency Framework

qualitative research design
Qualitative research design

-- Literature review -- Key informant interviews

Develop a recovery competency framework

for in-patient providers

step one data collection
Step One: Data Collection
  • Literature review: The literature review addressed the following issues:
      • 1) the therapeutic environment and culture of in-patient settings
      • 2) in-patient providers’ recovery competencies
      • 3) the challenges or barriers for providers to develop recovery competencies and deliver recovery-oriented services
step one data collection24
Step One: Data Collection

Key Informants Interviews

  • 3 consumers
      • with serious mental illness, who had previous experience with the Ontario provincial psychiatric hospitals in the last two years
  • 3 family members
      • who have a significant family member who was diagnosed with serious mental illness and admitted to the psychiatric hospitals in the last two years
  • 2 community mental health providers
      • who have previous experience in in-patient programs
  • 5 in-patient providers
      • who currently provide clinical services and have worked in these psychiatric hospitals for at least two years
  • 2 educators
      • with knowledge of recovery who are in strategic positions in workforce training in these psychiatric hospitals.
step one data collection25
Step One: Data Collection
  • The interviews were semi-structured, individual, and occurred face-to-face. Each interview was audio recorded and lasted for 30 to 70 minutes.
  • The participants were asked to discuss:
      • their views of recovery
      • the recovery competencies that they believed to be most important to in-patient providers
      • particular challenges providers may face in demonstrating recovery competencies.
step three competence modeling
Step Three: Competence modeling
  • A “tension-practice-consequence” model was developed to organize the first theme (tensions) and explain their relationships
  • A corresponding model illustrating the recovery enabling process was developed to address the tensions and explain the processes of enabling providers
slide30
The tension-practice-consequence model

Tensions inherent in delivering recovery-oriented services in in-patient context

slide31

Tensions

Personal level tensions

1. Psychotic symptom

2. Behavioral problem

3. Cognitive impairment

4. Emotional distress

5. Lack of motivation

6. Refractory to treatment

7. Side effects of medications

Providers’ own tensions

1. Various recovery competencies

2. Inefficient knowledge transformation

3. Pressure, tension, frustration

4. Low motivation

5. Inadequate colleague support

6. Negative belief toward SMI

Environmental level tensions

1. Poor physical environment

2. Inflexible routines

3. Unsafe atmosphere

4. Limited resources and support

5. Hierarchical power structure

6. Institutionalization

Medical model

Custodial framework

Risk control

Action & Practice

Limited engagement:

segregation, restriction,

constrained communication, passivity of patients

Consequences

Hopeless

Powerless

Compromised relationships

slide35

Reduce providers’ tensions

Reduce environmental level tensions

Reduce personal level tensions

Build relationship

Challenge 1. The environmental level tensions

Critical tension: Patients perceive the in-patient environment as non-humanistic, inflexible, unsafe, and lacking in stimulation.

a. non humanistic physical environment

b. inflexible ward routines

c. unsafe atmosphere

d. lack of resources

e. hierarchical power structure

f. institutionalization

slide36

Reduce providers’ tensions

Reduce environmental level tensions

Reduce personal level tensions

Build relationship

  • Engage with patients in creating an environment in which they feel safe, accepted, helped, and nurtured while also maintaining an ordered inpatient setting
slide37

Reduce providers’ tensions

Reduce environmental level tensions

Reduce personal level tensions

Build relationship

  • Competency 1: Reducing environmental tensions
  • create a warm and vital physical environment
  • create an environment in which patients’ privacy is respected
  • develop a flexible ward schedule and integrate balanced routine of self-care, productivity, and leisure activities
  • create a safe, supportive, and accepting atmosphere
  • provide initial orientation of all in-patient services to patients and families
  • involve community resources and support
  • ensure that patients have access to updated and good quality of activity resources
  • be willing to share information, knowledge, responsibility, and power with patients and significant others
  • control the environmental stimulation which is suitable for patients’ current status
slide38

Reduce providers’ tensions

Reduce environmental level tensions

Reduce personal level tensions

Build relationship

Challenge 2. The personal level tensions

Critical tension: Patients may be experiencing acute illness or other experiences of distress which prevents them from engaging in recovery planning.

a. psychotic symptoms

b. behavioral problems

c. cognitive impairment

d. emotional distress

e. lack of motivation

f. treatment-refractory illness

g. side-effects of the medications

slide39

Reduce providers’ tensions

Reduce environmental level tensions

Reduce personal level tensions

Build relationship

  • Engage patients in equipping themselves with knowledge and skills to manage their health and well-being in their preferred ways
slide40

Reduce providers’ tensions

Reduce environmental level tensions

Reduce personal level tensions

Build relationship

  • Competency 2: Reducing patients’ personal level tensions
  • integrate bio-psycho-social models of interventions through implementing evidence-based and best practices, such as psycho-pharmacotherapy, cognitive therapy, CBT, supportive therapy, reinforcement therapy, temporary controlling therapy, family psychoeducation, group therapy, activity health intervention …
  • apply motivational enhancement strategies
  • understand patients and their stages of recovery
  • provide patients with information
slide41

Reduce providers’ tensions

Reduce environmental level tensions

Reduce personal level tensions

Build relationship

Challenge 3. Providers’ own tensions

Critical tension: Providers do not demonstrate recovery attitudes, knowledge, skills, and behaviors in their daily practice.

a. various recovery competencies (belief in medical model, non recovery-oriented attitude…)

b. Inefficient knowledge transformation

c. feelings of pressure, tension, and frustration as a result of patients’ conditions, as well as apparent conflicts between human rights and some interventions

d. low motivation to change

e. inadequate colleague support

f. negative beliefs toward patients with serious mental illness

slide42

Reduce providers’ tensions

Reduce environmental level tensions

Reduce personal level tensions

Build relationship

  • Become a practitioner who believes in and is knowledgeable of recovery, and who is able to self-reflect and encourage changes
slide43

Reduce providers’ tensions

Reduce environmental level tensions

Reduce personal level tensions

Build relationship

  • Competency 3: Reducing provider level tensions
  • demonstrate recovery attitudes/beliefs
  • demonstrate a holistic understanding of recovery knowledge
  • be able to build collaborative and trustful relationships with patients and their significant others
  • practice in the role of recovery guide, coach, mentor, and facilitator
  • be able to self-reflect
  • use understandable, respectful, and empowering verbal and body language
  • advocate recovery within the impatient teams
  • be able to resolve conflicts or issues raised in recovery-oriented services, and facilitate interdisciplinary communication
  • convey attitude of active respect and dignity for patients’ rights and freedoms in all environments
slide44

Engage patients in setting goals and planning

Provide choices and individualized services

Challenge 4. Setting goals and planning and providing individually tailored services

Critical tension: Intervention and decision making are based on the medical model. Patients are not empowered to take responsibility.

a. stakeholders’ goals are different or don’t support recovery

b. patients insist on goals that appear unrealistic /unfeasible

c. patients depend on hospital care and don’t appear to move forward

d. time challenge 1- patients’ high turnovers. Acute inpatients do not have enough time to implement recovery planning

e. time challenge 2- practitioners’ time constraints. Practitioners do not have enough time to offer time-consuming services or cannot satisfy different patients’ needs at the same time

slide45

Engage patients in setting goals and planning

Provide choices and individualized services

  • Engage patients as collaborators in setting their own goals and planning, and help them work toward these goals
slide46

Engage patients in setting goals and planning

Provide choices and individualized services

  • Competency 4: Setting goals and planning with patients and providing individually tailored services
  • demonstrate a holistic understanding of patients by assessing people and their context objectively
  • interpret perceived deficits within a strengths and resiliencies framework
  • be able to effectively communicate to patients and significant others
  • incorporate stakeholders’ goals and involve them in decision making
  • educate significant others and involve them in interventions and approaches
  • help patients reframe situations and plan concrete next steps, along with specific timelines
  • set individual recovery outcome indicators
  • prioritize patients’ goals and needs
  • develop and lead groups which are organized to meet individualized goals for each patient
slide47

Engage patients in setting goals and planning

Provide choices and individualized services

Challenge 5. Provide choices based on individual needs

Critical tension: It is difficult to address different patients’ needs in a restricted environment.

a. tensions exist between patients’ needs/rights/choices and the structure of the units

b. patients’ decisions may lead to harmful/negative outcomes

slide48

Engage patients in setting goals and planning

Provide choices and individualized services

  • Address the unique needs of patients and find the balance between respecting patients’ choices and maintaining ward structure through negotiation of positive risk taking
slide49

Engage patients in setting goals and planning

Provide choices and individualized services

  • Competency 5: Engaging patients in decision making and satisfy their needs
  • demonstrate an understanding of patients’ experiences and be able to negotiate the dilemmas between patients’ choices and the ward structure
  • promote safety and positive risk taking
  • help people articulate their needs and voices
  • provide a wide range of options, activities, and education according to patients’ needs and current stages of recovery
  • encourage patients to make choices and help them through the decision-making process
  • engage patients at their own pace
  • support patients’ interim setbacks after they choose to take risks
slide50

Challenge 6. Foster a positive recovery cycle

Critical tension: patients can be in a negative cycle of hopelessness, powerlessness, vulnerability, and repeated relapse.

a. patients can be extremely fragile/have extremely low self-esteem

hope

Advocacy

Empower-ment

network

skills

readiness

slide51

Foster the positive cycle of hope, empowerment, meaningful life, and personal growth

hope

Advocacy

Empower-ment

network

skills

readiness

slide52

Competency 6: Fostering a positive recovery cycle -- know best practice of recovery

  • Hope instillation:
    • help patients and people around them develop or restore hope
    • convey to patients an understanding of the context of the illness
    • help patients find meaning in their life
    • help patients achieve successful experiences
    • provide spiritual care
  • Empowerment:
    • know and apply strategies to empower patients
    • help patients build confidence and positive self-identity
    • encourage patients to make meaningful contributions to their own recovery

hope

Advocacy

Empower-ment

network

skills

readiness

slide53

Competency 6: Fostering a positive recovery cycle -- know best practice of recovery

  • Strengths and skills building: enable patients to find their strengths, learn illness/crisis/behavioral management and prevention skills, coping skills, living skills, social skills ...
  • Network building:
    • help patients build and maintain more connections, relationships, and resources
    • connect with the community
  • Readiness in recovery: prepare patients to be ready for their next steps of the recovery processes

hope

Advocacy

Empower-ment

network

skills

readiness

slide54

Challenge 7. Promoting recovery and advocacy

Critical tension: Existing stigmas prevent patients from moving forward.

a. patients’ internalized stigma

b. social stigma

hope

Advocacy

Empower-ment

network

skills

readiness

slide55

Take a proactive role in diminishing stigma and promoting recovery in the community

hope

Advocacy

Empower-ment

network

skills

readiness

slide56

Competency 7: Promoting recovery and advocacy

  • help patients self-advocate and know their rights
  • involve peer-provided services in in-patient settings
  • facilitate patients’ access to self-help groups
  • take a proactive role in reducing stigma, for example, participating in public education

hope

Advocacy

Empower-ment

network

skills

readiness

slide57

Ensure continuity of recovery process

Challenge 8. Provide transitional services

Critical tension: Moving from the in-patient to community environment can be a complex transition. In-patients may not have access to supports to connect them to resources and opportunities in the community. .

a. insufficient resources and ongoing support in the community

slide58

Ensure continuity of recovery process

  • Connect patients and significant others to community services and resources they need
slide59

Ensure continuity of recovery process

  • Competency 8: Ensuring continuity of care
  • connect patients to their most significant healing relationships and supports
  • anticipate potential problems/issues in making community connections and strategize supports accordingly
  • help people solve the problems with their transition planning – finance, housing, relationships, resources …
  • integrate community resources and connect to patients and significant others
  • strengthen partnership with local community services and help patients with transitional processes (referral or follow-up)
the recovery competency framework62
The Recovery Competency Framework
  • This competency framework has a unique contribution to address specific needs of in-patient providers.
      • Some unique differences based on the in-patient context are highlighted specifically in this competency framework.
      • The in-patient setting features more environmental restrictions than other mental health services settings.
      • In-patient provider competencies incorporate specific considerations of environmental design.
limits
Limits
  • Data collection limited to tertiary mental health hospitals
  • Competencies would not address all issues related to recovery-oriented practices, such as resource issues and management issues
implications for practice
Implications for practice
      • Could serve as a tool for assessing and implementing mental health workforce training
  • Could be developed as professional practice guidelines
      • Increase in-patient mental health providers’ competencies in practicing recovery-oriented services.
      • Promote the movement toward recovery.
next study
Next study
  • Phase Two: Program Development
    • Construct and validate a recovery educational program for in-patient mental health providers
  • Phase Three: Program Evaluation
    • Test the effectiveness of the educational program
slide66
Thank you!

&

Questions….