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

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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

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

Introduction

Background – three levels

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

Restrictions
Unpredictability
Control

maintaining stabilization by means of rules and routines

Medical model

symptom reduction
problem-oriented interventions

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

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 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

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

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

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

Generic

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

Problem Statement (Cont.)

No recovery competency frameworks addressed the competencies specifically for in-patient providers has been developed.

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

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

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

Methods

Study design

Phase One:

The Development of

Recovery Competency Framework

Qualitative research design

-- Literature review -- Key informant interviews

Develop a recovery competency framework

for in-patient providers

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

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.

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 Two: Data converging and analysis

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

Findings

The participant profile

The tension-practice-consequence model

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

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

The recovery enabling framework for in-patient providers

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

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

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

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

Build relationship

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

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

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

Build relationship

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

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

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

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

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

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

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

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

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

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

hope

Advocacy

Empower-ment

network

skills

readiness

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

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

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

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

hope

Advocacy

Empower-ment

network

skills

readiness

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

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

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

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)

Discussion

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

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