- Oriented Care for Older People:
Staff Attitudes and Practices
Specialist Mental Health Service for Older People
Royal Prince Alfred Hospital
Koder D (2018) Recovery - Oriented Care for Older People:
and Practices. International
Journal of Psychosocial Rehabilitation. Vol 22 (2) 46-54
Dr Deborah Koder
Specialist Mental Health Service for Older People
Level 7 King George V Building
Royal Prince Alfred Hospital
Camperdown NSW 2043.
There is a push to change the focus of mental
health delivery from symptom reduction to recovery orientation where
self-determination and choice are central to programmes. Whilst there is a
robust literature on recovery definition, assessment and training, this has not
been matched with studies of recovery with older adult consumers or staff
working in older adult settings. The purpose of this sequential explanatory
study was to identify the recovery attitudes and practices of the staff from
the Sydney Local Health District Specialist Mental Health Service for Older
People (SMHSOP), Australia. Fourteen members of staff completed two self-report
recovery measures and subsequently took part in focus group interviews. Results
of this mixed methods study suggested that whilst mental health staff in this
sample supported the self-definition and individuality aspects within the
recovery model, risk management remains problematic with this population.
Clinical experience mediated the extent of knowledge and practices within a
recovery framework. Barriers to implementing recovery oriented practice
included client incapacity and the expectation of consumers. The suitability of
current recovery concepts and measures to older populations is discussed.
KEY WORDS: recovery, older adults, staff attitudes, mental health
Recovery has become the
guiding principle of public mental health care delivery, in recognition of the
lived experience and needs of consumers (Commonwealth of Australia, 2013; Tse
& Barnett, 2009). The focus of care has shifted from the clinical treatment
model in which mental illness symptoms had to be treated or cured to one of
collaborative care with self-determination, power, meaning and hope as its key
features (McKenna, Furness, Dhital et al, 2014). One definition of personal
recovery is “being able to create and live a meaningful and contributing life
in a community of choice with or without the presence of mental health issues”
(Commonwealth of Australia, 2013, p. 25). Australia’s Fourth
National Mental Health Plan has determined that recovery oriented principles be
a priority (Burgess, Pirkis, Coombs et al, 2011). However, the concept of
recovery is a complex one that can be challenging to implement. This can be
seen as a barrier to adopting recovery practices in health care.
A large body of
literature exists on recovery approaches to care in adults, including evaluation
of recovery programs for consumers. A study of United States veterans and
clinicians highlighted positive endorsement of recovery oriented practice, with
the study design enabling quantitative comparison of recovery orientation
amongst different programs for veterans (Leddy-Stacy, Stefanovics &
Rosenheck, 2016). Key concepts promoting recovery oriented care such as
knowledge about recovery in mental health professionals have also been
identified (Wilrycz, Croon, van den Broek et al, 2012; Bedregal,
O’Connell & Davison, 2006). Qualitative studies of recovery have echoed the
importance of knowledge of recovery relating to recovery oriented practice
(Piat & Lai, 2012). Other themes related to recovery emerging from
qualitative analysis methodology such as clinician focus groups, include
positive views of the future and supporting individual goals, as opposed to
clinician led disease focused plans (Dalum, Pedersen, Cunningham et al, 2015).
A common feature from studies examining recovery orientation, regardless of
methodological approach, is the need for a consistent definition of recovery
with examples of how to support recovery reform (Happell, Byrne &
Platania-Phung, 2015; Piat & Lal, 2012).
Recovery and older
projections of increased demand for mental health services in older adult
consumers (McKenna et al, 2014), there is very little research regarding
recovery in either clinicians working with older consumers or amongst the older
consumers themselves. Studies that have addressed recovery oriented care models
with older clients have utilized purely qualitative methodology. A Spanish
study utilizing qualitative grounded theory research methodology examined
recovery in nursing homes by interviewing care staff. However the sample size
was very small (ten), limiting generalizability. The investigators illustrate
important cultural factors positively influencing recovery oriented practice in
nursing home environments, in particular social interactions with residents
whilst delivering daily care (Saavedra, Cubero & Crawford, 2012).
A review of applying
recovery oriented principles to older adults highlighted maintaining identity
and coping with physical illness as key concepts pertaining to older adults,
following grounded theory analysis of thirty-eight interviews with consumers of
an older adult mental health service. In addition, the study found
components of recovery that relate to dementia: changing experience over time
and support (Daley, Newtown, Slade et al, 2013).
An Australian study
utilized qualitative focus group methodology to explore how recovery philosophy
was translated into everyday care in their older adult inpatient unit (McKenna
et al, 2014). This study of the views of twelve mental health nurses is of value
due to addressing the challenges of recovery with older adults. Providing hope
within the context of physical frailty and maintaining current level of daily
self-care and engagement were key recovery domains emerging from inductive data
analysis following interview coding.
To date, there is no
study of recovery with older adult consumers or staff working in older adult
settings utilizing mixed methods research methodology. This is of concern,
given the broad nature of attitudes and the lack of consensus regarding the
definition of recovery. In triangulating results, mixed method research has the
potential to explain quantitative findings regarding attitudes towards
recovery, identify barriers and illuminate recovery concepts from stakeholders’
perspectives. The projected rise in the ageing population underscores the
attention required to recovery oriented practice with older adults. Older
adults need to have a voice in their own mental health care in light of ageist
attitudes in health care. Studies have found age differentiated behaviour
amongst health care practitioners, with less emphasis on psychosocial issues in
older consumers, when compared to those under the age of 65 (Pasupathi &
The present study
The purpose of this
study was to identify the recovery attitudes and practices of the staff from
the Sydney Local Health District Specialist Mental Health Service for Older
People (SMHSOP) in Australia. The project aimed to firstly directly
quantify the attitudes, knowledge and recovery practices of community mental
health staff utilizing two scales. This was followed up by a qualitative strand
involving grounded theory analysis of focus group interviews with the staff in
order to better understand questionnaire findings. This project is the initial
step in a central change issue for mental health services: “reorienting
existing services to enable the recovery approach to be put into practice’ (Tse
& Barnett, 2009 p.96).
The central question is
asked: What are the attitudes and practices of mental health clinicians working
in older adult settings towards recovery oriented practice? What is the current
level of recovery oriented knowledge within the Specialist Mental Health
Service for Older People? How will information emerging from staff focus groups
help illuminate the barriers to implementing recovery oriented practice within
an older adult mental health setting? Are there unique aspects of recovery
specific to older adults?
A mixed methods explanatory
sequential design was performed, comprising both quantitative and qualitative
approaches. This allowed for triangulation where areas of convergence can be
identified (Bryman & Bell, 2003). The quantitative strand of the study
consisted of a cross-sectional survey. Given this is a study in
perceptions of recovery, a qualitative, inductive approach aimed to enrich
initial quantitative findings.
The measures consisted
of two standardized questionnaires that have been thoroughly researched in the
literature and found to have good validity and reliability (Hungerford, Dowling
& Doyle, 2015; Burgess et al, 2011; Campbell-Orde, Chamberlin, Carpenter et
al, 2005). Both use Likert scales with responses ranging for 1 to 5 in terms of
rating extent of agreement with the statement.
The Recovery Knowledge
Inventory (RKI) (Bedregal, O’Connell & Davidson, 2006).
This 20 item
questionnaire measures the knowledge and attitudes towards recovery within
mental health professionals. The tool can highlight areas of recovery that are
less familiar to staff, thereby directing future training in recovery oriented
Several factors have
emerged from psychometric evaluation of the tool including “Roles and
Responsibilities”, referring to consumer attitudes regarding consumer and staff
member roles in recovery, “Non-linearity of the Recovery Process”, involving
concepts and stages of symptom management, “Role of Self-determination and
Peers in Recovery”, referring to identifying beyond one’s mental illness and
including the role of peers and activities, with “Expectations Regarding
Recovery” being the final factor (Bedregal et al, 2006). Cronbach’s alpha
has been reported as at least 0.6 for these factors (Repique, Vernig, Lowe et
al, 2016). An Australian study of nurses suggested a lack of consistency
regarding the meaning of the term ‘recovery’ (Happell, Byrne &
Platania-Phung, 2015). Studies have utilized the RKI as a means of
identifying aspects of recovery that are less familiar to staff, thereby directing
future training in recovery oriented practices (Bedregal et al, 2006). Another
Australian study has validated its use both in terms of sensitivity in
evaluating training and internal validity for cultural appropriateness in
Australian mental health service contexts (Hungerford, Downing & Doyle,
The Recovery Self-Assessment (RSA-R) Provider version (O’Connell, 2007;
O’Connell, Tondora, Croog et al, 2005)
This 32 item tool
evaluates the degree of recovery oriented practices within a mental health care
setting. Five factors are contained within the original scale, namely Life
Goals (or how much staff help consumers develop and pursue individual life
goals), Consumer Involvement (or the extent to which consumers are represented
across several levels of mental health services including the development of
programs and representation on advisory boards), Diversity of Treatment Options
(the extent to which a service offers a range of therapeutic options
including peer support services and non-mental health interventions) Client
Choice ( includes facilitating access to medical records and less use of
coercion) and finally Factor 5 refers to Individually Tailored Services (or
services aligned with an individual’s culture and interests). The internal consistency
of all five factors identified in the initial study was at least 0.76 which is
considered robust (O’Connell et al, 2005). The tool is particularly attractive
in that it can also yield a recovery profile for each factor. This provides the
agency with a guide as to its strengths and weaknesses in working within a
recovery oriented framework. Several versions have been developed of this tool,
including a revised self-assessment practitioner version (item example: “staff
and agency participants are encouraged to take risks and try new things”),
including two new items corresponding to a sixth, “Inviting” factor (O’Connell,
2007). The RSA met all six criteria (for example, is manageable in terms of
administration, is acceptable to consumers, has been scientifically
scrutinized) to recommend its routine use in Australian mental health settings
(Burgess et al, 2011).
The survey also contained
demographic items indicating age range, designation and any previous training
in recovery training.
Subjects and Procedure
In order to ensure
informed consent and maximize response rate, the staff of the Specialist Mental
Health Service for Older People were informed about the study approximately one
month in advance at the beginning of the weekly clinical case review meeting.
The hardcopy paper based questionnaire was piloted for layout, timing and
readability, with two administrative officers of the SMHSOP team prior to
commencement of the study.
An information sheet
accompanied the survey, distributed just prior to the weekly case review
meeting when all team members were present. The survey was accompanied by an
envelope to be returned to the principal researcher within one week. This was
to minimize group pressure and researcher influences in responses to items on
the questionnaires and ensure anonymity.
component of the study consisted of focus group interviews. Two focus groups
were conducted separately at two separate health centers with SMHSOP staff
being a purposive sample. The team health promotion officer was a co-analyst
and transcriber of the data and its coding in order to maximize reliability and
validity (for example, addressing the potential for recall bias).
The quantitative data
collection time point was at the beginning of the study, prior to the
qualitative focus groups. This time frame was chosen in order to avoid any
measurement error or bias from material emerging from the focus groups that may
contaminate responses to the questionnaires. It is also consistent with an
explanatory sequential design with qualitative data adding to quantitative
The quantitative strand
of the mixed methods research involved descriptive statistics performed via
SPSS -21 (IBM, 2012), calculating means, standard deviations ranges and medians
as appropriate. Non parametric Spearman correlations were calculated to examine
interrelationships between variables, including the two questionaries.
Analysis of qualitative
data consisted of interview transcripts being hand coded, using open coding of
themes or categories of information (Liamputtong & Serry, 2014; Starks
& Trinidad, 2007). Themes were then developed into axial codes and further
analysed and reduced into selective codes, with the aid of NVivo software
(Gibbs, 2008). Codes were crosschecked with the health promotions officer.
informed of the anonymous nature of the study with written consent obtained.
The confidential nature of responses was again emphasized at the commencement of
each focus group. The study was approved by the Sydney Local Health District
human research ethics committee (Royal Prince Alfred Hospital Zone).
The 14 team members of
the Campderdown and Canterbury Specialist Mental Health Service for Older
People (SMHSOP) of Sydney Local Health District (SLHD) all participated in the
research. 43% of participants were female. In terms of professional
background, half the sample were nurses, with 29% being social workers and 22%
from the medical profession. 57% had reached senior professional grades (for
example, clinical nurse specialist). 36% of the sample had less than 5 years’
experience in mental health with 28.6% having over 20 years experience.
TABLE 1 Recovery
Knowledge Inventory Domain Scores
Responsibilities in Recovery
Non-Linearity of the
Self-definition and Peer Support
The highest endorsed
RKI items by sample were reported as:
-“Pursuit of hobbies
and leisure is important for recovery (M= 4.5; SD =0.52)
-“Defining who one is,
apart from their condition, is an essential component of recovery” (M= 4.5; SD
The lowest endorsed
knowledge items by sample were:
“Symptom management is
the first step towards recovery from mental health illness/substance abuse” (M=
2.79; SD =1.2).
“Not everyone is
capable of actively participating in the recovery process” (M =2.9; SD =1.39).
There were significant
intercorrelations between the Roles and Responsibilities domain score on the
RKI with Expectations Regarding Recovery sharing nearly 50% of variance
(Spearman’s Rho r = 0.691) and Non-Linearity of the Recovery Process sharing
35.5% of variance (Spearman’s Rho r = .596).
TABLE 2 Recovery Self-Assessment Sub-Scale Scores
Diversity of Treatment Options
Individually - Taylored Services
Of note was the high
number of missing values where 72% (23/32) of questions contained missing
items, most commonly rated as “not applicable”. The majority of missing items
loaded on the Life Goals (for example, “Staff routinely assist individuals in
the pursuit of educational and/or employment goals”) and Involvement factors
(for example, “People in recovery are regular members of agency advisory boards
and management meetings”).
The highest endorsed items by the sample on fully completed scales were:
“Agency staff do not use threats or bribes or other forms of coercion to
influence a person’s behaviour or choice” (M= 4.36 SD =0.84) and “Agency staff
believe people can recover and make their own treatment and life choices” (M =
4.15 SD = 0.37).
The least endorsed item
was “People in recovery have access to all their medical records” (M=2.1 SD
There were no
significant relationships between both scales and demographic items, based on
Kruskal-Wallis tests of significant. A significant negative correlation was
obtained between the Individual-Tailored Service factor on the RSA and years
worked (r= -0.71 or 50 % shared variance).
FOCUS GROUPS MAIN
Four main themes
emerged from qualitative analysis of focus groups:
1 Power/choice: Respondents referred to
ongoing issues relating to directing patient care and choices. For example:
“Its just so easy to be directive in the kind of relationship that I have with
my patients, I actually have a lot of power” (Registered Nurse); “Its being
paternalistic, but you know what’s good for them (Consultant)”; “There is an
expectation that we will come up with the answers” (Social worker).”
Risk: Respondents reported struggling with risk and that this
impeded adopting a recovery oriented approach to care. They spoke of the risk
averse culture of the service and fearing adverse events if they relinquished
control to consumers. For example: “Risk is inherent in recovery; we’re not
allowed to sit with risk” (Consultant); “Services like ours are fairly risk
averse in terms of establishing goals for clients” (clinical nurse specialist).
Language and culture: Actual definitions of recovery and how this translated
into care planning was discussed by respondents with an attitude that it was
not necessarily such a new concept in practice. For example: “I think
we’re doing it but we never called it recovery” (clinical nurse specialist);
“Just because we changed the words, does that mean we weren’t doing it in the
first place?” (Consultant).
Capacity and insight: Consumers’ ability to make decisions and set goals was an
issue discussed in focus groups in an environment where many consumers have
cognitive impairment and require substitute decision making. This issue of
capacity was defined as a practical, concrete barrier to adopting recovery
oriented care. For example, “They need help to make informed decisions around
their recovery” (Senior social worker); “Mental health acts, continued
treatment orders and other forms of involuntary care like the Guardianship Act
are needed especially with our clients because they may lack capacity”
Several other barriers
also emerged from analysis of qualitative responses related to resource
limitations, including clinician time availability, organizational expectations
of working within a medical model of symptom reduction, and client/family role
expectations of being a passive recipient of care: “The client themselves are a
barrier to recovery” (Registered Nurse).
This study aimed to examine recovery oriented knowledge
and attitudes amongst mental health professionals working in older
adult community settings. Knowledge of recovery in this sample
highlighted a similar pattern to other studies, with other age groups
also sharing the present sample’s low expectation regarding recovery
(Gaffney & Evans, 2016). The importance of self-definition beyond
one’s mental illness appears to be highly endorsed, again across age
populations with this factor having high scores in the present and
other studies utilizing the Recovery Knowledge Inventory (Repique et
al, 2016; Daley et al, 2012). The present sample indicated their
support for individually tailored services for their clients,
underscoring the heterogeneity of older populations and the importance
of collaboration with `the broader system surrounding the consumer,
distinct in older person’s mental health settings (McKenna et al,
2014). The involvement of significant others such as nursing home
staff, community support staff and family members is essential to
positive therapeutic outcomes. Of interest is the negative relationship
between clinical experience and a focus on client input and involvement
with other agencies. In contrast to other qualitative findings (Dalum
et al, 2015; McKenna et al, 2014), the present study failed to identify
hope as an element of service provision. The qualitative data in the
present results suggest an element of paternalism in attitudes towards
older consumers, a risk averse culture and continuing staff ownership
of interventions. As in other studies (Happell et al, 2015), the
concept of recovery is questioned, with staff not supporting a specific
need to change their practices in terms of recovery: “Just because we
changed the words, does that mean we weren’t doing it in the first
Examination of barriers
to utilizing a recovery focus illuminate the present findings with the
cognitive capacity of clients and current service provision models identified
as barriers to a person-centred, choice approach. Clinicians also suggested
that the expectations of clients and their families may be colluding with a
more traditional approach to mental health care with a focus on treating an
illness. The significant poor completion rate of items of the Recovery
Self-Assessment, in particular those items relating to life goals and consumer
involvement factors, is congruent with such a finding. High rates of
co-morbidity with medical conditions and dementia in older age groups further
strengthen such attitudes of dependence on health services.
Hence it appears that
there is tension between providing an individually based service promoting
self-determination, hope and choice and the practical need for substitute
decision makers on account of factors such as cognitive and physical
incapacity. The need to include the consumer’s broader system, (whilst an
important element of recovery oriented care), can also paradoxically decrease
the older consumer’s autonomy. Results from qualitative investigation into
concepts of recovery in older populations have discussed recovery components
for people with dementia, confirming the need for external support (Daley et
al, 2013). However the present study highlighted some differences in recovery
concepts relating to the needs of older adults, particularly in the area of
life goals and involvement. The large inter-correlations between factors on the
Recovery Knowledge Inventory are suggestive that its underlying constructs may
be different in older populations, based on the present study.
This may be a cohort
effect with current older populations that may shift in the future. A
decrease in the stigma of mental illness through education and the increase in
“baby boomer” consumers more comfortable with psychological issues may have
future impacts on these barriers to recovery oriented care. However the present
findings question the suitability of current recovery concepts and their
measurement with older adults. The importance of individual interest and
identity appears to be a stable concept across ages based on the present
findings. However this does not appear to extend to broader avenues for
representation such as advocacy on advisory boards. Opportunities for pursuing
employment goals or facilitating education programs may be rare in the present
clinical setting. The role of cognitive impairment and mechanisms of protection
such as Guardianship also need to be considered in the context of recovery
oriented care practices. The present study also raised the issue of risk
management: a common dilemma in recovery oriented practice implementation
(Gaffey & Evans, 2016), here possibly relating to low endorsement of hope.
The inverse relationship between individually tailored services and clinical
experience, together with the qualitative theme of power, raises issues around
paternalism and even possible burnout amongst more experienced
clinicians. Time poor clinicians faced with complex clinical
presentations may resort to making decisions on someone’s behalf.
Limitations of the
present study and future directions
This study was limited
to the staff of one mental health older adult service, restricting generalizability.
A larger sample is needed that also includes consumers. Conducting confirmatory
factor analysis can examine applicability of recovery constructs to older
populations. The poor response completion rate on the RSA also limits
interpretation of findings, as well as questioning its suitability for older
adult populations. Further factor analytic research with the RSA and a larger
cohort of both professionals and consumers of older adult mental health
services may illuminate the specific issues relating to the practice of
recovery oriented care with older adults. The present study supports the
development of a recovery oriented self-assessment tool specific to older adult
settings. This may guide guiding service provision towards hope and higher
expectations regarding recovery, whilst including important people and services
in the consumer’s environment.
Whilst older persons
mental health staff, in the present study, endorse the need for individually
tailored services and maintaining interests external to their illness, they
also have to balance this with individual and service based barriers to the
practice of recovery oriented care. This study has highlighted the unique
issues of recovery orientation with older consumers and the need for recovery
concepts that address their specific needs. Further identification of these
issues from studies with larger samples may then be translated into suitable
recovery definitions, policy and practice, thus promoting recovery oriented
care across the life span.
Acknowledgments: Special thanks to the
staff of the Specialist Mental Health Service for Older People for their
valuable assistance in this study.
Conflict of interest - None.
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