7 Objective 4: Support practice development
7.1 The SRN's final objective is to support practice development within mental health services. It has done this primarily through the development and wide-scale roll-out of the Scottish Recovery Indicator ( SRI) and training materials for mental health professionals.
Scottish Recovery Indicator
7.2 The SRI is described on the SRN website as "a mental health service development tool." It is a tool that is intended to help organisations evaluate, for themselves, whether and how they have adopted recovery-oriented practices. It is based on the Recovery Oriented Practices Index ( ROPI), which was developed in the United States, and adapted for use in Scotland as a result of a need identified in Rights, Relationships and Recovery, and the subsequent commitment made by the (then) Scottish Executive in Delivering for Mental Health (Commitment 1). 21 This commitment was reiterated and extended in Towards a Mentally Flourishing Scotland (Commitment 22) which states that the tool should be in use by the majority of mental health services by 2010.
7.3 The use of the SRI involves an assessment of 19 indicators which are focused around factors known to promote recovery. 22 The assessment involves interviews with staff and service users and an analysis of client case files. SRI documentation recommends that the tool be applied to 10 cases. The main output from administering the tool is an action plan focused on areas where change may be needed to make the service more recovery-focused. The SRN has promoted the SRI as a tool which enables services to reflect on their practice, rather than as an audit tool.
7.4 The SRN has developed a web-based interface to the SRI, and through this is able to monitor the use of the tool. The Network has also developed guidance on using the tool and has delivered an extensive programme of workshops to promote the SRI to local services and to deliver training in its use.
7.5 The SRI was piloted in five health board areas between September 2007 and April 2008, and the pilots were evaluated. 23 The SRI was subsequently revised in light of the findings of the evaluation, and the SRN is currently working with NHS Education for Scotland to develop regional learning networks and new research to assess the impact of the tool.
7.6 According to a report to the SRN's strategy group, as of June 2010, there were more than 850 registered users of the SRI. A report to the Scottish Government for the period September 2009 - April 2010 states that there were registered users in every health board in Scotland. In this same six month period, 16 workshops were delivered to 391 participants.
Effectiveness and impact
7.7 The evaluation of the pilot implementation of the SRI found that:
- The SRI had good potential for influencing service culture and service change towards more of a recovery orientation. Furthermore, service providers felt that the level of detail in the tool made it possible to identify good practice and areas for improvement.
- However, during the period of the evaluation, none of the pilot areas had produced a formal action plan for change.
- Some barriers to greater effectiveness of the tool were seen to be that it was quite time-consuming to complete, and that there had been a general lack of involvement and support for the SRI process from psychiatrists in the pilot areas.
- A series of recommendations were made in relation to further development and roll-out of the SRI. Most of these recommendations had the aim of improving the process of administering the SRI, preparing staff in advance of the process and planning for action following administration of the SRI.
7.8 The administration of the tool was reported to have had some positive impacts in each of the pilot sites. These included:
- The development of strengths-based care documentation and procedures
- Finding ways for service users to have greater input to service development
- Addressing the issue of employment for people with mental health needs
- A greater enthusiasm and passion for recovery within teams.
7.9 The administration of the tool was also reported to have created a sense among service users that they were at the centre of a service change process - that is, services were changing to help them move forward in their recovery.
Developing learning materials for professionals
7.10 The SRN, together with NHS Education for Scotland ( NES), has played a major role in developing a national framework for training in recovery-based practice.
7.11 There are two parts to this activity. The first involved the development of the Realising Recovery learning materials for NHS mental health nurses. The Realising Recovery materials are intended to build on a set of learning materials previously developed by NES called the 10 Essential Shared Capabilities (or 10 ESCs). The second part of this activity involved the development of a two-day training session for workers in the voluntary sector, called Recovery in Practice. Both these activities are described here.
10 ESCs and Realising Recovery Learning materials
7.12 In 2007, NHS Education for Scotland ( NES) developed the 10 Essential Shared Capabilities for Mental Health Practice learning materials (Scotland). 24 The materials were based on an existing resource originally developed in England, which NES adapted for a Scottish context following consultation with service users, carers and mental health workers. The 10 ESCs are described by NES as the foundation upon which good mental health practice is based.
10 Essential Shared Capabilities
1. Working in partnership
2. Respecting diversity
3. Practising ethically
4. Challenging inequality
5. Promoting recovery
6. Identifying people's needs and strengths
7. Providing service user centred care
8. Making a difference
9. Promoting safety and positive risk taking
10. Personal development
7.13 The Realising Recovery learning materials were developed by NES working together with the SRN. The Realising Recovery materials build on the 10 ESCs learning materials and address in more detail ESC 5 - Promoting Recovery. The materials contain six modules, and incorporate findings and extensive material from the SRN's Narrative Research project . Moreover, the Director of the SRN was a member of the editorial group, and was involved in writing one of the modules - so the SRN was directly involved in the development of these learning materials.
7.14 The aim of the Realising Recovery learning materials is:
- To enable mental health professionals to makes changes in their practice
- To support change by presenting key topic areas in relation to recovery and practical guidance to help workers develop new roles, relationships and ways of working with service users and wider communities.
7.15 Because the Realising Recovery materials build on the 10 ESCs materials, their use is intended to follow 10 ESCs training. Both the 10 ESCs learning materials and the Realising Recovery learning materials have been disseminated widely by NES to NHS staff (mainly mental health nurses) through a phased training programme. This has involved training individuals in each NHS Board to deliver the training at a local level.
7.16 Between February 2008 - January 2010, a national longitudinal evaluation, commissioned by NES, was undertaken of the impact of these resources. 25
7.17 The evaluation found that:
- Sixty-eight individuals (most from a nursing background) were trained as trainers. Attrition of trainers was low during the period of the evaluation.
- By the end of 2009, nearly all NHS Boards had taken forward 10 ESCs training, but only a few had taken forward Realising Recovery training. It was suggested that this may be because of the different status and priority seen to be given to the two forms of training in national policy documents.
- However, across Scotland, less than a quarter of the MH nursing staff (about 2,000 people) had received 10 ESCs training by autumn 2009.
Effectiveness and impact
7.18 In relation to the effectiveness and impact of the training:
- The training was found to have raised awareness among mental health workers of a range of issues relating to values in mental health practice. Some individuals reported that the training helped them to recognise where there was a need to develop / change aspects of their practice.
- The majority of trainees reported that the training had a positive impact on their individual practice, for example, through improvements in service user involvement; care planning based on users' own perceived needs and strengths; and development of positive risk-taking.
- For some people, the impact of the training was to reaffirm a perception that their practice already incorporated recovery-oriented values. However, these types of positive self-assessment were sometimes questioned by other survey respondents (and by some trainers and service managers).
Recovery in Practice training
7.19 In addition to these training materials, SRN commissioned two voluntary sector agencies (Health in Mind and Penumbra) to develop and deliver a two-day training programme called Recovery in Practice for people working in the voluntary sector.
7.20 This was intended as a small pilot, and therefore the question of 'reach' was not relevant to this particular training. An independent evaluation was commissioned to assess the effectiveness of the training. 26 This found that the training strengthened recovery values and beliefs in many of its participants. In addition, there was evidence to suggest that in its current form the training was more appropriate to those working directly with people with mental health problems, rather than service managers.