Tag: care planning

COCAPP-A main findings paper

COCAPP-ACOCAPP-A, funded by the NIHR Health Services and Delivery Research Programme, investigated care planning and coordination in inpatient mental health services. It was led by Alan Simpson, and I was mighty pleased to have been part of the research team. The full, 270 page, report appeared in 2017. Now, a derived paper reporting main findings has appeared in the journal BMC Psychiatry. Lead authored by Michael Coffey this article amounts to a more modest 18 pages, which means it stands a chance of actually being read by people able to make use of it.

As a gold open access article the paper is free to download to anyone with an internet connection. As a taster, here’s the abstract:

Background: Involving mental health service users in planning and reviewing their care can help personalised care focused on recovery, with the aim of developing goals specific to the individual and designed to maximise achievements and social integration. We aimed to ascertain the views of service users, carers and staff in acute inpatient wards on factors that facilitated or acted as barriers to collaborative, recovery-focused care.
Methods: A cross-national comparative mixed-methods study involving 19 mental health wards in six service provider sites in England and Wales. This included a survey using established standardised measures of service users (n = 301) and staff (n = 290) and embedded case studies involving interviews with staff, service users and carers (n = 76). Quantitative and qualitative data were analysed within and across sites using descriptive and inferential statistics, and framework method.
Results: For service users, when recovery-oriented focus was high, the quality of care was rated highly, as was the quality of therapeutic relationships. For staff, there was a moderate correlation between recovery orientation and quality of therapeutic relationships, with considerable variability. Staff members rated the quality of therapeutic relationships higher than service users did. Staff accounts of routine collaboration contrasted with a more mixed picture in service user accounts. Definitions and understandings of recovery varied, as did views of hospital care in promoting recovery. Managing risk was a central issue for staff, and service users were aware of measures taken to keep them safe, although their involvement in discussions was less apparent.
Conclusions: There is positive practice within acute inpatient wards, with evidence of commitment to safe, respectful, compassionate care. Recovery ideas were evident but there remained ambivalence on their relevance to inpatient care. Service users were aware of efforts taken to keep them safe, but despite measures described by staff, they did not feel routinely involved in care planning or risk management decisions. Research on increasing therapeutic contact time, shared decision making in risk assessment and using recovery focused tools could further promote personalised and recovery-focused care planning.

Meta-narrative review

PLoSOneAs promised, here’s a post about a new paper from COCAPP, published last month in gold open access form in the journal PLOS ONE. Led by Aled Jones, this reports on our meta-narrative review of research into care planning and coordination in community mental health care. Meta-narrative reviews are a relatively new approach to literature reviewing, and aim to track the (potentially diverse) traditions of research found in a given field. Guidance on their production can be found here.

For those interested, here’s this new article’s abstract:

Context

In response to political and social factors over the last sixty years mental health systems internationally have endeavoured to transfer the delivery of care from hospitals into community settings. As a result, there has been increased emphasis on the need for better quality care planning and care coordination between hospital services, community services and patients and their informal carers. The aim of this systematic review of international research is to explore which interventions have proved more or less effective in promoting personalized, recovery oriented care planning and coordination for community mental health service users.

Methods

A systematic meta-narrative review of research from 1990 to the present was undertaken. From an initial return of 3940 papers a total of 50 research articles fulfilled the inclusion criteria, including research from the UK, Australia and the USA.

Findings

Three research traditions are identified consisting of (a) research that evaluates the effects of government policies on the organization, management and delivery of services; (b) evaluations of attempts to improve organizational and service delivery efficiency; (c) service-users and carers experiences of community mental health care coordination and planning and their involvement in research. The review found no seminal papers in terms of high citation rates, or papers that were consistently cited over time. The traditions of research in this topic area have formed reactively in response to frequent and often unpredictable policy changes, rather than proactively as a result of intrinsic academic or intellectual activity. This may explain the absence of seminal literature within the subject field. As a result, the research tradition within this specific area of mental health service delivery has a relatively short history, with no one dominant researcher or researchers, tradition or seminal studies amongst or across the three traditions identified.

Conclusions

The research findings reviewed suggests a gap has existed internationally over several decades between policy aspirations and service level interventions aimed at improving personalised care planning and coordination and the realities of everyday practices and experiences of service users and carers. Substantial barriers to involvement are created through poor information exchange and insufficient opportunities for care negotiation.

It’s taken far longer than it should have done to get this paper into print. PLOS ONE’s peer review and editorial processes moved at glacial pace, and we’ve agreed as a team not to submit to this journal again. As it happens, this week another COCAPP paper completed its journey through peer review, and has been accepted for publication in the  International Journal of Integrated Care. This has been a much better managed publishing experience, and once this article – which reports on what care coordinators do when they coordinate care – appears online I’ll post something here about it.

COCAPP-A full report published

COCAPP-A front pageThe full and final report from COCAPP-A has been published, and can be downloaded here. Led by Alan Simpson, this cross-national comparative case study investigated inpatient mental health care planning and coordination and their relationships to recovery and personalised care in six NHS organisations in England and Wales. COCAPP-A is the partner project to COCAPP, which asked similar questions about community mental health care in the same six sites.

The full COCAPP-A report is a substantial document, but also comes with summaries. Here’s the plain English one to give people a flavour:

Care planning processes in mental health wards should be personalised, conducted in collaboration with service users and focused on recovery.

We conducted a study on 19 wards in six NHS mental health hospitals in England and Wales. Over 330 service users, 320 staff and some carers completed questionnaires and took part in interviews. We also reviewed care plans and care review meetings.

We aimed to identify factors that helped staff in, or prevented staff from, providing care that was discussed with service users and that supported recovery.

When the ward seemed more recovery focused, service users rated the quality of care and the quality of therapeutic relationships highly. Staff rated the quality of relationships with service users better than did service users.

Staff spoke of the importance of involving service users in care planning, but from both interviews and care plan reviews it appeared that, often, this did not happen. Staff were trying to work with people to help their recovery, but they were sometimes unsure how to achieve this when service users were very distressed or had been detained under the law. Service users and carers often said that care was good and provided in an individualised way. Keeping people safe was important to staff, and service users were aware of measures taken to keep them safe, although these were not always discussed with them.

Our results suggest that there is widespread commitment to safe, respectful, compassionate care. The results also support the need for research to investigate how staff can increase their time with service users and carers, and how they can involve people more in discussions about their own care and safety.

There’s plenty of work ahead with journal articles to be produced, derived from the larger document. As the COCAPP and COCAPP-A teams now have community and hospital data relating to the same organisations we also have the opportunity to draw conclusions from both studies. This work has already commenced: Michael Coffey and Sally Barlow have taken a paper titled, ‘Barriers to, and facilitators of, recovery-focused care planning and coordination in UK mental health services: findings from COCAPP and COCAPPA’ to this year’s #MHNR2017, Refocus on Recovery and ENMESH conferences.

Out with the old

Happy new year. In one of my earliest posts on this blog I wrote of coming across a fallen tree. Over the months and years following this became something of a local landmark for those of us fond of making the trip over Craig yr Allt by foot. The tree was removed sometime last autumn, with tyre tracks telling a tale. I’ll add its disappearance to the long list of last year’s losses, included on which are Carrie Fisher, George Michael and the security of Britain remaining in the EU.

2016-10-28-08-40-23

If 2016 had more than its fair share of trampling, and like the track up Craig yr Allt bowed out with its topsoil removed, perhaps this year will be different. Or maybe not. Anyway…

As 2017 gets underway I’ve opened my term of office as Vice Chair of Mental Health Nurse Academics UK with a fruitful conversation with Steven Pryjmachuk, the group’s Chair for this year and next. Ideas for refreshing the MHNAUK website, and our March meeting at the University of Hertfordshire, were amongst things on the agenda. We’ll have lots to talk about; as I observed in my last post, a number of important things are afoot with likely changes to the education of nurses and the beginnings of plans being laid for the next research excellence framework.

Elsewhere, the forthcoming care planning and care coordination themed issue of the Journal of Psychiatric and Mental Health Nursing which Michael Coffey, Alan Simpson and I are guest editing is taking shape nicely. We have some super articles lined up, and will be writing editorials in the near future.

Later in the year, in September, the newly renamed International Mental Health Nursing Research Conference (the NPNR, as was) meets in Cardiff. I’ll be off to a conference planning meeting in London in a week’s time where we’ll be talking about a theme for #MHNR2017 and possible keynote speakers. I’ll perhaps blog something about that when we’re done.

marie-et-al-2017On the publications front, Mohammad Marie has lead authored (with Aled Jones and me in support) this latest paper. It’s all about the challenges faced by Palestinian community mental health nurses, and represents the fourth article emerging from Mohammad’s PhD thesis in something like 18 months. That’s good going indeed. Here’s the abstract:

Background:
Nurses in Palestine (occupied Palestinian territory) work in a significantly challenging environment. The mental health care system is underdeveloped and under-resourced. For example, the total number of nurses who work in community mental health centres in the West Bank is seventeen, clearly insufficient in a total population of approximately three million. This research explored daily challenges that Palestinian community mental health nurses (CMHNs) face within and outside their demanding workplaces.
Methods:
An interpretive qualitative design was chosen. Face-to-face interviews were completed with fifteen participants. Thirty-two hours of observations of the day-to-day working environment and workplace routines were conducted in two communities’ mental health centres. Written documents relating to practical job-related policies were also collected from various workplaces. Thematic analysis was used across all data sources resulting in four main themes, which describe the challenges faced by CMHNs.
Results and conclusion:
These themes consist of the context of unrest, stigma, lack of resources, and organisational or mental health system challenges. The study concludes with a better understanding of challenges in nursing which draws on wider cultural contexts and resilience. The outcomes from this study can be used to decrease the challenges for health professionals and enhance the mental health care system in Palestine.

 

COCAPP main findings

In a post last week I drew attention to a recent run of publications, promising to write a single post for each as it appears. Yesterday saw the appearance of Recovery-focused care planning and coordination in England and Wales: a cross-national mixed methods comparative case study. This is the main findings paper from COCAPP, published in BMC Psychiatry. Here’s the abstract, for readers wanting a taster:

Background: In the UK, concerns about safety and fragmented community mental health care led to the development of the care programme approach in England and care and treatment planning in Wales. These systems require service users to have a care coordinator, written care plan and regular reviews of their care. Processes are required to be collaborative, recovery-focused and personalised but have rarely been researched. We aimed to obtain the views and experiences of stakeholders involved in community mental health care and identify factors that facilitate or act as barriers to personalised, collaborative, recovery-focused care.

Methods: We conducted a cross-national comparative study employing a concurrent transformative mixed-methods approach with embedded case studies across six service provider sites in England and Wales. The study included a survey of views on recovery, empowerment and therapeutic relationships in service users (n = 448) and recovery in care coordinators (n = 201); embedded case studies involving interviews with service providers, service users and carers (n = 117) and a review of care plans (n = 33). Quantitative and qualitative data were analysed within and across sites using inferential statistics, correlations and framework method.

Results: Significant differences were found across sites for scores on therapeutic relationships. Variation within sites and participant groups was reported in experiences of care planning and understandings of recovery and personalisation. Care plans were described as administratively burdensome and were rarely consulted. Carers reported varying levels of involvement. Risk assessments were central to clinical concerns but were rarely discussed with service users. Service users valued therapeutic relationships with care coordinators and others, and saw these as central to recovery.

Conclusions: Administrative elements of care coordination reduce opportunities for recovery-focused and personalised work. There were few common understandings of recovery which may limit shared goals. Conversations on risk appeared to be neglected and assessments kept from service users. A reluctance to engage in dialogue about risk management may work against opportunities for positive risk-taking as part of recovery-focused work. Research to investigate innovative approaches to maximise staff contact time with service users and carers, shared decision-making in risk assessments, and training designed to enable personalised, recovery focused care coordination is indicated.

People may be interested to learn that COCAPP will also be the subject of a Mental Elf blog and podcast in a week or so’s time:

And, for those wanting the fine-grained detail, there is always our main report to the National Institute for Health Research (NIHR) Health Services and Delivery Research (HS&DR) Programme.


Bus blogging

Time, just about, to use a bus journey across Cardiff en route to the University Hospital of Wales site (for the purposes of teaching) to post an update on recent activities.

There’s lots to say. Projects I’ve blogged about on this site (COCAPP, COCAPP-A, Plan4Recovery) are now being written up. Our main findings paper from COCAPP appears imminently in BMC Psychiatry. Alan Simpson, as lead author, completed checking the proofs of this in the last few days so we know it’s on its way. Michael Coffey has lead authored a COCAPP paper addressing risk; earlier this week this was accepted for publication in Health Expectations. Further papers will follow, as they will in the future from COCAPP-A. I’ll make a point of posting about each as they appear. Plan4Recovery has been about shared decision-making and social approaches to care, and here, too, work on a first publication is well underway. 

Meanwhile, Therapeutic skills for mental health nurses edited by Nicola Evans and me has just been published by Open University Press. This is a fine text indeed (though I say so myself), which we hope proves particular useful to students.

A big highlight of the last few weeks has been the award of a doctorate to my colleague and (now former) student Pauline Tang. Pauline used qualitative methods to investigate the use of electronic patient records in a medical assessment unit, and you can read her thesis here. And talking of doctorates: Mohammad Marie, writing with Aled Jones and me, has a second paper from his study of resilience in Palestinian community mental health nurses about to appear: this one in the International Journal of Mental Health Nursing

Right! I’m off the bus and walking to a classroom. Time to fly, and to remind myself that it is perhaps better to post more frequently than to cram so much into a single, short, piece like this. 

COCAPP findings published

This morning saw the publication of the full and final report from COCAPP. COCAPP has been led by Professor Alan Simpson from City University London, and (as readers of this blog will know) has been concerned with care planning and coordination in community mental health, and the relationships between these processes and recovery-oriented and personalised care.

Today’s report appears in a single issue of the NIHR’s Health Services and Delivery Research journal. Following the link above takes you to a page from which the complete, 218-page, document can be downloaded. For a shorter read, follow the links instead to either the scientific or the plain English summaries.

Over on the COCAPP blog site, meanwhile, Alan Simpson and Alison Faulkner have written this accessible summary:

Who carried out the research?

The research was carried out by a team of researchers from three universities: City University London in England, and Cardiff and Swansea Universities in Wales. The team was led by Professor Alan Simpson at City University.

Service user and carer involvement:

Of the 13 researchers working directly on the study, six were involved in part time roles as service user researchers: one as co-applicant and the others to interview service users and carers. In addition, there was an advisory group of people with lived experience.

Who funded the research?

The National Institute for Health Research (NIHR) Health Services and Delivery Research Programme (HS&DR 11/2004/12). This is a Government research funding body.

Why did we do the research?

Although there are two different systems in England and Wales, both mean that people receiving mental health services should have a care coordinator, a written care plan and regular reviews of their care. With the introduction of the recovery approach and personalisation, it is now expected that care planning and coordination should be recovery-focused and that people will be taking more control over their own support and treatment.

What were the aims of the research?

We wanted to find out what helps and what hinders care planning for people with mental health problems to be collaborative, personalised and recovery-focused.

By collaborative we mean that care planning is completed in partnership with the service user: the care coordinator works with the service user to plan their care.

By personalised we mean that care is designed with the full involvement of the service user and designed to meet their individual needs.

By recovery, we mean ‘a personal journey … one that may involve developing hope, a secure base and supportive relationships, being more in control of your life and care, social inclusion, how you develop coping skills, and self-management … often despite still having symptoms of mental illness.’

Where was the research carried out?

The research was carried out in six NHS mental health service provider organisations: four in England and two in Wales. One of the reasons for carrying out the research in both England and Wales is that Wales has a legal framework in place called the Mental Health Measure, introduced in 2010. This is intended to ensure that where mental health services are delivered, they focus more appropriately on people’s individual needs. In England, care planning is informed by guidance and is not legally required.

What did we do?

The focus of our research was on community mental health care. We wanted to find out the views and experiences of all of the different people involved: care coordinators (in community mental health teams), managers, senior practitioners, service users and their carers.

  1. We carried out an extensive literature review.
  2. We sent out questionnaires to large numbers of people, and received replies from service users (449) and care coordinators (205); these included questions on recovery, therapeutic relationships, and empowerment.
  3. We interviewed senior managers (12) and senior practitioners (27), care coordinators (28), service users (33) and carers (17).
  4. We reviewed 33 care plans with the permission of the service users concerned.

What did we find?

Summary of the survey findings:

  • There were no major differences between the six sites on the empowerment or recovery scores on the service user questionnaires;
  • There were some significant differences between the sites on therapeutic relationships: where there was good collaboration and input from clinicians, relationships were rated as more therapeutic;
  • We also found significant differences between sites on some recovery scores for the care coordinators: where they saw a greater range of treatment options, the service was rated as more recovery-focused;
  • We found a strong positive correlation between scores on the recovery scale and the therapeutic relationship scale for service users; this suggests that organisations perceived to be more recovery-focused were also perceived as having more therapeutic relationships.

First COCAPP publication

COCAPP BMC protocol

Here’s a brief post to flag this week’s appearance of a first published paper from COCAPP. This is the study protocol, and can be found in BMC Psychiatry. Clicking the image above will take you directly to the gold open access PDF of the article.

Protocol publishing is a fairly new phenomenon. It encourages transparency, and in the case of health intervention studies is a way of meeting the registration and reporting standards which organisations like AllTrials are campaigning for. COCAPP has not been an intervention study, but publishing the protocol is still valuable for the purposes of openness. When findings are published at a later point, readers can also be given the briefest of summaries of the methods used coupled with a reference to the protocol paper for the full detail.

COCAPP gets a blog

Time only this morning for a super-speedy post to draw readers’ attention to COCAPP’s new blog. COCAPP is funded by the NIHR Health Services and Delivery Research Programme, and is a cross-national study of care planning and care coordination in community mental health. I’ve written about COCAPP on my blog before, but now recommend interested people get over to the project’s dedicated site to meet the team and to find out the detail of what it’s all about.