Roads to Recovery
13 December 2011 Last updated:
19 January 2015
Authors: Matthew Keelan, Celia Campanella, George Chidwick, Amanda Jay, Suzanne Garcia, Natalie Cutler
Transforming 'paper rounds' into 'care reviews' at the Sutherland Hospital Mental Health Rehabilitation Unit
A paper outlining Sutherland MHRU's Essentials of Care (EOC) activity was published in NSW Health journal Cultures That Care and on the ARCHI website in August 2011. The paper, entitled Roads to Recovery, described the development of a mural that represented the parallels between the EOC process and the pathway to recovery undertaken by mental health clients, i.e. the generation of hope, optimism and gaining a 'voice' in relation to things that affect you. Mental health clinicians, support staff and clients all contributed to the mural concept, design and/or painting. Space was left on the rocks in the painting (picture below) for clients and clinicians to add new values as they emerge. The MHRU was the first SESLHD Mental Health team to embrace EOC in early 2010, and the first team at Sutherland Hospital to complete a full cycle of EOC. This paper builds on the first publication, and outlines the MHRU team's progress through each phase of the EOC program; their successes, disappointments and reflections for the future.
16 bed sub-acute mental health rehabilitation, staffed by a multi-disciplinary team (MDT).
1. Preparation phase
In 2010, over 50% of MHRU staff voted for the introduction of EOC. The idea of establishing shared values to guide 'ways of working' was considered important to the team of this new unit (opened April 2009).
Initial external facilitation was provided by Diane Mouhanna, before Anne Grimson took over briefly. Later Natalie Cutler became the ongoing catalyst for MHRU facilitators in 2011, with facilitator support provided by Tamara Watling. More recently, Robert Silburn has become a catalyst facilitator for the MHRU EOC team. The EOC program received the full support of the Nurse Unit Manager (NUM), Terri, and Acting NUM, Callum during Terri's leave of absence. Although EOC participation was non-mandatory, it was requested that those choosing not to participate refrain from comments or actions that might hinder the EOC forum and processes.
A staff satisfaction survey was carried out in 2010 (n=18) with a repeat survey in 2011 (n=21) which raised issues regarding whether or not staff felt that their contribution to the MDT was valued. Claims and concerns activities 'gave air' to the opinions and ideas of various staff about their experience of working in the MHRU. Staff who attended EOC sessions began to appreciate the idea of 'having a say', and contributed to constructive discussions and formulating the philosophy and 'ways of working' in the unit.
The sessions also provided a space for team members to raise concerns regarding conflicting areas of practice and the impact that business rules had on client-centred care. Some began to envision a work environment where genuine, respectful collaboration might be advanced beyond current levels.
As the values of the team emerged through group discussions, the theme of collaboration was mentioned frequently. Terms such as 'participation,' 'citizenship' and 'invitation' also popped up during our sessions, and it was proposed that values discussion might capture not only staff views, but also those of consumers. After all, with an average length of stay of 3-6 months (sometimes longer), those staying on the unit were well placed to talk about values in the context of life at the MHRU, and the road through and beyond to the wider community. Given the highly individual basis of the recovery journey, the idea of 'many roads to recovery' was envisioned.
A mural was developed entitled 'Roads to Recovery.' The large canvas, painted by staff and consumers, depicts many paths crossing around a central tree (common theme for life and growth), leading to houses and an urban community beyond. The road is paved with stones, upon which are written the values of the unit: Balance, Belief, Growth, Toil, Keep Going, Value Others and Rock n Roll (amongst many others). The mural (image below) was officially unveiled in February 2012 and is located in the foyer of the MHRU.
Many bricks are left blank - with the intent that over time, more words and phrases will be added to this evolving work. The canvas is a visual metaphor for the values defined by the team and consumers, reflecting their belief that each individual (team members included) is indeed a 'work in progress.'
'Roads to Recovery' by Staff and Consumers of MHRU, 2011-12
2. Assessment Phase
The Assessment Phase required the team to reflect on their values and choose an area of practice to further examine. It was decided to focus on an area where tensions between unit values and practice had been noted during preceding discussions. Since the inception of the unit, the fortnightly Mental Health Review meeting had been held as a round-table discussion between MDT members. This review was known as the 'paper round'. The meeting was, and still is, the primary forum during which planning concerning consumers' progress through the MHRU is discussed and interventions assigned to different staff members. An additional face-to-face review of progress is held by each Consultant later each week with only the consumer, medical staff and nurses in attendance. Since the team had expressed values such as participation, inclusion, having a say and citizenship, it was clear that an important voice missing from the paper rounds was that of the consumer. It was decided that the EoC Assessment phase would focus on the paper rounds. The method of gathering data on the paper rounds was split into four areas:
- File audits
- Consumer stories
- Staff stories.
Observations were conducted by three external facilitators (Harris, Cutler & Watling) over a total of 20 sittings between July and August 2012. Themes that emerged as issues were: communication, organisation, consumer participation and individualised care planning.
Concurrent with the observation period, 20 files were audited using a tool developed by the EoC team on the MHRU. The audits sought evidence of collaboration with consumers in Care Plans, Review Sheets or progress note documentation. Evidence of carer involvement was also sought. The audit found that:
- Less than 50% of consumers (9/20) were involved in collaborative care planning
- Only 6 consumers had been consulted about their own progress and had their views recorded
As participation is a central value of the unit, consumer perspectives on their participation in care planning, and their attendance (or not) at the paper round were sought. Interviews with nine consumers were conducted by external facilitators between May and July 2012. Comments revealed consumers had mixed feelings about a number of issues. About half the consumers felt comfortable with their level of involvement in care planning and paper round attendance. Positive responses included 'having a say'. Some consumers however, reported that they felt 'a bit funny with all the people' (at the paper round), felt 'anxious' and had not been informed in advance about when the paper round would occur.
A survey to capture staff views of the paper round process received only three responses, two of which were EoC facilitators. This made the extrapolation of data and themes difficult. However, the surveys enabled the organisation of Care Reviews, and the volume of paperwork encountered by nurses and its impact on care, to be raised as issues.
3. Feedback Phase
Analysis of the data highlighted that, whilst there was an intention by staff to encourage consumers to participate and have a voice in their care planning by attending the paper round, a relatively small proportion of consumers were actively participating. While it was acknowledged that 100% participation rate may not always be achievable or appropriate, it was proposed that all consumers be invited to participate. The idea of consumers 'having a say' was reinforced as the team moved towards the action planning phase. The EoC practice domains which were identified as requiring attention as a result of the Assessment phase were: documentation and communication; clinical interventions and promoting self management. Critical discussion occurred around the language used in the paper rounds, both written and verbal, particularly from a nursing / medical viewpoint. Team members struggled with whether or not to report symptoms, particularly psychosis or risk issues, in the presence of the consumer during the paper round. Further attention was paid to these concerns during the action planning stage.
EoC Care Domain: Documentation and Communication
External observers indicated that the review meetings were lacking structure and organisation. Uncertainty about who should lead discussions at the meeting sometimes resulted in disjointed communication. The relatively large audience for each consumer was suggested as a potential barrier to consumer participation (although this was not mentioned in the consumer stories). Lack of introductions, late arrivals of staff and poor timekeeping were also noted as areas for improvement. The need for clear action plans, resulting from discussions in the meeting, was seen of central importance. Observers noted that the verbal planning that occurred during the paper round was not always reflected in written documentation. Transfer of information about who is doing what, and how that information would be shared with staff not present at the meeting, was also an issue of concern. Observations and audits found that improvements could be made by assigning tasks to different team members to carry forward for the next fortnight. This would allow for progress towards collaborative goals to be tracked. With consumer involvement, this would also support progress toward goals, as well as accountability. While consumer stories indicated that many felt involved and listened to in the paper rounds, this was not always the case. One consumer stated: 'I don't get any say on when it is (review meeting) and sometimes I'm not in the right frame of mind. I'm not really involved.'
EoC Care Domain: Clinical Interventions
Observers noted that nursing staff attending the paper round were not always the client's current care coordinator, and were not always aware of the consumer's plans and outcomes. Audits of Care Plans suggested tensions between consumer versus staff goals. Question arose about whether the Care Plans were really collaborative in nature.
EoC Care Domain: Promoting Self Care and Wellbeing
Observers and file audits found inconsistencies regarding levels of engagement with consumers in collaborative Care Planning. Factors included tensions between consumer vs. staff goals, and clients' level of wellness.
4. Action Planning Phase
In the action planning phase, the team wished to advance the ways of working that supported the client's voice in decision-making. Forums were held to discuss ways in which the paper round might be improved. These were attended by staff and consumers. During one of these forums, a client came up with the name 'Care Review' in place of the (now) outmoded 'Paper Round.' This name change signalled a palpable shift in culture; from the reviews being seen as an administrative process, towards being genuinely collaborative, with consumers at the centre.
The team appreciated there were many variables regarding consumer involvement in Care Planning and Care Review meetings that were beyond the scope of EoC to address. These included the high proportion of client's who came to the MHRU under Order from the Mental Health Review Tribunal; varying levels of wellness and symptomatology; different capacities to engage with MHRU programs, and high levels of homelessness amongst the client population.
Areas chosen to focus on were:
- Alerting consumers of the fortnightly Care Review dates and times, and inviting them to attend
- Co-writing by consumers and staff of both Care Plans and Consumer Views of Progress on Mental Health Outcomes and Assessment Tools (MHOAT) Review forms
- Improving the structure and organisation of the Care Review meetings
- Inviting staff who were doing targeted work with individual clients to discuss relevant issues at the Care Review, whether or not the client was in attendance
- Managing the time taken for each Care Review, based to how many consumers were to be reviewed.
It is important to note that as topics were identified for improvement, actual changes of practice began to occur, even before the EoC Implementation phase had formally begun. This was thought to be due to the fact that light was being shed on simple practice habits that were relatively easy to rectify.
5. Implementation Phanse
Implementation of the 'new look' Care Review meetings commenced in May 2012 as part of a six-month trial. During the first month of implementation, the team conducted reflective sessions with staff and consumers in order to troubleshoot and refine the changes.
Concerns were expressed about the pace the changes were being implemented, with some staff feeling uncertain about what was expected of them, for example - how to extend an invitation to clients to attend the Care Review, and how to document consumer involvement on MHOAT Review forms. Support was provided by the CNC and CNS to assist in documentation and the use of appropriate language. Sample MHOAT Review forms assisted staff in formulating their own collaborative approaches to documenting and contributing to Care Reviews.
Examples were given of ways to discuss risk and symptom issues that were non-threatening to the consumer, e.g. 'We understand you are having these troubling thoughts / experiences. Do you mind if we talk about that?' Morning meetings provided an opportunity to advise consumers of upcoming care review meetings.
Consumers were educated about the aims of the Care Reviews, and how they could raise their concerns, and they were encouraged to attend. Names of consumers scheduled who were due for Care Review were written on the unit whiteboard, to ensure consumers knew about the meetings and had the opportunity to choose whether or not to attend.
Subsequent feedback showed the above strategies to be effective. Staff felt less rushed and more prepared for the Care Reviews, and an increased number of MHOAT Review forms were being completed with consumer views documented. Staff appreciated structured time spent on each Care Review without this being overly rigid. Improvements were noted each week with more clients attending.
6. Evaluation Phase and Outcomes
At the end of the six-month trial period, data was collected again using the previous sources: Observations, File audits, Consumer stories and Staff stories. Sixteen Care Reviews were observed during March-April 2014 by a combination of four external facilitators (Cutler, Silburn, Jandzio & Ball).
During this period, the MHRU changed the Care Review location from the less formal setting of the rear patient lounge to a large group room to allow electronic medical records (eMR) to be accessed via the available portal. The post-implementation evaluation highlighted a number of substantial improvements in the way Care Reviews are conducted on the unit. These are listed below in each of the care domains.
EoC Care Domain: Promoting Self Care and Wellbeing
- Respectful, professional communication occurred between clinicians
- Documented plans address main points raised in meeting
- No concerns re medico-legal compliance of documentation
- Generally noted respectful, consumer centred approach, open-ended questions and conversation style. Affirmation by staff of difficulties faced by consumers is noted
- Psychiatrist not dominating Care Review, allowing space for other team members to offer comment, questions, feedback
- On one occasion, consumer is noted to be leading the discussion. The format for the care review and style of the forum is supportive of this
- Some humour used which was inclusive of, and not at the expense of, the consumer.
EoC Care Domain: Therapeutic Interventions
- Client present in most care reviews and discussions
- The care review meetings showed evidence of good coordination and organisation
- Sufficient time and space provided for clients to actively participate in care reviews
- All clients are encouraged to ask questions and raise concerns
- Evidence of use of different MHRU team members working on different issues with clients
- Relaxed atmosphere, use of humour in care reviews
- Evidence of coordination and collaboration of therapeutic interventions
EoC Care Domain: Clinical Monitoring and Management
- Environment noted to be adequate, well lit and comfortable for the purpose of reviews
- Good focus on physical health, weight, sleep, exercise, leisure and work
- Experience of benefits of specific intervention offered from consumer's point of view
- Questions exploring how consumers were feeling about a specific intervention
- Explanation and rationale given about length of stay
- Discharge planning emphasis noted including NGO's, socialisation and work prospects
- Discussions of consumer strengths and strategies. Problem solving, brain storming with consumer.
13 files were audited between March-April 2014. Marked improvements noted in documentation of collaborative care planning and input by consumer towards their Care Review, whether or not consumer chose to attend. The language of Review documentation now reflects the values of inclusivity and the notion of consumers 'having a say' in their own care and treatment.
Seven consumers responded to a questionnaire. Their feedback reveals a positive shift towards consumer involvement in Care Review meetings in response to invitations to give feedback on their progress in the MHRU.
A questionnaire was circulated to staff in May 2014. Feedback mirrored the outcomes reflected in the other data sources.
Faclitator Reflection and Key Learnings
The length of time that planning, implementation and evaluation has taken has meant that staff, some of whom may have been involved in EoC, have lost focus (and interest) in changes that - as a team we are trying to implement. Without the momentum provided by the EoC facilitators, the process would not have continued to operate.
Issues of 'buy in' by the wider staff at MHRU remain barriers to EoC, and are yet to be fully surmounted. Without all staff undergoing some kind of formal EoC Introduction, much time is spent explaining basic EoC concepts, rather than staff valuing and participating in the actual work of EoC, that is, practice development.
A component of mandatory training regarding EoC may be a possible remedy to this issue. Team-wise, it is this author's view that the main benefit from the EoC process was the provision of a forum at the formation stages of the new MHRU to begin defining our shared values. From a personal perspective, it is not so much the 'end result' that is of central importance in practice development, but rather those more intangible processes, such as stakeholders engaging collaboratively towards achievable goals using conversations, stories, humour, observations, trial and error and addressing tensions that arise through democratic means.
These processes, in many ways are as important as the end result. Notwithstanding this, consumers being invited to be at the centre of important planning sessions is a worthy 'tangible' outcome that has occurred. In fact our ways of working have, in very real ways, come to mirror the values we are trying to promote in this specialised healthcare setting, that is - inclusion, collaboration, celebrating achievement and moving towards positive change.
Celia (Social Worker)
EoC provides each team with a flexible framework to reflect on practice in the workplace. The EoC meetings provide a regular time and space on the work agenda to examine, discuss and action plan changes in practice. Whilst the EoC process can take some time and can be an ongoing challenge, the different stages promote reflection and enables culture change to be implemented and sustained.
We would like to acknowledge that one of the challenges faced by the team has been the transfer from paper based records to electronic format. This has meant that we are no longer able to sit down with clients and go through their care review form prior to the actual review taking place; instead, we have to do so verbally and type their responses directly onto the computer. There is nowhere for clients to record their own opinions, or for them to sign to say they have been consulted.
This also means that 'the system' now relies on staff to document the level of client involvement and to accurately record their opinions. Some staff feel this has been a real 'step back' in implementing a more client focused review format.
I became interested in EoC as I wanted to be part of a collaborative, progressive team and to work on making positive changes in the workplace. I found the Facilitation Development Workshops incredibly interesting. Creative activities and useful topics built a foundation for me to become an EoC facilitator.
I have enrolled in the further two workshops and have attended the EoC NSW statewide Showcase. The Showcase was encouraging; to listen to other participants in EoC and hear their stories was very enlightening. I found listening to the presenters and hearing how they made their changes occur very helpful.
- Suzanne Garcia, CNC – (moved to new NUM role late 2013)
- Celia Campanella, Social Worker
- Matthew Keelan, CNC (acting)
- Emma Palmer, OT
- Amanda Jay, RN
- George Chidwick, RN
- Melanie Van Holland, RN
Mental Health Rehabilitation Unit
South Eastern Sydney Local Health District
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