Recovery-Oriented Practice in Mental Health Inpatient Settings: A Literature Review

The following research question was addressed: What is the current state of recovery-oriented practice in inpatient settings? The review was conducted in accordance with the ENTREQ guidelines for reporting qualitative reviews (16). It was based on a systematic literature search (17,18) designed by the first and last authors. The search was carried out by the first author in January 2015. The following six databases were used: MEDLINE via PubMed, PsycINFO, CINAHL, the Cochrane Library, Web of Science, and EMBASE. The search strategy was based on a preliminary pilot search to determine relevant search terms on the basis of three primary subject areas: mental health, inpatient settings, and recovery. The literature search was conducted systematically as a keyword Boolean search combining keywords with OR and AND and by using truncations after each search term (19). [A table in an online supplement to this article lists the search terms.]

We included articles meeting the following criteria: qualitative and quantitative studies published from 2000 to 2014; studies carried out in adult mental health inpatient settings or using informants from adult mental health inpatient settings, such as mental health staff working in inpatient settings or patients currently or formerly admitted to inpatient wards; and studies aimed at investigating a recovery-oriented practice in the context of mental health inpatient settings defined by an explicit reference to the concept of recovery. We excluded studies that included forensic mental health care wards, alcohol and drug treatment wards, and child and adolescent wards or that were conducted with a mix of informants from inpatient settings and community services and that did not distinguish informants from inpatient settings in the results. Quality improvement studies with the exclusive aim of describing or evaluating specific interventions were also excluded.

The literature search resulted in 2,527 “hits,” of which 678 were duplicates and removed. The first author decided whether to include each of the remaining 1,849 articles on the basis of its title. The first and last authors screened the 178 articles that remained, first screening the abstracts independently and then meeting to discuss their results. In cases of disagreement or uncertainty, the two authors discussed the case with all authors until agreement about inclusion was achieved. The first and last authors then screened the articles by full text, discussing cases of disagreement or uncertainty with all authors. The main reasons for excluding articles were as follows: did not examine mental health services, was conducted in a setting other than the mental health inpatient setting, did not examine recovery or recovery-oriented practice, and mixed informants from inpatient settings and community services without distinguishing the informants in the results. [A flowchart of this process is included in the online supplement.]

This selection process left us with a total of eight studies conducted in the United States, the United Kingdom, Canada, Australia, and Ireland from 2004 to 2014 (20–27): one quantitative study (26), five qualitative studies (20–22,25,27), and two qualitative literature reviews (23,24) (Table 1).

The first author assessed the scientific quality and relevance of the eight studies by using the Critical Appraisal Skills Program (CASP). CASP is a checklist developed for systematically assessing scientific studies in terms of whether the aim, methodology and design, data collection, participant selection, and data analysis are appropriate and comprehensive, sufficiently rigorous, and clearly stated. It also examines whether the researchers have considered ethical issues and bias and whether they explicitly report and discuss their findings. The assessment is conducted by answering yes, no, or unsure to ten questions (28).

The CASP assessment was conducted by using the appropriate checklists for the various types of studies—for example, qualitative studies, reviews, and quantitative studies. Overall, on the basis of CASP criteria, the included studies were assessed as having sufficiently high quality. Four qualitative studies had nine positive answers and one negative; and one qualitative study had eight positive answers, one negative, and one unsure. One review had eight positive answers and two unsure; and the other review had seven positive answers, one negative, and two unsure. The quantitative study had nine positive answers and one unsure. None of the eight studies were excluded on the basis of the quality assessment.

The first author then followed the steps of a text-driven content analysis (29,30) in which overall themes were identified on the basis of repeated occurrences of similar content within and across the eight studies. The studies, which were based on different research methods, were integrated through juxtaposition—that is, they were analyzed side by side instead of being arranged by method or CASP assessment results (31).

Initially, the first author read all eight articles repeatedly to become familiar with their content. All text under the headings “Results” and “Conclusions” was extracted and entered into a single Microsoft Word document. Results from quantitative studies were incorporated by extracting the part of the Results section in which the authors described the results of their measurements in words and their interpretation of the results. The extracted text was arranged in alphabetical order by the first author of each study, and condensed meaning units were created by dividing the text into small paragraphs. The meaning units were coded according to their content and meaning—for example, “an unwelcoming environment,” “no time to interact with patients,” and “the paradox of collaboration and coercion.”

The meaning units were then rearranged in accordance with their initial codes. On the basis of the codes’ similarities, they were arranged into categories, such as “physical structures,” “pressure,” and “contradictions.” Subsequent codes were grouped into the existing categories, and new categories were created when deemed necessary. Categories were refined on the basis of their similarities and differences, resulting in three overall themes: definitions and understandings, current practice, and challenges. Definitions and understandings describes how staff define and understand the concept of recovery and recovery-oriented practice. Current practice describes the application of a recovery-oriented practice in inpatient settings, as perceived by staff members, patients, and researchers. Challenges consists of the factors that staff members, patients, and researchers identify as challenging when applying a recovery-oriented approach in mental health inpatient settings.

The eight studies differed in type of inpatient setting and geographical setting. The settings were described as public psychiatric hospitals, psychiatric state hospitals, psychiatric hospitals, acute inpatient wards, state hospital wards, and psychiatric intensive care units. In presenting the results of the studies below, we use only the term inpatient setting. The studies were also based on interviews with different types of informants—that is, those from various professional groups working in mental health inpatient settings, primarily mental health nurses or individuals currently or previously hospitalized in inpatient settings. Below we refer to informants from professional groups as staff or staff members. We recognize that “patient” is not a term commonly used in the recovery literature to describe individuals experiencing mental health issues. However, in consideration of the fact that this review focused on inpatient settings, we refer to these individuals as patients.

This literature review examined recovery-oriented practice in mental health inpatient settings and to what extent a recovery-oriented approach is an integrated part of such settings. Our findings highlight two particularly salient aspects of recovery-oriented practice in these settings. First, the literature explicitly describing recovery-oriented practice in inpatient mental health settings is very limited. Second, the extent to which recovery-oriented practice is integrated into inpatient mental health settings is also limited. We recognize that inclusion criteria for this review were very strict in that only research studies that explicitly aimed to explore recovery-oriented practice were included, thereby excluding literature on specific recovery-oriented interventions in inpatient mental health care, such as shared decision making, peer support programs, and various psychosocial rehabilitation strategies (32–34). Nonetheless, it must be concluded that recovery-oriented practice in mental health inpatient settings is as yet not very well described in the literature and that the existing literature reveals several challenges to be met.

Overall, the review found that staff in inpatient settings had a positive attitude toward the values and principles of recovery-oriented practice. However, the review revealed differing understandings of the concept of recovery and difficulties in translating this concept into everyday practice. Many staff members across the studies tended to equate recovery-oriented practice with a traditional medical approach revolving around medical stabilization and symptom relief.

Moreover, poor levels of engagement, communication, and collaboration between patients and staff appeared to be common in inpatient settings. The studies highlighted concerns that low capacity created competing demands for staff members, which tended to overshadow the individual needs of patients. High bed occupancy, quick patient turnover, and high acuity levels tended to reinforce traditional crisis-driven care that was primarily directed at rapid medical stabilization. This tendency seemed exacerbated by physical designs that did not support a recovery approach and contradictory structures in organizational standards and procedures.

The review highlighted several challenges. First, differing understandings of recovery and difficulty translating the concept of recovery into practice call for conceptual clarifications of the aims of recovery-oriented practice and how this approach applies to mental health inpatient settings. Second, the challenges created by low capacity and contradictory organizational procedures call for extensive consideration of the current organization of mental health inpatient settings. This challenge also raises the central question of whether mental health inpatient care can or should be based on recovery-oriented practice. The high levels of acuity that characterize these settings (35,36) underline a need for care aimed at treating people in severe and acute distress. Providing recovery-oriented care in this environment may simply not be possible under the current capacity and organizational structures of these settings. However, even though this review focused on studies of inpatient settings, similar results have been found in mental health services in the community. Research in these settings suggests that implementation of recovery-oriented practice is affected when the demands of the organizational system take precedence over an approach that supports personal recovery (37,38). Moreover, studies on outpatient and community mental health settings have noted the same differences found in this review in regard to how staff members understand the concepts of recovery and of recovery-oriented practice (37–39). Thus the challenges of adopting recovery-oriented practice are not solely related to mental health inpatient settings but to mental health service systems in general.

Some limitations of this review should be noted. The results are based on the secondary analysis of results and conclusions of other researchers, not on primary data. This is a potential source of bias because secondary analysis can distort the meaning of the primary data. Our literature search found a limited number of studies, suggesting that the evidence in this field is scarce. However, we acknowledge the possibility that our search strategy may have inadvertently omitted relevant studies that could have added important information to the findings. We searched for studies that included the words “recovery” and “recovery-oriented practice”; however, many additional concepts, such as user involvement, empowerment, hope, and shared decision making, are central aspects of the recovery paradigm (7,32,40). Although including these concepts in our search terms could have led us to additional relevant studies, we are confident that the narrow focus of the search strategy strengthened the review because it limited the risk of conceptual misrepresentations.

Although the eight included studies took place in inpatient settings, they varied in context because they were conducted in different countries and in various types of inpatient settings. Nevertheless, the findings were remarkably similar, indicating that the nature of mental health care in these settings has strong basic characteristics and is therefore suitable for examination and comparison across countries and inpatient contexts. The similar findings also indicate that the challenges related to implementation of recovery-oriented practice in mental health inpatient settings are fundamental and need to be addressed.

The results of this review showed that research explicitly focused on recovery-oriented practice in mental health inpatient settings is limited. Moreover, the existing literature suggests that the extent to which a recovery orientation is practiced in these settings is limited. The studies reviewed highlighted several challenges. Practice in inpatient settings appears to be characterized by a lack of collaboration, communication, and engagement between patients and staff. Low capacity and contradictory structures in the organization create competing demands, which take priority over the individual needs of the patient, thereby reinforcing traditional crisis-driven care that ultimately challenges the values and principles of recovery-oriented practice. This raises a central question of whether recovery-oriented practice can or should be an integrated part of inpatient mental health settings, which are primarily aimed at stabilization and symptom relief, and calls for further research aimed at clarifying the concept of recovery and how it applies to inpatient settings. The challenges to recovery-oriented practice posed by the current organization of mental health inpatient settings should also be considered.