Service User Involvement in Recovery-oriented Care Planning: A Realist Synthesis

Background: Service user involvement (SUI) is one of the main guiding principles in mental health care and is widely accepted as integral to recovery-oriented practice. Yet whilst there is a wealth of literature that advocates its benefits, service users are marginalised from recovery-oriented care-planning processes. A lack of effective implementation support; little guidance about how to facilitate SUI; and a number of barriers to genuine SUI in recovery-oriented care planning in acute inpatient units all indicate the complex nature of this issue. It remains an area that is currently under-researched and inadequately understood and warrants more sophisticated theorisation and explanation in order to support practice improvement.

Aim: This study investigated which changes to practice work best, in what circumstances, and to what extent, to embed an active role for service users' involvement in recovery-oriented care planning during acute inpatient care.

Design: A realist synthesis, combined with qualitative methods, was conducted to theoretically explore the causal mechanisms that underlie SUI in care planning and how contextual factors influence the link between these causal mechanisms and outcomes. The study was conducted in three stages: theory gleaning; theory refinement and theory consolidation. Initial programme theories related to SUI in recovery-oriented care planning were developed in the theory gleaning stage. These theories were refined iteratively, using evidence from a realist review (secondary data) and interview data (primary data). With stakeholder involvement, refined programme theories were finely tuned using 'if-then' statements in the consolidation stage.

Setting: This study was conducted in NHS mental health hospitals and community mental health centres in the south-east of England, which provide secondary mental health care for service users with mental health problems.

Results: Five programme theories relating to the acute care pathway were identified following the realist synthesis: 1) 'Provider-controlled care transition' (admission to acute inpatient units), referring to the limitations to service users' active involvement at this stage; 2) 'Care plan as a recovery tool?' - addressing the infrastructural and organisational limitations to active SUI in recovery-oriented care-plan formulation; 3) 'Ward rounds as a non-inclusive arena for shared decision making', highlighting their unfulfilled potential for shared decision making about treatment; 4) 'Peer support worker intervention as a key factor in service users' recovery', concerning their positive impact; and 5) 'Provider-controlled care transition from acute inpatient units' (discharge practice), highlighting limitations of current practice in preparing service users for transition into the community.

Conclusions: The study identified practices required to embed an active role for service users to be involved in recovery-oriented care planning, namely multi-contextual interventions at various levels (macro, meso and micro) of the mental health system. The study uncovered blockages and contentions that restrain SUI in recovery-oriented care planning throughout the mental health system, impacting upon desirable outcomes.

Implications for practice: Five key practice improvement areas were identified:

1) The focus of care and access to acute inpatients units should be on a needs-led, rather than resource-led or demand-driven, basis. 2) The use of multidisciplinary meetings as a forum for care-plan formulation can create a cohesive approach and provide equal opportunities to contribute to the care plan, facilitating a shared ownership. 3) Limiting the number of professionals, particularly those who have not been involved with the service users' care, may enhance an environment conducive for shared decision making. Service users should feel their views are validated by professionals. Professionals should focus on preparing service users for the ward-round process and meetings. Opportunities and access for service users to build therapeutic relationships with the treating doctors is a vital component. 4) Adding peer support workers as part of a multidisciplinary team has the potential to promote SUI in care planning. Their presence in ward rounds and care-planning meetings might create a more user-friendly atmosphere for service users. 5) Practice in acute inpatient units should have an increasing focus on preparing service users for transition into the community, and constraints on resources should not dictate or anticipate decisions on discharging service users, instead, wherever possible, it should be collaborative in nature.