Therapeutic Culture and Climate: Using the EssenCES and the RSA-R in a Canadian Mental Health Care Setting

Transcription

1 Therapeutic Culture and Climate: Using the EssenCES and the RSA-R in a Canadian Mental Health Care Setting EssenCES - Jennifer Roters, Elke Ham, Laura Ball & Nick West RSA-R - Laura Ball, Elke Ham, Jennifer Roters & Nick West Waypoint Research Institute, Waypoint Centre for Mental Health Care

2 Overview Introduction to therapeutic culture and climate, and the recovery philosophy Introduction to the Therapeutic Climate Study (TCS) How it started? Why was it done? What did it entail? Essen Climate Evaluation Schema (EssenCES) and the Recovery Self-Assessment Revised (RSA-R) What are they? Are they valid for use? What did we find?

3 Therapeutic Culture and Climate; Recovery Philosophy March 24,

4 Recovery Philosophy Recovery-oriented services are what mental health providers offer in support of the person s recovery (Chen et al, 2013; Tondora & Davidson, 2006) The recovery philosophy has increasingly gained acceptance among policy-makers and consumer advocacy groups in Canada, but faces significant barriers to buy in and implementation among providers (Battersby & Morrow, 2012; Piat & Lal, 2012; Piat & Sabetti, 2012)

5 Recovery Philosophy Waypoint has recently completed a Clinical Services Plan (CSP) calling for the implementation of a number of high priority initiatives designed to improve the quality of care These four pillars are: Adoption of the Recovery Philosophy Trauma-Informed Care Least Restraint Cultural Competency All of these are intended to create a significant impact on therapeutic culture, climate, and outcomes

6 Therapeutic Culture & Climate Social climate is the interaction of aspects of the material, social and emotional conditions of a ward, which may over time influence the mood, behaviour and self-concept of the persons involved. Schalast & Redies (2005); translation available in Milsom, et al (2014, p. 2)

7 Therapeutic Culture & Climate Significant correlation between climate and several indices for staff and patients Relationships between social climate and clinical and organizational outcomes Patient and staff satisfaction (e.g., Rossberg & Friis, 2004) Staff performance and morale (e.g., Moos & Schaefer, 1987) Motivation to engage in treatment (e.g., Long, 2010) Treatment outcomes (e.g., Bressington, et al, 2011) Attachment style (e.g., Campbell, et al, 2014) Seclusion (e.g., Ching, et al, 2010)

8 Therapeutic Culture & Climate How do we operationalize and measure initiatives as they roll out?

9 Therapeutic Climate Study March 24,

10 Therapeutic Climate Study Purpose To track change of the therapeutic climate over time in light of several high-level initiatives implemented across the organization Implementation of recovery philosophy Restraint and seclusion minimization Moving the forensic program into a new building To use data from validated, psychometrically-sound instruments to inform decision-making and CQI

11 Therapeutic Climate Study Method Survey staff, leadership, and patients annually for 5 years Staff & Leadership EssenCES RSA-R RSR-OQ Patients & Clients EssenCES RSA-R RAS-R

12 Essen Climate Evaluation Schema (EssenCES) March 24,

13 EssenCES Essen Climate Evaluation Schema (EssenCES) was developed in German by Schalast et al (2008) English version has been validated in med and max secure forensic settings in the UK (Howell, et al, 2009; Milsom, et al, 2013; Tonkin, et al, 2012) Features Short (17 questions, only 15 are scored) Staff and patient version Psychometrically sound (internal consistency = , solid 3 factor structure and construct validity) Norms for comparison Free for use

14 EssenCES Therapeutic Hold (TH) Experienced Safety (ES) Patient Cohesion (PC) EssenCES Full Scale Score

15 Recovery Self-Assessment - Revised (RSA-R) March 24,

16 RSA-R The RSA-R was developed in the US to measure the perceived degree to which clinical programs follow recoveryoriented principles and implement recovery-oriented practices Features: Has several versions Person in Recovery, and Provider versions (32 Qs each), Administrator/CEO version (36 Qs) and Family/Significant Other version (40 Qs) Psychometrically sound (internal consistency = for dimensions,.84 for full scale, good convergent validity) Norms for comparison Free for use

17 RSA-R Diversity of Treatment Options Choice Involvement Individually- Tailored Services Life Goals RSA-R Full Scale Score Inviting

18 Therapeutic Climate Study Demographics March 24,

19 Study Design Time Period 1 st annual: February/March more years to go! Population Staff and leaders (referred to as staff for presentation) Patients Setting Provincial Forensics Division 4 programs Regional Division 7 programs, including Regional Forensics Program Clinical Support Services Central Recreation, Security, etc.

20 Staff Demographics 60% 50% Age Gender 40% 30% 20% prefer not to answer 15% male 26% 10% 0% 18 to 24 years 25 to 44 years 45 years or over prefer not to answer female 59%

21 Staff Demographics Role prefer not to answer Years Worked in Mental Health 100% other 80% Physician 60% Nurse 40% Manager 20% Allied Health 0% 5 years and under over 5 years prefer not to answer or unknown 0% 10% 20% 30% 40% 50%

22 Staff Demographics 40% Security Level 30% 20% 10% 0% other non forensic medium secure forensic high secure forensic

23 Patient Demographics 60% Age Gender 40% female 19% prefer not to answer 5% 20% 0% under 25 years 25 to 44 years 45 years and over prefer not to answer male 76%

24 Patient Demographics 60% Security Level 60% Length of Stay 40% 40% 20% 20% 0% non forensic medium secure forensic high secure forensic 0% under 1 year 1 to 5 years over 5 years prefer not to answer

25 Therapeutic Climate Study EssenCES Results March 24,

26 EssenCES Results Reliability Internal Consistency (Chronbach s ɑ) EssenCES Factors Staff Patients Total Sample Therapeutic Hold Experienced Safety Patient Cohesion Full Scale

27 EssenCES Results *Therapeutic Hold **Patient Cohesion **Experienced safety Staff Patients *p<0.05, **p<0.001

28 EssenCES Results Hospital-wide, staff reported greater therapeutic hold than patients Therapeutic Hold Staff Patient Mean Mean Sig. Hospital-Wide <0.01 Staff in the non-forensic programs reported greater therapeutic hold than their counterparts in the forensic programs Staff in forensic programs reported greater therapeutic hold than their patients did Therapeutic Hold Non-Forensic Forensic Mean Mean Sig. Staff <0.05 Patient ns Sig. ns <0.05

29 EssenCES Results Other notable findings Staff group differences Therapeutic Hold and Experienced Safety with Role Allied Health staff reported feeling more safe and having better therapeutic relationships than Nursing staff Patient group differences Experienced Safety with Age The older patients are, the less safe they reported feeling

30 Therapeutic Climate Study RSA-R Results March 24,

31 RSA-R Results Reliability Internal Consistency (Chronbach s ɑ) RSA-R Factors Staff Patients Life Goals Involvement Diversity of Treatment Options Choice Individually-Tailored Services Inviting.60.58

32 RSA-R Results Life Goals Involvement Diversity of Treatment Options Choice Individually Tailored Services Inviting Staff (n=306) Patients (n=83) *p<0.05, **p<0.001

33 RSA-R Results Life Goals Non-Forensic Forensic Mean Mean Sig. Staff <0.01 Patient <0.01 Sig. <0.05 ns Involvement Non-Forensic Forensic Mean Mean Sig. Staff <0.01 Patient <0.05 Sig. ns ns

34 RSA-R Results Diversity of Treatment Options Non-Forensic Forensic Mean Mean Sig. Staff <0.001 Patient <0.001 Sig. ns ns Individually-Tailored Services Non-Forensic Forensic Mean Mean Sig. Staff <0.001 Patient <0.01 Sig. ns ns

35 RSA-R Results Other notable findings Staff group differences Involvement and Individually-Tailored Services with Age Younger staff are more likely to endorse involving patients in decisions, and believing in the value of individually-tailored services Involvement and Choice with Role Allied Health are more likely to endorse involving patients in decisions, and providing choices in treatment options

36 Therapeutic Climate Study Convergent Validity March 24,

37 Convergent Validity Patient responses on therapeutic hold on the EssenCES were predicted by their responses to reliance on others in the RAS-R, and all dimensions of the RSA-R, especially diversity of treatment options The more a patient was willing to ask for and receive help from others, the more dignity in their environment, and choice and diversity in treatment options, the greater their perceived therapeutic relationship with staff Staff responses on therapeutic hold on the EssenCES were predicted by their responses on individually-tailored services on the RSA-R The more staff believe in the benefits of individually-tailored services, the greater their perceived therapeutic relationship with patients

38 Discussion March 24,

39 Discussion Measurement for decision-making and CQI Useful to be able to evaluate current therapeutic culture and climate, and recovery-orientation Quality improvement Improve indices of organizational and clinical success for staff and patients based on continuous measurement of recoveryorientation, and therapeutic culture and climate Tools The EssenCES is a reliable, valid and useful tool for assessing general therapeutic climate and culture Particularly useful on forensic programs, but shows promise for non-forensic programs as well The RSA-R is a reliable, valid, and useful tool for assessing general recovery-orientation Shows promise on forensic and non-forensic programs

40 Thank you!

41 Selected References Battersby, L., & Morrow, M. (2012). Challenges in Implementing Recovery-Based Mental Health Care Practices in Psychiatric Tertiary Care. Canadian Journal of Community Mental Health, 31(2), Ching, H., Daffern, M., Martin, T., & Thomas, S. (2010). Reducing the use of seclusion in a forensic psychiatric hospital: Assessing the impact on aggression, therapeutic climate, and staff confidence. Journal of Forensic Psychiatry and Psychology, 21, doi: / Colton, D. & Xiong, H. (2010). Reducing seclusion and restraint: Questionnaire for organizational assessment. Journal of Psychiatric Practice, 16, doi: /01.pra Corrigan, P. (2012). Toolkit for evaluating programs meant to erase the stigma of mental illness. Illinois: Illinois Institute of Technology. Retrieved from:

42 Selected References Howells, K., Tonkin, M., Milburn, C., Lewis, J., Draycott, S., Cordwell, J., Price, M., Davies, S. & Schalast, N. (2009). The EssenCES measure of social climate: A preliminary validation and normative data in UK high secure hospital settings. Criminal Behaviour and Mental Health, 19(5), Milsom, S., Freestone, M., Duller, R., Bouman, M., & Taylor, C. (2013). Factor structure of the Essen Climate Evaluation Schema measure of social climate in a UK medium-security setting. Criminal Behaviour and Mental Health. Advance online publication. doi: /cbm O'Connell, M., Tondora, J., Croog, G., Evans, A., & Davidson, L. (2005). From rhetoric to routine: Assessing perceptions of recovery-oriented practices in a state mental health and addiction system. Psychiatric Rehabilitation Journal, 28, doi: / Piat, M., & Lal, S. (2012). Service providers' experiences and perspectives on recovery-oriented mental health system reform. Psychiatric Rehabilitation Journal, 35(4), doi: /

43 Selected References Piat, M., & Sabetti, J. (2012). Recovery in Canada: Toward social equality. International Review of Psychiatry, 24, doi: / Salyers, M. P., Tsai, J., & Stultz, T. A. (2007). Measuring recovery orientation in a hospital setting. Psychiatric Rehabilitation Journal, 31, Schalast, N., Redies, M., Collins, M., Stacey, J., & Howells, K. (2008). EssenCES, a short questionnaire for assessing the social climate of forensic psychiatric wards. Criminal Behaviour and Mental Health, 18, doi: /cbm.677 Tonkin, M., Howells, K., Ferguson, E., Clark, A., Newberry, M., & Schalast, N. (2012). Lost in translation? Psychometric properties and construct validity of the English Essen Climate Evaluation Schema (EssenCES) social climate questionnaire. Psychological Assessment, 24, doi: /a