Key learning points
- The recovery approach to care is applicable for patients with life-changing conditions; whether physical or mental
- This approach focuses less on clinical symptomology, limitations and disabilities and more on working with patients’ capabilities, strengths and positive qualities
- This approach ensures that care intervention is patient centred
According to the Department of Health,[1] more than 15 million people – 30% of the UK population – live with one or more long-term physical health conditions.[2] Of those, more than four million individuals have a co-existing mental health problem. Evidence suggests that individuals living with two or more long-term conditions are seven times more likely to experience depression than those who do not have a long-term condition.[3]
Evidence shows that people living with severe or chronic physical illnesses often have co-existing mental health problems.[4,5] Conversely, individuals with a primary mental illness diagnosis suffer poorer physical health outcomes and are expected to live 10 years less than their peers living without mental disorders.[6]
People with serious mental illness (SMI), such as schizophrenia and mood disorders, are reported to have higher rates of physical illness than the general population.[5]
Physical health problems often remain undetected or untreated for the majority of these individuals.[4] The consequences of co-occurring physical illness and mental health problems often result in decreased life expectancy.[4]
Given the shortage of acute hospital beds, the aging but ailing population and the competing demands made on healthcare resources, it is inevitable that the majority of patients with co-existing long-term chronic physical and mental health will be looked after in primary care.[7]
Health professionals, for fear of doing or saying the wrong thing,[7] are sometimes reluctant to intervene with the psychological care of patients who present with a primary diagnosis of mental health disorder. However, nurses are often best placed and have unparalleled opportunities to enable individuals to optimise their mental and physical wellbeing.[6]
This article will focus on the recovery approach[7] as a mode of intervention, giving consideration to the skills and attitudes needed by nurses and discussing the evidenced benefits when looking after individuals presenting with co-existing long-term physical and mental health issues.
Rationale of the recovery approach as intervention
Increasing numbers of mental health professionals have adopted the recovery principles for enhancing care delivery within the past two decades.[8] The approach is also gaining momentum in physical healthcare contexts.[9,10]
The recovery model of care views the individual holistically and focuses on maximising their quality of life through social inclusion and community connectedness. The aim is to encourage skills development and promote independence and autonomy, serving to give patients hope for the future, promote successful community living and purposeful citizenship.[10] This pragmatic approach is beneficial in sustaining wellbeing when engaging with patients who have chronic complex co-existing life-changing mental and physical health issues.[11,12]
Benefits of the approach
The cornerstone of this approach is the relationship between the patient, health practitioner and supportive others, so that reciprocal, effective therapeutic alliances are developed. Such relationships are necessary to establish complex goals of care and jointly work on them.
Health and social care professionals committed to working from this paradigm need to understand that a long-term process of engagement and empowerment is necessary. The recovery approach emphasises that, while individuals may not have full control over their symptoms, they can have full control over their lives. Recovery is not about ‘getting rid’ of problems. It is about seeing beyond a person’s health issues, while recognising and promoting their abilities, interests and the personal goals of their recovery journey.[13]
The process requires an organised system of support from family, friends and health professionals, calling for pragmatic optimism and long-term invested commitment from all concerned.[8]
The stigma and social attitudes associated with mental illness often impose limits on people living with chronic ill-health. Health professionals can be overly protective or pessimistic about what someone with a long-term chronic illness or those experiencing mental health problems will be able to achieve.[14]
Practitioner knowledge, skills and attitudes
Recovery-orientated practice requires that nurses and other clinicians are prepared to transition from primarily a clinical focus on patients’ symptoms, disabilities and limitations to focusing on patients’ capabilities, strengths and positive qualities.[15]
Research suggests[16] that patients need help with the following issues in order to improve their quality of living and their physical and mental wellbeing:
- Development and sustaining of good relationships.
- Signposting to agencies that help with financial issues.
- Engagement in satisfying work, hobbies and recreational pursuits.
- Having a conducive living environment.
- The valuing and acknowledgement of cultural and spiritual perspectives and the significance of these for living and dying peacefully.
- Educating and supporting the individual (and meaningful others) to be aware of triggers for illness, and the development of resilience and coping strategies.[15]
Patients highlight the following attributes as necessary for health professionals to support them on their recovery journey:
- Being believed in.
- Being actively listened to and understood.
- Others maintaining a positive attitude.
- Getting informed explanations for problems, issues and experiences.
- Having the opportunity to temporarily resign responsibility during periods of crisis.[8]
All nurses, by being aware of the factors mentioned above,
can positively contribute to the recovery journey for patients in their care.
Communication and interpersonal skills and the development of the therapeutic alliance are always desirable when working with individuals accessing health services.
This approach to intervention is particularly suited to primary and community nurses as it is the development of sustained relationships built over time that increases the potential for positive recovery, promoting well being and enhancing quality of life.
The recovery approach requires a mind shift for professionals; working with the individual as opposed to doing things to or for the patient. All those who are involved in supporting and facilitating care with these individuals should actively endorse autonomy, personal voice and engagement in all aspects of care.
Challenges of the recovery approach
A commonly reported challenge of this approach is the conscious effort needed to consider and engage with patient decisions – particularly when they conflict with the ideas and priorities advocated by working in the medical model framework. In re-establishing control, autonomy and individuality, patient decisions may resist or defy or be incompatible with the risk-averse healthcare culture that has developed within the UK.[17,18]
Engaging and working with patient choices that seem risky will become an additional source of stress for healthcare professionals. Nevertheless, for the benefits of this approach to be realised, recovery-orientated practice emphasises building and strengthening patients’ positive attributes, positive coping mechanisms and celebrating autonomy.[19]
Time investment is another challenge presented by this approach because total patient involvement and their pace of change may not coincide with the efficiency pace and time allowances allocated by health practitioners. However, commitment to collaborative working at the patient’s pace ensures not only concordance with care interventions but enhances the potential for sustainability.[19] For the practitioner in both instances, using peer support strategies or mechanisms such as case conferences, multi-professionals meetings and clinical supervision can act as useful forums for gaining support when working with the demands of such challenges.[20]
The recover principle
Using the mnemonic RECOVER, the core tenets of the recovery approach emphasise:
R Respectful, responsible relationships.
E Engagement and empowerment, total involvement of the patient in all care decisions.
C Commitment to open communication, collaborative working, building confidence and celebrating autonomous decision-making.
O Optimism and hope – working positively with the patient’s perspective and values.
V Valuing the patient and validating their lived experience.
E Endorsing and encouraging their goals.
R Resilience development – reinforcing the appropriate access to all available resources and support to enhance quality of life.
Applying the recovery approach to care facilitates and potentiates the individual’s prospects for living a meaningful life while adapting and coming to terms with the effects and impact of illness on their mental and physical wellbeing.
The fundamental skills required to engage in this approach tocare are those of effective non-judgmental communication and active listening skills. These, in conjunction with building therapeutic relationships, are deemed key.
Such skills are already core to effective practice, but embracing this approach will require the progression from total observance and reliance on the traditional medical model of care, where health professionals are deemed the expert, to a less well-defined role where professionals facilitate and create opportunities for patients to regain autonomy, their own voice and – most importantly – belief in their own ability to direct the transformational processes needed to optimise and adapt to living with their issues.
The recovery approach to care is now inherent in health and social care policy directives[13,21] as the way forward for long-term co-morbid health conditions.
Conclusion
Recovery-orientated practice is aspirational and nurses need to be continually open to creatively and collaboratively rethinking and reframing how person-centred care can be achieved, and at the pace of the patient. This will dictate that service delivery must adapt and respond to the complex and individual needs and preferences of real people who want to positively experience all that life has to offer.
References
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2 Office of National statistics. Health, Social Trends 2011;41:1-36.
3 World Health Organisation. World Health Statistics. 2007: WHO.
4 WFMH, Mental Health and Chronic Physical Illnesses: the need for continued and integrated care, 2010; Woodbridge: World Federation for Mental Health.
5 Robson D, Gray R. Serious mental illness and physical health problems: a discussion paper. International Journal of Nursing Studies 2006;44:457-66.
6 Nursing, Midwifery and Allied Health Professions Policy Unit. Improving the physical health of people with mental health problems: Actions for mental health nurses. London: Department of Health. May 2016.
7 Naylor C, Parsonage M, McDaid D et al. Long term conditions and mental health – the cost of co-morbidities. The King’s Fund Centre 2012;1-32.
8 Shepherd G, Boardman J, Slade M. Making recovery a reality. Sainsbury Centre for Mental Health. 2008.
9 Phillips J. Can the concept of recovery in mental health be applied to all conditions? British Journal of Community Nursing 2011;16:116.
10 Killaspy H, Harden C, Holloway F. What do mental health rehabilitation services do
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11 Las S. Prescribing recovery as the new mantra for mental health: does one prescription serve all? Canadian Journal of Occupational Therapy 2010;77:82-9.
12 Bennett B, Breeze J, Neilson T. Applying the recovery model to physical rehabilitation. Nursing Standard. 2014;28:37-43.
13 Sainsbury Centre for Mental Health. Implementing Recovery – A New Framework for Organisational Change, Position Paper, 2010.
14 Davidson L. Recovery, self- management and the expert patient – changing the
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16 LaBoube J, Pruitt K, Pamela R G et al. Partners in change: bringing people into recovery into the process of evaluating recovery orientated services. American Journal of Psychiatric Rehabilitation 2012;15:255-73.
17 Brown P, Calnan M. The Risks of Managing Uncertainty: The Limitations of Governance and Choice, and the Potential for Trust. Social Policy and Research 2010;9;13-24.
18 Boardman J, Roberts G. Risk, safety and recovery. NHS Confederation & centre for mental Health 2014. 1-2.
19 Thornicroft G, Rose D, Kassam A. Discrimination in health care against people with mental illness. International Review of Psychiatry 2007;19:113-22.
20 Curtis J. Working together: A joint initiative between academics and clinicians to prepare undergraduate nursing students to work in mental health settings. International Journal of mental Health Nursing 2007;16:285-93.
21 Department of Health. Achieving Better Access to Mental Health Services by 2020. NHS England. 2015.
