Recruitment and participants

The community enhanced rehabilitation team members were approached by a clinical psychologist who works in inpatient services, while service users were approached by their care coordinator. Inclusion criteria for service users were having received transition interventions from the team, for example emotional and practical support to meet the person’s goals, and having capacity to consent to an interview. Six service users participated in phone interviews lasting approximately 15 minutes. Eleven of the 12 community enhanced rehabilitation team members were invited to take part (one team member conducted the evaluation and was not therefore eligible to participate) and five staff interviews were conducted, each of which lasted around 60 minutes. Staff participants included team leaders (nurses), nurses and healthcare support workers.

Measures

Semi-structured interview schedules were developed by a clinical psychologist in the rehabilitation service and quality reviewed by two other clinical psychologists from the service. Table 1 details the interview schedule for staff and service users.

Procedure

Interviews with staff and service users were conducted by phone due to COVID-19 restrictions. Before each interview the interviewer read the information sheet and consent form to the participant. Consent was gained verbally as outlined by the NHS Health Research Authority (2019). Responses were typed verbatim by the interviewer.

Ethical approval

As it was a service evaluation, review by a full ethics committee was not required, therefore the evaluation was approved by Leicestershire Partnership NHS Trust’s quality improvement programme (Further resources) on 20 June 2020.

Analysis

Analysis of interview data followed Braun and Clarke’s (2006) thematic analysis procedure. Thematic analysis was chosen because it enables a flexible approach to the data and outlines the main themes of the interviews. A critical realist perspective was taken during the analysis. Critical realism states that although reality exists, an individual’s perceptions of it are influenced by their knowledge and experience (McEvoy and Richards 2006, Fletcher 2017).

Service user and staff interviews were analysed together to develop a comprehensive understanding of the community enhanced rehabilitation team. Each interview was coded individually and themes for each interview were considered. The themes were then considered across all interviews and areas of overlap and difference were identified. The interview data were consulted in an iterative process to ensure that the themes represented the data accurately.

To test data saturation, the sixth service user interview was conducted after analysis to identify whether further interviews would add to the identified themes. No new themes or subthemes were identified, indicating that satisfactory data saturation may have been met. With regard to staff, no further recruitment was possible following the five interviews because all potential participants had been approached.

Developing staff competency

Staff described their experiences of joining the community enhanced rehabilitation team when redeployed from inpatient wards, which was initially a stressful change:

‘It was quite nerve wracking to begin with ward closures.’ (Staff member 2)

Some were concerned about their competence given the team’s lack of experience of community work, with comments including:

‘It’s been a big change going from inpatients to community.’ (Staff member 1)

‘I feel there is a gap from community leadership.’ (Staff member 4)

However, several discussed enjoying the community work once they settled into it, stating that:

‘I was really lucky to be reallocated to this team.’ (Staff member 2)

‘It’s been good. It’s a change from the ward. I don’t think I could go back to the ward.’ (Staff member 3)

Experiences of the training provided when staff joined the team were variable, with some reporting they had undergone a lot of training and others that they had none. Some identified further training needs in relation to community working:

‘Supporting staff members to attend training related to the community [would be an improvement].’ (Staff member 4)

Staff discussed using informal supervision to develop their competence and clarify areas of uncertainty:

‘As the community aspect is new to us, we take a collaborative approach to managing care and risk.’ (Staff member 4)

This was regarded as useful by many staff, one of whom stated:

‘Clinical support has been excellent.’ (Staff member 1)

Several staff participants likened informal clinical support to clinical supervision, with one stating that:

‘How people view supervision is a meeting set up called “supervision”, but actually in the team we get a lot of supervision, there is always someone to talk to.’ (Staff member 1)

Overall, no negative experiences of clinical support were reported by staff; however, experiences of formal supervision were mixed with some participants praising the quality of supervision and others commenting that they did not have time to participate.

One service user participant reported that staff were ‘very professional’ and that ‘they know their job and they do their job well’ (service user 3), which indicated that they believed staff were competent. This was a sentiment reflected in many of the service user interviews.

Doing ‘proper rehab work’

Staff demonstrated a passion for rehabilitation work, with comments including:

‘It is a really needed service, so it is exciting.’ (Staff member 1)

‘I feel really lucky to… be able to work doing rehab and that’s what I love doing.’ (Staff member 2)

Rehabilitation work included practical and emotional interventions. For example, one service user said:

‘They have really helped me. [Healthcare support worker] has helped me to put the curtain poles up.’ (Service user 4)

Staff also emphasised the importance of practical support, commenting that:

‘My colleague has skills where he can support with cooking or activities of that nature that can help with rehab.’ (Staff member 3).

Service users described times when interventions helped them to develop coping skills:

‘[The psychologist] treating me with CBT over the phone [has been helpful].’ (Service user 6)

‘They reminded me of coping mechanisms that I learned.’ (Service user 3)

One staff participant stressed the importance of psychologically informed interventions:

‘What was nice about this team is that it is more psychologically led.’ (Staff member 3)

Service user and staff participants described completing rehabilitation work with a person-centred approach. For example, one service user described the genuine interest taken in them by the team:

‘They seemed like they really wanted to help… it made me feel good. Like there are some people out there who really do care.’ (Service user 2)

One staff member demonstrated a person-centred attitude, commenting that:

‘I feel my work has been more trying to understand the person from their perspective.’ (Staff member 3)

Having enough time to complete interventions was important to service users and staff. Service users described times when their worker went the ‘extra mile for me’ (service user 1), while others described team members as follows:

‘Doing everything they can to help me in the community and it be a success.’ (Service user 3)

‘I don’t think they could do any more.’ (Service user 5)

Staff, meanwhile, commented that it was ‘good to have more time with service users’ (staff member 1), and described interventions for which intensive support was needed, for example when going into the community, ‘It can take three hours… if you do intensive or time-consuming interventions’ (staff member 2), or when supporting a person in crisis, ‘The chap who was in crisis, that took all day’ (staff member 3).

Having more time was also associated with enhanced outcomes, with one staff member stating:

‘[Having more time] means a better outcome for service users, I think they feel that there is a route to recovery.’ (Staff member 1)

This requirement on their time led to staff members stressing the importance of smaller caseloads, with one commenting:

‘We don’t want big caseloads for each individual nurse.’ (Staff member 3)

Two staff described how the community enhanced rehabilitation team provided a service that had a distinct function and remit compared with community mental health teams (CMHTs). One said it was ‘very different from a CMHT’ (staff member 2), while another was concerned about it becoming ‘like a CMHT and becoming overrun with paperwork’ (staff member 3). This suggested that team members valued being able to offer a different type of service from CMHTs and wanted to retain their unique function.

Managing anxiety and crisis

Service users described overwhelmingly positive experiences of how the team supported them to feel safe when they were feeling anxious. They also talked about staff members’ positive interpersonal styles, ‘The way they spoke to me and looked after me was calming’ (service user 3), and how team members spent time listening to them, ‘It’s been very good to have someone who can listen to your problems’ (service user 5), which led to them feeling better, ‘It was reassuring with my anxiety. It reduced my anxiety’ (service user 1).

One staff participant discussed the benefits of having ‘someone to ease anxiety and get through the worries they might have when they are first discharged’ (staff member 1). Participants also discussed management of crisis situations. For example, one service user described how the team’s interventions ‘… helped me get through the crisis without me going back into hospital… they helped calm me and helped me deal with it.’ (service user 3)

One staff participant described helping ‘… some people through crisis and they have come out the other end without needing hospital admission’ (staff member 1), while another commented that managing a patient crisis was ‘… a bit… anxiety-provoking’ but that ‘we got through and he didn’t go into hospital’ (staff member 3).

Good teamwork

Staff participants said the community enhanced rehabilitation team worked well together, was very supportive and had good communication. They also valued members’ different areas of expertise, with one stating that:

‘In this team we get listened to if we have our own point or issues or raise a concern.’ (Staff member 5)

Several staff participants discussed team members as having ‘varying expertise and knowledge’ (staff member 5), and talked positively about working with colleagues who ‘all bring a particular set of skills’ (staff member 3).

Others described the team leaders as ‘approachable’ (staff member 2) and ‘really good at supporting us’ (staff member 3), and felt ‘encouraged to contact senior members of staff if you are unsure’ (staff member 1).

Having leaders with different expertise was also appreciated, with one commenting:

‘They all have different areas they can help with.’ (Staff member 2)

Mode of working

Staff participants preferred face-to-face working for a number of reasons, for example: because it enabled better assessment, ‘It’s very difficult to assess if you’re not going into a patient’s property’ (staff member 2); developed better relationships, ‘It’s got to be face-to-face contact to show someone you actually care’ (staff member 5); and prevented situations escalating to crisis point, ‘Face-to-face visits will really improve things and will stop people from coming into crisis’ (staff member 1).

However, face-to-face contact was not always possible due to COVID-19 restrictions, which generated comments such as:

‘We have to follow policy.’ (Staff member 2)

Service users did not discuss whether they had received care face-to-face or remotely.

Staff had mixed experiences of working remotely, for example: working from home reduced distractions, ‘You can get completely engrossed in what you are doing’ (staff member 2); increased the availability of team leaders, ‘[The team leaders] have been more accessible for advice’ (staff member 4); and reduced commuting time, ‘I like not having to commute’ (staff member 1).

However, working from home also had disadvantages, for example: having children around and the lack of differentiation between work and home, ‘If someone did commit suicide, that’s in your home. That’s not healthy’ (staff member 3); a lack of connection with team members, ‘Staying at home in a small office can feel like a lonely experience’ (staff member 3); and a lack of physical activity, ‘It gets to the end of the day and I’m like, have I even got up?’ (staff member 1).

Joining up the pathway

Service users’ experiences of transition between inpatient and community services within the pathway varied. Two service users stated that transition was ‘very sudden’, with one commenting, ‘I got annoyed because it kept being put back… I didn’t know why’ (service user 2), and the other saying, ‘I would have liked to… know what support would be carrying on’ (service user 1).

Other service users were unsure why certain decisions had been made about their transition. However, some discussed enhanced transition experiences, with one stating:

‘It was the right time for me to leave because I could cope.’ (Service user 4)

Another described good communication during transition:

‘It was made quite clear I wouldn’t be sent out on my own.’ (Service user 5)

Staff, meanwhile, emphasised the importance of ‘integrating into the inpatient wards to offer continuity and to ensure smooth transition of the patients’ rehab journey’ (staff member 4), while another staff member reported:

‘There have been a couple of really good examples where we have had the referral come in, attend discharge CPA [care programme approach] and we have had good communication throughout, and it makes a really big difference [but] there could be better communication between the wards and our team.’ (Staff member 1)

Another staff member acknowledged that communication between inpatient and community services was a joint responsibility:

‘It is a two-way thing.’ (Staff member 1)

Ideas for the future

Staff discussed other interventions the team could use including group work, ‘conversation cafes’, working on an allotment and driving service users to appointments. They also discussed having more team members because, as one staff member stated:

‘… if we’re starting to feel we’re pressurised and rushing I think we’re going to lose what the team is all about.’ (Staff member 3)

Staff members also discussed how having enough staff to dedicate time to complete intensive rehabilitation would ‘benefit the patient and a lot of them appreciate the work that you will put in’ (staff member 2). Another staff member believed that working weekends would improve the support offered, stating that:

‘Some patients just feel lost at the weekend.’ (Staff member 5)

Another said they would appreciate having more team members with varying expertise and knowledge.

Although clinical support was described as good, staff believed having a physical base would improve this and help them feel more ‘part of a team’ (staff member 1). One staff member stated that having a base would offer ‘the opportunity to meet up with other colleagues within the team to discuss anything that you want to’ (staff member 2), adding that it could also improve informal supervision:

‘It’s for those little niggly things, so it’s not enough for an email.’ (Staff member 2)

With regard to the future, staff participants hoped for ‘a real focus on engaging carers and families in discharge/recovery plans’ (staff member 4), and ‘teaching sessions for carers’ (staff member 3).

Most service user participants stated that nothing could have been improved from their perspective, variously commenting that: ‘Everything was great’ (service user 1); ‘I can’t think of an area where they need to improve’ (service user 3); and ‘I’m not just saying this… I’ve not had any bad experiences’ (service user 6).

Limitations

The evaluation took place in one service during the unique changes required in response to the COVID-19 pandemic, which may limit the generalisability of the findings to other community mental health services.

Service user participation was voluntary, therefore those with positive experiences of the team may have been more likely to volunteer, which may have skewed the findings. However, these service users still offered constructive criticism about the transition process, which suggests that although some had more challenging experiences, they were willing to share these.