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• To learn about the Recovery Star and how its use can empower patients to develop their skills and self-reliance
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The Recovery Star is a collaborative tool used by staff to support the recovery of adults who are using mental health services, including inpatient rehabilitation services. However, staff experiences of completing this tool with patients have seldom been reported. Therefore, a service evaluation was undertaken to explore staff perspectives about the useful elements and barriers associated with using the Recovery Star, to determine whether staff believe it is an appropriate tool to use in inpatient rehabilitation services, and to understand the reasons for the tool’s underuse.
Semi-structured interviews were conducted with nine staff members who worked across four wards in an inpatient rehabilitation service in Leicester, England. Four main themes were identified through a thematic analysis of the interview transcripts: it is a helpful tool; it is patient-dependent; it is underused due to constraints such as lack of time; and wider issues affecting its use. Subthemes for each of these themes were also identified. Staff reported that the Recovery Star is an appropriate tool to use in mental health rehabilitation services, although they recognised some barriers to its use and amendments required to ensure the tool is used more often.
Mental Health Practice. doi: 10.7748/mhp.2021.e1466
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Kadir S, Fenton K (2021) Staff perspectives on using the Recovery Star in mental health inpatient rehabilitation services. Mental Health Practice. doi: 10.7748/mhp.2021.e1466
Published online: 02 March 2021
The Recovery Star is a tool that was initially designed for use with people who are homeless to promote positive change and motivation (MacKeith 2011). It has since been adapted for use in mental health services, to support patients and staff to adopt a holistic approach to recovery by focusing on ten domains (Box 1) (Dickens et al 2012).
• Managing mental health
• Physical health and self-care
• Living skills
• Social networks
• Work
• Relationships
• Addictive behaviours
• Responsibilities
• Identity and self-esteem
• Trust and hope
*A fourth edition of the Recovery Star has since been published, but the third edition continues to be available and was used in the service at the time of the project detailed in this article
(Good et al 2018, Triangle Consulting Social Enterprise Limited 2021)
In the Recovery Star, a patient rates themselves between one and ten for each domain to indicate how well they feel they are doing, with higher ratings representing that they are doing well in that domain (Dickens et al 2012). A staff member – usually the patient’s key worker – also rates the patient between one and ten for each domain separately. The patient can then identify which domains they would like to develop their skills in and set appropriate and manageable goals to assist them in achieving this (Lloyd et al 2016). The tool encourages patients to identify goals and staff to support them to feel empowered to achieve these goals (MacKeith and Burns 2008), thereby fostering collaborative working between patients and staff.
The aim of the Recovery Star is not for patients to achieve a score of ten in each domain, but to develop their skills, empower them and foster self-reliance (MacKeith and Burns 2008). When a patient does not want to engage in completing the tool, the staff member can rate the patient without the patient providing a rating, which is referred to as a staff-only rating.
Staff have an integral role in the use of the Recovery Star. The tool can support patients to develop self-reliance through collaborative working between patients and staff, with staff assisting patients by improving their confidence in each of the domains (Baum et al 2006). The staff ratings for each domain can enable the patient to see how mental health professionals view their skills in that area. To ensure it remains person-centred, adaptations of the Recovery Star may be required, for example considering a patient’s cultural background when using the tool. This relies on staff being able to adapt the tool for the individual patient (Mental Health Providers Forum 2009).
• The Recovery Star can be a useful tool in inpatient adult mental health rehabilitation services when used collaboratively with patients
• The Recovery Star can support person-centred care and facilitate conversations with patients, although it may not be appropriate for all patients
• It is important to consider the appropriateness of staff-only ratings when a patient does not want to engage with the tool, to ensure it remains useful and does not burden staff unnecessarily
• It may be beneficial to simplify the Recovery Star to overcome constraints in using the tool, such as a lack of time
• Further staff training is required to increase confidence in using the Recovery Star and to enable other staff members – for example allied health professionals – to use it
Studies have demonstrated that the Recovery Star is widely used by mental health professionals and is reliable and valid with different populations, for example people who are homeless and mental health service users (Onifade 2011, Dickens et al 2012). Research has shown that most patients who used the Recovery Star considered it to be valuable (Mental Health Providers Forum 2009). Overall, in the literature, the Recovery Star is deemed a valid and useful tool. However, the appraisal of the tool has been criticised as misleading, because much of the literature published about it has been by its authors (Killaspy et al 2012a). Beazley (2011) stated that the Recovery Star has been widely adopted by mental health services and championed by mental health professionals, but emphasised that there is a lack of peer-reviewed publications appraising the tool.
The literature suggests that the Recovery Star enables patients to develop self-reliance, which often leads to positive outcomes (Baum et al 2006). Baum et al (2006) stated that self-reliance was achieved through feeling empowered, which was accomplished by staff supporting the patient to integrate their knowledge and skills into situations and encouraging self-reflection. In part, this was due to the staff ratings, which enabled patients to see how healthcare professionals viewed their skills in each domain of the tool (Mental Health Providers Forum 2009). The tool providers state that the patient and staff member should score the domains to ensure collaboration, which is an essential aspect of the tool. In addition, the Recovery Star has been found to be an acceptable tool for mental health patients and staff in Italy, with the collaborative approach between the staff and patient deemed its most valuable element (Placentino et al 2017). However, in practice this collaboration often does not appear to be taking place.
Despite staff involvement being important to the Recovery Star, staff perspectives about the tool have seldom been reported. Killaspy et al (2012b) investigated staff use of the tool and found some discrepancies. For example, 47% of staff thought that collaborative scoring was easier than scoring alone, but 21% thought this was harder. They identified that staff-only ratings for the domains were lower compared with collaborative ratings, and found inadequate inter-rater reliability for staff-only ratings. This indicated that, despite staff believing staff-only ratings are better for care planning, the Recovery Star needs to be completed collaboratively with the patient for it to be reliable. Therefore, it appears to be important to explore staff perspectives of the tool, since these underpin its use.
The service where the evaluation was conducted was a rehabilitation service in Leicester, England, that provides inpatient care for adults requiring mental health support. The service is divided into four wards – three mixed open wards and one male-only locked high-dependency ward. Each ward has a team leader, with ward staff including nurses and healthcare support workers. Nursing students are also usually undertaking clinical placements on the ward.
The Recovery Star was introduced in the service in 2014, and since 2017 it had been integrated with the Care Programme Approach. This means that the tool needs to be completed with patients at least every three months, but is expected to be completed more often during key working sessions. The ward teams are appraised on their use of the tool by senior management and are therefore expected to use the tool to inform care planning, even when patients do not want to engage with it. The service’s clinical psychologist (KF) provides staff training in the use of the tool. The ward team leaders had been auditing the use of the Recovery Star and identified that it was being underused across the four wards. Anecdotally, some staff members had also reported they thought it was not a useful tool. Therefore, the authors thought it was important to explore staff perspectives about the Recovery Star, to understand the reasons for its underuse in the service.
To explore staff perspectives about the useful elements and barriers associated with using the Recovery Star, to determine whether staff believe it is an appropriate tool to use in inpatient rehabilitation services, and to understand the reasons for the tool’s underuse.
This service evaluation was undertaken between February and July 2019, and involved conducting qualitative, semi-structured interviews with ward staff to obtain their views on the Recovery Star. The interviews lasted for approximately ten minutes and involved open and closed questions.
Different staff groups used the Recovery Star across the wards; on some wards it was used exclusively by healthcare support workers and nursing students, while on other wards nurses also used the tool. Therefore, all ward staff involved in using the Recovery Star – approximately 100 in total – were invited to take part. Allied health professionals and ‘bank’ staff were excluded since they did not use the tool. A promotional poster outlining the project was displayed across the wards, and an email was sent to all ward staff containing the same information. The trainee clinical psychologist (SK) then attended the wards to discuss the project with staff and answer any questions they had about it.
Nine staff members volunteered to be interviewed. Participants’ experience of using the Recovery Star with patients varied, but they had all undertaken the training and completed aspects of the tool within the past year. Participants included two team leaders (both of whom were nurses), three nurses, two healthcare support workers and two nursing students.
The trainee clinical psychologist conducted the interviews, which were recorded using a Dictaphone. Nine interviews were undertaken, at which point data saturation was achieved. The trainee clinical psychologist transcribed audio files verbatim, to ensure nuances were captured.
The data were analysed using thematic analysis (Braun and Clarke 2006) to enable rich, detailed descriptions about the Recovery Star to be obtained and patterns to be identified across the data set. The trainee clinical psychologist transcribed the interviews to begin immersion into the data. They and a second analyst (KF) then read through the transcripts independently. On the second reading, they each began to look for patterns, noting potential ideas and data-driven codes. After further coding, the codes were sorted into broader themes. At this point the researchers shared their codes and themes, which revealed similar findings. The themes were reviewed and a thematic map was developed to ensure that this accurately represented the data set as a whole. The themes were revisited and named, and the narrative of each theme was considered.
A critical realist perspective was used when analysing the data. Critical realism offers a set of philosophical underpinnings for social research and maintains that although reality exists, an individual’s perception of reality is influenced by their knowledge and experience of the world (McEvoy and Richards 2006). In the context of this project, this meant that participants’ experiences of the Recovery Star were influenced by their knowledge and previous experiences of the tool. This gave importance to how they viewed reality, rather than attempting to ascertain what the ‘real’ reality was. For example, if participants reported feeling unsupported by their healthcare organisation, this was accepted rather than exploring if it was truly the case.
The Clinical Audit Standards and Effectiveness Group at Leicestershire Partnership NHS Trust reviewed the project, considering ethical issues and the validity of the interview schedule. They granted ethical approval and deemed the project a service evaluation, meaning that ethical approval from the NHS Research Ethics Committee was not required. The service’s senior clinical team also approved the project. All participants read an information sheet and discussed the relevant issues before giving consent to take part in the project. To ensure confidentiality and anonymity, participants were assigned an individual participant number, which was used throughout the project. Identifiable data such as their names and the ward they worked on were not collected.
Four themes, along with nine subthemes, were identified from the data (Table 1).
A strong theme identified across the interviews was that the participants believed the Recovery Star was a helpful tool. Many participants thought the Recovery Star was positive and person-centred, which was in keeping with the care they aimed to provide to patients:
‘If they’re willing to engage then it’s great because you’re getting their views and it’s definitely centred [on] them.’ (Participant 8)
However, it appeared that many participants did not know the purpose of the Recovery Star.
The reasons why it was considered a helpful tool were divided into three subthemes: focuses on the patient’s journey; facilitates conversations; and realises potential.
Participants thought that patients understanding their ‘journey’ was an important aspect of their recovery, which the Recovery Star facilitated by enabling patients to compare their own and previous staff ratings to their current ratings, which often demonstrated improvements:
‘I think it helps us to see where they feel they are and it probably helps them to see where we feel they are, because often, sometimes that can be quite different… so it encourages discussions.’ (Participant 8)
Participants considered the Recovery Star a motivating tool that could assist patients to become goal oriented. They also thought it supported staff empathy by enhancing their understanding of the patient’s journey, which supported person-centred and collaborative goal setting:
‘Recovery is trying to understand.’ (Participant 1)
‘[It’s] good to see where they are and where they would like to be.’ (Participant 9)
Participants stated the Recovery Star facilitated challenging conversations with patients by providing a context and structure that guided staff in asking relevant questions. They also reported that the one-to-one session in which the Recovery Star was completed provided a valuable space for patients to talk about their experiences or goals that might otherwise be overlooked. For example, if their rating on a particular domain decreased, this could be discussed and contextualised:
‘It gives not just the patients but staff [a] focus.’ (Participant 5)
‘It encourages [patients] to explore things and think of things.’ (Participant 8)
By having these conversations, staff noticed that their therapeutic relationship with the patient grew stronger. This became cyclical; patients being open during these discussions assisted in developing stronger relationships with staff, which subsequently led to patients being increasingly open. Participants thought the Recovery Star provided a non-threatening way to then express and discuss differences of opinion with the patient:
‘If they have low self-esteem they may be down-marking themselves, when actually you could say [they are doing well in a domain], so it encourages discussions.’ (Participant 8)
Participants strongly thought that the Recovery Star supported patients to realise their own potential. They believed that the different domains could show a patient’s strengths and progress, which could be used as a basis to make improvements in other domains. They also thought that this fostered hope and positivity. For example, one participant said the goals they set with patients facilitated discussion around potential:
‘Realising the potential and work with it.’ (Participant 7)
Participants thought that engaging with the tool assisted patients to engage with their rehabilitation more broadly, since the achievement of the goals set seemed realistic. Becoming involved in their rehabilitation meant that patients could make meaningful decisions about their care:
‘[It’s] quite good because [patients] can go, “right, this is what I’m aiming for,” this is what they want do in the future. The work [domain] is good if they want to go back to work or volunteer work.’ (Participant 2)
From participants’ responses, it was clear they thought that the use and success of the Recovery Star depended on the patient themselves. Participants reported that patients’ mental health and engagement often affected their willingness to use the tool, and most of them said the patient was the most significant barrier to completing the Recovery Star.
Participants reported that patients’ mental health could affect their ability to engage with the Recovery Star; for example, they were less likely to engage with it if they were experiencing increased mental health issues. Participants thought this was due to patients’ lack of motivation and not feeling well enough to engage, and in some cases their belief that they did not need mental healthcare:
‘When they were poorly [they] wouldn’t engage, but now they’re coming through so [they] can start to engage.’ (Participant 1)
‘Some patients don’t know they’re mentally ill so don’t want to do it.’ (Participant 3)
Participants also questioned how useful the Recovery Star was when patients were unwell, even if they engaged in it. One participant thought it was demotivating for patients who had no goals, and unhelpful for those whose goals might be unrealistic:
‘Some of them have unrealistic goals… some of them don’t have any goals to work towards.’ (Participant 3)
Therefore, they thought it should not be used when participants were too unwell to engage meaningfully with it.
Participants also thought that some patients consciously chose not to engage with the tool:
‘Some patients like doing it and some patients don’t want to do it.’ (Participant 2)
They acknowledged that, at times, this represented patients not wanting to engage with rehabilitation more broadly. Some participants thought that if patients were consciously choosing not to engage with the tool, staff were left feeling discouraged. When asked about how the Recovery Star supported patient care, one participant thought it was only helpful for patients who wanted to engage with their recovery more broadly:
‘[It’s] a tool that’s going to be for those that have actually decided “I want change”.’ (Participant 1)
Participants emphasised that collaborative working was necessary for the tool to be meaningful, since staff-only ratings were not clinically useful if they could not be discussed with the patient:
‘If someone doesn’t want to engage you still do it… from our perspective, I don’t know how that would be really supportive.’ (Participant 1)
It was identified that the use of the tool was limited by ward constraints and the format of the tool, with an interaction between these barriers. Staff indicated that the tool would be used more often if these issues were overcome.
Ward constraints were frequently cited as a significant barrier for staff engaging with the Recovery Star. For example, participants thought they often did not have the time to complete it, which meant that the tool was used infrequently:
‘Because of these long days and stuff I didn’t get a chance.’ (Participant 6)
‘[It] depends on what else is happening at any given time on the ward.’ (Participant 5)
‘I’ve done a little bit of work on one but I would say [that was] months ago.’ (Participant 9)
All participants said the Recovery Star required some amendments, reporting that it was too ‘long’ and ‘complicated’ for patients. Some participants thought some flexibility was necessary to ensure it was accessible for patients with additional needs:
‘A different way of perhaps doing that without it being overwhelming for the client. So probably a bit simpler.’ (Participant 1)
‘[The patient] just didn’t want to engage with anything written down.’ (Participant 9)
Participants thought the tool took a long time to complete:
‘[It’s] time consuming… so that’s a long time to be away off the ward.’ (Participant 1)
Therefore, amending the tool might make it easier for staff and patients to use, less time-consuming and more meaningful for the service.
The final theme related to wider issues about the status of the Recovery Star in the service, which participants thought was often not recognised by other members of the multidisciplinary team (MDT). Participants wondered whether this was amplified by ward constraints.
Several of the participants described the Recovery Star as ‘pointless’ in relation to the tool’s lack of application outside of the one-to-one sessions. Some participants stated that the tool needed to be integrated in the MDT for it to be more meaningful for patients:
‘Went into the [Care Programme Approach review meeting, and the MDT] weren’t really bothered about it. They didn’t really look through it, it was like it’s just a tick-box [exercise].’ (Participant 3)
For example, it could be beneficial to evaluate a patient’s progress in terms of the Recovery Star during MDT meetings. Some participants thought this would reduce repetition in completing other care planning tools, while giving the Recovery Star importance:
‘So you’re doing the Recovery Star then you’re doing the collaborative care plan, so it’s a little bit [repetitive]… but if we’ve got the Recovery Star in place then that is collaborative.’ (Participant 1)
Participants thought that, despite its lack of integration in the MDT, the Recovery Star was given a high status on the ward by service commissioners. This meant some participants felt pressure to complete the tool, because they were being appraised on this by senior management. They reported that this adversely affected morale on the ward and increased stress levels, particularly when patients did not want to engage:
‘It’s just difficult sometimes if you have someone that’s not willing to engage.’ (Participant 8)
‘It’s hard to know – are we doing it, are we not doing it, do we carry on with it? So yeah, it just seems very, very unclear at the moment.’ (Participant 5)
However, when patients did engage, participants believed the tool had positive effects:
‘It was brilliant… you want everyone to have it because it makes you feel good. Because you feel [good] when you’ve helped someone.’ (Participant 1)
This suggests that staff need further support, particularly when the ward is busy and patients do not want to engage. Participants also alluded to the ineffectiveness of the tool when staff did not feel confident in its use:
‘[It supports patient care] if staff know what they’re doing and feel comfortable and confident in relation to what they’re doing.’ (Participant 5)
The final interview question was a closed question, ‘Is the Recovery Star an appropriate tool within the service?’. Of the nine participants, five agreed and three responded ‘to some extent’, with the suggestion that the amendments they had proposed would make it more appropriate. Only one participant answered no.
This service evaluation aimed to explore staff attitudes in relation to the useful elements, barriers and appropriateness of the Recovery Star in an inpatient rehabilitation service and to understand the reasons for the underuse of the tool. Collaboration between patients and staff is essential when using the Recovery Star (Mental Health Providers Forum 2009), therefore it is important to explore staff attitudes towards the tool and their engagement with it. In the mental health inpatient rehabilitation service, the tool was being underused despite staff being audited on its completion.
This service evaluation found that staff believe the Recovery Star is a useful tool because it provides a framework and a contained space for important conversations, alongside strengthening the therapeutic relationship with patients. This demonstrates that the ethos of the Recovery Star is in keeping with the positive and person-centred care that staff aim to provide, and that they are encouraged to complete it with patients as a result. However, one participant stated the tool had become a tick-box exercise, so thought they would be less likely to prioritise its use. Therefore, it appears to be important that staff value the tool to prioritise its use, particularly when considering the ward constraints they also experience.
The interviews revealed that staff had experienced several barriers to completing the Recovery Star, which may partly explain its underuse in the service. These barriers were related to patients, wider ward and service issues, the length of time it takes to use the tool and staff confidence. Staff thought that, despite the healthcare organisation promoting person-centred care and this being the reason why the Recovery Star was introduced, other issues often took precedence, for example general ward tasks, patient activities and managing ward incidents. The interviews also identified that there was a lack of understanding about the Recovery Star among staff and some were unsure what it set out to achieve. The lack of staff confidence in using the tool and the effects this may have had on its use was also recognised as an issue. Staff using the tool in an ad hoc manner and without the patient may have influenced this.
The staff who took part in this service evaluation described feeling unsure about what to do when a patient did not want to engage with the tool; they were expected to complete staff-only ratings, but all the participants reported that these were not clinically useful or meaningful for the patient. This was in contrast to the finding by Killaspy et al (2012b) that more than half of participants who conducted staff-only ratings believed it was useful as an outcome measure. Some of the participants suggested that adapting the tool might encourage staff and patients to use it. Staff perspectives about the use of the tool align with the finding by Chen et al (2013) that assisting patients to engage with individually tailored services can support their recovery. Furthermore, some staff thought they needed further training and support to adapt the tool, particularly when a patient did not want to engage. This emphasised that staff thought the collaboration between staff and patients made the Recovery Star a meaningful and useful tool for the patient.
Eight of the nine participants agreed that the Recovery Star is an appropriate tool to use in the service, demonstrating that staff and patients (Mental Health Providers Forum 2009) consider it to be a useful tool. This service evaluation also demonstrated that staff thought that the Recovery Star achieved what it set out to, for example focusing on a patient’s journey. However, it was clear that some amendments, further staff training and service-level considerations were necessary.
Some participants believed that the Recovery Star was a helpful tool, despite not being aware of its aim. It could be suggested that this is because the tool is inherently helpful and achieves its aims without users being fully aware of them. Alternatively, it may be that the ethos of the Recovery Star was in keeping with the ethos of staff and therefore it was suitable for them. Either way, this finding indicates that staff needed further training on the Recovery Star, since the tool might be used more often in the service if more staff were aware of its aim.
The findings of this service evaluation suggest that collaboration between staff and patients is essential for the tool to be used more frequently and appropriately. While staff-only ratings have served a purpose in providing a focus for discussions with the patient, they appeared to be redundant if this could not be achieved. The participants thought staff-only ratings were not clinically useful, while Killaspy et al (2012b) identified that they may be unreliable. Therefore, given the importance of the tool being used collaboratively, perhaps it would be beneficial to place an emphasis on patient and staff scoring, with staff-only ratings not being used when a patient does not want to engage.
This service evaluation also suggested that for the Recovery Star to have greater benefit for patients, there needs to be further collaboration between healthcare professionals. Some participants thought the tool was a tick-box exercise and that it was often not recognised by the wider MDT. There may be various reasons for this, such as questions about the validity of the tool or power dynamics in the service. However, without collaborative working between healthcare professionals, staff completing the tool with patients may feel underwhelmed and frustrated.
The interviews were brief, lasting approximately ten minutes, which limited the depth of exploration. This was due to ward constraints since staff could not leave the ward for longer periods. In-depth interviews might have enabled the reasons for the participants’ views to be explored. In addition, staff members volunteered to take part in the project, so there is a risk that the participants may not be representative of the ward staff.
It is recognised that the service’s clinical psychologist was involved in the project, which may have affected participants’ responses during the interviews. For example, they may not have thought they could be completely open in their responses because the clinical psychologist had trained them in using the Recovery Star, so they may not have wanted their views on it to be shared with her. Finally, the Recovery Star is owned by a limited company and it publishes much of the research on the tool. Therefore, the findings of such research must be interpreted with caution due to a potential conflict of interest.
This service evaluation found that, overall, staff considered the Recovery Star to be a useful tool. It also identified several issues about the underuse of the tool, with its use affected by patients’ willingness to engage, the need for further staff training, and ward constraints such as a lack of time. Despite these issues, staff thought that – with some amendments – the Recovery Star would be increasingly beneficial in inpatient mental health rehabilitation services and should continue to be used.
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