VA is committed to transforming mental health services to a recovery orientation. The SAMHSA/VA definition of recovery is "A journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential." (VA Uniform Mental Health Services Handbook, 2008). For mental health staff, promoting Veteran recovery requires a fundamental shift from an orientation built around the medical model, symptom management, and maintaining a Veteran in care perhaps for the rest of his/her life to one focusing on recovery and reintegration into the community. This shift in both perspective and practice is difficult to attain, as the values underlying practice are deeply rooted, and fundamental operational and cultural change are needed to transform practice and programs to a recovery orientation. To support the goal of a recovery orientation, VA has mandated the establishment of Psychosocial Rehabilitation and Recovery Centers (PRRC). Although there were Central Office supports to assist VAMCs in creating PRRCs, there remains substantial variation in the extent to which sites have implemented PRRCs that are truly recovery-promoting both in practice and in spirit. Central Office partners have indicated a desire for research guided recommendations on how to continue supporting PRRC transformation into recovery-promoting environments. To conduct this research, a valid instrument is needed to assess the extent to which recovery-promoting structures, practices and values are implemented in PRRCs. Since such an instrument was not available, this pilot project developed and validated one.
The objective of this study was to develop and validate an instrument to assess recovery-promoting structure, practices, climate, and culture in VA Psychosocial Rehabilitation and Recovery Centers (PRRCs) to be used in subsequent research on recovery transformation of VA mental health services.
This was a mixed-methods study, using both surveys and interviews. Building on a review of the recovery literature conducted by investigators in the CHOIR Recovery Focus and informed by a conceptual model of organizations whose central concepts are climate and culture, the following approach was pursued to develop and validate the survey: First, based on the recovery and organizational culture and climate literatures, an item pool was developed. Second, a panel of experts in the field of recovery was convened to review and reduce the working pool of survey items in development by the investigators. Third, cognitive testing of the reduced pool of items was performed with 6 PRRC staff. Fourth, the survey was revised based on feedback from cognitive testing and was programmed as a web-based survey that was administered to all 750 PRRC staff across the country. Fifth, psychometric analysis of the survey responses was performed, and scale and composite scores were computed for each PRRC. Sixth, investigators conducted blinded site visits to 4 PRRCs to assess recovery-promoting core aspects. Finally, we compared survey and site visit data and ratings to validate the survey. We then vetted survey results with another group of recovery experts.
280 PRRC staff completed the web-based survey (approximately 35% response rate). Results of the exploratory factor analysis determined 7 factors present in the data, which were categorized as the following organizational dimensions: staff expectations, staff values, leadership, education and training, staff rewards, policies, and quality improvement. Each factor had high internal scale reliability. We eliminated 3 of the lowest-performing items, which resulted in a shortened version of the instrument. Resulting scales had good internal consistency.
We computed each site's average score in each of the 7 identified dimensions, and used those scores to rank sites as high or low performers. Generally, sites' scores on each dimension reflected their overall ranking across all dimensions, i.e. sites that scored high on quality improvement (or any other dimension) scored high overall. We used these rankings to select two high sites and two low sites to invite for site visits.
Researchers conducted site visits to two high and two low sites, blinded to the sites' survey results. Based on the data they obtained and analyzed from the site visits, they rated the sites as high or low on recovery climate overall and on each survey dimension. The site visitors' ratings matched the survey ratings, thereby validating the instrument.
The SAMHSA/VA definition of recovery is "A journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential." (VA Uniform Mental Health Services Handbook, 2008). This project has developed an instrument for assessing recovery orientation in PRRCs and collected baseline information on the level of recovery orientation in PRRCs throughout VHA. This information will assist VA in implementing recovery-promoting services so that more Veterans with serious mental illness are able to reach their full potential and live satisfying, meaningful and self-directed lives in the community. The validated instrument will be used in future research focused on implementation of practices in PRRCs to develop greater recovery orientation.
- Ellison ML, Reilly ED, Mueller L, Schultz MR, Drebing CE. A supported education service pilot for returning veterans with posttraumatic stress disorder. Psychological Services. 2018 May 1; 15(2):200-207.