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To describe the provision of evidence-based psychological therapies for the treatment of psychosis in a large Australian mental health service; and to explore the barriers and facilitators to providing these therapies. Mixed-methods study including: 1) a retrospective audit of 100 clients with schizophrenia spectrum disorder to estimate adherence to guideline recommended psychological therapies; and 2) a cross-sectional survey of community based mental health practitioners, based on the Theoretical Domains Framework, to understand the barriers and facilitators to delivering psychological therapies to clients with psychosis. Twenty-five percent (25/100) of the audited sample engaged with psychological services. Of those who did, two received the recommended dose of evidence-based therapy. Thirty-three percent (37/112) of mental health practitioners completed the survey. Barriers to the delivery of psychological therapies related to perceived lack of knowledge, skills, and confidence with the therapies, and beliefs about who will (and will not) benefit. Other barriers included lack of time, demanding caseloads, and a culture of risk and crisis management. People with psychosis have poor access to evidence-based psychological therapies. The barriers to providing psychological therapies are multifactorial and should be systematically addressed to improve health and quality of life outcomes for people living with psychosis. Abbreviations: CBT: Cognitive behaviour therapy; CBTp: cognitive behaviour therapy for psychosis; CRT: cognitive remediation therapy; FIp: family intervention for psychosis; PORT: Patient Outcomes Research Team; RANZCP: Royal Australian and New Zealand College of Psychiatrists; NICE: UK National Institute of Clinical Excellence; TDF: The Theoretical Domains Framework; HoNos: Health of the Nation Scale; EBPIs: Evidence Based Psychological Interventions; ACT: Acceptance and Commitment Therapy. What is already known about this topic: Clinical practice guidelines for the past two decades have recommended psychological interventions be routinely offered to clients with psychosis. There exists a substantial and widely acknowledged evidence-practice gap concerning the implementation of evidence-based psychological interventions for psychosis within public mental health services. Despite knowledge of effective interventions, the translation into clinical practice continues to fall short. Barriers to the provision of evidence-based psychological interventions for psychosis are evident at various levels, including challenges among staff, service recipients and organisational culture. These factors collectively impede the translation of evidence-based psychological interventions into routine psychosis care. What this topic adds: Identifying and understanding local structural, cultural, resourcing, and attitudinal barriers, while emphasising enablers, becomes essential. This understanding forms the foundation for enhancing access to evidence-based psychological interventions, ultimately elevating the quality of care outcomes for people with psychosis. To foster equitable access and awareness of evidence-based psychological interventions for psychosis, initiatives such as increased staff training, service redesign emphasising the value of psychological interventions, improved referral processes, advocacy, role clarification for clinicians, and enhanced supervision opportunities are crucial. These multifaceted strategies collectively may contribute to a more informed and effective approach to evidence-based psychological interventions for psychosis, promoting optimism and treatment choice. Once local structural, cultural, resourcing, and attitudinal factors are recognised and understood targeted improvements in service delivery for psychosis can be strategically implemented, aligning with the unique dynamics of the local context and care setting. [ABSTRACT FROM AUTHOR]

Objective: This paper describes the establishment of training in cognitive remediation for psychosis within a community mental health service.Methods: Clinical staff working in the community of a mental health service were surveyed to ascertain their interest in cognitive aspects of psychosis and skills training in cognitive remediation (CR). Based on the results of the survey a tiered training programme was established with attendance figures reported for each level of training. Fidelity assessment was conducted on the five CR programmes operating.Results: Of 106 clinical staff working in the community with people diagnosed with a psychotic illness 51 completed the survey (48% response rate). The training needs varied with all 106 staff receiving the fundamental (mandatory) training and 51 staff receiving CR facilitator training. Thirty three percent of staff trained as facilitators were delivering CR.Conclusions: Up skilling the mental health workforce to incorporate an understanding of the cognitive aspects of psychosis into care delivery can be facilitated by a tiered training structure. Fundamental training on the psychosocial aspects of psychosis can act as a platform for focussed CR skills based training. There is also a need for accessible therapy based supervision for staff wishing to develop competencies as CR therapists. [ABSTRACT FROM AUTHOR]

Mental health services are increasingly incorporating the views and expertise of people with a lived experience of mental illness in service delivery. A novel approach to this is the 'integrated staffing model' being trialled at two Australian public residential mental health rehabilitation services (Community Care Units, CCUs) where peer support workers (PSWs) occupy the majority of staff roles and work alongside clinicians. Semi-structured interviews were completed with fifteen staff 12-to-18-months after service commencement. Transcripts were analysed following principles of grounded theory analysis. Key emergent themes were: (1) recovery is a deeply personal and non-linear process; (2) The CCU as a transitional learning environment; (3) the integrated staffing model facilitates an effective rehabilitation team; and (4) coming together under the integrated staffing model required a steep learning curve. The findings suggest that the integrated staffing approach may provide a pathway to facilitate the meaningful inclusion of PSWs in rehabilitation settings. [ABSTRACT FROM AUTHOR]

Background: Compensation and adaptation therapies have been developed to improve community functioning via improving neurocognitive abilities in people with schizophrenia. Various modes of delivering compensation and adaptation therapies have been found to be effective. The aim of this trial is to compare two different cognitive interventions, Compensatory Cognitive Training (CCT) and Computerised Interactive Remediation of Cognition-Training for Schizophrenia (CIRCuiTS). The trial also aims to identify if mismatch negativity (MMN) can predict an individual's response to the compensation and adaptation programmes.Methods: This study will use a randomised, controlled trial of two cognitive interventions to compare the impact of these programmes on measures of neurocognition and function. One hundred clinically stable patients aged between 18 and 65 years with a diagnosis of a schizophrenia spectrum disorder will be recruited. Participants will be randomised to either the CCT or the CIRCuiTS therapy groups. The outcome measures are neurocognition (BACS), subjective sense of cognitive impairment (SSTICS), social functioning (SFS), and MMN (measured by EEG) in people with schizophrenia spectrum disorders.Discussion: This trial will determine whether different approaches to addressing the cognitive deficits found in schizophrenia spectrum disorders are of comparable benefit using the outcome measures chosen. This has implications for services where cost and lack of computer technology limit the implementation and dissemination of interventions to address cognitive impairment in routine practice. The trial will contribute to the emerging evidence of MMN as a predictor of response to cognitive interventions.Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12618000161224 . Registered on 2 February 2018. Protocol version: 4.0, 18 June 2018. [ABSTRACT FROM AUTHOR]

Introduction: Dementia is now responsible for the greatest burden of disease of any chronic illness in older Australians. Rural and remote communities bear the impacts of this disproportionately. Additional training and education for healthcare staff to support people living with dementia is needed. Objective: The objective of this scoping review was to map and synthesise the evidence related to barriers and enablers of accessing dementia training for Australian healthcare workers located in rural and remote areas. Design: This scoping review systematically searched multiple databases in January 2023 for peer‐reviewed literature on the topic. Reviewers used Covidence to screen titles and abstracts of located sources, and to screen full‐text articles. Findings: From 187 articles screened, seven peer‐reviewed journal articles were included in the final data analysis; all were from Australia or Canada. The most common barrier described was low staffing, precluding release of staff for dementia training. Enablers to participation in dementia training were availability of online training programs, as well as training providers collaborating with end users to ensure the training met their learning needs. Discussion: This review provides evidence of barriers and enablers specific to rural and remote healthcare workers accessing dementia training. It also explores other approaches to training that have been trialled successfully in different settings. Conclusion: Addressing the identified barriers and enablers may assist in developing training approaches appropriate for existing staff, and in meeting training needs for the future workforce. [ABSTRACT FROM AUTHOR]

This study explores how consumers expect community-based residential mental health rehabilitation to compare with previous experiences of care. Understanding what consumers hope to receive from mental health services, and listening to their perspectives about what has and has not worked in previous care settings, may illuminate pathways to improved service engagement and outcomes. A mixed-methods research design taking a pragmatic approach to grounded theory guided the analysis of 24 semi-structured interviews with consumers on commencement at three Community Care Units (CCUs) in Australia. Two of these CCUs were trialling a staffing model integrating peer support work with clinical care. All interviews were conducted by an independent interviewer within the first 6 weeks of the consumer's stay. All participants expected the CCU to offer an improvement on previous experiences of care. Comparisons were made to acute and subacute inpatient settings, supported accommodation, and outpatient care. Consumers expected differences in the people (staff and co-residents), the focus of care, physical environ, and rules and regulations. Participants from the integrated staffing model sites articulated the expected value of a less clinical approach to care. Overall, consumers' expectations aligned with the principles articulated in policy frameworks for recovery-oriented practice. However, their reflections on past care suggest that these services continue to face significant challenges realizing these principles in practice. Paying attention to the kind of working relationship consumers want to have with mental health services, such as the provision of choice and maintaining a practical and therapeutic supportive focus, could improve their engagement and outcomes. [ABSTRACT FROM AUTHOR]

In the present study, we explored the experiences of staff working at a recovery-oriented, community-based residential mental health rehabilitation unit in Brisbane, Australia, called a 'community care unit' (CCU). A pragmatic approach to grounded theory was taken in the analysis of the transcripts of semistructured interviews with eight staff. Convenience sampling was used, and there was representation of junior and senior staff across nursing, allied health, and non-clinical support roles. Four key themes emerged from the analysis: (i) rehabilitation is different to treatment; (ii) the CCU is a positive transitional space; (iii) they (consumers) have to be ready to engage; and (iv) recovery is central to rehabilitation practice. Staff understandings of recovery in rehabilitation work were complex and included consideration of both personal and clinical recovery concepts. Rehabilitation readiness was considered important to the ability to deliver recovery-oriented care; however, the shared role of staff in maintaining engagement was acknowledged. Threats to recovery-oriented rehabilitation practice included staff burnout and external pressure to accept consumers who are not ready. The reality of working at a community-based recovery-oriented rehabilitation unit is complex. Active vigilance is needed to maintain a focus on recovery and rehabilitation. Leadership needs to focus on reducing burnout and in adapting these services to emergent needs. [ABSTRACT FROM AUTHOR]

Background: A novel staffing model integrating peer support workers and clinical staff within a unified team is being trialled at community based residential rehabilitation units in Australia. A mixed-methods protocol for the longitudinal evaluation of the outcomes, expectations and experiences of care by consumers and staff under this staffing model in two units will be compared to one unit operating a traditional clinical staffing. The study is unique with regards to the context, the longitudinal approach and consideration of multiple stakeholder perspectives. Methods/design: The longitudinal mixed methods design integrates a quantitative evaluation of the outcomes of care for consumers at three residential rehabilitation units with an applied qualitative research methodology. The quantitative component utilizes a prospective cohort design to explore whether equivalent outcomes are achieved through engagement at residential rehabilitation units operating integrated and clinical staffing models. Comparative data will be available from the time of admission, discharge and 12-month period post-discharge from the units. Additionally, retrospective data for the 12-month period prior to admission will be utilized to consider changes in functioning pre and post engagement with residential rehabilitation care. The primary outcome will be change in psychosocial functioning, assessed using the total score on the Health of the Nation Outcome Scales (HoNOS). Planned secondary outcomes will include changes in symptomatology, disability, recovery orientation, carer quality of life, emergency department presentations, psychiatric inpatient bed days, and psychological distress and wellbeing. Planned analyses will include: cohort description; hierarchical linear regression modelling of the predictors of change in HoNOS following CCU care; and descriptive comparisons of the costs associated with the two staffing models. The qualitative component utilizes a pragmatic approach to grounded theory, with collection of data from consumers and staff at multiple time points exploring their expectations, experiences and reflections on the care provided by these services. Discussion: It is expected that the new knowledge gained through this study will guide the adaptation of these and similar services. For example, if differential outcomes are achieved for consumers under the integrated and clinical staffing models this may inform staffing guidelines. [ABSTRACT FROM AUTHOR]

Semi‐structured interviews were used to explore the consumer experience of community‐based residential mental health rehabilitation support at Community Care Units in Australia. These clinical services provide recovery‐oriented residential rehabilitation to people affected by severe and persistent mental illness. Typically, nurses occupy the majority of staff roles. However, two of the three sites in the study were trialling a novel integrated staffing model where the majority of staff were people with a lived experience of mental illness employed as peer support workers (PSWs). The interviews explored consumers' experiences of care 12–18 months after admission. Fifteen interviews were completed with an independent interviewer. Most participants were diagnosed with schizophrenia or a related psychotic disorder. The analysis followed a pragmatic approach to grounded theory. Consumers viewed the CCU favourably, emphasizing the value of the relationships formed with staff and co‐residents. No major differences in consumers' experience under the traditional versus integrated staffing models were identified; however, those from the integrated staffing model sites valued the contributions of the peer support workers. The understanding of the consumer experience emerging through this study aligned with their expectations of the service at the time of commencement. [ABSTRACT FROM AUTHOR]

Background: Deficits in social cognition are common in people with schizophrenia and are associated with impaired functioning. Finding effective interventions to address these deficits is a priority. Social Cognition Interaction Training (SCIT) is a psychosocial intervention that has demonstrated acceptability and feasibility in various health care settings. Larger, well‐designed randomized controlled trials are needed to examine the effectiveness of this intervention. Design: A randomized controlled trial. Methods: One hundred and twenty adults diagnosed with schizophrenia spectrum disorder were randomized to receive SCIT (n = 61) or Befriending Therapy (BT) (n = 59). Both intervention groups were delivered weekly for 2 hr over 12 weeks. Neurocognitive assessment was completed at baseline. Participants completed assessments of social cognition, social functioning, and meta‐cognition at baseline, post‐intervention, and 3‐month follow‐up. Results: There were no clinically significant differences between group outcomes on any measure of social cognition or social functioning. There was a trend for both groups to improve over time but not at a level of statistical significance. Conclusions: SCIT did not show any additional benefits on measures of social cognition compared to Befriending Therapy for people with schizophrenia spectrum disorder. The findings are discussed in terms of potential improvements to the programme. Practitioner points: Effective interventions for the social cognitive deficits of schizophrenia spectrum disorders are still being refined.Social Cognition Interaction Training is a promising therapy but requires further modifications to improve its effectiveness. [ABSTRACT FROM AUTHOR]

Background: Strategies to implement evidence-based practice have highlighted the bidirectional relationship of organisational change on organisational culture. The present study examined changes in perceptions of organisational culture in two community mental health services implementing cognitive therapies into routine psychosis care over 3 years. During the time of the study there were a number of shared planned and unplanned changes that the mental health services had to accommodate. One service, Metro South, had the additional challenge of embarking on a major organisational restructure. Methods: A survey of organisational culture was administered to clinical staff of each service at yearly intervals over the 3 years. Results: At baseline assessment there was no significant difference between the two services in organisational culture. At the midpoint assessment, which was conducted at the time the Metro South restructure was operationalized, there were less positive ratings of organisational culture recorded in Metro South compared to the other service. Organisational culture returned to near-baseline levels at endpoint assessment. Conclusions: These findings are consistent with the literature that organisational culture is relatively robust and resilient. It is also consistent with the literature that, at any one time, a service or organisation may have a finite capacity to absorb change. Consequently this limitation needs to be taken into account in the timing and planning of major service reform where possible. The results also extend the literature, insofar as external factors with a high impact on the operation of an organisation may impact upon organisational culture albeit temporarily. [ABSTRACT FROM AUTHOR]

Background: Treatment outcomes for people diagnosed with psychosis remain suboptimal due in part to the limited systematic application of evidence based practice (Adm Policy Ment Health, 36: 1-7, 2009) [1]. The Implementation science literature identifies a number of factors organisationally that need to be considered when planning to introduce a particular EBP. Profiling these organisational characteristics at baseline, prior to commencement of service reform can determine the focus of a subsequent implementation plan. This study examined the organisational baseline factors existing in two services promoting the routine use of cognitive interventions for psychosis. One of the services studied has since undertaken organisational structural reform to facilitate the greater uptake of Evidence Based Practice (EBP). The results of this study were used to design an implementation strategy to make cognitive therapies a part of routine psychosis care. Methods: One hundred-and-six mental health staff from two metropolitan mental health services in Australia was surveyed to ascertain their attitudes, competencies and interest in Cognitive Behavioural Therapy for psychosis (CBTp) and Cognitive Remediation Therapy (CRT). In addition perceptions of organisational values were profiled using the Organisational Culture Profile (OCP). Fifty five participants were excluded because they completed less than 50 % of the survey. The final sample consisted of 51 participants. Results: 48.1 % of surveys were completed. Over 50 % of staff were interested in CBTp and CRT approaches to psychosis. Staff were aware of existing CBTp and CRT programs but these were not uniformly available throughout the services. Fourteen percent of staff identified as CBT therapist and 35 % were trained CRT facilitators. Only 12 % of staff were receiving therapy specific supervision. The Organisational Culture Profile (OCP) at baseline revealed highest scores amongst leadership, planning, and humanistic workplace domains, with communication receiving the lowest rating indicative of organisational weakness. Conclusion: Profiling the factors associated with successful implementation of service reform informed the implementation planning and the efficient deployment of resources in a mental health service introducing cognitive therapies for psychosis into routine clinical care. The majority of staff had positive attitudes to the evidence based cognitive therapies allowing a focus on training and supervision and the development of supporting organisational elements. [ABSTRACT FROM AUTHOR]

Background: Treatment outcomes for people diagnosed with psychosis remain suboptimal due in part to the limited systematic application of evidence based practice (Adm Policy Ment Health, 36: 1-7, 2009) [1]. The Implementation science literature identifies a number of factors organisationally that need to be considered when planning to introduce a particular EBP. Profiling these organisational characteristics at baseline, prior to commencement of service reform can determine the focus of a subsequent implementation plan. This study examined the organisational baseline factors existing in two services promoting the routine use of cognitive interventions for psychosis. One of the services studied has since undertaken organisational structural reform to facilitate the greater uptake of Evidence Based Practice (EBP). The results of this study were used to design an implementation strategy to make cognitive therapies a part of routine psychosis care. Methods: One hundred-and-six mental health staff from two metropolitan mental health services in Australia was surveyed to ascertain their attitudes, competencies and interest in Cognitive Behavioural Therapy for psychosis (CBTp) and Cognitive Remediation Therapy (CRT). In addition perceptions of organisational values were profiled using the Organisational Culture Profile (OCP). Fifty five participants were excluded because they completed less than 50 % of the survey. The final sample consisted of 51 participants. Results: 48.1 % of surveys were completed. Over 50 % of staff were interested in CBTp and CRT approaches to psychosis. Staff were aware of existing CBTp and CRT programs but these were not uniformly available throughout the services. Fourteen percent of staff identified as CBT therapist and 35 % were trained CRT facilitators. Only 12 % of staff were receiving therapy specific supervision. The Organisational Culture Profile (OCP) at baseline revealed highest scores amongst leadership, planning, and humanistic workplace domains, with communication receiving the lowest rating indicative of organisational weakness. Conclusion: Profiling the factors associated with successful implementation of service reform informed the implementation planning and the efficient deployment of resources in a mental health service introducing cognitive therapies for psychosis into routine clinical care. The majority of staff had positive attitudes to the evidence based cognitive therapies allowing a focus on training and supervision and the development of supporting organisational elements. [ABSTRACT FROM AUTHOR]

Background: To evaluate the planned implementation of group based Cognitive Remediation therapy (CR) and Social Cognitive Interaction Training (SCIT) into routine psychosis care in a mental health service in Australia.Method: The study was conducted over 3 years in a mental health service in a metropolitan city in Australia. Participants were 22 program facilitators and 128 patients attending the programs. Implementation outcomes were assessed using administrative data, staff surveys and program audits.Results: There was fidelity to the particular therapies at a program level. Programs were assessed as being feasible within the study setting with each hospital district developing a capacity to run CR and SCIT. The establishment of new programs improved the reach, but waiting lists indicate a need to expand capacity. There was a relatively high dropout and several factors impacted on completion of the programs - notably, acute exacerbation of psychosis. Once initiated the therapies were acceptable with no-one ceasing SCIT due to loss of interest and only 10% of participants ceasing CR due to loss of interest. Annual audits of programs found programs established were maintained and facilitators were retained.Conclusion: SCIT and CR programs were successfully implemented in three hospital districts. Several factors impeded participants receiving the recommended "dose" of the programs. The maintenance of the programs in the short term is encouraging in regards to organisational fit. Dissemination of cognitive rehabilitation programs to a service population takes planning. An implementation plan is essential for guiding development and maintenance of programs. These therapies are best suited to people in a stable phase of illness. Service user co-production is recommended to improve recruitment in future studies. [ABSTRACT FROM AUTHOR]