Exploring Secure Recovery Knowledge, Skills, and Education Needs of Forensic Staff

Needs Assessment Survey

A needs assessment survey (available from the authors) was developed to explore staff knowledge, skills, and education needs, in addition to familiarity with and prior education in secure recovery. Survey questions were cocreated with an advisory council that included content experts in secure recovery, CAMH forensic division leadership, education specialists, and interprofessional forensic mental health care staff. Our team carefully considered the composition of the council to ensure equitable representation of social groups and patient advocates.

The survey included closed and open-ended questions regarding prior experiences and current interests in secure recovery education, as well as preferred teaching modalities (e.g., didactic lectures, small group discussion, case-based discussion, role play and simulation, use of videos). Questions also explored staff education needs and experiences of implementing secure recovery in practice, with explicit attention to the therapeutic alliance. Demographic information collected on the survey included age, gender identity, number of years worked in the forensic mental health system, ethnoracial background, and current professional role (see Appendix I).

The survey was emailed to all 300 clinical staff in the forensic division at the Centre for Addiction and Mental Health, including all physicians, psychologists, nurses, and allied health staff. The survey was administered electronically through REDCap (Research Electronic Data Capture, a secure web-based data collection platform) and took an average of 15 minutes to complete. Participation was voluntary and confidential. Survey responses (n = 108) were collected between July and September 2022 and included free-text responses, which were incorporated into the qualitative analysis below. Following data collection, investigators met with the advisory council for feedback on the survey results and to define areas for further exploration in the focus groups.

Focus Groups

Purposive sampling was used to select focus group participants to ensure that the diverse perspectives across disciplines in the hospital were adequately represented. As with the survey, eligible participants included frontline nurses, social workers, and recreational, behavioral, and occupational therapists working in the forensic program. Focus group participants were recruited via an email invitation. This email included information about the study, contact information, and a link to a survey with eligibility criteria. Eligible participants were directed to an informed consent form (ICF) page if they were interested in participating.

Four focus groups were conducted using Webex, a CAMH-approved online conference platform. Two focus groups were conducted with nurses and two with interdisciplinary allied health staff. Each group had between six to nine clinicians from various inpatient forensic teams, with the exception of one group, which had just two nurses participate. Participants in formal leadership roles (e.g., unit managers) were not in the same group as their direct reports to avoid perceptions of coercion and undue influence on responding. Focus group duration ranged from 50 to 90 minutes. Focus groups were recorded via Webex and transcribed either using the Webex transcription function or by a research assistant (the recording malfunctioned for one focus group, so the facilitator’s detailed notes were used for analysis). The study was approved by the Quality Performance and Ethics Review Panel at CAMH prior to the commencement of data collection.

Knowledge of Recovery-Oriented Care

Several staff reflected on various principles of recovery-oriented care. Many staff described a person-centered approach as central to recovery-oriented care. Staff described various approaches under the umbrella of “person-centered,” including facilitating a collaborative relationship with FSUs, promoting empowerment and autonomy, focusing on goals that are meaningful to FSUs, providing a personalized approach, and “meeting the person where they are at.” Many staff further described recovery-oriented care as a holistic approach that focuses on all aspects of a person’s life, including mental health, social connection, spiritual well being, employment, and housing. Staff also referenced the importance of cultural competency and acknowledged that limited awareness and a lack of shared lived experience can affect their ability to provide support. In addition, several staff broadly described recovery-oriented care as requiring a trauma-informed approach.

Further, many staff described recovery as a journey that does not follow a linear pathway and that a personalized approach is necessary. For example,Sometimes it’s hard to follow an…exact pathway as people have all different situations and for us, we might see people only for a short time or maybe for a slightly longer time they may be in different states of wellness. (Allied Health 1)

Although many staff demonstrated an understanding of recovery-oriented care, there was also evidence of interclinician differences in knowledge as well as variable preferences for a medical model (whereby care is more narrowly conceptualized as symptom management and restoring or maximizing functioning) versus a recovery-oriented one. Relatedly, some staff described different approaches to care that can operate at odds with recovery principles, such as an overemphasis on the medical model and a “corrections-like” culture.

Knowledge of Secure Recovery

In addition to recovery-oriented care more generally, staff also reflected on their knowledge of recovery-oriented care within the forensic setting (i.e., secure recovery). When reflecting on secure recovery, some staff described the need to strike a balance between a personalized approach that upholds recovery-oriented principles while managing FSUs’ level of risk in order for them to move through the forensic system safely. One participant described “tensions” that exist within team discussions when working along this continuum and managing this balance:We could benefit from being explicit in terms of…where we’re balancing secure recovery principles…I think teams are always kind of practicing in terms of secure recovery, so maybe it’s just like helping people to see where they are doing that…and like a lot of the tensions that exist within team discussions and risks that we’re taking versus protective measures that we’re taking and how that’s always kind of along that continuum. (Allied Health 3)

The ability to assess and manage risk in a manner that still aligns with recovery-oriented principles can be challenging. In this domain, one participant described the importance of integrating into the milieu and having ongoing engagement with FSUs, as opposed to an approach that is more detached and task-based:When you're integrated into the milieu more of like a direct supervision model where you’re within an embedded, you really can hear, see, smell, understand what’s happening and measure risk differently than if you’re behind a closed door. (Allied Health 4)

Staff also described a lack of shared understanding of secure recovery, which they believe acted as a barrier to its implementation. Staff saw a need for a more consistent understanding of secure recovery between FSUs, their families, within clinical teams, across disciplines, and at a systems level within leadership. In addition, some staff provided responses that suggested gaps in knowledge related to secure recovery. These responses did not articulate the meaning of recovery-oriented principles or go into depth about how this informed their work in a secure setting. Different approaches to care also emerged between allied health and nursing staff, with some allied health staff describing a “divide” in knowledge because of their different training, skills, and day-to-day job requirements. This gap in knowledge appeared to pertain especially to the use of risk- and recovery-oriented assessment tools, where allied health staff described having greater familiarity with these instruments. The variation in knowledge and skills across different professions was described as creating a “disconnect,” which in turn can affect the consistency of care that FSUs receive from different members of their clinical team.Right now it sounds a lot like it is individual practitioners using their own knowledge and using their own skills. Which is awesome, but also does have a huge disconnect between really everything. (Allied Health 6)

Staff also varied in their descriptions of the “end goal” of secure recovery. Some staff focused on the movement of the FSU through the forensic system, with hospital discharge or movement to a less secure environment as the desired outcome. Some staff focused on community reintegration as the outcome, whereas others focused on working in partnership with FSUs to support them in building a meaningful life, as they define it.

Integrating Recovery-Oriented Principles into Care

Staff identified several practices through which recovery-oriented principles are integrated into care. They described the importance of building a therapeutic alliance to foster trust and rapport and to promote safety and transparency with FSUs. Some strategies to develop a therapeutic alliance were identified, included taking a person-first approach, while also being transparent about the limits of the role. Building on the survey responses, which suggested high levels of confidence in engaging in shared decision-making, focus group participants identified collaborative goal setting as a key practice that promotes secure recovery. Some allied health staff described their skills in taking a personalized approach with FSUs and working toward goals that are personally meaningful while balancing that with risk management plans.

Some staff described the importance of empowerment in their practice. For staff, this meant actively involving FSUs in their own care, providing them with the resources and tools they need to maintain their recovery, and upholding autonomy and choice. Nursing staff identified strategies they use to promote choice and control, such as giving FSUs options in the day-to-day aspects of their care. Staff also described the importance of activities and programming that foster connections among clients, “create community,” and help to build trust and support for FSUs. Also noted was the importance of programming that extends beyond risk and risk management-related problems. They described the importance of fostering hope and optimism, which was perceived as necessary for motivating FSUs in their recovery.

Consistent with the survey findings, where just under half of respondents felt that power dynamics and different social categories affected their ability to support the recovery of FSUs, some staff described the forensic mental health system as oppressive with an inherent imbalance of power between staff and patients. This power imbalance can create challenges in developing a therapeutic alliance and reinforcing a dynamic where FSUs see themselves as passive in their own care. Some staff described the impact of their social position and identity on their ability to build a therapeutic alliance and create a sense of safety for FSUs. They also described the potential impact of unconscious bias and stereotypes (e.g., those related to race, gender, or culture) on care provision and a lack of shared ethnoracial backgrounds between staff and patients as potentially affecting outcomes. Staff identified strategies to minimize power imbalances, including reflexive practice (e.g., recognizing unconscious bias, privilege, assumptions, imposing of value systems, etc.), self-education, adapting their approach to meet the FSU’s needs, recognizing that FSUs are the experts of their own lives, and taking a “person-first” approach.

Integrating Recovery-Oriented Assessment Tools

Although allied health staff demonstrated good knowledge of risk and recovery-oriented tools, such as the HCR-20 and the DUNDRUM, some felt that this knowledge did not routinely affect clinical practice or enhance the shared understanding of treatment goals between patients and staff. Indeed, although half of survey respondents reported excellent or good knowledge of recovery-oriented assessment tools, fewer were confident in integrating such tools into their practice. In the focus groups, some staff expressed a belief that the tools should directly inform the creation of patient goals and treatment plans but that this does not always happen in practice.

Allied health staff also described a discrepancy between themselves and nursing staff in terms of their knowledge and skills in implementing risk and recovery-oriented assessment tools. In the focus groups, this was reported to undermine the practice of secure recovery, especially because nursing staff provide 24-7 care to FSUs and support the implementation of behavioral plans.I think there’s a heavy emphasis on ensuring that our allied health professionals are skilled and trained in those risk assessment tools and I think that’s great, and I think that’s absolutely necessary, but I would say that there is still a large gap among the nurses who are 24/7 care providers of our patients and who provide care on the weekends and they, what I see is just, they don’t have enough opportunities. (Allied Health 4)

Instead of an overarching approach informed by structured risk and recovery-oriented assessment tools, nursing staff described more discrete strategies to promote secure recovery. These included making the most of “small moments” to promote secure recovery, engaging with FSUs to build trust, and identifying opportunities to provide choice and control.

Training and Development

Expanding upon the survey responses, where over half of respondents expressed their view that education in recovery-oriented principles was insufficient, in the focus groups, some allied health staff described a “baptism by fire” when starting their forensic role. Here, they indicated that there was a lack of formal training for new hires about secure recovery implementation and a lack of information on the forensic mental health system more generally. One staff described having to “just learn on the go” and to pick up things from more senior staff when possible. A need for a comprehensive orientation to secure recovery and associated training was identified, consisting of content to support staff in understanding the forensic mental health system and secure recovery principles, and training on how to implement these principles effectively. The importance of having discipline-specific training that focuses on role expectations in the context of a secure recovery framework was also highlighted.

Some staff identified a further training gap with respect to the risk and recovery-oriented assessment instruments currently utilized within our MOC and indicated that everyone should have access to training in the administration of these assessment tools, including nursing staff. Some nursing staff recognized a need for training specific to the forensic population and broadly referenced the need for ongoing training in secure recovery.I think that we have a long way to go to make sure that also the nurses are provided with enough skills and training opportunity for those formalized risk assessment tools. (Allied Health 4)

Several staff described the need for education and training in competencies they believe will improve the implementation of secure recovery. This included training in psychotherapeutic interventions for addictions and trauma as well as other evidence-based treatment modalities (e.g., cognitive and dialectical behavioral therapy (CBT, DBT), motivational interviewing). Training and discipline-specific supervision in particular clinical skills (e.g., de-escalation training, building therapeutic alliances with people experiencing psychosis, interpersonal effectiveness training) were also discussed. Staff further highlighted the need for peer support to discuss complex cases and share resources or structured opportunities to continue practicing skills (e.g., a motivational interviewing community of practice). Finally, staff identified training needs to address power imbalances inherent to the forensic system, from social position or identity, unconscious bias, and stereotypes (as described above).

Policies and Procedures

Finally, staff described the need for standardized policies and procedures to concretize the implementation of secure recovery. This, ideally, would include the application of secure recovery principles within specific disciplines and across units and programs and would promote consistency with how an FSU should move through the system. They felt that this work could then inform the development of training booklets or guides to support staff. At the same time, given the personalized nature of care in secure recovery, one staff member felt that the opportunity to discuss specific cases with peers would be more beneficial than standardized procedures.