A handbook for staff working in assertive outreach was developed with the involvement of service users and carers. A mental health trust explains how
Nathan Gregory, MSc, BSc, RMN, is community service manager; Rob Macpherson, MB ChB, MRC psych, MD, is consultant psychiatrist; both at 2gether Foundation Trust for Gloucestershire.
Gregory N, Macpherson R (2010) Assertive outreach handbook will aid mental health staff in maintaining client engagement. Nursing Times; 106: 7, early online publication.
The model of assertive outreach is one of the most internationally researched areas of community mental healthcare. An assertive outreach team at a mental health trust developed a handbook on the model, involving contributions from service users, carers, local clinicians and the voluntary sector. This article outlines the process of developing the handbook, and summarises its content and user feedback.
Keywords Assertive outreach, Mental health, Service user involvement
- This article has been double-blind peer reviewed
- Completing the handbook has inspired and motivated contributors currently working in the assertive outreach field, leading to further initiatives including attempts to develop a service user advisory group.
- The handbook is a useful resource for the extended team and has been disseminated widely, including to local universities where it can be used for training student nurses.
The vision for developing a handbook came from a group of managers and clinicians in the Gloucester assertive outreach team, who attended the annual conference of the National Forum for Assertive Outreach in 2006. During this event it became apparent that the influential UK assertive outreach book Manual for Practitioners (Burns and Firn, 2002) needed updating.
Although we had published articles on our work in assertive outreach, for example, on routine outcome measures (Macpherson et al, 2008), we felt local colleagues were extremely skilled and innovative, and the quality of their work had not been disseminated. We were also inspired by the participation of service users and carers involved in training and development projects.
The assertive outreach model (initially referred to as assertive community treatment) was first developed in the US during the 1980s (Stein and Test, 1980). The intention was to meet the complex heath and social care needs of people living in the community with severe mental health problems and to counteract sharply rising readmission rates.
The model is now delivered internationally. In the UK it has developed to support service users who are considered to be at high risk of disengaging from services, have a long history of severe and enduring mental health problems, high levels of social chaos, high use of inpatient beds and present with multiple, complex needs. National guidance recommends adopting this model, including The NHS Plan and the national service framework for mental health (Department of Health, 2000; 1999). There are now approximately 250 assertive outreach teams nationally.
Developing the handbook
Colleagues in the trust and national experts responded enthusiastically to the idea of the handbook, and so the process of drafting an outline handbook began. We secured support at an early stage from the trust chief executive, and the director of operations provided funding. The trust communication department supported us to ensure the handbook met internal and NHS guidelines for publication.
Initially we intended to produce a handbook of about 60-80 pages with about 16 contributors. However, over time the project grew with each revision, and following feedback from contributors, we continued adding sections to improve the design and make the handbook more user friendly. As it evolved, it was also influenced by key government publications, such as the NHS next stage review (DH, 2008).
We were determined to remain true to the original intention, which was to provide a tool to help people working in, or associated with, the work of assertive outreach teams. A key aim was to involve service users and carers at all stages.
We contacted colleagues from the voluntary sector, including Rethink and Gloucestershire Emergency Accommodation Resource (GEAR), who agreed to contribute chapters. National experts also made contributions, including the chair of the National Forum for Assertive Outreach. In total 58 contributors wrote individual sections, most of whom were colleagues working in assertive outreach in the trust.
How to use it
We hope that service users, carers or staff in a number of settings can use the handbook in whole or in parts. Staff can use it to explain the philosophy and style of assertive outreach work to service users or carers. There are many case discussions and vignettes, which could be used in training, either individually or in teams. The handbook may be useful for staff induction when practitioners are new to working in assertive outreach.
We believe the essence of good practice relies on developing positive, trusting relationships with service users and carers and relies on careful, reflective judgement. The handbook contains many examples of good practice points and descriptions of projects within teams, which have made a huge difference to service users, and sometimes to entire communities.
The handbook has 149 pages with 30 specific subject areas broken into sections. A group of chapters focus on engagement and developing therapeutic relationships, and these could be particularly useful to help those starting work in assertive outreach to understand the challenges and stresses of this work.
We included a list of useful websites and each section contains a list of recommended further reading. A glossary explains technical terms, and four key assessment scales used in assertive outreach are also included as appendices.
During the drafting process further key areas emerged, which led to requests for contributions at short notice; other chapters such as spirituality and values could not be included due to time constraints in this edition.
The finished product
The process of reviewing, editing and checking the chapters for accuracy, spelling and formatting was long and painstaking, although using an IT consultant was invaluable. It was important to set a final deadline for producing the handbook, in this case July 2009 for the NFAO Conference. With the benefit of hindsight, we would recommend involving a publisher from the start of the project.
Although we had hoped to develop a user led project to generate images for the handbook, this did not prove feasible. The trust communication department provided a photographer, who was skilled in photographing staff and service users in a way that made them appear relaxed. We believe the design of the handbook in its electronic format is easy to use.
Launch and dissemination
Three years after the initial idea, the handbook was officially launched at the NFAO annual conference in July 2009, where copies were distributed free of charge. It can be downloaded free on the 2gether Foundation Trust website or the NFAO website (click here). Paper copies are also available although we have tried to limit production of these, preferring an electronic format for environmental reasons.
Since producing the handbook we have received a range of positive comments including:
“This is a really exciting and highly useful handbook and I am looking forward to sharing it with the assertive outreach team” (consultant psychiatrist);
“It is easy to follow and has helped me to understand the work of assertive outreach, particularly when considering referring service users to the service” (early intervention social worker);
“I have given the handbook to medical and nursing students who have found it an invaluable aid to their induction into the assertive outreach team” (assertive outreach team manager).
We aim to revisit the handbook on a 3-5 year basis, updating chapters and providing new ones as required. We hope that over time, it will make a major contribution to service development in this important and rewarding area of practice.
An unexpected outcome is that the team has used the handbook to support applications for an NFAO demonstration site and the south west division of the Royal College of Psychiatrists innovation award, as well as a nomination for the NHS Gloucestershire Innovate award.
We hope the handbook demonstrates the importance of pursuing a collective, team based approach, and having the tenacity to see ideas through. Involving service users, carers and a range of colleagues throughout the process, although challenging, has been a richly rewarding experience for all involved, particularly the sense of achievement with the end product.
- Internationally, assertive outreach is one of the most researched models of community mental healthcare (Burns et al, 2007).
- UK studies suggest that compared with well organised, standard community mental health teams, the model has little impact on hospital admission rates or clinical wellbeing (Killaspy et al, 2006).
- Evidence has been more favourable on the effects of assertive outreach in maintaining engagement of clients at risk of disengaging from services (Weaver et al, 2003), and it has been reported to be popular with staff and service users (Killaspy, 2007).
Burns T et al (2007) Use of intensive case management to reduce time in hospital in people with severe mental illness: systematic review and meta-regression. British Medical Journal; 335: 7615, 336.
Burns T, Firn M (2002) Assertive Outreach in Mental Health. A Manual for Practitioners. Oxford: Oxford University Press.
Department of Health (2008) High Quality Care For All: NHS Next Stage Review Final Report. London: DH.
Department of Health (2000) The NHS Plan: A Plan for Investment, A Plan for Reform. London: DH.
Department of Health (1999) National Service Framework for Mental Health. London: DH.
Killaspy H (2007) Assertive community treatment in psychiatry. British Medical Journal; 335: 311-312.
Killaspy H et al (2006) The REACT study: randomised evaluation of assertive community treatment in north London. British Medical Journal; 332: 815-820.
Macpherson R et al (2008) The relationship between user, carer and staff perceptions of need in an assertive outreach team. Journal of MentalHealth; 17: 5, 452-461.
Stein L, Test M (1980) Alternative to mental hospital treatment. I. Conceptual model, treatment program, and clinical evaluation. Archives ofGeneral Psychiatry; 37: 392-397.
Weaver T et al (2003) Assessing the value of assertive outreach: qualitative study of process and outcome generation in the UK 700 trial. British Journal of Psychiatry; 183: 437-445.