REFOCUS-PULSAR recovery-oriented practice training in specialist mental health care: a stepped-wedge cluster randomised controlled trial
Open accessAbstract
Background Recovery-oriented practice promotes the strengths and recovery potential of individuals. We aimed to establish whether individuals who access mental health services where staff have received the REFOCUS-PULSAR intervention, an adaptation of the UK's REFOCUS recovery-oriented staff intervention for use in Australia, show increased recovery compared with people using non-intervention services.Methods We did a pragmatic, two-step, stepped-wedge, randomised controlled trial at 18 sites grouped into 14 clusters across public mental health services and mental health community support services in Victoria, Australia. Eligible staff were working part-time or full-time in a direct service role at one of the 18 sites and had consumers being recruited for this study. Eligible consumers were receiving care from a participating cluster, with contact in the 3 months before data collection; aged 18-75 years; and not imprisoned. Clusters were randomly assigned with a web-based randomisation tool to receive the REFOCUS-PULSAR intervention in either the first year (step one) or second year (step two). Consumers, but not staff, were masked to treatment assignment. The primary outcome was the Questionnaire about the Process of Recovery (QPR), for which cross-sectional data were collected across three timepoints (baseline [T0], year 1 [T1], and year 2 [T2]). The primary analysis was done by intention to treat. This trial is registered with ANZCTR, number ACTRN12614000957695.Findings 190 staff (111 from public mental health services and 79 from mental health community support services) received the REFOCUS-PULSAR recovery-oriented training intervention. Between Sept 18, 2014, and May 19, 2017, 942 consumers were recruited across the three timepoints (T0: n=301; T1: n=334; T2: n=307). The mean QPR score was 53·6 (SD 16·3) in the control group and 54·4 (16·2) in the intervention group (adjusted difference 3·7, 95% CI 0·5-6·8; p=0·023). The Cohen's d value for the intervention effect was small (d=0·23).Interpretation The REFOCUS-PULSAR intervention had a small but significant effect on the QPRs of individuals using community mental health services and might be effective in promotion of recovery-oriented practice across sectors.Funding Victorian Government Mental Illness Research Fund.
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The QPR has been validated as a measure of personal recovery in the UK and Australia.
“The QPR has been validated as a measure of personal recovery in the UK and Australia [8, 26].”
From Consumers lived experiences and satisfaction with sub-acute mental health residential services (2024) · cites this paper as [8]
The Outcomes section (page unavailable) describes the QPR as a questionnaire used to assess personal recovery, and the trial uses it in Australia. The paper does not state that the QPR was validated in either the UK or Australia; its reference to a UK intervention concerns the training programme, not QPR validation. (LLM, conf=0.82)
Experimental — accuracy not yet measuredThe MASS has subsequently been used in other studies to measure service delivery satisfaction.
“it was adapted from a satisfaction survey developed by Rethink in the UK [27] and has subsequently been used in other studies to measure service delivery satisfaction [8, 29].”
From Consumers lived experiences and satisfaction with sub-acute mental health residential services (2024) · cites this paper as [8]
Average INSPIRE ratings of recovery-oriented support among PARC service participants were similar to previous UK findings but higher than those reported in the PULSAR trial.
“In comparison, average INSPIRE ratings of recovery-oriented support among PARC service participants were similar to previous UK findings but higher than those reported in the PULSAR trial, whereas their average INSPIRE ratings of relationships with workers were higher than those reported in all three previous studies.”
From Consumers lived experiences and satisfaction with sub-acute mental health residential services (2024) · cites this paper as [8]
Average INSPIRE ratings of relationships with workers among PARC service participants were higher than those reported in all three previous studies.
“In comparison, average INSPIRE ratings of recovery-oriented support among PARC service participants were similar to previous UK findings but higher than those reported in the PULSAR trial, whereas their average INSPIRE ratings of relationships with workers were higher than those reported in all three previous studies.”
From Consumers lived experiences and satisfaction with sub-acute mental health residential services (2024) · cites this paper as [8]
Only three of 18 controlled studies (17%) reported that the sample size was sufficiently large to be confident in the findings with at least 80% power.
“Only three of 18 studies (17%) reported that the sample size was sufficiently large enough to be confident in the findings with at least 80% power (Hugo et al. 2002;Forbes et al. 2012;Meadows et al. 2019).”
From Effect of community mental health care programs in Australia: A systematic review (2020) · cites this paper as Meadows et al. 2019
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Recovery orientation of services - Narrative review
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Shawyer, F., Wilson, K., Dhungana, R. R., Atkinson, B., Hipgrave, L., Dawadi, S., Enticott, J., & Meadows, G. N. (2026) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2026.1964444
Self-citation
- Authors
- Meadows, G., Brophy, L., Shawyer, F., Enticott, J. C., Fossey, E., Thornton, C. D., Weller, P. J., Wilson-Evered, E., Edan, V., & Slade, M.
- Affiliations
- The University of Melbourne (AU)
- Monash Health (AU)
- The University of Sydney (AU)
- Monash University (AU)
- RMIT University (AU)
- University of Nottingham (GB)
- Corresponding author
- Meadows, Graham
- ORCID
- Venue
- The Lancet Psychiatry
- Publisher
- Elsevier BV
- Published
- 2019-02
- Volume
- 6
- Issue
- 2
- Pages
- 103-114
- ISSN
- 2215-0366 (ISSN-L)
- OpenAlex
- W2909374653
- Cited by
- 59
- References
- 35
- Citations by year
- 2026: 4 · 2025: 8 · 2024: 6 · 2023: 5 · 2022: 8 · 2021: 14 · 2020: 8 · 2019: 6
- FWCI
- 12.27
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The Lancet Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Monash University Research Portal (Monash University) (acceptedVersion, other-oa)
- Repository@Nottingham (University of Nottingham) (acceptedVersion, other-oa)
- Minerva Access (University of Melbourne) (submittedVersion, other-oa)
- Victoria University Research Repository (Victoria University) (submittedVersion)
- RMIT Research Repository (RMIT University Library) (submittedVersion)
- Figshare (submittedVersion)
- Minerva Access (University of Melbourne) (submittedVersion)
- Funders
- U.S. Department of Health and Human Services
- National Institute for Health and Care Research (RP-PG-0707-10040)
- State Government of Victoria
- NIHR Nottingham Biomedical Research Centre
- Topics
- Health Sciences › Health Professions › General Health Professions › Mental Health and Patient Involvement
- Social Sciences › Psychology › Clinical Psychology › Psychiatric care and mental health services
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Keywords
- recovery-oriented care, staff training intervention, mental health services, public mental health services, recovery, strengths-based care, Victoria, Australia, mental health workforce development
- MeSH terms
- Mental Health Recovery, Adolescent, Adult, Aged, Mental Disorders, Cross-Sectional Studies, Female, Health Personnel, Humans, Male, Mental Health Services, Middle Aged, Surveys and Questionnaires, Victoria, Young Adult
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