The Mental Health Rehabilitation Unit (MHRU) is a 20 bed declared facility. It opened in February 2009 as part of The Sutherland Hospital Mental Health Services.

The MHRU provides a safe setting utilising rehabilitation and recovery-oriented principles for people with severe and enduring mental illness. The MHRU multidisciplinary team comprises a variety of disciplines and roles: Nurses, Social Worker, Nursing Unit Manager, Health and Security Assistants, Occupational Therapist, Diversional Therapist, Consumer Worker, Hospital Assistants, Administration Officer and Medical Staff. Each individual brings a unique set of skills and experience to the team to provide holistic care to the clients.

As a new team and unit, a great opportunity existed to build a positive work culture and practices from 'the ground up' and we were unified in our enthusiasm to provide recovery-oriented care and interventions.

Prior to Essentials of Care (EOC), team members' suggestions for improved work processes and practices were challenged by traditional avenues for communication, such as monthly multidisciplinary team meetings and clinical handovers. These meetings often involved only clinical staff, centred on illness issues and allowed only limited reflection on practice and recovery-oriented interventions.

The principle of 'recovery' recognises the individual journeys of people with mental illness striving for new purpose and meaning in their lives despite the presence of symptoms (Anthony 1993).

Recovery-oriented practice positions the client as expert in their own life and sees health professionals as facilitators of care and enablers of a space in which hope, an essential ingredient of recovery, might be engendered (Glover 2005).

The MHRU team was committed to the principles of recovery but divided about how it could be practised within a medical model and locked hospital environment. Reflection prior to EOC showed the team was committed to change but did not have a mechanism by which to start.

A baseline Staff Satisfaction (SS) Survey was conducted in 2010 (Garcia 2010). Clinical and non-clinical team members were invited to reflect on their role, their own values and the culture within the team. 

The results showed that approximately 94% of respondents were happy with their work roles and felt part of the team. A concerning minority (6%) however indicated they did not feel part of the team.

Responses were also divided in areas such as communication and team culture. Approximately 27% of respondents for example felt unable to or uncertain about expressing their views as part of the team's decision making processes (see Figure 1).

In addition, exactly half (50%) of the MHRU team members disagreed or were ambivalent about the team having a positive attitude at the time of the survey (see Figure 2).

While the SS survey results overall highlighted many team strengths, the above items revealed an underlying negativity and less-than-satisfying mechanisms for team discussion and decision-making. It was clear that further development of the team and culture within the MHRU was required.

But how to start? It was around this time that the team was oriented to and invited to participate in the EOC program.

In March 2010 EOC was voted in by a majority of the team. There were representatives from each discipline and standing invitations to the medical team to attend initial meetings. The recovery philosophy of the MHRU practice strongly influenced the implementation of EOC. It was apparent that if we really wanted to be 'recovery-oriented, the involvement of MHRU clients in EOC was essential to ensure their voices were heard.

To achieve this, fortnightly EOC meetings were held, with identical sessions for staff and clients. Claims, concerns and issues were explored and values clarification sessions held. These sessions allowed us to constructively discuss issues emerging from the SS survey. While team strengths were acknowledged, concerns about communication and some team processes were openly explored.

Some team members described feeling "out of the loop". One client said: "I like activities that involve us equally". Notably, staff and clients alike expressed frustration about trying to apply principles of recovery in a locked MHRU.

EOC has contributed significantly to our work culture by providing opportunities for facilitated reflection on our team values and how to make these tangible on a day-to-day basis.

EOC meetings have provided a constructive forum in which staff and clients can have a voice and share ideas for improving the way we do things.

Strategies for broader communication within the team have been developed:

• An EOC newsletter is emailed to all team members after each EOC meeting for those who could not attend
• An EOC notice board has been placed in the staff lunch room to display creative work and records of discussions held in EOC meetings. This has taken on a life of its own, becoming an interactive platform for all team members to contribute.

Strategies to encourage ongoing client participation in MHRU processes have been implemented. These include bi-monthly client surveys to capture client interests, group planning meetings and regular 'complaints and compliments' sessions led by the MHRU Consumer Worker.

The monthly MHRU in-service program has been opened to both staff and clients including information sessions from external community agencies.

The MHRU has now completed the 'Preparation' phase of EOC culminating in a shared values visual image: 'Roads to Recovery' as seen at the head of this paper.

This is a joint project by staff, clients and an art therapy student on placement to the MHRU. The plan is to paint the image on large canvas to be hung in the reception area of the MHRU. The team's shared values will be handwritten onto the image to welcome clients, carers, staff and visitors on entry to the MHRU.

'Roads to Recovery' represents the individual recovery journeys of MHRU clients as well as being a metaphor for the evolving journey of EoC in the MHRU. New values will be added as the team grows and develops over time.

As we move into the 'Assessment' phase of EoC, new challenges and opportunities will undoubtedly present. The SS survey will be repeated to provide a snapshot of the team's progress a year on. 

As a relatively new team the MHRU is using the EOC process to build a shared vision and work culture from the ground up. The exciting thing is that through EOC, collaboration and inclusivity are becoming the standard for communication and policy development in the MHRU.

Not only has EOC assisted with creating a team culture that encourages change and new ideas, it has created a space for ongoing reflection within the team. The 'Roads to Recovery' will continue to lead us toward improved practice and the best possible outcomes for the clients we work alongside of.

• Anthony, W. A. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990's.  Psychosocial Rehabilitation Journal, Vol 16, no.4, pp 11-23.
• Garcia, S (2010). MHRU Staff Satisfaction Survey Results.
• Glover, H (2005). Recovery Based Service Delivery: are we ready to transform words into paradigm shift?. Australian E-Journal for the Advancement of Mental Health, Vol 4, no.3, pp. 1-4.
• Farkas, M., Gagne, G., Anthony, W., Chamberlin, J. (2005). Implementing Recovery Oriented Evidence Based Programs: Identifying Critical Dimensions. Community Mental Health Journal, Vol 41, no.2, pp. 141-158.