Over the last three decades, the notion of recovery and adoption of recovery-oriented practice has gained prominence in mental health services (1, 2). Shifting from a dominant focus on symptom amelioration (3), recovery refers to a “deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles - a way of living a satisfying, hopeful and contributing life, even with limitations caused by illness” (4, p. 527). Recovery-oriented practice is grounded in the belief that individuals experiencing mental illness can recover. Practice should embody a collaborative and person-centred approach that fosters self-determination, choice, and hope (5).

Concurrent with shifts towards recovery-oriented practice, mental health services are increasingly expected to evaluate service delivery through use of routine outcome measures (6, 7). Routine outcome measurement was also introduced to support mental health workers in clinical decision-making and engaging consumers in care-planning (6, 8). Current routine outcome measures mandated in countries such as Australia include a mixture of clinician-rated (e.g., Health of the Nation Outcome Scales (9)) and self-rated (e.g., Behaviour and Symptom Identification Scale-32 (10)) measures that focus on symptomology, hospitalisation rates and level of functioning (7). However, in the context of moving towards recovery-oriented practice, Lakeman (11) and Happell (12) argued that mandating routine use of such symptom-focused measures does little to inform recovery-oriented approaches and is not aligned with what is meaningful to consumers in their recovery. Indeed, this may create barriers to recovery-oriented practice (13).

The ability to assess and measure recovery-focused outcomes from the consumer’s perspective supports the adoption of recovery-oriented practice (14, 15). Using self-rated recovery measures presents opportunities for workers to focus on what is important to individual consumers, and actively engage consumers through collaborative goal-setting and care-planning, all fundamental to recovery-oriented practice (16, 17). While mandating completion of a recovery measure by consumers would be antithetical to the choice and autonomy inherent in the concept of recovery, routinely offering it and explaining the benefits is valuable in developing recovery-oriented services.

Consequently, efforts have been made to establish psychometrically sound recovery measures that can be used for routine outcome measurement (18–20). However, none of these measures have been comprehensively examined for their feasibility, with typically only brevity explored. To support the uptake of self-rated recovery measures in routine practice, it is important that measures are not only psychometrically sound but also feasible. For example, low or variable completion rates of routine outcome measures are common (6, 7, 21) and these are often related to feasibility issues such as completion times, scoring complexity, unmet training needs, and, in particular, limited valuing of the measures by workers (22–26).

RAS-DS is a 38-item self-rated recovery measure that encompasses four recovery domains: “Doing things I value” (functional aspects), “Looking forward” (psychological aspects), “Mastering my illness” (symptom management), and “Connecting and belonging” (social aspects). Users rate items on a four point scale (1 untrue, 2 a bit true, 3 mostly true, 4 completely true). It was developed from the Recovery Assessment Scale (RAS) (27), with revised structure and items to address identified problems with RAS measurement properties (28). Formal training is not required to administer RAS-DS and a user-manual can be readily accessed online to guide workers (29). Items are all positively phrased so that a total recovery score can be obtained by simply adding all items and domain scores are obtained by averaging item scores in each domain. RAS-DS has demonstrated good reliability, validity, and sensitivity to change (30, 31). Beyond measuring outcomes, however, RAS-DS was designed as a tool to guide workers’ collaborative practice with consumers (29). It has been translated into 18 languages and uptake has been widespread across 26 countries. While these features make it a promising candidate for a routine outcome measure, little work has been done to establish its feasibility. Previous studies have suggested that it was relatively quick and easy to use and contributed towards goal-setting and the therapeutic alliance (31, 32). However these studies touched on feasibility issues in the context of broader analysis of measurement properties. Given the barriers to implementing routine outcome measures, a more comprehensive assessment of the feasibility of RAS-DS is required. The aim of this study was to explore the feasibility of RAS-DS in detail from the perspectives of mental health workers.

The purpose of this study was to examine the feasibility of RAS-DS in detail from workers’ perspectives. Overall, results support previous findings that have suggested that RAS-DS is easy to use and valued by consumers and workers for its ability to facilitate goal-setting, prompt discussions about recovery, and track recovery progress (31, 32). This study provides additional information and detail, however, especially about aspects of feasibility that most support routine use and aspects that warrant further consideration.

Applicability was the highest-rated feasibility domain of RAS-DS and a large proportion of participants described applicability aspects as what they found most useful about RAS-DS. This is promising as research has repeatedly demonstrated that workers are more willing to adopt routine measures that contribute to practice (25, 40) and promote discussions that inform care-planning (41–43). Free-text responses also show how RAS-DS can promote recovery-oriented practice. For example, understanding consumer perspectives, stimulating reflections on recovery and actively engaging consumers in goal-setting are seen as critical to ensuring that interventions are person-centred and meaningful to consumers (44). Some participants, however, indicated using RAS-DS in a more service-oriented way, for example, for staff to monitor individual progress or the overall impact of services. While a number of barriers have been found to workers implementing RAS-DS as a recovery planning tool rather than just an outcome measure (45), this study demonstrates its potential for use for many purposes. However, it is clear from the minority of participants who appeared to make little use of the results, that mandating RAS-DS is of little use if workers do not have the time, understanding or the will to use it as designed.

Despite many positive responses, some participants raised concerns regarding the acceptability of RAS-DS. First some participants found it was too long overall, or too long for certain consumers. Although RAS-DS takes most consumers 15 minutes or less to complete (31), this is worth considering given that workers are less likely to use tools they deem too long (22, 40). However, the same studies have concurrently evidenced that workers are more likely to use a tool they believe informs practice (22, 40). In the current study, some participants suggested that the length of RAS-DS was of lesser importance compared with its benefits and that the length was necessary to explore recovery holistically. A shorter measure, although more practical, may be less applicable. Crawford et al. (46) found that compared to shorter tools, consumers valued in-depth tools that examined different aspects of life and facilitated discussions. Therefore, this prompts the question: how brief should a measure be to be practical, whilst still applicable and useful to workers and consumers? Promotion of the benefits of RAS-DS for use as a recovery planning tool rather than just an outcome measure (45) and education around different ways to complete the RAS-DS, such as across multiple sessions, may help to alleviate this perception. However, further exploration of worker and consumer perspectives on how to achieve this balance is warranted.

Related to practicality, many participants believed additional support or training was needed to optimally use RAS-DS and its results to guide practice. The type of training provided on the use of a routine measure can be pivotal in determining whether it is used solely as an administrative tool or as a tool to guide and inform practice (47, 48). For self-rated measures such as RAS-DS, training focused on how they can be used collaboratively with consumers can increase workers’ perceptions of their value and facilitate uptake (22, 49). Although developing a tool that is easy to use with minimal training is critical for uptake (50), further consideration is needed to ensure that RAS-DS is used optimally and as intended. The authors have conducted additional research into the facilitators and barriers to using RAS-DS as more than an outcome measure (45) and, based on these findings, are currently developing an app that will incorporate guidance for workers on the implementation of RAS-DS and interpreting the results as well as support its use for recovery focused conversations and person-centred goal setting. This app will also address other practicality issues by eliminating the need for paper copies and by calculating scores, thus making the RAS-DS easier to use.

Some participants believed the usefulness of RAS-DS was dependent on consumer factors such as their understanding of their illness, mood, or how much they wanted to disclose. Similar criticisms have been reported previously with clinicians expressing concerns that consumers may over or under-represent their experiences and doubting the validity and results of self-rated measures if they did not align with their clinical judgement (51–53). However, considering the deeply personal and unique nature of recovery (4), it is argued that no one apart from consumers themselves can measure their recovery (54). Perhaps, workers should instead view differences in opinions as opportunities to further explore consumer perspectives and to develop shared understandings of consumers’ experiences. Further, consideration should be given to relational issues. Consumers may respond “strategically” if there was mistrust or fear about how their self-ratings would be interpreted and whether it would affect services they received (55, 56). Developing a strong and trusting therapeutic alliance with consumers is key in creating a safe environment for consumers to respond honestly when using self-rated measures (56).

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by The University of Sydney Human Research Ethics Committee. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

SR: Data curation, Formal Analysis, Investigation, Writing – original draft. JS: Conceptualization, Methodology, Supervision, Writing – original draft. AH: Formal Analysis, Writing – review & editing. NH: Methodology, Supervision, Writing – original draft.