Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

A cluster randomised controlled trial of a staff-training intervention in residential units for people with long-term mental illness in Portugal: the PromQual trial



This study aimed to assess the efficacy of a staff-training intervention to improve service users’ engagement in activities and quality of care, by means of a cluster randomised controlled trial.


All residential units with at least 12-h a day staff support (n = 23) were invited to participate. Quality of care was assessed with the Quality Indicator for Rehabilitative Care (QuIRC) filled online by the unit’s manager. Half the units (n = 12) were randomly assigned to continue providing treatment as usual, and half (n = 11) received a staff-training intervention that focused on skills for engaging service users in activities, with trainers working alongside staff to embed this learning in the service. The primary outcome was service users’ level of activity (measured with the Time Use Diary), reassessed at 4 and 8 months. Secondary outcomes were the quality of care provided (QuIRC), and service users’ quality of life (Manchester Short Assessment of Quality of Life) reassessed at 8 months. Generalized linear mixed effect models were used to assess the difference in outcomes between units in the two trial arms. The trial was registered with Current Controlled Trials (Ref NCT02366117).


Knowledge acquired by the staff during the initial workshops increased significantly (p ≤ 0.01). However, the intervention and comparison units did not differ significantly in primary and secondary outcomes at either follow-up.


The intervention increased the level of knowledge of staff without leading to an improvement in service users’ engagement in activities, quality of life, or quality of care in the units.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2


  1. 1.

    Priebe S, Badesconyi A, Fioritti A, Hansson L, Kilian R, Torres-Gonzales F, Turner T, Wiersma D (2005) Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries. Br Med J 330:123–126

  2. 2.

    Krupa T, McLean H, Eastabrook S, Bonham A, Baksh L (2003) Daily time use as a measure of community adjustment for persons served by assertive community treatment teams. Am J Occup Therapy 57(5):558–565

  3. 3.

    Shimitras L, Fossey E, Harvey C (2003) Time use of people living with schizophrenia in a North London catchment area. Br J Occup Therapy 66(2):46–54

  4. 4.

    Caldas de Almeida JM, Killaspy H (2011) Long-term mental health care for people with severe mental disorders. European Union, Luxembourg

  5. 5.

    Oshima I, Mino Y, Inomata Y (2003) Institutionalisation and schizophrenia in Japan: social environments and negative symptoms. Nationwide survey of in-patients. Br J Psychiatry 183(1):50–56. doi:10.1192/bjp.183.1.50

  6. 6.

    Wing JK, Brown GW (1970) Institutionalism and schizophrenia. Cambridge University Press, London

  7. 7.

    Savill M, Banks C, Khanom H, Priebe S (2015) Do negative symptoms of schizophrenia change over time? A meta-analysis of longitudinal data. Psychol Med 45:1613–1627

  8. 8.

    Bejerholm U, Eklund M (2007) Occupational engagement in persons with schizophrenia: relationships to self-related variables, psychopatology, and quality of life. Am J Occup Therapy 61(1):21–32

  9. 9.

    Cook A, Birrell M (2007) Defining an occupational therapy intervention for people with psychosis. Br J Occup Therapy 70(3):96–106

  10. 10.

    Cook S, Mundy T, Killaspy H, Taylor D, Freeman L, Craig T, King M (2016) Development of a staff training intervention for inpatient mental health rehabilitation units to increase service users’ engagement in activities. Br J Occup Therapy 79(3):144–152

  11. 11.

    Ministério da Saúde (2007) Relatório—Proposta de Plano de Acção para a Reestruturação e Desenvolvimento dos Serviços de Saúde Mental em Portugal 2007–2016. Lisboa

  12. 12.

    Cardoso G, Papoila A, Tomé G, Killaspy H, King M, Caldas-de-Almeida J (2016) Living conditions and quality of care in residential units for people with long-term mental illness in Portugal: a cross-sectional study. BMC Psychiatry 16:34. doi:10.1186/s12888-016-0743-7

  13. 13.

    Killaspy H, Marston L, Green N, Harrison I, Lean M, Cook S, Mundy T, Craig T, Holloway F, Leavey G, Koeser L, McCrone P, Arbuthnott M, Omar RZ, King M (2015) Clinical effectiveness of a staff training intervention in mental health inpatient rehabilitation units designed to increase patients’ engagement in activities (the Rehabilitation Effectiveness for Activities for Life [REAL] study): single-blind, cluster-randomised controlled trial. Lancet Psychiatry 2(1):38–48. doi:10.1016/S2215-0366(14)00050-9

  14. 14.

    Killaspy H, Cook S, Mundy T, Craig T, Holloway F, Leavey G, Marston L, McCrone P, Koeser L, Artbutnott M, Omar RZ, King M (2013) Study protocol: cluster randomised controlled trial to assess the clinical and cost effectiveness of a staff training intervention in inpatient mental health rehabilitation units in increasing service users’ engagement in activities. BMC Psychiatry 13:216

  15. 15.

    Killaspy H, White S, Wright C, Taylor TA, Turton P, Schützwohl M, Schuster M, Cervilla JA, Brangier P, Raboch J, Kališová L, Onchev G, Alexiev S, Mezzina R, Ridente P, Wiersma D, Visser E, Kiejna A, Adamowski T, Ploumpidis D, Gonidakis F, Caldas-de-Almeida J, Cardoso G, King MA (2011) The development of the Quality Indicator for Rehabilitative Care (QuIRC): a measure of best practice for facilities for people with longer term mental health problems. BMC Psychiatry 11:35. doi:10.1186/1471-244X-11-35

  16. 16.

    Hatton C, Emerson E, Robertson J, Gregory N, Kessissoglou S, Walsh PN (2004) The Resident Choice Scale: a measure to assess opportunities for self- determination in residential settings. J Intell Disabil Res 48:103–113

  17. 17.

    Priebe S, Huxley P, Knight S, Evans S (1999) Application and results of the Manchester Short Assessment of Quality of Life (MANSA). Int J Soc Psychiatry 45(1):7–12

  18. 18.

    Webb Y, Clifford P, Fowler V, Morgan C, Hanson M (2000) Comparing patients’ experience of mental health services in England: a five-trust survey. Int J Health Care Qual Assur 13:273–281

  19. 19.

    Røssberg JI, Friss S (2003) A suggested revision of the Ward Atmosphere Scale. Acta Psychiatr Scand 108:374–380

  20. 20.

    Jones SH, Thornicroft G, Coffey M, Dunn G (1995) A brief mental health outcome scale. Reliability and validity of the Global Assessment of Functioning (GAF). Br J Psychiatry 166:654–659

  21. 21.

    Doumit G, Gattellari M, Grimshaw J, O’Brien MA (2007) Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 1:CD000125

  22. 22.

    O’Brien MA, Freemantle N, Oxman AD, Wolf F, Davis DA, Herrin J (2001) Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 1:CD003030

  23. 23.

    Miller WR, Rollnick S (2002) Motivational interviewing: preparing people for change. Guilford Publications, New York

  24. 24.

    Prochaska JO, Norcross JC (2001) Stages of change. Psychotherapy 38:443–448

  25. 25.

    Jamtvedt G, Young JM, Kristoffersen DT, O’Brien MA, Oxman AD (2006) Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2:CD000259

  26. 26.

    Jolley S, Garety P, Ellet I, Kuipers E, Freeman D, Bebbington PE, Fowler DG, Dunn G (2006) A validation of a new measure of activity in psychosis. Schizophr Res 85:288–295

  27. 27.

    Lean M, Leavey G, Killaspy H, Green N, Harrison I, Cook S, Craig T, Holloway F, Arbuthnott M, King M (2015) Barriers to the sustainability of an intervention designed to improve patient engagement within NHS mental health rehabilitation units: a qualitative study nested within a randomised controlled trial. BMC Psychiatry 2(15):209. doi:10.1186/s12888-015-0592-9

Download references


We wish to thank the Directorate-General of Health of the Ministry of Health for their support, and the professionals and users involved in the intervention: Marta Ferraz, Maria João Casaca, Maria João Gaudêncio, Cláudia Catalão, Helena Carlos, Luísa Felgueiras, Ana Margarida Casimiro, Marta Nunes, Belarmino Ferreira, Sílvia Almeida, and Luís Pereira. We also thank Isabel Fazenda and José Ornelas for being project consultants, Deborah Taylor and Lara Freeman for the training of the PromQual intervention teams, Catarina Pacheco for the baseline assessments and data management, and Ana Rita Silva for confirming databases coherence. We acknowledge the work and support of members of the Maristán network in making these collaborations possible

Author information

GC, AP, HK, MK, and JCA designed the study. GC, MF, and GT oversaw data collection. GC and AP conducted the analyses and conceptualized and wrote most of the manuscript. All authors revised the manuscript and approved its final version.

Correspondence to Graça Cardoso.

Ethics declarations


This study was funded by the Directorate-General of Health of the Ministry of Health, and the funding agency had no role in the design or execution of the study.

Conflict of interest

The authors report no potential conflicts of interests.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 123 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Cardoso, G., Papoila, A., Tomé, G. et al. A cluster randomised controlled trial of a staff-training intervention in residential units for people with long-term mental illness in Portugal: the PromQual trial. Soc Psychiatry Psychiatr Epidemiol 52, 1435–1445 (2017).

Download citation


  • Intervention
  • Recovery
  • Residential units
  • Staff training
  • Severe mental illness