Recovery-oriented practices and role perceptions of healthcare staff providing community-based mental healthcare as team in Central and Eastern Europe: an observational study

Background: CMHTs deliver healthcare that supports the recovery of people with mental illness. They should achieve a sucient level of good quality teamwork, composed of individual professional skills as well their adaptation within the clearly dened roles in teams in order to work eciently. This paper analyses to what extent team members of ve CMHTs newly implemented in ve countries had introduced aspects of the recovery-oriented approach and evaluates what the team members’ perceptions on their collaborative care roles and their level of condence with this role are. Method: A quantitative survey was administered among 66 professionals and peer worker including the Recovery Self-Assessment Tool Provider Version (RSA-P), the Team Member Self-Assessment Tool (TMSA), and demographic questions. Result: The RSA-P showed that all teams had the perception that they provide recovery–oriented practice to a moderately high degree after a training week on recovery-oriented care. Healthcare providers with fewer years of professional experience perceived more frequently that they operated in a recovery-oriented way (p=0.036, B -0.268). Nurses and peer workers did not feel condent or responsible to full specic roles. Conclusion: Trainings on community-based practices and collaborative teamwork may facilitates recovery-oriented care and helps to improve team cohesion. Person in recovery, Family member/advocate, provider, and CEOs/Directors. In this study the provider version (RSA-P) was used. The measure covers the following ve subscales: Life Goals, Involvement, Diversity of Treatment Options, Choice, and Individually Tailored Services. The Life Goal domain refers to the extent to which staff helps with the development and achievement of life goals based on the preferences of the patient. Involvement indicates to what degree healthcare provider and clients perceive that clients are involved in their healthcare and in decision-making. Diversity of Treatment Option Subscale refers to what extend the healthcare organisation provides different treatment options and supports clients to get involved in non-mental health activities. The Choice domain indicates to what degree healthcare provider and clients feel that choices are available to clients and if the choice is respected. The subscale Individually Tailored Services refers to the perception that healthcare services are tailored to individuals’ personal needs, culture and affectations (27). Higher scores indicate a greater degree of implementation of recovery-oriented practices (24).

Boundaries between the profession can act as barrier and in uence communication and coordination negatively which has an impact on patient safety and care integration (19). Previous research shows that not all healthcare providers work effectively in a multidisciplinary team (18). Unclear role allocation, lack of clarity regarding leadership can also hinder team functioning (18).
Research has shown that comprehensive community-based mental health services lead to an improvement in healthcare and patient outcomes, including quality of life, treatment adherence, healthcare accessibility, and social outcomes (6,(20)(21)(22). Additionally, CMHTs reduce the number of days spent in hospital, increase patient satisfaction, reduce suicide rates, and number of admissions to the hospital (6,18). Furthermore, most people with SMI favour recovery-oriented healthcare services provided in their community in order to participate in social life and sustain employment (13,15,16).
These insights have led to the design and implementation of CMHTs for providing inclusive mental healthcare based on the recovery-oriented approach and social support in ve sites in ve Central and Eastern European countries within the Large-scale implementation of community-based mental health care for people with severe and enduring mental ill health in Europe project (RECOVER-E) (23). The ultimate aim of the RECOVER-E project is to implement and evaluate multidisciplinary CMHTs delivering care in a recovery-oriented way to people with SMI and compare it to the treatment as usual on three levels: 1) patients outcome, 2) team members; and 3) socioeconomic evaluation (23).
The present study aimed to assess to what extent members of the ve CMHTs in ve sites had introduced aspects of the recovery-oriented approach after they received a one-week training on the recovery-oriented approach to care for people with SMI in community settings aimed to support the organisation of the their local CMHTs. The secondary aim was to evaluate what the team members' perceptions on their collaborative care roles and their level of con dence with this role, according to their background profession.

Study Design
The research presented in this manuscript is part of the RECOVER-E project, a European research project with ve patient-randomized trials on the implementation of community-based mental healthcare for people SMI (23). In each of the ve sites, the study was designed as a clinical and health-economic evaluation on the basis of a hybrid effectiveness-implementation trial, which assesses both implementation outcomes and patient health outcomes. Each of the ve hybrid trials is conducted as pragmatic randomised trial in two parallel groups with measurements among service users and healthcare providers (members of the CMHTs within each site).
The present study reports the ndings from a paper-based survey among all team members of the CMHTs in each project site at local start of the study, after having completed a one-week training session on the concept of CMHT and the principles of the recovery-oriented practice approach. The local research teams were responsible to distribute the survey to the CMHT members after the training.

Study setting
Community mental health teams were established and implemented in Croatia, Zagreb; Montenegro, Kotor; Romania, Siret; North Macedonia, Skopje; and Bulgaria, So a ( Table 1). The full rationale and selection criteria for these sites is described in a prior publication (23). Table 1: Characteristics of the study settings/project sites Participants Healthcare providers were eligible for joining the CMHT and then participating in the study if they were over the age of 18 working with people with SMI in the ve project sites. Additionally, peer workers (persons with lived experience of a SMI). over the age of 18 were asked to join the CMHT and to participated in this study. Each team had to consist of at least one nurse, psychiatrist, psychologist, social worker, and a peer worker. Healthcare professional and peer worker were excluded if they did not meet the inclusion criteria, did not give consent to participate in this study, or were not able to give consent to participate. Each team member of each project site participated on a voluntary basis and gave consent prior to the start of the study. Sampling and recruitment were organised by the local research team in each project site individually.

Sampling and recruitment
Zagreb, Croatia During a daily meeting at the department of psychiatry at the University Hospital Centre Zagreb (ZUHC) the RECOVER-E project and its goals were presented. Healthcare professionals who were interested in this topic could approach the local principal investigator and decide if they want to participate. All healthcare professionals who accepted to become a part of the CMHT participated in this study, and were employees of the ZUHC. Peer workers were recruited from patients that were treated at the ZUHC due to SMI and were recovered during psychosocial treatment afterwards.

Kotor, Montenegro
In Montenegro CMHT members were employed by the Special Psychiatric Hospital in Kotor. They have been selected by the director of the clinic based on their commitment to work, their previous work results and on their own motivation and interest to work in this kind of programme and their awareness of the need to provide more than just hospital-based services for service users. The directors explained the project and the nature of the study and asked if they want to participate on a voluntary basis. In early October 2018 three peer worker were recruited from a group of locally treated clients at the hospital and the Mental Health Centre in Kotor. Inclusion criteria were a presence of severe mental health disorder, the willingness to participate in working activities of mental health team, and the capacity to offer peer support based on the opinion of the treating psychiatrist. All healthcare proffesionals and peer workers who accepted to become a part of the CMHT participated in this study.

Siret, Romania
In Romania CMHT members were selected out of the people working at the hospital in Siret by the local principle investigator. All team members were willing to spend some of their free time on pioneering a new service in mental health. Moreover, they were the most active during the on-site training provided by the project coordination. The peer worker was selected together by the social worker, psychiatrist and psychologist based on their professional experience.
All healthcare professionals and the peer worker who accepted to become a part of the CMHT participated in this study.

Skopje, North Macedonia
All CMHT members were employed at the University Clinic of Psychiatry Skopje and were recruited by the directors of the clinic. They selected the employees based on their willingness and motivation to try something new. The directors explained the project and the nature of the study and asked if they want to participate. The two peer workers, who were recruited, were treated at the clinic due to SMI previously and were recovered during psychosocial treatment. They are not employed at the clinic but were also selected by the directors of the clinic. Everybody took part in the rst training that was organized in Skopje. All healthcare professionals and the peer worker who accepted to become a part of the CMHT also decided to participated in this study. Six members went to the second training in the Netherlands and updated the others.

So a, Bulgaria
Healthcare providers were recruited by the director of the MHC Shipkovenski. They decided on a voluntary basis if they want to participate in this project. All CMHT members were employed at the MHC "Prof. N. Shipkovenski" a hospital for the district So a. The psychiatrists who work at the MHC Shipkovenski and those who collaborate with the centre suggested patients who were interested to ll in the role as peer workers. The director of the MHC Shipkovenski selected ten potential participants which participated in the training in July 2019. Three of them were invited and agreed to participate in the project. All healthcare professionals and the peer worker who accepted to become a part of the CMHT also decided to participated in this study.
Training on recovery-oriented practices After members of the CMHTs were appointed by each mental health service in the ve sites, CMHT members participated in a two-week training programme, with one week of the training carried out in their home country and one week as an intensive site visit and training week in the Netherlands, hosted by GGZ Noord-Holland-Noord. In this training, healthcare professionals had the chance to improve their understanding of community based mental health approaches, with the aim of being able to implement a cohesive team in their city or district. The training programme for the CMHT were developed by a multidisciplinary Expert Panel (including a peer worker) and reviewed closely by the implementation site coordinators for local relevance and adaptation. The training covered key components of community mental health care, working with a shared caseload, and home treatments. It focused on building the handson skills and competencies necessary for delivering high quality community care, as well as working with peer specialists and families. A substantial component of the training (and subsequent mentoring and hands-on coaching) focused on the most di cult change process in building a sustainable CMHT, which is changing the mindset from viewing treatment for people with SMI as custodial (protection from communities/societies, care in institutions and hospitals) and shift to perceiving services as an aid to a meaningful life in the community.

Data collection
Data was collected using a paper-based survey administered among CMHT members at the local start of the study during a staff meeting in each site by the local research team after the rst week of training in their home country ( Table   2). The questionnaire items had been translated prior to the start of the study at each site into the local language by members of the local research team who were uent in English and in the local language and back translated. It took the team members approximately 15 to 20 minutes to complete the questionnaire. An informed consent was signed by all selected staff members prior to the start of the study. The sociodemographic part of the questionnaire included questions such as year of birth, sex, profession, years of professional experience, and place of work.
Recovery Self-Assessment (RSA-Provider Version) The Recovery Self-Assessment (RSA) is a 32-item measure developed to assess to what degree a program implements recovery-oriented practice (24). It is a self-re ective tool that is designed to identify efforts made by healthcare agencies to provided recovery-oriented care. Research has shown that the RSA has moderate to strong internal reliability (Cronbach's α 0.63 -0.90) (24)(25)(26)(27). Response options include a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree) and two additional answering options (Don't know and Not Applicable) (28). There are four different Adjust Treatment if Patients are not responding, and other tasks Important for our Program. Response options for the rst question "Is this your role" include yes or no. Answering option for the second question "Your level of comfort with this task" include high or medium/low.

Data analysis
All questionnaires were included in the analysis. Prior to analysis, all variables were checked for data entry errors and missing values. The two response options ('Don't Know' and 'Not Applicable') were set as user missing value when conducting the rst analysis since this is a common method for categorial variables with response options like 'Not Applicable' or 'Don't Know'. Then the standard technique to calculate scale scores for each subscale of the RSA-P was used (30). This meant that, for each subscale all associate items were summarized and aggregate measures were constructed for further analysis for the whole sample as well as per project site. This method only allows for a few missing values. Thus, items with a high number (n > 6) of 'Not Applicable' responses were reviewed and discussed with the local research teams of each site to understand in what way this response option was interpreted by the CMHT members who completed the questionnaire. Most of these items turned out to be relating to services/treatment options which were not offered by the hospitals, the mental health institutes or not within the scope of the RECOVER-E project.
Thus, the answering option 'Not Applicable' was combined with 'Strongly Disagree' in the second and nal analysis, as both indicated that those services were not provided. Bivariate linear regression analyses were applied to explore the impact of predictors on the ve aggregate measures for the whole sample. Predictors with signi cant effects were included in multiple regression models, albeit these were considered as highly tentative given the small sample size. The internal consistency of the RSA-P and its ve subscales were evaluated using Cronbach's alpha coe cient.
Descriptive statistics were used to calculate the means and standard deviations for continuous variables and frequencies and percentages for categorical variables for the TMSA tool and demographic data. For interpretation of the ndings the cut-off points for the TMSA tool for each profession was 50% indicated that half of the given profession felt like a listed role is their responsibility or that half of them felt con dent to ful l these roles. Two participants indicated 'other' as profession and were excluded TMSA analysis. Data was analysed with the Statistical Package for Social Science SPSS version 25 (31). Statistical signi cance was de ned as p<0.05.

Results
Description of the sample All team members from each site lled in the questionnaire (n=66). Table 3 presents the descriptive characteristics of the sample categorised by countries. The largest community mental health team was the Croatian team with 21 (31.8% of the total sample), the smallest team was the Romanian team with 6 (9.1% of the sample) individuals. Of the total study population 65.2% (n=43) were female. The mean age was 40.02 (SD=10.96) years. A third of the participating professionals were nurses (31.8%). A vast majority of the healthcare professionals had more than ve years of experience.
Recovery Self-Assessment Provider Version (RSA-P) Overall Recovery Self-Assessment Scale The members of the CMHT in Romania and Bulgarian reported the highest means of the RSA-P subscales, with an overall scale 4.46 (SD 0.327) and 4.46 (SD 0.211), respectively. The team members of the Croatian team reported an overall mean of 4.16 (SD 0.404). The lowest means were indicated by the Macedonian team 4.05 (SD 0.694) and the Montenegrin team 3.58 (SD 0.275). This pattern was similar for the different subscales (Table 4). Associations between individual characteristics and Recovery Self-Assessment Profession (p=0.029, beta coe cient= 0.271) and professional experience (p=0.008, beta coe cient= -0.328) were associated with the total RSA-P score. However, only professional experience (p=0.036, beta coe cient= -0.268) remained signi cant in the multiple regression analysis with both predictors. The effect of professional experience on the total RSA-P implied that healthcare providers with fewer years of professional experience were more likely to perceive that their healthcare practice operated recovery-oriented compared to team members with more years of professional experience.
RSA-P-Subscales: The amount of professional experience had an impact on the degree to what healthcare provider perceived choices are available to clients and if these choices are respected (p=0.027, beta coe cient= -0.286). More speci cally, professionals with fewer years of professional experience were more likely to perceive that individual choices are available to clients and that these choices are respected than with team members with more years of work experience. Additionally, work experience (p=0.003, beta coe cient= -0.357) and profession (p=0.012, beta coe cient= 0.311) were associated with the extent to which staff helps with the development and achievement of life goals based on the preferences of the patients. In the multiple regression analysis with both predictors, only professional experience remained signi cant (p=0.023, beta coe cient= -0.286,). Thus, CMHT members with more years of professional experience perceived that their role was less supportive regarding helping clients with achieving and developing their individual life goals. Healthcare provider with less years of work experience had a higher tendency to perceive that clients are involved in their healthcare and in decision-making compared to their those with more years of experience (p=0.016, beta coe cient= -0.311). Professionals with more years of work experience felt less like their healthcare organisation provides different treatment options or supports clients to get involved in non-mental health activities (p=0.017, beta coe cient= -0.302). The expected effect of professional experience on the subscale Individually Tailored Services was not signi cant although close (p=0.051, beta coe cient= -0.251).

Team Member Self-Assessment
The ndings of the TMSA are reported by professions. More than 50% indicate that a majority of members of a profession saw themselves in a certain role and/or felt highly con dent in ful lling these roles. The questionnaire was completed after the healthcare professionals received the rst week of training, and started to work as CMHTs. Thus, it is to expected they evaluated their role and responsibilities within the team.
Nurses: A large majority of the nurses (n=81.0%) saw themselves in the role of identifying and engaging patients.
Nevertheless, only a small number (n=33.3%) stated that they feel highly con dent to ful l the different responsibilities within this role on the CMHT. A third stated that diagnosing behavioural health disorders is their responsibility (n= 33.3%). Over 50% also saw themselves as having a role in tracking treatment outcomes, although only a few felt con dent to ful l this role. A vast majority of nurses saw their role in different responsibilities within this role as well, such as by conducting behavioural health assessments, developing and updating behavioural health treatment plans, educating patient about symptoms and treatment option, brief counselling, activity scheduling, behavioural activation, facilitating referral to specialty care or social services, and creating and supporting relapse prevention plan. However, only a few felt con dent to ful l these responsibilities. A large majority of nurses also stated that proactively adjust treatment if patients are not responding is their role, however less than a third of them felt con dent to ful l these roles.
Although other tasks like e.g. administrative support for program (scheduling, resources) is a role more than 50% of the nurses also saw themselves in, only a few felt con dent to ful l these roles (Table 5 -7).
Psychiatrists: The large majority of psychiatrists saw themselves in all listed roles, and also felt con dent to ful l these roles. They particularly identi ed with the role of tracking treatment outcomes and initiating and providing treatment (Table 5 -7).
Psychologists: A vast majority of psychologists identi ed with all roles listed and felt highly con dent to ful l these roles. Although they felt like they were responsible for some tasks such as prescribing psychotropic medications, patient education about medications and side effects, identifying and treating coexisting medical conditions, and facilitating referral to specialty care or social services of within the role of tracking treatment outcomes, they saw themselves more in the roles of identifying and engaging patients and initiating and providing treatment (Table 5 -7).
Social workers: A majority of social workers saw themselves in all roles listed, but did not feel con dent to ful l these roles. All social workers stated that they were responsible for identifying people who may need help, engaging patients and introducing the care team to the patient. Interestingly, all social workers saw themselves in the role of tracking outcome of referrals and other treatments, but only two felt con dent to ful l this role (n=25.0%). Initiate and provide treatment is a role mainly psychiatrists identi ed with; however, all social workers stated that they saw themselves in facilitate referral to specialty care or social services and create and support relapse prevention plans, and indicated feeling highly con dent to ful l these tasks (Table 5 -7).
Peer workers: Almost all peer workers saw themselves in the role of engaging patients in the care program and introduce care team to the patient (n=78.6%), only around a third felt con dent to ful l this role (n=28.6%). Interestingly, more than half of peer workers saw themselves in the role of tracking treatment outcomes, except for tracking patients' symptoms with measurement tools, although they did not feel con dent to ful l this role. They also stated to be responsible for some tasks within the role of initiating and providing treatment like performing behavioural health assessment, develop and update behavioural health treatment plan, patient education about symptoms and treatment option, and brief counselling, activity scheduling, behavioural activation. However, they only felt con dent to ful l the task of educating patients about symptoms and treatment options. Less than 50% felt responsible for the role of proactively adjusting treatment if patients are not responding. Half of the peer workers identi ed with the role of ful lling other tasks important for the program, nevertheless only a few felt con dent enough to ful l this role (Table 5 -7).

Discussion
The overall aim of this study was to explore to what degree members of the ve CMHTs had introduced aspects of the recovery-oriented practice in community settings after they received the rst week of a two-weeks of training session covering the concept of recovery-oriented practice and started to work as CMHT. The secondary aim was to evaluate what the team members think about what collaborative care roles they currently practice within the CMHT, how con dent they feel with this role, and to explore differences between the professions involved.
In general, we found out that all CMHTs had the perception that they provide recovery-oriented practices to a moderately high degree base on the ndings of the RSA-P. Nevertheless, speci c aspects such as connecting clients with self-help, peer support or advocacy groups and programs, and encouraging them to attend advisory boards and management meetings showed room for enhanced implementation. Healthcare professionals with less professional experience had the tendency to perceive that their healthcare practice implemented recovery-oriented practice compared to team members with a higher degree of professional experience. Nurses saw themselves mainly in the role of identifying and engaging patients, tracking treatment outcomes, proactively adjusting treatment if patients are not responding and other tasks important for this project. Nevertheless, compared to the psychiatrists and psychologists, most of the nurses did not feel con dent to ful l speci c roles. Psychiatrists, psychologists, and social workers saw themselves in almost all roles listed. In comparison with the psychologists and social workers, psychiatrists felt highly con dent to ful l each role. Peer workers mainly saw themselves in the role of engaging patients and ful l other tasks important to the project. Nevertheless, they did not feel con dent to ful l speci c roles. Interestingly, a majority of peer workers saw themselves in roles included within the domain of track treatment outcomes and initiate and provide treatment.
In 2013, the WHO released the Mental Health Action Plan (32) stating the need for availability of recovery-oriented mental health services in the community. In our study, all CMHTs had already introduced various aspects of recoveryoriented practices. However, it needs to be considered that most team members were highly enthusiastic about community care prior to the start of the project which might had a positive impact on the results. This ndings are consistent with those by Simmonds et al. (22), they reported that a high level of enthusiasm for community care has been seen by all members of CMHTs which have been evaluated. Nevertheless, it cannot be concluded that enthusiasm and motivation alone have an impact on the quality of care provided by healthcare professionals. Additionally, members of each CMHTs of this study have been selected by the research team based on their commitment or were motivated to be part of this project. Thus, it is possible that the motivation to provide recovery-oriented care within the teams is higher compared to healthcare providers who have not been selected or are not interested in community care. These ndings are consistent with those by Malone et al. (6). They conducted a systematic review on the effects of CMHT management compared to non-research CMHT management. All healthcare professional working as CMHT included in their review have been selected or linked to the research programme. Hence, it is not clear if the results can be generalised from selected or highly committed professionals to non-selected professionals. The same applies to the ndings of this study. The members of each CMHT of this study attended the rst week of two-weeks training on the concept of recovery provided by the coordinating project team. This training might have a positive impact on the perceptions of the healthcare provider regarding degree of recovery-oriented care within their organisation. These ndings agree with those of Hornik-Lurie et al. (12). In their study they found out that staff which had been trained in recovery-oriented interventions had higher perceptions of recovery-oriented care compared to nontrained staff (12). Thus, training on recovery-oriented practices may be an effective strategy to facilitate implementation of this care approach.
In this study, higher RSA-P scores and thus the tendency to perceive that more aspects of recovery-oriented practice were introduced were detected in healthcare professionals with limited professional experience. Since the Substance Abuse and Mental Health Services Administration (SAMHSA) of the US incorporated a curriculum on recovery-oriented care into the training of mental health professionals in 2009, the recovery-oriented approach has become more conversant (33). Thus, it is possible that the younger generation is more trained in the principles of the recovery-oriented approach due to changes to the curriculum over the last years (33).
CMHT members of this study, especially nurses and peer workers, are not always aware of their role or responsibilities or do not feel con dent to ful l speci c roles. It makes sense that for example nurses do not feel con dent doing some of the tasks that a psychiatrist usually does, as it is not necessarily their role in the teams, it may be something that they have not been trained for and/or it is something that they are legally not allowed to. Moreover, it may be due to the speci c training/education these professionals acquire through their university career as well as longstanding traditions. In Croatia for example university level education of nurses is very new (34). Thus, nurses may have not yet acquired their professional identity. This might have an impact on how nurses identi ed with certain roles and responsibilities. Additionally, peer workers, in general, do not have any speci c peer support education to de ne their professional identity. This ndings are consistent with those by Carpenter et al. (35); in their study they investigated the impact of working in multidisciplinary CMHTs in North England on social workers and health professionals. They particularly examined the relationship between team identi cation, team functioning, psychological well-being and job satisfaction (35). Although they found out that there is a moderate to high level of role clarity within the members of CMHTs, various role con icts were detected (35). Con icts included disagreements between professions or discipline, workload, misunderstandings of roles and responsibilities or an increase in paperwork (35). Carpenter et al. (35) concluded that role clarity promoted job satisfaction and decreases work related stress. In our study role clarity seems to be problematic, thus con icts and disagreements may be pre-programmed. In addition, psychiatrists, psychologist, and social workers saw themselves in almost all listed roles, regardless of being con dent to ful l those roles, an unclear division of roles impeded effective team collaboration and cooperation. The existing stigmatisation in the society and among healthcare professionals may had an impact on the role of peer workers. The fact that peer workers are more and more involved in providing mental health care requires a huge shift in the way mental health professionals think. Additionally, the level of self-stigmatisation among peers may be very high and in uencing these results of this study as well (36).
Another source of role con ict detected by Carpenter et al. (35) was inadequate allocation of resources for people with SMI e.g. access to appropriate service based on individual needs. These ndings agree with those by Singh (18), in his study he reported that the rapid reduction of beds for people with SMI had an negative impact on the care provided by CMHTs. Although CMHTs may operate effectively, a majority of patients with SMI need to be admitted to acute hospital care to receive the care they need (18). Thus, access to an adequate number of acute beds and hospital care is necessary not only for patients with SMI but also for CMHTs to provide effective community-based mental health care and to avoid con icts.

Implications for practice and policy
It is important that CMHTs consist of healthcare professionals with a wide range of professional experience and different competences to ensure high quality of community-based mental health services.
Role clarity, particularly the role of nurses and peer workers, is important to run CMHTs effectively and to avoid con icts within the teams.
More training and different steps for ensuring team cohesion may be necessary.

Strengths and Limitations
The study had a high participation rate and used some validated measures. However, this is a descriptive study in ve mental health centres in different Eastern and Central Europe countries, hence the generalizability of the ndings is uncertain. Moreover, all healthcare providers of all ve CMHT volunteered to be part of a mobile team, so their personal commitment and their own motivation might in uence the results positively compared to healthcare provider who are not involved in such a project. In addition, results may be driven by particular countries due to the difference in sample size. Due to relatively small sample sizes per country, country-speci c analysis cannot be performed.

Conclusion
Trainings on community-based practices and collaborative teamwork may enhance recovery-oriented practice and helps to allocate roles and responsibilities clearly. Recovery-oriented care is a complex concept which requires time, skills and professional mindset to shift different care approaches to this new way of working. Thus, investments are needed to support CMHT members to gradually shift towards seeing strengths and weaknesses of providing community-based recovery-oriented care and being a part of the recovery process of patients rather than being leading role of this process.
Furthermore, roles and responsibilities within the CMHT should be clear to everyone, particularly the role of peer workers.
Additional training is needed support the role of peer workers within the CMHT and enhance their self-esteem. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.

Consent to participate
Written informed consent was obtained from all participants before enrolment.

Consent for publication
Not applicable

Availability of data and material
The dataset generated and analysed during the current study will not be made publicly available due to European Data Protection Law but maybe available by the corresponding author on reasonable request.

Competing interests
The authors declare that they have no con ict of interest.   (1).pdf *** Data gathered from hospital and mental health centres in each municipality (free estimation / there is no published source) **** https://www.nsi.bg/en/content/6704/population-districts-municipalities-place-residence-and-sex *****Data form NCPHA database (not published)    Absolute Numbers; a Answering categories were: yes; no; b Answering categories were: high; Med/low con dent; 'other n=1' was excluded from this analysis Absolute Numbers; a Answering categories were: yes; no; b Answering categories were: high; Med/low con dent; 'other n=1' was excluded from this analysis