The Teamworking Challenges of Care Planning

The impact of workplace culture on the accountability of mental health nurses to involve consumers in care planning: A focused ethnography

Recovery-oriented mental health practice guidelines recommend regular consumer involvement in care plans, yet in many acute settings, these are not routinely created thereby compromising accountability. This study explored the impact of workplace culture on the capacity of mental health nurses to involve consumers in care planning and consequently to work accountably. A focused ethnography was undertaken in one Australian inpatient unit involving mental health nurses and other health professionals. Data were derived from in-depth semistructured interviews with 12 nurses and 6 months of nonparticipant observation of multidisciplinary meetings and clinical handovers. Workplace culture had an impact on mental health nurses' accountability practices. A culture that prioritized reduction in length of stay resulted in less recovery-oriented care. Health professionals who paid more attention to crisis and risk management resulted in fewer opportunities for consumer-involved care planning.

A lack of therapeutic engagement and consumer input in acute inpatient care planning limits fully accountable mental health nursing practice

It is mental health consumer's human right to lead a fulfilling life as they are empowered to actively manage their recovery. This can be facilitated through care planning, yet research suggests that the care plan is not routinely created, discussed, or updated in acute mental health settings. Research on care planning and the role of the mental health nurse highlights the importance of therapeutic communication in care plan development. This paper argues that the lack of meaningful care plan discussions between consumers and mental health nurses in an acute setting is a limitation to the practice of fully accountable mental health nursing care. We explore this limitation in quality care provision by examining literature on accountability and conclude that in mental health nursing, accountability is frequently enacted through an overarching focus on the organizational need to manage risks, rather than on therapeutic engagement.

Work-related variables associated with perceptions of recovery-oriented care among Quebec mental health professionals

BACKGROUND

Provider working conditions are important in mental health service delivery.

AIMS

To identify variables associated with perceived recovery-oriented care among mental health professionals.

METHOD

A total of 315 mental health professionals and 41 managers across four Quebec service networks completed questionnaires. Univariate and multilevel mixed-effects linear regressions for bivariate and multivariate analyses were performed using independent variables from the input-mediator-output-input model and recovery-oriented care.

RESULTS

Recovery-oriented care related to: working in primary care or out-patient mental health services, team support, team interdependence, prevalence of individuals with suicide ideation, knowledge-sharing, team reflexivity, trust, vision (a subset of team climate), belief in multidisciplinary collaboration and frequency of interaction with other organisations.

CONCLUSIONS

Optimising team processes (for example knowledge-sharing) and emergent states (for example trust) may enhance recovery-oriented care. Adequate financial and other resources, stable team composition, training on recovery best practices and use of standardised assessment tools should be promoted, while strengthening primary care and interactions with other organisations.

DECLARATION OF INTEREST

None.

The methodical work approach and the reduction in the use of seclusion: how did it work?

The prevention of seclusion and other coercive measures has become a priority for mental health facilities, and numerous comprehensive programs to reduce the use of these containment procedures, have been developed. It is, however, poorly understood which interventions or elements of programs are effective and by which mechanisms or processes change is mediated. The present study explores the effects of an intervention by which a reduction in the use of seclusion was achieved. The intervention concerned a transformation of the treatment process, based on the principles of the methodical work approach, at a ward for the intensive treatment of patients with psychosis and substance use disorders. Changes in the working practice and team process were analyzed on the basis of case examples and team evaluation. The methodical work approach appears to have provided a guidance for the multidisciplinary team, the patient and the family to work together in a systematic and goal-directed way with cyclic evaluation and readjustment of the treatment and nurse care plan. Also implicit, positive changes were found in the team process: increased interdisciplinary collaboration, team cohesion, and professionalization. It is argued that the implicit or non-specific effects of an intervention to prevent seclusion may constitute a major contribution to the results and therefore merit further research.

Improving the effectiveness of multidisciplinary team meetings for patients with chronic diseases: a prospective observational study

Background

Multidisciplinary team (MDT) meetings have been endorsed by the Department of Health as the core model for managing chronic diseases. However, the evidence for their effectiveness is mixed and the degree to which they have been absorbed into clinical practice varies widely across conditions and settings. We aimed to identify the key characteristics of chronic disease MDT meetings that are associated with decision implementation, a measure of effectiveness, and to derive a set of feasible modifications to MDT meetings to improve decision-making.

Methods

We undertook a mixed-methods prospective observational study of 12 MDTs in the London and North Thames area, covering cancer, heart failure, mental health and memory clinic teams. Data were collected by observation of 370 MDT meetings, completion of the Team Climate Inventory (TCI) by 161 MDT members, interviews with 53 MDT members and 20 patients, and review of 2654 patients’ medical records. We examined the influence of patient-related factors (disease, age, sex, deprivation indicator, whether or not their preferences and other clinical/health behaviours were mentioned) and MDT features (team climate and skill mix) on the implementation of MDT treatment plans. Interview and observation data were thematically analysed and integrated to explore possible explanations for the quantitative findings, and to identify areas of diverse beliefs and practice across MDT meetings. Based on these data, we used a modified formal consensus technique involving expert stakeholders to derive a set of indications of good practice for effective MDT meetings.

Results

The adjusted odds of implementation were reduced by 25% for each additional professional group represented [95% confidence interval (CI) 0.66 to 0.87], though there was some evidence of a differential effect by type of disease. Implementation was more likely in MDTs with clear goals and processes and a good team climate (adjusted odds of implementation increased by 7%; 95% CI 1% to 13% for a 0.1-unit increase in TCI score). Implementation varied by disease category (with the lowest adjusted odds of implementation in mental health teams) and by patient deprivation (adjusted odds of implementation for patients in the most compared with least deprived areas were 0.60, 95% CI 0.39 to 0.91). We ascertained 16 key themes within five domains where there was substantial diversity in beliefs and practices across MDT meetings. These related to the purpose, structure, processes and content of MDT meetings, as well as to the role of the patient. We identified 68 potential recommendations for improving the effectiveness of MDT meetings. Of these, 21 engendered both strong agreement (median ≥ 7) and low variation in the extent of agreement (mean absolute deviation from the median of < 1.11) among the expert consensus panel. These related to the purpose of the meetings (e.g. that agreeing treatment plans should take precedence over other objectives); meeting processes (e.g. that MDT decision implementation should be audited annually); content of the discussion (e.g. that information on comorbidities and past medical history should be routinely available); and the role of the patient (e.g. concerning the most appropriate time to discuss treatment options). Panellists from all specialties agreed that these recommendations were both desirable and feasible. We were unable to achieve consensus for 17 statements. In part, this was a result of disease-specific differences including the need to be prescriptive about MDT membership, with local flexibility deemed appropriate for heart failure and uniformity supported for cancer. In other cases, our data suggest that some processes (e.g. discussion of unrelated research topics) should be locally agreed, depending on the preferences of individual teams.

Conclusions

Substantial diversity exists in the purpose, structure, processes and content of MDT meetings. Greater multidisciplinarity is not necessarily associated with more effective decision-making and MDT decisions (as measured by decision implementation). Decisions were less likely to be implemented for patients living in more deprived areas. We identified 21 indications of good practice for improving the effectiveness of MDT meetings, which expert stakeholders from a range of chronic disease specialties agree are both desirable and feasible. These are important because MDT meetings are resource-intensive and they should deliver value to the NHS and patients. Priorities for future work include research to examine whether or not the 21 indications of good practice identified in this study will lead to better decision-making; for example, incorporating the indications into a modified MDT and experimentally evaluating its effectiveness in a pragmatic randomised controlled trial. Other areas for further research include exploring the value of multidisciplinarity in MDT meetings and the reasons for low implementation in community mental health teams. There is also scope to examine the underlying determinants of the inequalities demonstrated in this study, for example by exploring patient preferences in more depth. Finally, future work could examine the association between MDT decision implementation and improvements in patient outcomes.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Steps towards effective teamworking in Community Mental Health Teams

Objectives

This paper aims to show how effective teamworking can be achieved in Community Mental Health Teams (CMHTs), in the context of recovery-focused care.

Methods

A narrative review of various governmental policy documents and selected papers relevant to teamworking and recovery-focused care within mental health services, in an Irish context.

Findings

Effective teamworking within CMHTs is a prerequisite to the provision of quality, recovery-focused care. It requires the management of various environmental (e.g. adopting a ‘recovery’ model of mental health), structural (e.g. sharing of responsibilities and capabilities) and process (e.g. utilising a clear referral pathway) factors that influence teamworking, as CMHTs develop over time.

Conclusions

Completion by CMHT members of teamworking and other evaluative measures can assist teams in highlighting potential interventions that may improve recovery-focused team functioning and effectiveness.