Multidisciplinary team working: collaboration and conflict

Factors Influencing Staff Perceptions of Inpatient Psychiatric Hospitals: A Meta-Review of the Literature

Staff perceptions of inpatient psychiatric hospitals ultimately impact a range of organisational and care-related variables, including staff retention and quality of care for inpatients. The aim of this study was to conduct a meta-review to synthesise themes reported by staff to influence their perceptions of inpatient psychiatric hospitals. The review followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines for systematic reviews. PsycINFO, CINAHL, MEDLINE and EMBASE were systematically searched. Reviews were eligible for inclusion if they examined the perception/experience of paid staff involved in caring for adults with mental illnesses admitted to an inpatient psychiatric hospital. Eligible reviews were assessed for methodological quality and bias. Thematic synthesis was used to merge thematically similar findings into an aggregate summary. Fifteen reviews were included, from which seven themes were reliably extracted: staff and patient safety, views on inpatients' experiences, relationships on the ward, ward rules, knowledge and experience, service delivery issues and coercive measures. Confidence in the evidence underlying each theme was analysed using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) criteria. Results indicate that staff perceptions of inpatient psychiatric hospitals overlap with inpatients' perspectives, particularly regarding the therapeutic relationship, coercive measures and ward safety, in addition to unique experiences. Factors identified can help guide ways to improve staff retention, satisfaction and quality of treatment.

Acceptability and barriers of a GP-physiotherapist partnership in the diagnosis and management of COPD in primary care: A qualitative study

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is commonly diagnosed and managed in primary care but there is evidence that this has been suboptimal, with low confidence expressed in providing interventions requiring behaviour change. The aim of this study was to determine the acceptability of a general practitioner (GP)-physiotherapist partnership in the diagnosis and management of COPD in primary care and to explore the experiences of participants during the implementation of the model.

METHODS

Semi-structured interviews were conducted with physiotherapists (n = 3), GPs (n = 2), practice nurses (PNs) (n = 2) and patients (n = 12) who had participated in the InNovaTivE Gp-physiotheRapist pArTnErship for copD (INTEGRATED) trial. We sought to explore participants' views about their experiences and perceived benefits, barriers and facilitators to the implementation of this model of care. Interviews were transcribed, coded and thematically analysed. Synthesis of the data was guided by the Theoretical Domains Framework for clinician interviews and the health belief model for patient interviews.

RESULTS

All clinicians felt that this integrated model helped to optimise care for patients with COPD by facilitating evidence-based practice. GPs and PNs valued the physiotherapist's knowledge and skills relating to diagnosis and management, which was reported to complement their own management and improve patient outcomes. Patients reported a sense of empowerment following their appointments and acknowledged improved self-management skills. However, physiotherapists reported many patients were already engaging in positive health behaviours. Responses were mixed on the effectiveness of the model in facilitating teamwork between clinicians with different perspectives concerning management, communication pathways and logistical issues, such as time and room availability, being cited as barriers.

CONCLUSIONS

An experienced cardiorespiratory physiotherapist embedded into a small number of primary care practices to work in partnership with GPs for COPD diagnosis and management was acceptable and viewed as beneficial for patients. Barriers relating to logistics and resources remain, which must be addressed to optimise implementation.

PATIENT OR PUBLIC CONTRIBUTION

Patient input was obtained from qualitative feedback from a prior study conducted by two authors and was used to refine the model of care to determine the added value of a physiotherapist integrated into the primary care team. This feedback was also used to refine the interview guides utilised in this study determine the acceptability of this model of care. We had health service involvement from the rehabilitation service of the local health district who were directly involved in determining study aims and establishing the project around the priorities for their chronic disease integration service. For example, this project aimed to engage with a less severe patient population in primary care who would benefit from pulmonary rehabilitation. The findings from this study will be used to further tailor the model of care to the needs of the public and patients.

TRIAL REGISTRATION

ACTRN12619001127190.

'It's working together with what you've got': Healthcare professionals' experiences of working with people with combined intellectual disability and personality disorder diagnoses

BACKGROUND

People with intellectual disability often receive diagnoses which may complicate their clinical care. Among these, personality disorder diagnoses are still considered contentious. Little is also known on the perspectives of staff caring for people with intellectual disability who have received a personality disorder diagnosis.

METHODS

Three focus groups were carried out to explore 15 healthcare professionals' subjective experiences of working with people with intellectual disability who also have a recorded additional diagnosis of personality disorder. Data were analysed through thematic analysis.

FINDINGS

Four overarching themes were identified: (a) diagnostic issues and the need for person-centred approaches; (b) challenges and adjustments to working with combined intellectual disability and PD diagnoses; (c) the importance of multidisciplinary team training, support, and cohesion; (d) provision issues and barriers to service access.

CONCLUSIONS

The themes are outlined in depth and a number of implications for clinical management and service improvement are discussed.

Enabling leaders of multispecialty teams via cross-training

Background

Teamwork across medical specialties improves patient outcomes. However, it also places an additional strain on team leaders, who must mediate between the medical specialties while at the same time belonging to one of them. We examine whether a cross-training incorporating communication and leadership skills can enhance multispecialty teamwork in Heart Teams and enable Heart Team leaders.

Method

In a prospective observational study, the authors surveyed physicians working in multispecialty Heart Teams worldwide, who participated in a cross-training course. Survey responses were collected at the beginning of the course and 6 months later, after course completion. Furthermore, for a subsample of participants, external assessments of course participants’ communication and presentation skills at the beginning and at the end of the training were elicited. The authors conducted mean comparison tests and difference-in-difference analysis.

Results

Sixty-four physicians were surveyed. A total of 547 external assessments were collected. The cross-training significantly improved participant-rated teamwork across medical specialties, and communication and presentation skills as rated by participants and external assessors who were blind to the time structure or training context.

Conclusion

The study highlights how a cross-training can enable leaders of multispecialty teams in their leadership role by raising awareness of other specialties’ skills and knowledge. Cross-training combined with communication skills training is an effective measure to improve collaboration in Heart Teams.

Novice nurses' experiences from teamwork in the emergency department: A qualitative content analysis

BACKGROUND AND AIM

Teamwork is assumed crucial in nursing. Nevertheless, nursing shortages in medical centers have thus far compelled nurse managers to use novice nurses. The present study aimd to explaining the challenges and experiences of novice nurses regarding teamwork in emergency departments.

MATERIALS AND METHODS

Using qualitative content analysis, 11 novice nurses working at emergency department, participated in this study. Data were collected with semi structured interview and analyzed by Graneheim and Lundman.

RESULTS

The data analysis led to the emergence of four themes of "essential teamwork skills development", "contradictory relationships between team members", "unpleasant feelings and experiences", and, "personal growth and maturation during teamwork".

CONCLUSION

Fostering different personal aspects as prerequisites for teamwork, novice nurses will be able to deal with unpleasant feelings and experiences as well as contradictory relationships between team members in an effective manner. This challenging experience will thus give rise to personal growth and maturation during teamwork among them in emergency department.

The process of transprofessional collaboration: how caregivers integrated the perspectives of rehabilitation through working with a physical therapist

Objectives

To clarify the process of how caregivers in a nursing home integrate the perspectives of rehabilitation into their responsibilities through working with a physical therapist.

Design

This study was conducted under an action research approach.

Setting

The target facility was a nursing home located in Japan. The researcher, a physical therapist, worked at the nursing home once a week from April 2016 to March 2017. During the study period, he created field notes focused on the dialogue and action of caregivers regarding care, responses of caregivers to the physical therapist and reflections as a physical therapist. Caregivers were also given a short informal interview about their relationship with the nursing home residents. For data analysis, two researchers discussed the content based on the field notes, consolidating the findings.

Participants

The participants were caregivers who worked at the target facility. Thirty-eight caregivers agreed to participate. Average age was 39.6±11.1 years, 14 (37%) were male and average caregiver experience was 9.8 years.

Results

Two cycles of action research were conducted during the study period. There were four stages in the process of how caregivers in the nursing home integrated the perspectives of rehabilitation through their work with the physical therapist. First, caregivers resisted having the rehabilitation programme carried out in the unit because they perceived that rehabilitation performed by a physical therapist was a special process and not under their responsibility. However, the caregivers were given a shared perspective on rehabilitation by the physical therapist, which helped them to understand the meaning of care to adapt the residents’ abilities to their daily life. They practised resident-centred care on a trial basis, although with a sense of conflict between their new and previous role, which emphasised the safety of residents’ lives and personhood. The caregivers increased their self-efficacy as their knowledge and skills were supplemented by the physical therapist and his approval of their attempted care. They were then able to commit to their newly conceived specialty of care as a means of supporting the lives of residents.

Conclusions

The process of working with a physical therapist led to a change in caregivers’ perception and behaviours, which occurred in four stages: resistance to incorporation, recapture of other perspectives, conflicts and trials in the role of caregiver and transformation to a resident-centred perspective.

Improving care coordination in community physical rehabilitation: A qualitative study of the change framework

Introduction

Contemporary rehabilitation change relies on effective collaboration and ongoing social interactions among stakeholders. The study objective was to explore the influence of the selected change framework and underlying social interactions during a care coordination improvement project.

Methods

A qualitative study collected data from 35 employees in a community physical rehabilitation service. Participants were not only undergoing change to improve client care coordination but were also facilitating the change processes themselves. Symbolic interactionism guided the research design, and data were collected using interviews and observation. Blumer’s six root beliefs were used for deductive data analysis and provided the framework for the findings.

Results

Findings highlight that the perceptions of the selected change framework were mixed yet dynamic, with modification occurring via social interaction. Elements of Kotter’s eight steps, lean thinking, and transformational change models were trialed. Implementation of the change processes required formal and informal group social interactions. Participants’ different outlooks explained their mixed response to the change processes. Participants who supported the implemented changes believed the processes and outcomes were clear, appropriate, and inclusive. Time, energy, and positive social interactions enabled employees to drive change, with more of these resources desired to refine the vision, problem-solve implementation, and further improve care coordination.

Discussion

This study enhances the understanding of how employees and the community physical rehabilitation service shaped each other during the change processes. The focus on social interactions highlights the slow rate of improved care coordination and need for increased resources and/or duration for successful change.

From parallel to partnership

PURPOSE

In the USA, there has recently been an unprecedented convergence of complementary/alternative medicine (CAM) with mainstream biomedical care. This confluence may lead to a deeply rooted philosophical conflict. This qualitative study works to identify factors that health-care leaders can use, which will build a pathway to greater integrative practice between medical doctors and CAM practitioners - from parallel existence to partnership - by examining the tensions between biomedical medicine and naturopathic medicine. The purpose of this study is to offer short-term suggestions for partnership and long-term recommendations for better understanding.

DESIGN/METHODOLOGY/APPROACH

An original qualitative study using semi-structured with CAM practitioners and biomedical practitioners.

FINDINGS

Areas of conflict that are preventing synergy are identified and a pathway for health-care leaders to follow to create greater integration and partnerships is suggested.

RESEARCH LIMITATIONS/IMPLICATIONS

This is a qualitative and exploratory study that has significant limitations on generalizability.

PRACTICAL IMPLICATIONS

This study suggest steps that both types of health-care practitioners can take to increase their success at working together on an individual level, a group level, an organizational level and on an industry-wide basis, as well as provide a specific pathway to create greater integrative practice for health-care leaders.

SOCIAL IMPLICATIONS

The results indicate that stronger partnerships between different types of medical practitioners increase patient choice, patient satisfaction and outcomes.

ORIGINALITY/VALUE

Increasing interested in CAM modalities is driving more contact between CAM practitioners and biomedical practitioners. This contact is best established in partnership between practitioners rather than in parallel. This original research outlines the sources of conflict and provides recommendations for encouraging greater synergy.

Structural, Organizational, and Interpersonal Factors Influencing Interprofessional Collaboration on Sexual Assault Response Teams

Sexual Assault Response Teams (SARTs) are multidisciplinary teams that coordinate multiple systems (e.g., medical, law enforcement, prosecutors, and rape crisis center advocates) to provide comprehensive care to victims and to collect high-quality forensic evidence to facilitate investigation and prosecution. Relatively little guidance is provided about effective teamwork strategies in resources on forming SARTs. Using in-depth surveys with the SART coordinators and telephone surveys (including close-ended and open-ended questions) with 79 professionals involved in three active, formal SARTs in one state, this study examined structural, organizational, and interpersonal factors that influence interprofessional collaboration on SART. Study findings indicate that perceived structural factors and interpersonal factors were significantly associated with SART members'/responders' perceptions of the quality of interprofessional collaboration on their SART. Findings suggest that individuals' perceptions of professionalization and power disparities between professions pose challenges to perceived interprofessional collaboration on SART. Compared with criminal justice and medical professionals, victim advocacy rated the level of collaboration on their SART significantly lower. The overall picture from the data was that SART professionals perceived mutual respect, trust, and commitment to collaboration to be pervasive on their SARTs, even though recognition of professional conflicts was also prevalent, suggesting that professionals understood that interpersonal conflict was distinct from professional conflict. Initial SART trainings should address the benefits of the team response, professional roles, and communication and conflict resolution skills, and ongoing training should provide professionals the opportunity to raise positive and negative examples of their collaborative efforts to explore existing tensions and constraints on the team for conflict resolution.

Internists' and intensivists' roles in intensive care admission decisions: a qualitative study

BACKGROUND

Intensive care Unit (ICU) admission decisions involve collaboration between internists and intensivists. Clear perception of each other's roles is a prerequisite for good collaboration. The objective was to explore how internists and intensivists perceive their roles during admission decisions.

METHODS

Individual in-depth interviews with 12 intensivists and 12 internists working at a Swiss teaching hospital. Interviews were analyzed using a thematic approach.

RESULTS

Roles could be divided into practical roles and identity roles. Internist and intensivists had the same perception of each other's practical roles. Internists' practical roles were: recognizing signs of severity when the patient becomes acutely ill, calling the intensivist at the right moment, having the relevant information about the patient and having determined the goals of care. Intensivists' practical roles were: assessing the patient on the ward, giving expert advice, making quick decisions, managing access to the ICU, having the final decision power and, sometimes, deciding whether or not to limit treatment. In complex situations, perceived flaws in performing practical roles could create tensions between the doctors. Intensivists' identity roles included those of leader, gatekeeper, life-death decision maker, and supporting colleague doctors (consultant, senior and helper). These roles could be perceived as emotionally burdensome. Internists' identity roles were those of leader and partner.

CONCLUSIONS

Despite a common perception of each other's practical roles, tensions can arise between internists and intensivists in complex situations of ICU admission decisions. Training in communication skills and interprofessional education interventions aimed at a better understanding of each other roles would improve collaboration.

Service failures and challenges in responding to people bereaved through drugs and alcohol: An interprofessional analysis

This article reports findings from the first two stages of a three-stage qualitative study which considered the role of services, including public, private and charitable organisations, in responding to the needs of adults bereaved following the drug and/or alcohol-related death of someone close. The study, the first of its kind to explore the landscape and role of services in substance use deaths, was conducted over two sites: south west England and Scotland. In stage 1 of the research, adopting both convenience and purposive sampling, data were collected via semi-structured interviews on experiences and support needs of bereaved individuals (n = 106). In stage 2, six focus groups were conducted with a purposive sample of practitioners (n = 40), including those working for the police, coroner's service, procurator fiscal depute (Scotland), health service, funeral service, press, clergy, Public Health England, Drugs Policy Unit, bereavement counselling/support and alcohol and drug treatment services, to investigate how services may better respond to this bereavement. Thematic analysis from both data-sets identified two overarching themes. The first, focusing on practitioner responses, captures how these bereaved people may meet with inadequate, unkind, and discriminatory responses from services. Having to navigate unfamiliar, fragmented, and time-consuming procedures compounds the bereaved's distress at an already difficult time, illustrated by a 'mapping' of relevant services. The second relates to challenges and opportunities for those responding. Service failures reflect practitioners' poor understanding of both substance use bereavement and the range of other practitioners and services involved. Those bereaved are a poorly understood, neglected and stigmatised group of service users. There is a need for services to respond without judgement or insensitive language, and provide information about, communicate and work closely with, other services despite differences in working practices and cultures. These recommendations could positively affect bereaved peoples' experiences, alleviating stress and overwhelm at a particularly vulnerable time.

Job satisfaction among mental healthcare professionals: The respective contributions of professional characteristics, team attributes, team processes, and team emergent states

Objectives

The aim of this study was to determine the respective contribution of professional characteristics, team attributes, team processes, and team emergent states on the job satisfaction of 315 mental health professionals from Quebec (Canada).

Methods

Job satisfaction was measured with the Job Satisfaction Survey. Independent variables were organized into four categories according to a conceptual framework inspired from the Input-Mediator-Outcomes-Input Model. The contribution of each category of variables was assessed using hierarchical regression analysis.

Results

Variations in job satisfaction were mostly explained by team processes, with minimal contribution from the other three categories. Among the six variables significantly associated with job satisfaction in the final model, four were team processes: stronger team support, less team conflict, deeper involvement in the decision-making process, and more team collaboration. Job satisfaction was also associated with nursing and, marginally, male gender (professional characteristics) as well as with a stronger affective commitment toward the team (team emergent states).

Discussion and Conclusion

Results confirm the importance for health managers of offering adequate support to mental health professionals, and creating an environment favorable to collaboration and decision-sharing, and likely to reduce conflicts between team members.

A comparative study of job satisfaction among nurses, psychologists/psychotherapists and social workers working in Quebec mental health teams

BACKGROUND

This study identified multiple socio-professional and team effectiveness variables, based on the Input-Mediator-Output-Input (IMOI) model, and tested their associations with job satisfaction for three categories of mental health professionals (nurses, psychologists/psychotherapists, and social workers).

METHODS

Job satisfaction was assessed with the Job Satisfaction Survey. Independent variables were classified into four categories: 1) Socio-professional Characteristics; 2) Team Attributes; 3) Team Processes; and 4) Team Emergent States. Variables were entered successively, by category, into a hierarchical regression model.

RESULTS

Team Processes contributed the greatest number of variables to job satisfaction among all professional groups, including team support which was the only significant variable common to all three types of professionals. Greater involvement in the decision-making process, and lower levels of team conflict (Team Processes) were associated with job satisfaction among nurses and social workers. Lower seniority on team (Socio-professional Characteristics), and team collaboration (Team Processes) were associated with job satisfaction among nurses, as was belief in the advantages of interdisciplinary collaboration (Team Emergent States) among psychologists. Knowledge sharing (Team Processes) and affective commitment to the team (Team Emergent States) were associated with job satisfaction among social workers.

CONCLUSIONS

Results suggest the need for mental health decision-makers and team managers to offer adequate support to mental health professionals, to involve nurses and social workers in the decision-making process, and implement procedures and mechanisms favourable to the prevention or resolution of team conflict with a view toward increasing job satisfaction among mental health professionals.

DisTeam: A decision support tool for surgical team selection

OBJECTIVE

Surgical service providers play a crucial role in the healthcare system. Amongst all the influencing factors, surgical team selection might affect the patients' outcome significantly. The performance of a surgical team not only can depend on the individual members, but it can also depend on the synergy among team members, and could possibly influence patient outcome such as surgical complications. In this paper, we propose a tool for facilitating decision making in surgical team selection based on considering history of the surgical team, as well as the specific characteristics of each patient.

METHODS

DisTeam (a decision support tool for surgical team selection) is a metaheuristic framework for objective evaluation of surgical teams and finding the optimal team for a given patient, in terms of number of complications. It identifies a ranked list of surgical teams personalized for each patient, based on prior performance of the surgical teams. DisTeam takes into account the surgical complications associated with teams and their members, their teamwork history, as well as patient's specific characteristics such as age, body mass index (BMI) and Charlson comorbidity index score.

RESULTS

We tested DisTeam using intra-operative data from 6065 unique orthopedic surgery cases. Our results suggest high effectiveness of the proposed system in a health-care setting. The proposed framework converges quickly to the optimal solution and provides two sets of answers: a) The best surgical team over all the generations, and b) The best population which consists of different teams that can be used as an alternative solution. This increases the flexibility of the system as a complementary decision support tool.

CONCLUSION

DisTeam is a decision support tool for assisting in surgical team selection. It can facilitate the job of scheduling personnel in the hospital which involves an overwhelming number of factors pertaining to patients, individual team members, and team dynamics and can be used to compose patient-personalized surgical teams with minimum (potential) surgical complications.

Contested Discourses in Multidisciplinary Sexual Assault Response Teams (SARTs)

This qualitative study explored how law enforcement officers, forensic nurses, and rape crisis advocates who are members of coordinated service delivery models such as Sexual Assault Response Teams (SARTs) describe their process of engaging with one another and managing their differences in professional orientation, statutory obligations, and power. Using semi-structured interviews with 24 SART responders including rape crisis center advocates, law enforcement, and medical personnel, we examined the ways that SART members discursively construct one another's role in the team and how this process points to unresolved tensions that can manifest in conflict. The findings in this study indicate that interdisciplinary power was negotiated through discursive processes of establishing and questioning the relative authority of team members to dictate the work of the team, expertise in terms of knowledge and experience working in the field of rape response, and the credibility of one another as qualified experts who reliably act in victims' and society's best interests. Implications of these findings for understanding and preventing the emergence of conflict in SARTs are discussed.

"Catching flies with honey": the management of conflict in Sexual Assault Response Teams

Sexual Assault Response Teams (SARTs) are models of service delivery characterized by coordination between rape crisis, health care, and criminal justice sectors. Expanding on research documenting the extent and nature of conflict in SARTs, this study qualitatively explores the strategies used to manage conflict and variations in the use of strategies between professions. Analysis of interviews with SART members (n = 24) revealed five types of strategies: (a) preventative strategies sought to prevent conflict and build capacity for resolving conflict, (b) problem-solving strategies identified and responded directly to conflicts, (c) forcing strategies involved one person attempting to force a perspective or solution on others, (d) unobtrusive strategies covertly worked toward change, and (e) resigned strategies limited direct responses to conflict to protect the coordination. Rape crisis advocates talked the most about conflict management strategies and were almost exclusively responsible for unobtrusive and resignation strategies.

Handover of patient information from the crisis assessment and treatment team to the inpatient psychiatric unit

Handover, or the communication of patient information between clinicians, is a fundamental component of health care. Psychiatric settings are dynamic environments relying on timely and accurate communication to plan care and manage risk. Crisis assessment and treatment teams are the primary interface between community and mental health services in many Australian and international health services, facilitating access to assessment, treatment, and admission to hospital. No previous research has investigated the handover between crisis assessment and treatment teams and inpatient psychiatric units, despite the importance of handover to care planning. The aim of the present study was to identify the nature and types of information transferred during these handovers, and to explore how these guides initial care planning. An observational, exploratory study design was used. A 20-item handover observation tool was used to observe 19 occasions of handover. A prospective audit was undertaken on clinical documentation arising from the admission. Clinical information, including psychiatric history and mental state, were handed over consistently; however, information about consumer preferences was reported less consistently. The present study identified a lack of attention to consumer preferences at handover, despite the current focus on recovery-oriented models for mental health care, and the centrality of respecting consumer preferences within the recovery paradigm.

The challenges of home enteral tube feeding: a global perspective

The aim of this review is to provide a global perspective of Home Enteral Tube Feeding (HETF) and to outline some of the challenges of home enteral nutrition (HEN) provisions. It is well established that the number of patients on HETF is on the increase worldwide due to advances in technology, development of percutaneous endoscopic gastrostomy techniques, and the shift in care provisions from acute to community settings. While the significance of home enteral nutrition in meeting the nutritional requirements of patients with poor swallowing reflexes and those with poor nutritional status is not in doubt, differences exist in terms of funding, standards, management approaches and the level of infrastructural development across the world. Strategies for alleviating some of the challenges militating against the effective delivery of HETF including the development of national and international standards, guidelines and policies for HETF, increased awareness and funding by government at all levels were discussed. Others, including development of HEN services, which should create the enabling environment for multidisciplinary team work, clinical audit and research, recruitment and retention of specialist staff, and improvement in patient outcomes have been outlined. However, more research is required to fully establish the cost effectiveness of the HEN service especially in developing countries and to compare the organization of HEN service between developing and developed countries.

Pumps, feed and sets: is procurement limiting outcomes?

This article aims to review the unique ways in which enteral feed, ancillary items and pumps are procured in the UK and to evaluate whether these are inhibiting innovation and reducing the choices of patients. There are a number of models that have been developed across the UK for the procurement of enteral feed, feeding accessories and pump. The two most common are the hospital-based nutrition support team, which may have an overarching role in the community, and the home enteral nutrition (HEN) team, a multidisciplinary community-based team with skilled health professionals dedicated to the delivery of the enteral nutrition service. While the HEN service has its advantages over other models in the community, it is primarily driven by its clinical role. The lack of significant opportunity for clinical audits and research within the service limits the prospects for service improvement, innovation and patients' choices.

The Teamworking Challenges of Care Planning

Background: Care planning is a multidisciplinary process used to develop an individualised recovery plan for each service user. The success of this process will depend on the extent to which members of mental health teams can work with one another, with service users, and with other service providers in developing a coordinated plan that meets service user needs across multiple domains.

Aims: This paper examined the teamworking challenges that Community Mental Health Teams (CMHTs) face during the care planning process and how such challenges may be managed.

Method: A narrative review of published articles and policy documents relevant to teamworking and recovery-focused care planning within mental health teams.

Findings: Teamworking challenges include the provision of integrated rather than fragmented care, the empowerment of the service user, and development of a distributed model of leadership, responsibility and decision making.

Conclusions: CMHTs face a range of substantial but manageable challenges in attempting to implement recovery-focused care planning. Recommendations include the need to integrate recovery-orientated skills and values into professional training, the need for greater multidisciplinary training opportunities, and the need to evaluate CMHTs based on recovery-orientated criteria.

Perceptions from the front line: professional identity in mental health nursing

In the context of a growing population of people experiencing mental illness worldwide, mental health nurses are a crucial workforce. Their recruitment and retention, however, is in decline. Drawing on qualitative data obtained from interviews with mental health nurses (MHN) in Victoria, Australia, the paper employs a range of concepts from role theory to explore professional identity within mental health nursing. The data highlight three key issues in relation to the future recruitment and retention of MHN: (i) the ambiguity of the MHN role; (ii) the weak definition and lack of understanding of the scope of the MHN role by nursing students; and (iii) a lack of communication about MHN as a profession to a wider audience. These findings indicate three avenues through which recruitment and retention in mental health nursing could be improved: (i) public communication; (ii) training and educating of the next generation of MHN; and (iii) more accurately defining the role of the MHN.

The impact of changes in health and social care on enteral feeding in the community

This paper examines the impact of the changes to health and social care on enteral feeding in the community, outlines implications for practice and offers recommendations to ameliorate the challenges. It is now clear that there have been significant changes especially in the last 10 years in health and social care provisions in the UK with an overarching effect on enteral nutrition in the community. Advances in technology, increasing demand and treatment costs, the need for improvement in quality, economic challenges, market forces, political influences and more choices for patients are some of the factors driving the change. Government’s vision of a modern system of health and social care is based on initiatives such as clinically led commissioning, establishment of Monitor, shifting care from acute hospitals to community settings, integrating health and social care provisions, Quality, Innovation, Productivity and Prevention (QIPP) program and the concept of “Big Society”. These strategies which are encapsulated in various guidelines, policies and legislation, including the health and social care Act, 2012 are clarified. The future challenges and opportunities brought on by these changes for healthcare professionals and patients who access enteral nutrition in the community are discussed and recommendations to improve practice are outlined.

Clinical handover in acute psychiatric and community mental health settings

This study collected an area-wide snapshot of current handover practice in psychiatric settings which included acute care units and community mental health centres. The study was conducted in two stages. Firstly, a questionnaire was sent to all clinical mental health staff within an area-wide health service regarding normal handover procedures and processes. The second part of the study used non-participant observers to evaluate actual handovers in inpatient and community settings. Of the 1125 surveys distributed in stage one, 380 (34%) were returned completed. Of the 40 handovers observed in stage two in which 637 patients were discussed, 40% included at least one consultant psychiatrist or registrar as a participant. Almost all the handovers were completed face-to-face in a specific location with a set time and duration. Eighty-six per cent of respondents reported that deteriorating patients were escalated for rapid response. The results of the survey and structured observations support the issues emerging from the literature from medical, surgical and clinical team handovers. Additionally, the issue of identifiers for deterioration of a psychiatric patient emerged as an area worthy of further investigation and incorporation into clinical handover education and training for psychiatric services.

A multidisciplinary approach to team nursing within a low secure service: the team leader role

PURPOSE

This article critically examines the clinical utility of redesigning a nursing practice model within the Intensive Support and Intervention Service, a new low secure mental health facility in the United Kingdom. Specifically, the "team nursing" approach to care delivery has been adapted to consist of multidisciplinary team leaders as opposed to nursing team leaders.

FINDINGS

The authors describe the role, properties, and functions of the multidisciplinary team leader approach. The authors provide examples of the benefits and challenges posed to date and the ways in which potential barriers have been overcome.

PRACTICE IMPLICATIONS

Nursing care leadership can be provided by multidisciplinary staff. An adapted model of team nursing can be implemented in a low secure setting.

Promoting the implementation of evidence-based practice: a literature review focusing on the role of nursing leadership

OBJECTIVES

Despite a growing interest in evidence-based practice (EBP), the implementation into clinical practice of knowledge derived from research has proved to be a cumbersome process. Additionally, the literature seems to present a fragmented picture with research mainly focusing on a few factors of possible importance, among which leadership appears to be one of the more important. Thus, this study aimed to systematically review the literature regarding leadership and its possible influence on the process of implementing EBP.

APPROACH

A literature review was conducted. Electronic database searches were conducted to identify studies on leadership, administrators, managers, implementation, evidence-based and nursing. The search identified 43 potentially relevant papers, of which 36 were excluded after an appraisal was performed by two independent reviewers. Results were extracted and synthesised into a narrative text.

FINDINGS

Seven papers were included in the literature review. The findings can be divided into three major areas: (1) characteristics of the leader, (2) characteristics of the organisation and (3) characteristics of the culture. Our findings indicate that leadership is vital for the process of implementing EBP in nursing and also highlights the possible importance of the organisation and the culture in which the leader operates. These factors together with their characteristics were interpreted to be intrinsic in the creation of a nursing milieu that is open and responsive to the implementation of EBP.

CONCLUSIONS

Although there seems to be scholarly agreement that leadership is a vital part of the process of implementing EBP, more rigorous research is needed concerning the possible role of the leader. Our findings also indicate that leadership cannot be studied in isolation or without being clearly defined.

Interdisciplinary treatment planning in inpatient settings: from myth to model

The staffs of many mental health facilities describe their treatment planning processes as interdisciplinary, but as most practicing clinicians know, this is more of a myth than reality. Individualized, person-focused treatment planning itself is not a simple endeavor. Effective treatment planning is further complicated by the fact that most discipline training programs teach neither treatment planning nor interdisciplinary methods to provide care and treatment. Psychiatric treatment teams are at a disadvantage from the start. Additionally, although facility and agency administrators expect treatment planning to occur, often the infrastructure to support the work is not there. This article describes a practical and effective treatment planning implementation model or framework developed by the authors, concentrating on three sub-sets of the treatment planning system: structure, content, and process.

Once-a-week psychiatric ward round or daily inpatient team meeting? A multidisciplinary mental health team's experience of new ways of working

Evidence indicates that while service users are dissatisfied with current ward round practices, studies of how professionals experience this practice are sparse. This study highlights staff view of the once-a-week psychiatric ward round compared to a reformed ward round taking place every weekday. Interviews were conducted at one acute psychiatric ward in north-west England. Our analysis revealed a core theme, 'forming a new way of working', which could be understood from three themes. The theme, 'bound by tradition', emphasized how the traditional ward round represented a double-edged sword: it provided a safe structure, but it also highlighted a shared awareness of an urgent need to leave old ways of working behind. The process of change became discernable in the themes 'juggling the change' and 'light at the end of the tunnel', which showed that restructuring the traditional ward round was both possible and valued. We found that staff views on ward rounds are more complex than had been earlier understood, but new ways of working can be implemented, if the impact of tradition, the process of change, and the time to bed down are taken into account.

Communication channels in general internal medicine: a description of baseline patterns for improved interprofessional collaboration

General internal medicine (GIM) is a communicatively complex specialty because of its diverse patient population and the number and diversity of health care providers working on a medicine ward. Effective interprofessional communication in such information-intensive environments is critical to achieving optimal patient care. Few empirical studies have explored the ways in which health professionals exchange patient information and the implications of their chosen communication forms. In this article, we report on an ethnographic study of health professionals' communication in two GIM wards through the lens of communication genre theory. We categorize and explore communication in GIM into two genre sets-synchronous and asynchronous-and analyze the relationship between them. Our findings reveal an essential relationship between synchronous and asynchronous modes of communication that has implications for the effectiveness of interprofessional collaboration in this and similar health care settings, and is intended to inform efforts to overcome existing interprofessional communication barriers.

Nursing handover within mental health rehabilitation: an exploratory study of practice and perception

Nursing handover is an established practice that involves an interchange of information between nurses to inform of the condition of patients. It is essential to nursing practice in terms of continuity and quality of patient care. However, there is a lack of agreement about the quality, content, and process of handover and, in particular, a lack of information specific to mental health contexts. This paper reports the results of exploratory research of the practice and beliefs about verbal nursing handover within an inpatient mental health rehabilitation setting. Qualitative data were obtained from audiotaped handovers and interviews with nurses and analysed using content analysis. Handovers were found to lack structure and content, be retrospective, problem-focused and inconsistent. The findings were fairly consistent with the literature and would likely be applicable across nursing settings; however, the need to appraise nursing handover in unique contexts was also revealed. The study raised questions about how nursing handover reflects the goals and philosophies of mental health rehabilitation and whether nursing handover is an activity fully integrated with the focus of mental health rehabilitation.

Bridging the gap between primary and secondary care: use of a clinical pathway for the investigation and management of deep vein thrombosis

BACKGROUND

Clinical processes that span the boundary between primary and secondary care often suffer from poor standardization of practice and lines of communication. One example is the clinical management of suspected deep vein thrombosis (DVT). Making or excluding the diagnosis can be complex. Tools to investigate DVT were not available to family physicians so patients had to be referred to the hospital emergency department and endure a long wait which could exacerbate the condition. In addition, urgent referrals to the ultrasound department disrupted the scheduled list of patients.

ASSESSMENT OF PROBLEM

A team of stakeholders including all relevant specialties and professions from primary and secondary care was established. After reviewing the literature and interviewing those involved in delivering care, an evidence-based scoring system to calculate the clinical probability of a DVT was adopted and introduced as part of a clinical pathway from primary to secondary care. Its introduction was based on the Plan, Do, Study, Act (PDSA) cycle.

RESULTS

In the first year after the introduction of the clinical pathway, 70% of family physicians had used it and were very satisfied. Patients found it efficient (75%) with 96% very satisfied or satisfied. The waiting time in the emergency department fell from a mean of 379 minutes to 285 minutes. Although the incidence of initial investigations (D-Dimer tests) increased by 42%, the proportion of patients undergoing a subsequent ultrasound test found to have a DVT was unchanged (14%). This suggested the level of suspicion of a DVT in the community had risen. Referrals to the hospital's DVT clinic increased by 14% overall, driven partly by a large increase in those who had come from the new clinical pathway from primary care.

LESSONS AND MESSAGES

Key lessons include the importance of including all relevant stakeholders and the benefits of using PDSA to make rapid changes during implementation. We are now seeking to extend the use of the clinical pathway to other hospitals and more family physicians. In addition, the clinical pathway approach will be applied to other conditions and interventions. We have demonstrated how a multidisciplinary group of stakeholders in a clinical care process can develop and introduce a clinical pathway that allows smooth transit of patients over the barriers between different sectors of the health care system and between independent disciplines. We have also demonstrated the use of untapped non-physician potential in the system to safely facilitate patient care.

Psychotherapy and mental health teams

Mental health teams in different configurations and settings are under increasing pressure to offer formal psychotherapies as well as psychologically informed management to large numbers of 'difficult' patients with severe and complex presentations. This pressure has arisen variously from consumers, governmental agencies and commissioning bodies. Although these teams are an important resource, they receive limited training, supervision or support in models of psychotherapy, especially those incorporating a relational dimension and offering a coherent 'common language'. This commonly results in impairment of collective team function, including the quality and consistency of assessments, and may result in stress, splitting and 'burn out' for team members. This situation is due in part to their burden of casework and responsibility but also to prevailing, largely symptom-based and biomedical, models of mental disorder which tend to minimize the importance of psychosocial dimensions in either aetiology or treatment. Formulating and delivering appropriate, evidence-based and robust models of psychotherapy in generic team settings represents a significantly different challenge from that posed by delivery of psychotherapy in specialist settings. Approaches to this important challenge are discussed and summarized drawing on general considerations and the limited direct research evidence, and are illustrated by a cognitive analytic therapy (CAT)-based training project.