The following report will consist of two parts. Part one will firstly define, and then address some of the issues that have highlighted the need for inter-professional collaboration. Secondly it will look at some of the policy initiatives that advocate inter-professional collaboration and attempt to identify opportunities and benefits, whilst also examining some of the difficulties, barriers and challenges to effective collaborative working, between both professionals and e.g. professionals and service-users.
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Finally, part two of the report will attempt to illustrate my personal experience of collaboration in the form of a three reflections based on assessment, implementing and learning experiences on placement. Critically analysing the skills used in working collaboratively with a client and the multi-disciplinary team (MDT), within the context of mental health care. It should be noted therefore that the names of all individuals within this part of the assignment will be fictionalised in order to protect their confidentiality, in accordance with the Nursing & Midwifery Council (NMC 2008) Code of Conduct guidelines. The reflections will be based in Gibbs 1988 model of reflection.
Part 1: Definition of collaboration
The literal translation of collaboration from the Latin is ‘together in labour’, whilst the dictionary definition of ‘to collaborate’ is ‘to work with another or others on a project’ (Chambers 1999). However, Clifford (2000) in re-iterating Henneman et al’s. (1995) earlier argument stated that, in practice, the process of defining collaboration remained a “complex, sophisticated, vague and highly variable phenomenon” (pp103). This often resulted in the term being used inappropriately, as issues relating to collaboration were (and still are) referred to using a range of terms, all intended to indicate broadly similar processes e.g.: ‘teamwork’, ‘co-operation’, ‘inter/multidisciplinary’, ‘multi-agency’, ‘intersectional and inter-professional’, although, Barrett et al. (2005) concluded that In practice these refer to similar ideas of collaborative effort, even if the composition of the team(s) or group(s) varies.
Hall & Weaver (2001) stated that inter-agency partnerships are created at a formal organisational level when two or more agencies agree to work together to share information or to jointly plan services, whilst multi/inter-professional collaboration involves two or more people from different professions communicating cooperatively to achieve a common goal, passing the client to the next practitioner in a chain of care.
They also stressed the importance of co-ordination in inter-professional working in order to ensure that each professional’s effort is acted upon and that each practitioner is aware of what the others are doing.
The move towards interagency collaboration began with the shift in emphasis from institutional to community-based care, when it was felt that the demarcations and hierarchical relations between professions were neither sustainable nor appropriate (Barr et al. 1999 & Sibbald, 2000).
New ways of working that crossed professional boundaries, had to be found, in order to allow a more flexible approach to care delivery (Malin et al., 2002), the promotion of inter-professional working in the delivery of healthcare has long been regarded by practitioners as of great importance, in providing a better quality of service, as highlighted by e.g. the NMC (2008) and in UK government policy over the last two decades, at least. However Whitehead (2000), also highlighted the fact that one example of team working that was surprisingly neglected in the nursing literature of the time, was the partnership between client and nurse, which she argued should be regarded as part of the collaborative framework as well as in a team context.
However, this factor was not ignored by the NMC who in the Code of Conduct have consistently specified that nurses should not only work with their peers, but also with other professionals and importantly with clients in developing their care-package (2008). Similarly, as indicated, the DOH (1999) with the up-date of the CPA via Effective Care-coordination (ECC) specified the need for all service providers, including all members of MDT’s, too work with their clients, highlighting the belief that such collaboration, increased, client satisfaction and improved client engagement with their planned care package, when implementing the National Service Framework for Mental Health (NSFMH: DOH 1999a) as highlighted by the Sainsbury Centre for Mental Health (SCMH) Keys to Engagement (1998a, 2002 – see appendix 1 for further information).
It was recognised by the government in 1997 that there was a clear boundary between health and social care, and so they called upon the NHS and local authorities to build partnerships and break down organizational barriers (DOH 1997). This was important as many people had complex needs spanning both services, but found themselves receiving inadequate care due to ‘sterile arguments about boundaries’. Thus the government introduced incentives to encourage joint working and improve all aspects of health and social care through e.g. integrated care/service provision (DOH 1998). Modernising Mental health Services (DOH, 1998a), set out the way in which mental health services would deliver care in the future, whilst ‘Safe, Sound and Supportive’ (DOH, 1998b), emphasized the involvement of service users in the planning and the delivery of care, offering choices and promoting independence for individuals.
To implement such changes in relation to mental health, the NSF for Mental Health (DOH, 1999), represented the first set of national standards for mental health, frameworks (e.g. ECC) and how these standards, based in up-to-date evidence, would be achieved for the best possible care.
One role that was introduced through the NSF and ECC guidelines was that of the care-coordinator, and although the role is not attributed to any one profession. In order to be an effective co-ordinator the nurse must appreciate the roles of the other members of the MDT, and possess excellent communication skills (Bonney. in Davis & O’Connor 1999). Demonstrating competence in communication and collaborative working is now a prerequisite of qualifying as a nurse (DOH 2006b) and of all mental health workers (DOH 2004) as based in the SCMH’s (2001) ‘Capable Practitioner’
However, a variety of barriers to interdisciplinary working exist that hinder the developments of close collaborative relationships, Hudson (2002) outlined several barriers to effective inter-professional working relating to relationships between members of different professions. These include the fact that where members of a certain profession have similar or shared values, perceptions and experiences, there will be more agreement between members of that profession than between members of different professions. This is partly because each discipline has very different levels of training, education and legal restrictions on their role. McCray (2002) supports this view stating that social workers, may be more concerned with achieving outcomes for service-users based on recognition of oppression and inequality in society, mental health nurses, may be focused more on psychological factors in their work with clients and psychiatrists who see the illness of the patient as their top priority. However, changes that had been proposed to implement across professional common foundation programme of training of all healthcare workers to enhance inter-disciplinary communication (NHS Plan: in Lilley. 2001), have been introduced (to varying degrees) within approved educational institutions.
Returning to the role of the nurse as a care-coordinator, it should be noted that s/he is not one who simply follows an established ‘pathway’ but someone who challenges existing practice and leads the way in developing new evidence based clinically effective care (Seaman in Smith M: 1999:198). However by 2015 (SCMH 2005) not only should every patient have a comprehensive, tailored care plan, they should have taken the lead in determining how they want their needs to be met according to the NHS plan (1998). As long ago as 1984 Benner considered that, nurses played an essential role in the management of care of patients and as coordinators and educators they must keep up-to-date with the latest developments in care and local and National policies, to ensure their practice conform to the standards of clinical governance and that they must be central to the MDT to ensure that the patient is the focus of that care. As the DOH (1999, 1999a) indicated they are best placed to encourage interdisciplinary working and provide a channel for communication, with characteristics essential to a nurse’s role in collaborative practice.
The following will provide three reflections summarising my involvement in the collaborative assessment, planning & implementation of the treatment/care provided for a selected client, who will be known as ‘Jane’, within an acute forensic inpatient psychiatric unit. Before conducting the initial assessment with ‘Jane’, under the supervision of my mentor, I was conscious of the requirements under the NSFMH & ECC (DOH 1999a & 1999b) guidelines that the assessment must be comprehensive in order for the MDT to develop an appropriate care package. I was also conscious that this required not only my use of effective communication skills with Jane, but also with the nursing and multidisciplinary team members (SCMH 2001, DOH 2004, 2006b). in order for the assessment data to be used as a basis for Jane’s initial care-plan, which would allow for further assessment data to be gathered prior to her MDT review.
While Stuart (2005) stated that psychiatric care requires the completion of an assessment of the client’s bio-psycho-social status, Barker (2003), asserted that the way in which an assessment is carried out and the methods used in the process make it a worthwhile exercise or largely a waste of time. Therefore I was conscious of the need to not only adhere to the ECC framework but also to the ‘Best practice competencies’ guidelines for pre-registration mental health nurses (DOH 2006) and those of the NMC (2008).
Reflective Essay 1 (Assessment)
Critical incidents are snapshots of something that happens to a patient, their family or nurse. It may be something positive, or it could be a situation where someone has suffered in some way (Alphonso, 2007). The incident to be discussed took place at my current placement a medium secure psychiatric hospital. Any names mentioned are fictitious in accordance with the Nursing and Midwifery Counsel (NMC) Code of Professional Conduct (NMC, 2007).For the purpose of this reflection I will be using The Gibbs model (1988), cited in Burns and Bulman (2000) as it gives an opportunity to produce a structured account of the discussion, and clearly shows that true reflection in practice has occurred during its research.
During my management placement my mentor Alan assigned me as named nurse to a recently admitted patient (Jane), with the purpose of co-ordinating her care. I found this service user to be very difficult to engage with as she could become extremely paranoid and believed people could read her thoughts and interfere with her mind. Therefore she was very hard to engage with and very reluctant to disclose any information, this gave me limited information regarding her background at the start of the assessment process. Jane was also presenting with challenging behaviour and could become very verbally hostile. I did find her to be challenging overall and I pursued a different method of working with her whereby I made conversation and talked about other things not relating to her problems, to get to know her, it didn’t take too long before I began to begin to build a therapeutic relationship with Jane. However when it came to undertaking the assessment Jane became quite withdrawn and guarded and did not fully engage with myself or my mentor. When we had completed the assessment and was back in the ward day area Jane became very hostile and began to shout at myself stating that I had stolen her thoughts and replaced them with files, Jane continued to shout and swear so staff intervened. However, we did complete the assessment but I felt disappointed that Jane did not interact well as I felt we had begun to communicate well with each other and had started to build a therapeutic relationship prior to undertaking the assessment.Using the information ascertained during the assessment and information I had gathered from Jane’s clinical file, I also contacted Jane’s social worker (Lynn) for any additional information, she assured me that she would make contact with Jane’s family and feed back her finding at the MDT meeting. I also contacted Jane’s consultant and informed her that I was leading Jane’s care package and the plan that I had put into place in order to maximise the efficiency of the up and coming MDT review.
I learnt a lot from this experience, by analysing the critical situation; it is plain to see how bureaucratic style was effective in handling the situation. The following of procedures by staff was effective in dealing with the possibility of further hazards and ensured the safety of the patient and nurses (Palombara, 2006).
Utilising individual members of the multi- disciplinary team taught me the importance of inter disciplinary team working. The assessment, gave me the ability to gather information from Jane although the information was very limited. It would appear that an assessment of this description would not benefit from having a structured format, because the patient leads as much as the nurse. The support I received from my mentor, gave me the independence to organise the assessment in my own way, and I feel proud to be able to have achieved all the relevant information despite the difficult situation. I was able to obtain information which gave me great satisfaction. I feel I have the ability to fulfil the role of care co-ordinator and do things independently as well as collaboratively. I learnt from taking a leadership role that I was able to, think logically and will hopefully carry this attitude forward throughout my future nursing career. I learnt for the future to expect the unexpected and handle situations as they arise. I have learnt the importance of collaboration and support/supervision is paramount for one to achieve.
Reflective Essay 2 (Implementation)
This reflection will be based on attending the MDT meeting and the outcome. For the purpose of this reflection I have chosen Gibbs (1988), as the model to help guide this process. This is an iterative model with stopping points, using these stopping points as headings; I will be able to reflect fully on the incident.
As indicated the NMC 2008 requires nurses to work with clients as partners, which involves identifying their preferences regarding care, and respecting these within the limits of professional practice, existing legislation, resources and goals of the therapeutic relationship. To facilitate this I had encouraged Jane to identify her needs, and to point out which were of greatest importance in her life. These were:-
To build a good relationship with her parents
To get out of hospital
To stop smoking
All information gathered from the initial assessment could now be discussed at Jane’s (MDT) meeting.
Also in attendance was Jane’s consultant psychiatrist, social worker, psychologist my mentor and myself. I explained to the team that Jane had wished to attend the meeting but due to the location of the meeting, security and hospital policies this was not possible. I discussed the aforementioned to the team, along with Jane’s presentation over the past week.
The consultant was quite happy for the nursing team to continue with their assessment work, and made no alterations to her medication regime. The social worker had managed to make contact with Jane’s family, she reported that Jane’s family have expressed that they would very much like to build up a loving and positive relationship with Jane and would be quite happy to look after her when she has been released from hospital until suitable accommodation can be found for her close to the family home.
Once the meeting was completed I took the opportunity to thank the team for their support and help I also thanked my mentor for all the advise, help, guidance and support he had given to me. I felt that as a team we had developed a good package of care for Jane and also had helped to set in motion the chance for Jane to build a relationship with her family. However I was disappointed that Jane could not attend the meeting due to risk. I did speak to my mentor regarding this and he agreed with my thoughts.
On returning to the ward, my mentor gave me the opportunity to reflect on the situation before handing over the outcome of the ward round to the on duty staff and Jane herself, it was understandable that Jane was unable to attend due to security policy, and hospital protocol and this was something that I would have to explain to Jane and make her aware of.
Writing this reflection made me aware about how members of a team can provide support and how this can help to provide a much better duty of care to service users. Communication played an important part in this learning experience. I believe that in nursing the ability to work in a team is one of the key elements. Furthermore, Sully and Dallas (2005) go on to say the reasons that enhance effective inter- professional team work is the clear goals that are set by the team to make the significant differences for the patient. When the members are competent, committed and know the expected standards of excellence that also enhance inter-professional team work. Team work between nurses and multidisciplinary team is important.
Reflection 3 (learning within placement)
This reflection will be on the nature of teaching and learning process within my practice placement. Some of the factors influencing a learning experience will be discussed and linked to known teaching and learning theories. Physical and psychosocial factors that affect the learning process will also be explored. To help facilitate this assignment, a reflective model (Gibbs model 1988) will be incorporated to discuss how I have achieved the necessary level of competence during the placement. To assist in the development of learning for future students, an action plan will be formulated from the issues recognised throughout this paper.
Any names mentioned are fictitious in accordance with the Nursing and Midwifery Counsel Code of Professional Conduct (NMC, 2008).
During the initial discussion with my mentor (Alan), I was able to express what learning needs I wanted to develop throughout my time on this placement. we agreed to be in close contact for the initial four weeks and also that I would work with Alan to ensure I had as much one-to-one mentoring as possible. This was extremely beneficial as he could track my progress and provide me with guidance during the weeks (Chow & Seun, 2001). At this point my learning was being promoted because he was skilled in student-led strategies. For example, he consistently explored my understanding of a task whilst providing support (Heron, 2001). I also felt positive about having the opportunity to develop a good relationship with him which is recognised as being beneficial to the learning process (Dix & Hughes, 2004).
According to Maslow (1971) the humanist theory of learning is concerned with feelings and experiences. My learning was definitely influenced by his positive attitude and manner, which, as suggested by Maslow leads to personal growth and individual fulfilment.
During my time on placement it was clear that Alan was creating learning opportunities, such as attending MDT meetings, taking the lead role as care co-ordinator and offering resources at all times. I also found he was able to explain tasks clearly and to answer any questions that I had. This is something typically favoured by nurse educators (Li, 1997).
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My mentor was extremely approachable and would often demonstrate tasks with which I was unfamiliar, such as new assessments such as the START. Also if I was unclear on something he had asked me or if I did not know the answer to a question he had asked he would ask me to find out the information and then feed back to him. I found this an excellent way of building my knowledge.
Alan would consistently enquire about my existing knowledge on a subject or task which helped me to perform thorough self-assessment, and to re-examine what I had already learnt, Neary (2000) states that revisiting areas that have already been studied can enhance cognitive learning. This is associated with a major theme in the theoretical framework of Bruner (1996), who explains that learners are able to construct new concepts and ideas based upon their current or past knowledge. Feedback sessions were typically planned but were sometimes spontaneous. This was due to time restrictions and nurse workload. These unprompted sessions could perhaps be improved if they were more structured (Hinchliff, 1999). This is also supported by Quinn (2000) who believes that lesson planning is vital for learning because it ensures that all areas of learning are addressed, which results in higher productivity in terms of learning (ENB/DOH 2001).
Morgan (2002) states that it is vital that qualified nurses ensure students become part of the team, because this can be beneficial to their learning. In addition, the NMC requires that nurses support the development of student nurses. This was evident because each member of staff readily contributed to my learning experience through their willingness to share their professional knowledge with me (NMC, 2007).
My placement has been a positive and memorable learning experience. Primarily I learnt by observation and role modelling whilst utilising cognitive processes. Regular discussion is vital to ensure the learner is provided with some form of direction, as well as provide the opportunity to express any needs. Planned and structured teaching sessions are particularly beneficial to the learner because they enable the mentor to teach a session logically, and to maximise learning efficiency by utilising time effectively. Multidisciplinary team members with the same level of knowledge as the main mentor are also preferable. Additionally, factors influencing learning with regards to the physical learning environment are significant in the enhancement of learning for students, as stated in the action plan.
Collaboration – On-Going Assessment, Care Planning &Skills Used.
In-depth assessment tools like the START (see appendix 1) only offer a guide to areas requiring further discussion and any assessment of risk should include risk to others as well as to the individual and an individual’s social, family, and environmental circumstance, also need considering, as well as the need for positive risk taking as part of the risk assessment process (DOH 1999, 1999a). However to make assessment, including risk assessment and management as valid and reliable as possible it is essential that care planning within mental health is collaborative (DOH 1991,1999, 1999a) and more recently the (DOH 2008), have published ‘Refocusing the Care Programme Approach: Policy and Positive Practice Guidance’ to facilitate this. This need for collaboration is further supported by specific National Institute of Clinical Excellence (NICE) guidelines on care provision &/or treatment for a variety of client groups & specific disorders including: Schizophrenia (2002) which applies to Jane. As indicated, the (NMC 2008) also requires nurses to work with clients as partners; and there is widespread agreement that mental health service-users and their carers should be fully involved in care planning (Warner 2005) as this increases their satisfaction and engagement with services (Rose 2003).
This involves identifying their preference regarding care; the START facilitated this by identifying Jane’s needs, as Jane’s key co-ordinator it was my (supervised) role to ensure that all due procedure was carried out regarding recording of the outcomes which also included the planning of therapeutic engagement.
However, although I was aware of Jane’s paranoia, I also realised that to work with her effectively that I needed to put my personal feelings aside (Stuart 2005b) and on further reflection, I feel that I was eventually able to therapeutically work with Jane in her on-going assessment, which also needed me to utilize my observation skills (Barker, 2003, Ryrie & Norman 2004, Stuart 2005b). This I feel also facilitated my engagement with Jane in the process of deciding together and with the team the best potential strategies to facilitate development of her on-going care-package.
Theoretical knowledge and experience are required to make informed decisions in deciding a plan of action for patients (Stuart 2005a, NMC 2007/8, DOH 2004, 2006). This is supported by Wilkinson (2007) who argues that the nursing process promotes collaboration, for when team members have an organised approach, communication is good, and patient problems are prevented. Further the ability to transfer/adapt knowledge and skills, especially communication skills, based in self-awareness, mutual trust and understanding of each other’s roles facilitates effective collaboration with different people (staff, clients and carers) in different situations (Hadland 2004, NMC 2008, Onyett 2004, Stuart 2005a/b) and are required as one of the competencies identified by the DOH (2004) for mental health practitioners and for nurses (DOH 2006). The (NMC, 2008) also make it clear that nurses must always act on what they believe to be the service-users best interests, and the Healthcare Commission’s (2005b) core standards emphasise the need for employers to ensure that employees follow their professional codes.
As indicated MDT collaboration regarding Jane, began before the formal review meeting, however when I formally presented my initial and on-going assessment findings to the team, using guidelines from ‘The New Ways of Working programme’ (DOH, 2005b), I came across barriers to collaboration with Jane. The fact that, due to legal and safety requirements of the environment (Mersey Care Risk Management Policy and Strategy, 2007; Best Practice Guidance for Risk, DOH, 2007) Jane was prevented from attending because the review was held in a non-secure area of the hospital.
This lack of patient involvement by services was identified by the SCMH’s (1998) ‘Acute Problems’ report, which criticised in-patient’s services for lack of collaboration with patients and although the hospital provides an advocacy service for patient’s to overcome this to an extent, non was present for Jane.
As evidenced by my reflections I feel that I was effective in utilising the skills outlined above in respect of gaining Jane’s positive and collaborative engagement with me and the strategies agreed by the MDT. To help me develop my self-awareness and skills in relation to such issues, and those outlined above I found that keeping a reflective diary at this placement, was a crucial way of ensuring critical events that needed further review, to benefit my practice, would not be forgotten.
Throughout my experience my mentor has proven to be a valuable resource and without his support I feel collaboration with both Jane and the MDT would have been significantly more difficult.
In addition to my personal reflections and supervised experiences, which gave me the opportunity to better understand the roles of the other team members and helped create a collaborative partnership between people with varying knowledge, skills and perspectives (Hornby & Atkins 2000; Nancarrow 2004), I feel that the opportunity for clinical supervision with my mentor has played an important part in my role development.
Finally one specific criticism I have concerns the lack of collaboration with families and carers, as their involvement I feel was actively discouraged, unless clients gave their permission for this. The only information they were giving were visiting arrangements and telephone numbers. Although confidentiality has to be considered, the family were never invited to the MDT meeting. To work effectively in partnership with service-users and carers, it is essential that we are able to form and sustain relationships and offer meaningful choice (Care Services Improvement Partnership/National Institute for Mental Health in England, DOH, 2005).
If true collaboration is to be achieved family and carer involvement must be advocated as far possible and their needs must be considered in line with the 1990 Carer (Recognition and Services) Act.
There is a small but significant group of severely mentally ill people who have multiple, long-term needs and who cannot or do not wish to engage with services. Unless engagement is achieved and people in the group are provided with safe and effective services, they will continue to face social exclusion. Public confidence in services is determined partly by the adequacy of services for this group. Staff must be able to provide a range of services within the team and access other services across a wide group of agencies. In order to achieve this it will be necessary for the relevant agencies locally to come together to prepare and implement a specific plan for the group. The task for the staff and agencies involved is to tackle the social exclusion of this client group. Unless this is done it will be difficult to achieve positive outcomes in either health or social functioning. The Review underpins this analysis with six key findings supporting 15 recommendations.
The six key findings:
1 There must be a strategic approach to the needs of
the client group both nationally and locally
Each Health Authority should set up an inter-agency strategy group to plan and monitor provision for the group
(Recommendation 1). Its first tasks will be to establish a local definition of the group, to commission a needs
assessment, to benchmark local services, and to develop a plan for services.
2 Assertive outreach is the core function required from
mental health services in relation to the client group
All Health Authorities with a sufficient client-base (i.e. 100-150 people) should create one or more assertive outreach
teams to take the lead in engaging with the client group (Recommendation 2). Where the client-base is too small to
justify this, other appropriate arrangements should be made to deliver the assertive outreach function.
3 A human resource plan is required to enable the
implementation of assertive outreach
The lead agencies should agree a set of core criteria for the selection of staff to work with the client group
(Recommendation 3) based on those suggested by this Review. Teams will require a range of expertise so that
individual team members can act as resources for the team as a whole (Recommendation 4). Training strategies
must also be developed and implemented (Recommendation 5).
4 Teams must be effectively managed
Managers of front-line staff must be visible to staff and accountable for service delivery (Recommendation 6). Team
members must have protected caseloads of around 10-15 clients (Recommendation 7).
5 Teams must develop a style of working which
matches the n
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