As you’ll all know, I’m keen to improve patient care due to my role as a nurse and as a patient myself. Having experienced and been on the receiving end of some quite frankly poor, even dangerous care/services, I feel that many of these serious issues can and should be paid more attention for change.
What aspect am I talking about now?
Professionals from different disciplines working together effectively. Sometimes there are missing cogs in the care planning wheel so to speak and it doesn’t take a genius to conclude that patients lose out. It’s not acceptable at all. Much can be improved with a renewed focus on strong working relationships. There is still too many instances of professionals working in silos.
So, here again is another paper I wrote in university. I do hope it’s of some use. Any feedback and discussion I welcome please!
This reflective assignment will give an account of my learning during the module. I will initially give a brief explanation of the module structure followed by relevant definitions and history of interprofessional education (IPE), collaboration (IPC) and working (IPW), as this formed the basis of my learning.
The module used a student-led, enquiry based learning approach opening at one of two conferences. We were assigned to a small team to work with throughout the module focussing on the dynamics and nature of IPC within H&SC. This consisted of students from a range of H&SC professional backgrounds and a university facilitator to guide us through 5 weeks of online collaboration based on a series of questions to research and discuss. The purpose of creating such groups was essentially simulating the way in which we aim to work within multi-disciplinary teams during our university placements and once qualified out in practice but in a safe environment (Corkin and Morrow, 2011). IPE, therefore, occurs when two or more professionals learn with, from and about each other to improve collaboration and the quality of care (CAIPE, 2002). This includes learning during university and after professional registration.
The notion of IPE has been around in the UK since the 60’s arising from changes in the way healthcare was organised and delivered. By the 70’s, as medical technologies and personnel grew, there were many different types of healthcare interactions feeding into patient care as healthcare began to include both the “early sick” and “worried well”. Costs and patient numbers increased and a more diversified system, utilising existing resources was needed to meet these needs through efficiently matching provider skills, necessitating collaboration between providers (Dewitt and Baldwin, 2007, p. 97). There was also the recognition that patients may have social needs relating to their medical needs (Irvine, Kerridge, Mcphee and Freeman, 2002, p. 200). Primary care teams and community care was introduced (Barr, 2002) but it has taken failures in H&SC to promote the agenda for more effective interprofessional working. Cases extensively publicised in the media, such as Baby P (Laming, 2009), Victoria Climbie (Laming, 2003) and Christopher Clunis, (Department of Health, 1994) highlights the serious negative outcomes that can occur through a breakdown of sufficient care delivery. In 1996, The Department of Health (1996) cited in Fletcher (2011, p. 17) published their intentions stating:
“all professionals in the H&SC services should adopt a collaborative approach to working across organisational boundaries, so that patients and their formal and informal carers receive help which is timely, well co-ordinated, effective and appropriate to their needs”.
This process is IPC whereby quality client care is promoted through a co-ordinated collaborative team approach (Fletcher, 2011) across a range of public, private and third sector providers such as police, housing and education.
Since 1997, policymakers picked up pace in taking this work forward. The NHS Plan (Department of Health, 2000) cited in Barr (2002) called for IPE to promote the skills essential for such collaboration between the NHS, providers and patients. CAIPE promoted and developed IPE in collaboration with HEA’s, lending their expertise to make this a reality (Caipe, 2012). Lord Darzi’s report (Great Britain. Department of Health, 2008) and the newly passed Health and Social Care Bill (Department of Health, 2012) which builds on this is taking forward the modernising of the NHS to meet the new challenges of the 21st Century.
It is important to note patients should no longer be passive recipients of care; their involvement (and carers) in care decisions should be heard within all interprofessional settings. (Pollard, Thomas and Miers, 2010).
As a year two Mental Health Nursing Student, I am aware I am in the early stages of developing my identity as a mental health professional. At the first conference day I felt apprehensive, questioning my role compared to other students in my group. I wondered if I would represent mental health sufficiently, given my limited knowledge and experience. When I met my new team, I was anxious and did not say very much, despite feeling really enthusiastic. This was also a barrier toward my contribution online, spending much time researching and lacking confidence in my contribution. I thought it may not be valuable in comparison to the medical student in particular. This resulted in my taking a more background position when formulating my responses.
According to MacIntosh and Dingwall (1978) cited in Goodman and Clemow (2010), nursing learns its subordinate role to medicine during their training and nurses still play to this submissive culture (Curtis, 2004 cited in Goodman and Clemow, 2010). Stern et al (1991) cited in Goodman and Clemow (2010) suggests that doctors see themselves as more valuable to patient care than nurses. I have noticed this in the practice environment. I am very aware of being a student nurse and becoming more of a participator, which is difficult when at the bottom of the hierarchy and referred to as “the student”. The module made me realise that if one person does not speak up, then the service user is disadvantaged (Martin, 2011).
During the online collaboration, as well as sharing the same viewpoints about care pathways we added unique perspectives according to our individual professions, highlighting how, with full participation, valuable a care package could be. This lack of confidence impacting care quality was cited in a study exploring interactions in multidisciplinary team meetings. It found inequality in participation between its members. Occupational therapists, physiotherapists, social workers and nurses rarely asked or voiced opinions, or asked for orientation whereas consultants did all three regularly, as well as giving orientation. Gender, status and team size could be factors when competing to express an opinion against a dominant medical team. It highlighted important functional and social needs are missed compared to physical needs (also echoed in Adamson et al, 1995 cited in Goodman and Clemow, 2010); wrong decisions can be made without full information as staff are not acting as an effective advocate for the service user. It concluded patient goal setting should be effective and to participate in IPE to develop leadership and Interprofessional skills (Atwal and Caldwell, 2005).
Our first online question challenged our group to consider stereotyping within H&SC. Upon careful reflection, part of my worries stemmed from how I perceive others to stereotype mental health nursing. For example, there is a lack of appreciation from other areas of nursing for its demand of specialist knowledge and skills (Ng et al, 2010) and there is a deep rooted stigma attached to mental illness (Time to Change, 2008), which can affect mental health professionals. According to Goffman (1963) cited in (Ng et al, 2010) this can be explained through “courtesy stigma” where being associated with something stigmatised will also render the associate stigmatised. In a paper published in the Archives of Psychiatric Nursing (2008) cited in the Nursing Times (2008), it echoes the lack of understanding of mental health nursing by other specialities; using words such as ‘unskilled, illogical, idle, disrespected, incompetent and weak. Being mindful of these attitudes contrasted with the power and respect doctors have in practice, it is little wonder I felt slightly unconfident. My team members had also witnessed a lack of knowledge and value for others roles in practice. Goodman and Clemow (2010) states this originates from the professional roles we are socialised into and associated beliefs. Despite these initial views, we explored our similarities as a group and agreed by bringing us together we were able to see past our professions, seeing the person, as we do with our clients.
We realised that we were very similar in our approach to our work; being client centred, non-judgemental, holistic, caring and respecting. Pettigrew (1997) cited in Hean et al (2006), explains that through such identification positive relationships are formed which appeared to be the case. We proceeded to discuss the hierarchy out in practice with particular focus on doctors; as a student radiologist put it “given doctors prestigious position, power and wisdom that people listen to”. I can identify with this as a patient as we tend to follow their orders. Perhaps being fresh to our professions and the heavy focus on equality and diversity in our multi-professional training has meant that, although we are aware of prejudice, we seemed to be brought together early enough to combat them. Hean et al (2006) reports students hold consistent stereotypes of other H&SC groups upon commencing university, which can make a significant impact on how they operate in a team. I recognise this from exploring my own attitudes and how this affects my confidence in group participation. For instance, doctors are viewed as strongly academic with high ratings for leadership, decision making, working independently and confidence with lower ratings on interpersonal skills and being a team player. Nurses, Social Workers and Midwives are viewed as having stronger interpersonal skills and stronger team players but nurses were viewed as least independent and lower on decision making. Doctors and Nurses scored differently on most characteristics. These opinions can be formed from personal experience, as a patient, or through media reporting. The contact hypothesis (Allport, 1979, cited in Hean et al, 2006) can explain the positivity our group developed working together. The fact that we had a facilitator from the university giving us institutional support whilst we worked on a common goal and there was no hierarchy thus we had equal status created a more positive experience. We came to the group keen to embrace the opportunity to learn and work together. This of course can work the other way in that negative stereotypes can be reinforced if the interactions are not so successful.
Referring back to The Nursing Times (2008), it also suggested bringing professionals together during training or, for those already trained, through job shadowing to break down the negative views of mental health nursing. Reflecting on the online collaboration, the lack of face to face contact and being online at different times affected the flow of conversation which became more an exercise of posting our opinion, once per week, than having a more enriched collaborative discussion. Other commitments, such as differing workloads affected the contributions some students, including myself, could make to some work set and once behind it was harder to catch up. This resulted in learning gaps. We did not challenge each other about this as I do not think we had established a clear sense of individual roles and responsibilities. This process could be explained by the ‘team development model’ (Tuckman, 1965 cited in BusinessBalls, 2009) as we shared the characteristics of the first stage of development (norming) but not progressed beyond this. This lead to thinking about the ability to develop effective relationships with professionals in practice who have differing working patterns/shifts. Some worked in different offices, buildings and/or for different employers. Communication often relied on technology (computers/telephones/fax/email) to discuss and record patient care and handovers sometimes lacked information. This slowed up progression of patients through the system, creating frustrations and misunderstandings within the team and bed blocking. One example of poor communication in my work setting resulted in a patient unable to utilize her accompanied section 17 leave because of a lack of ward staff to accompany her. The patient was upset but felt unable to challenge it herself. I helped her address this issue in ward round and was asked by the psychiatrist, in the absence of ward staff, to find out why she had not left the ward in over a week. I became the communication vehicle between the ward manager and psychiatrist but they needed to talk to each other. It was clear the patient lost out and all parties were incredibly frustrated. Cott (1997) cited in Irvine et al (2002) mentions such tensions arising as a result of differing structures to the working day which can negatively impact developing close working relationships, increasing conflict. Had a member of ward staff been able to attend the meeting there would have been a greater understanding of the issues and effective patient goal setting. As described in Atwal and Caldwell (2005), doing so has the potential to improve this.
My learning has highlighted the part nursing will play in the delivery of the H&SC system (Goodman and Clemow, 2010 and Professional Leadership Team – Chief Nursing Officer’s Directorate, 2011). I realise the professional standards, set by the NMC, to which I am accountable. The student guidance (NMC, 2011) states I need to “Work with others to protect and promote the health and wellbeing of those in your care, their families and carers, and the wider community” and “Be aware of the roles and responsibilities of other people involved in providing health and social care”. Once registered, the Code (NMC, 2008) contains specific references to team working, collaborating with those in my care, sharing information and making a referral to another practitioner when it is in the best interests of someone in my care. I need to expand my knowledge of others’ roles within H&SC and the systems/policies to which they work. Through this I can draw upon resources and expertise not available in the NHS such as specialist counselling and advocacy (Tait and Shah, 2007) adding value to patient care when they may be unaware of such services. Working on the trigger exercises I realised the implications to our patients of this lack of knowledge.
Researching failures in H&SC, particularly Christopher Clunis, (Department of Health, 1994) echoes the importance of collaboration not only in terms of benefit to the patient but the public to which I have a duty. To do this, I need to develop more confidence to speak up and a stronger identity, being mindful of the historical aspect of the hierarchy and identity change that will inevitably take place at a time of radical change. I will seek to become a more autonomous individual to become a more effective advocate for patients, ensuring their best possible well-being, bearing in mind those who lack capacity. This will be challenging and I will need to keep in mind the barriers; communication/time/cost/workload/structural difficulties and attitude and ways to overcome them. By paying attention to my part in IPC, I will be contributing to the best quality of care possible.
1) To be able to make referrals to another practitioner, I need to expand my knowledge of others’ roles within H&SC and the systems/policies to which they work. In mental health, if a patient lacks capacity then H&SC services temporarily manage the patient’s life. This can be a complicated web of people: Occupational therapists, GP, Primary Care, Psychiatrists, Nurses, other H&SC staff (Social Workers etc), Health Care Assistants, Admin, Family/carers, Counsellors, Psychologists, Community and Inpatient Teams, CPN’s, Care Coordinator, Students, and other organisations: MIND, Saneline etc, housing, finances, Criminal Justice System. I will:
• Meet with staff on next placement. Discuss how they work interprofessionally and the systems in place for referral. Find out how we can work to best set effective goals to meet patient needs through care planning and how decisions are made/affected. Explore difficulties and limitations within the work environment addressing the barriers identified in this assignment. I will particularly focus on strengthening the medical staff/nurse relationship given close contact in Mental Health settings by increasing time spent with them through shadowing.
• Read the Government policies relating to other H&SC professions to see how they have driven practice, as well as in the involvement of carers.
2) Develop emotional intelligence, communication, leadership and assertiveness skills to increase participation in care. I will:
• Purchase books relating to these. Learn and practice on next placement.
• Reflect on the contributions I make within meetings to make sure I am actively participating. This will be through reflection and feedback through supervision.
3) Show a keen interest in IPW to keep abreast of developments in H&SC in respect of IPE/IPC and IPW. I will:
• Read the Journal of Interprofessional Care on a regular basis.
• Join the Health Professional Network http://www.hpgn.org and CAIPE as a student.
• Attend a patient group to hear their voice, the issues and the contribution they make on the ground to changing services.
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