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Citation: Jones, A. (2002). Perceptions on the development and implementation of a care pathway for people with schizophrenia. (Unpublished Doctoral thesis, City University London)
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City Research Online: http://openaccess.city.ac.uk/ [email protected] Perceptions on the development and implementation of a care pathway for people with schizophrenia
(Volume Two)
Adrian Jones
A thesis submittedin partial fulfilment of the requirementsof the City Universityfor the degreeof Doctorof Philosophy
St. Bartholomew"s School of Nursing & Midwifery
City University
April 2002
245 Contents Page No. Chapter Six: Development of the care pathway & organisational change
Introduction 248 Problemswith development& implementation 248 ViSibilityOf PSYChlatriC work InsertIng care delays Exaggeratedview of work skills Natureof changeenvironment 271 Turnoverof staff 'Wejust couldn'tbe bothered' Managerialimpact upon empoweringprocess 283 Paradox of power Managerial styles 290 Approach used by the researcher Conclusion 298
Chapter Seven: Macro issues impacting on development & implementation Introduction 302 Businessethic within the NHS 303 Presence of a managerial agenda Extendina managerial structures ffirougI7 a care pad7way 'Big broffier watcl7ing` Evidenceguiding psychiatric practice 323 'Professlonalversus Me cleanerl 'WeV like to but? ' use evidence .. Experientlal learnin & practice Conclusion 343
Chapter Eight: Implications for psychiatric services
Introduction 346 Mainfindings 347 Managementof psychiatricservices - politicalimperative 351 Convergenceof appeal UnkIngprimaty and speciallstservIces Controlover corporaterisk Refocusingpractice: the evidencebased culture Managementof morale Realignmentof care for the consumer Psychiatricnursing 361 MDTworking 370
246 Page No. Education & training 374 Treatment and care of schizophrenia 378 Limitations of the study 383 Other research approaches Recommendations 398 CommissionIngagencies Managers of care Future research Psychlatricprofessionals Conclusion 402
References 404 Appendix 469 AppendixOne: Carepathway documentation
247 Chapter Six
Development of the care pathway & organisational change
Introduction
In this chapter,,some of the problemsin developingand implementingthe care
pathwaywill be describedsuch as the ability to describeand represent
psychiatricwork. The researchstudy took placewithin a volatile change
environment.Particular problems were maintaininginterest and engagement
with the project and moralewithin the team.Throughout the entire process,the
researcherendeavoured to follow an action researchcycle (Carr & Kemis1986)
through a seriesof working group meetingsand individualdiscussions. Some of
the difficultiesin conductingthe study will be reviewed.
Problems with development & implementation
Visibility ofpsychiatric work
Muchresearch has been undertakento establishthe role and function of major
occupationalgroups in psychiatry(Miles 1977) althoughthis has beenfound
difficult for hospitalsettings (Walton 2000). The first major theme identifiedin
the data was the difficulty in describingthe processof psychiatriccare and how
respondentsidentified the most and least visible parts of work tasks.A second factor was the perceivedcomplexity or simplicityof the care pathwayfor practice.
248 Somerespondents identified a whole list of rolesand functionsfor psychiatric
professionalswhilst others focusedon taskssuch as administeringmedication.
For exampleLinda who was a staff nurseworking on the ward suggestedthat
the work of mental health nurses was difficult to quantify into tasks:
Youl-eseen to give out medicationbut talkIng w1tha patient on a one to one is invisible,managers can t see what youý-e doing.
Simonexperienced difficulties in describingthe processof psychologicalcare
largelybecause of the traditionalway, in which he worked.In both the working
groupsand interviewdata Simonclaimed that he neverconceived his work to fit
into a standardpattern. For example,following a patientassessment a case
formulationwould be developedwhich would then leadto an unpredictable
numberof contactsessions. Each session would then be guidedby the response
of the patient. Illustratingthe difficulty in specifyingthe processof psychological
care, Simondescribed the processof care pathwaydevelopment as a 'discovery"
and a 'challenge'.Similarly for other respondents,their descriptionsof usualcare were very nebulous,particularly when describingsymptom management and
predictingresponse to treatment.George described the experienceas 'atone stage itý7in focusand next it becomesblurred and suddenlyit becomesa hugely diffl'cultquestion to answer.
249 Althoughsome respondentsidentified that the care processand the human
conditionwas beyondclearly described processes, the view from Gileswas that
care could be describedas a seriesof tasks:
Wehave treatmentsand outcomesand given the unshakablereality of those thlngs,,it is not a myth to tty and pursuea better way of doing that. ThereIs a beast in thatjungle you are trying to catch;itý7 not an empty jungle.
Georgealso observedthe difficulty for cliniciansto identify core tasks in the
working group meetings but took solace from the research nature of the studY.
Duringa later interview,George suggested that the care pathwaywould be more
accuratewith 'futuregeneratlons'of development and shapedby the patients
treated within it. However,this ability to developthe care pathwaywould be
limited by the professionalteam to explaintheir action.
Derrinfound it difficult to identify the work tasksof an OT and arguedfor the
individualisednature of patient care. In line with other respondents,there were someaspects of practicethat were easyto identify (assessments),whilst the less visibleparts were moredifficult to definesuch as motivatingpatients and setting aimsand objectives for any resultantproblems. This observation can be comparedto the processof 'caring,which is again difficult to define, and in many respects,invisible in the care process(Barker 2000). The nursing professionhas found it difficult to identify practiceparameters (Witz 1992)
250 largelydue to parts of practicebeing lessvisible and this has been partly
supportedby this study. Likewisethe OT professionhave found it difficult to
explainpractice to others becauseof the varioussettings in which they work and
the many interventionsthey proclaimto use (Finlay1997).
Pat identified that he had problems in specifying the work that he carried out
with psychiatricpatients and attributedthis to the complexityof psychiatricwork.
Coupledto this was difficulty in decidingthe exact interventionleading to the
improvement.Pat suggestedthat most patientswho presentto the servicewould
follow a set progressionof tasks, althoughnoted the difficulty in describingthis
list of tasks. Similarexperiences were found in a casestudy into developinga
care pathwayfor mentallydisordered offenders (McQueen & Milloy2001). These
authorsfound that as the monthlydevelopment groups took place,the care
pathwaychanged to includeaspects of best practiceand particularlegal issues
pertainingto this type of clientgroup. Pat suggested that it wouldtake a number
of generationsof care pathwaysfor it to becamea true representationof care:
Findingthat keypathway of a schizophrenicpatient is ektremelydiffl`cult to pin down.The first fewpathways are nothIngmore than theoretical quoting,because you I/ sayI do suchand such,, but that won'tbe defined or accurate.
Mikeobserved that nurseswere contentto identify those tasks attributableto the medicalmodel and mental health legislation.However they were unableto move
251 beyondtasks that he describesas 'the old sort of mentalhealffi issues"suchas
I. rIvemedication;'monitor for s1deeffects'and !5igns and symptoms of illness'.
Thesevisible tasks were very easyto describeand placeonto a care pathway.
The dangerwith this point is that the care processmay be brokendown into only the most visible and 'meclwlcal'parts and not on the centralvehicle of nursing practice (nurse-patient relationships), which has been identified in previous sectionsand also in the theoreticalliterature (Buckingham & Adams2000).
Although some clinicians stated their difficulties in identifying the tasks that cliniciansperform, others such as Stevewere stronglyin favor of clarifying professionalroles, if only to do it in the most basicof processes:
M; possible to itemlse what clinIcianýý do from day to day for the Sc7keOf accountability and clarity, so that we ý-eall working towards the SaMe goals and aren t using Interventions that are going to work against each other.
Simonoffered a competingperspective of the task-orientatednature of the care pathwayby drawingon his experienceas an educationalpsychologist working with the nationalcurriculum. Simon questioned whether the approachof a care pathwaywas ultimatelyaccurate or costeffective to the organisation:
Taskanalysis doesn t fit reality becausepeople tend to jump steps,SO you've got a problem if you baseyour practiceon a theory, and then And itý7false. A pathway isjust an ideal and it may be more paln to implement than the servicesas they are,
252 A further problemwith presentingpsychiatric work as a task is that it shapesthe
way practitionersview the patientand perhapsdenies other sourcesof
information.Giles argued that it might lead cliniciansto treat all patientsthe
same(the intention of standardisation)regardless of whether it is appropriate:
When the care path way says have your Arst assessmentWithin tWOdaYS, and on day two and a half a really crucial plece of information comes alorg, that piece of information isn t seen in the same light because Youý, e no longer thinking about assessment,
It could be consideredthat those visibletasks, (e.g. as carryingout the care
programapproach, or patientsresponding to medicationby set times) are more
amenableto stanclardisation.However, those tasksthat are lessvisible, (e. g.
relationshipbuilding or patientscoping with their illnessor developmentof
insight), may be lessamenable to stanclardisation.The leastvisible parts of the care processwere more likely to be includedas examplesof individualised practiceand the resultanteffect of these occurrencescould arguablybe a less representativesequence of care on the pathwaycompared to the realitiesof psychiatriccare. The natureof a care pathwaywould be to includeaspects of carethat couldbe standardised.However, when respondents were unable to achievethis it led respondentsto view the care pathwayas lackingdetail or too simple.The followingexamples will unpackthese contrastingviews and examine how they compareto the complexitiesof psychiatricpractice.
253 The logic of a care pathwayis to attempt to haveall carethat is delivered
adequatelydescribed (Petryshen & Petryshen1992) although respondents spoke
about how their conceptionsof the care pathwaywould not alwayscapture the
totality of care. For example doctors who designed the medication care pathway
promptedthe responseit was too simplisticto accountfor the complexityof
psychiatriccare. Kerry felt there was a dangerin that it may lead peopleto
providean idealisedpicture of healthcare:
Onlyprescribe L orazepam if this person is aggressl.ve, but the reality is that you wouldprescribe in casethey becameaggressive, you would use it a lot more frequentlythan the carepathway states.
The processof developingthe care pathwaymay haveconstrained respondents
to identify the most visible parts of care and in doing so respondentsmay have
perceivedthe carepathway to focuson singleinterventions that leadto clear outcomes.For example,giving medicationand symptomreduction. Other respondentsmay have beenaware that the !goals of interventionare multi- dimensional'(Perkins2001) and that a care pathwaymay distort the view of psychiatriccare.
For Giles,the care pathwayneeded to be developedin a way that offered a network of optionswith more complexinteractions. Giles suggested that the care
254 pathwaywould needto reflect a patient'scondition where progressand treatmentschanged constantly:
For any one instant there is no correctdrug treatment,but 20 or 30 forms drug Mý that this into of treatment.. not as simpleas saying persongoes box A then do B...care pathways reflects a crudedigital sIgnalof a much more subtle analoguecurve.
Georgesuggested that it would be more appropriateto start off with a basic versionof a care pathwayadding more elementsto build up to a greateraccount of psychiatric practice and so 'reflect more honesty about whatpeople do.
Georgebuilt on this theme in a later interviewby suggestingthat the care pathwaywas not reflectiveof the reality of psychiatriccare (in supportof a view that the care pathwaywas too simple).The care pathwaywas constructedby the participants,but ultimatelynot delivered:
It representeda large economicalchunk of it whereit comesdown to this Purchaserlprovider requirementbut it wasn't whatý7delivered to the patient becausevery little wasbeing delivered,
Simonidentified that a standardpackage of psychologicalinterventions could be developedbut arguedfor this to be at a basicinclusive level so that it's relevance for all patientscould be maintained.An examplewas a simplestatement where
'evef Yone must be offeredtherapy, the chanceto talk to somebodyand to standardisea repertoireof actionsand responses at a simplele Vel'. si rn on feIt that the danger in determiningcare in more preciseterms was that 'nOOne can
255 fit the reality ofit"and so invalidatingthe care pathway.However, Simon may be indicatinga problemexperienced by other respondentswhere only the most visible parts of psychiatriccare could be illustrated.Alternatively Simon may be deliberatelyevading the processof specifyinghis role. Johnson(1972: 43) noted that professionsentered into a ;orocess of mystification'when examiningwhat they do. The researcheralso observedthat uncertaintyof role was not completelyattributable to an inabilityto describepsychiatric work. In both the working groupsand individualdiscussions respondents were unwillingto specify their role and function and focused on the most visible parts of their role.
Cliniciansmay highlightthe uncertainparts of their role to hinderthe ability of managersto control the work process.
The care pathwayattempted to representwork tasks into a singleworking documentby negotiatingthe content of a clinician'srole that was acceptableto them. This led to the criticismthat the care processlacked the requireddetail and focus and misrepresentedthe nature and workloadattached to patient groups.George offered further deficitson the care pathwaystructure:
it will identify what servicesare offered and identify housIngneeds, but then can't specify what those workersare going to do about those problemsor the actual clinicianwork load, it will say the personhas social care deficitsbut doesnt say how the OT will tacklethem.
256 Kerrynoted other problemssuch as the care pathwaynot recordingmedical
contactsessions with the patients.For example,Kerry could see somepatients every day and this may not be recordedwhilst for others it was unnecessaryto see them as prescribedon the care pathway.Essentially, the care pathwayfailed to take accountof the intensecontact at the start of the admissionand the taperingoff later. However.,the functionof the care pathwaywas to ensurethat psychiatricpatients were seenat regularset intervalsthroughout the admission period. Moreover,as Kerrycommented earlier, she felt constrainedby a care pathway.
The nature of writing down problems,interventions and outcomesfor in-patients with schizophrenialed to somerespondents feeling that it failed to representthe realitiesof psychiatriccare on hospitalwards. However,others suggestedthat the care pathwayillustrated a crude minimumof what a patient shouldreceive in hospital.It has also been notedthat describingthe visible parts of psychiatric work attemptsto make practicemore transparent.The questionasked of respondentsassumes that psychiatriccare can be describedand to a certain extentrespondents attempted to describeit. However,they werelimited to only the mostvisible parts of psychiatricwork. Observations carried out by the researcherfound that cliniciansperformed more tasksfor the patient than was detailedon the care pathway.For example,the doctor assessedthe patient more frequentlythan that detailedon the care pathway.Moreoverr evaluations of
257 nursingcare occurreddaily in thehand-overs' but neitherwere they
documentedin the clinicalnotes or includedon the care pathway.This could be
due to the difficultiesin describingpsychiatric work such as cliniciansnot
knowingabout their role or poor preparationfor undertakingthe task.
Alternatively, respondents may be deliberately evading the process of describing
psychiatricwork due to a perceptionof vulnerabilityin the working group
process.In all, the ability to describepsychiatric work was problematicand
constrainedby a numberof complexfactors.
Insetting care delays
A secondmajor problemfor the developmentof a care pathwaywas the
insertionof delaysin the care pathway.Some respondents have suggested
delayswere insertedinto the care pathwayin order to give cliniciansWme'to
carry out tasks. The most commonlynoted delaywas the patient'smental state
preventingservices from being carriedout. In this sectionsome of these care
delayswill be reviewedas one of the problemsin developinga care pathway.
Manyrespondents who were both positiveand negativeabout the ideology
behinda carepathway noted the patient'spathology as a reasonfor why some
servicescould be accessedand not others.The difficulty in predictinga patient's
clinicalprogress was rigorouslydefended in all working group meetings.From a communityworker perspectiveMike spoke about someof the delaysthat he
258 attributedto the mentalstate of the clientfollowing implementation of the
pathway:
I d1dnt see Peter on the ward for the first two weeksbecause he was vely paranold.It wouldhave been fruldessfor me to comearound and sort out communityneeds or do a CPAon h1m,it wouldhave harmedour relationshivand wastingmy time ftying to get things done.
Observingthis factor from an in-patientperspective, George also highlightedthe
need for symptomcontrol as a barrierto accessingservices in the care process:
With Tanyathere is nothIng we can do until symptomcontrol, she ý; not even willin9 to entertainthe idea of lookingat the reasonsfor her requiringadmission and she wont do becauseher deluslonsare extremely fixed.
Pat felt that clinicalsymptoms could be controlledwithin a 'reasonableNme"but
was unableto say what this would be. Alternatively,for Zeb the problemlay with
the interfacebetween external departments such as housingand welfare
agencies:
Thelocality will say we know what were dolng, we don't need anything new to tell us how to oloit, the bad things are to do with not enough housingand not enoughbeds and getting benefiltsquickly.
Somestudies have found that diagnosisaccounts for only 6% of the variationin hospitalstay (Horn et al. 1989)whilst Creedetal. (1997b) identifiedother factors such as levelsof suitablehousing. Many reports have identifiedthat
259 psychiatricpatients remain in hospitalbeyond clinical need due to the lack of
supportedaccommodation (Fullop etal 1996). For Steve,,this producedfeelings
of 'frustration-at being unableto makethe systemmore efficient:
Nurses feel fairly helpless in that they phone up the key- worker or the hostel and try and get thIngs pushed along the padent isjust hanging around waiting to go, the problem is organ1sationaland it needs to be standardised,
The Governmenthas identifiedthat NHSTrusts needto produceefficient
mechanismsof ordering clinical information (NHS Executive 1998). Moreover,,
other studieshave found that communityworkers do not alwaysintegrate with
the ward team to plan for effectivedischarge as quicklyas necessary(Barker &
Walker2000). For Tina, problemswere observedin the way the hospital
implementedits clinicalinformation policy and so impactingon the hospital-
communitydivide. This problemmanifested itself as a care delay in the care
pathway:
M7 an ad hocprocess where clinIcal information passes from onesector to anotherand thIsdelays the wholeprocess of admissionand discharge, it cantake the CMHTa weekto processa patientand allocate a social workeror a nurseand thatý;down to poor communIcadon.
A view from Zac who workedfor the HealthAuthority was that the emphasison
acute mental health care neededto change,were the ward becamemore of a
resourcefor the communityteam. Zac suggestedthat the majority of care should
260 be relocatedto a communitysetting with the emphasisbeing to get V7epatient
fast Zac for the team to the out as as possible'. advocated community monitor frn 1,equency of admissionbut also managethe speedby which peoplewere
allocateda key-workerand dischargedfrom hospital.However during a second
Interview,Zac built in the delayof finding accommodation(resource issue) and
the possibilitythat this may be a realisticfactor preventingpeople from going
through a care pathway:
However much you refine the care pathway so that somebody makes /aIrly rapid progress, if at the end of that time, there is no where for them to live, then the phenomena of bed blocking will prevail
Similarlyto Tina, Georgeidentified the allocationof the key worker as a possible
delay in the care system,which supportssome of Zac'spoints above. Reluctance
was expressedin the workinggroups to changethe processof patient allocation.
Respondentsidentified that unlessa patientwas allocated to a community
worker then a care pathwaywould not start. Georgesuggested a greater role for
the community mental health team where the community worker becomesthe central personfrom the start of the admission.Reconfiguring the role of the communityworker to act as the initial start to the care pathwaysuggested that not all participantsacted to insert delays.
Likewise,it was the perceivedbureaucratic blocks in the systemthat actedas a stimulusfor Miketo engagewith the project. For Mike,care delayswere both a
261 bureaucraticand clinically related problem but the importantissue was to
distinguishwhen each barrieroccurred. Using a care pathwayincludes variance
analysis,which aims to providesome record of care delays(Schriefer 1995).
However,before this systembecomes useful it is necessaryto be clearthat
somecare delaysare legitimateand not insertedfor the needsof the staff
groups.The processof psychiatriccare requiresadequate description for a care
pathwayto be designed.
Care delays may come from a source external to the care process such as
accessingsupported living projects.For example,Jude usedthis factor to
suggestthe care processshould 'bulldin Nme"toaccount for this problem,and
for this respondent,it was difficult to predict if or when accommodationwould
becomeavailable:
Theaccommodation people will place time delaysuntil tenancycan begin and so that needsto go on the carepath way becauseit takesabout 4 months from the date of referral, and if the patient is accepted,the patient cannotcome until a vacancybecomes available, put the patient on a waiting list.
Bill perceivedthat the pressurein the serviceaffected his ability to say when he would carry out an assessmentof need:
M; reasonableto have an assessmentcompleted within a month, but the difficulty is getting the appropriateaccommodation, securing their
262 assessmentdate,,, having enoughstaff In the localityteam to do the assessment
With repeatedinterviews and discussionwith communityworkers, respondents
were eventuallyable to developa sequenceto assessand obtain a rangeof
accommodation types for the care pathway. For example, the care pathway
would determinehigh, mediumand low supportedaccommodation and
determinethe stage for consideringthe accommodationtype. For those patients
that requiredintensive rehabilitation, a referral route was developedto quickly
determine this need. This sequence would be the starting point to determine a
future estimatefor supportedaccommodation in communitysettings and displays
again the ability to describepsychiatric work and reversepotential delays in the
system.However, in only a few casesdid the patientsfollow these routesand so
the successin predictingthe sequenceremains questionable.
Additionalto the problemsin describingpsychiatric work, respondentsidentified that parts of the care pathwaywere inaccuratedue to the insertionof care delaysor blocksin the system.The nature of the patient'sillness or the problems in interfacingdifferent agencies was a majorfactor. However, there could be other reasonssuch as participantsexpressing the viewthat they 'knowbestl through their clinicalexperience. Closs & Cheater(1999) also consideredthis with the interpretationand applicationof evidencebased practice. Zeb suggested that this attitude would underminethe processof developinga care pathway:
263 Peoplehave this genuinebelief that they'vecracked it and got a way of workIngthatý; effective,its meaningful,it gives them satisfactionand if only evetybodyelse did what they d1d,it will be even more wonderfulbut this gives them control wh1chis not alwaysin the best Interestsof the system.
There have beenvarious examples of respondentsboth buildingin and removing
time delaysin the care system.Delays may be due to the unpreclictabilityof a
patient'sprogress or bureaucraticissues such as the interfacebetween the
mental health systemand other agencies.However, the inabilityfor respondents
to adequatelydescribe their role affectedthe developmentof the care pathway.
The ability to build in or removetime delayssuggests that clinicianshave a
degreeof control over the care sequenceto either increaseor decreasecostly
resources.By implication,respondents would influencethis by the particularview they have over patient care. For example,if clinicianshold the view that care can
be controlledit may lead to improvedco-ordination of patient care. In this section,the scopeto insert delaysin psychiatriccare was possibleand one that a care pathwaydevelopment process has beenable to identify.
Exaggerated view of work skills
The difficultiesin developinga care pathwaymay also be due to the difference betweenthe practiceand theory of psychiatriccare. Muchhas been documented about the theory-practicerelationship within clinicalpractice for nurses(Conant
1967, Fealy1997,1999) and socialworkers (Reay 1986, Marshall 1990). This
264 may have led to respondentsgiving an exaggeratedview of their work skills.
There may have beenan appreciationof this supposed'gap' in practiceand
respondentsmay haveattempted to bridgeit by exaggeratingtheir role and
function. Carr (1986) identifieddifferent ways of viewingthe theory-practice
relationship and identified four typologies, which can be extracted from the views
of the respondents.Various examples of this theory-practicegap will be explored
alongsidehow the care pathwaywas perceivedto uncoverthese instances.
Clinicians experienced difficulty describing usual care for the care pathway and
Georgefor examplefirmly plantedthis problemwith a tendencytowards
identifyingtheory as opposedto practice:
Lookingat theoriesof what shouldhappen and then workIngout how that fits In with what doeshappen, you ýe golng to get a carepathway W17IC17is halfpraCdCal half theOretiCal,
This exampleillustrates a searchfor theory to guide practice(applied science approach),but also the dual existenceof theory and practiceas two entities
(Carr 1986).The surprisingobservation from the working groupsis that people who playeda large part in the developmentof the care pathwayexpressed the view that much of the role and function of the clinicianwent beyondthat of the care pathway.This becameapparent when the care pathwaywas implemented into clinical practice.
265 Nursetraining has beencriticized for not providingnurses with the correct
complementof skills (Gournay1995). Respondents identified with this position
and felt that a care pathwayillustrated the gap betweenwhat nurseswould like
to do comparedto what they have beentrained to do. Peteridentified that the
care pathway was a version of ideal practice as opposed to usual care:
Assessingmental states or educatingon prodromerelapse states is a specialisedskill beyondthat of basiclevel trainingand in Makin thecare pathway doesnt changewhat we do.
Other respondentsfrom a nursingdiscipline disagreed with this perceptionand
positedthat basicnurse training providedone with manyskills includedwithin the care pathway.However for George,the nursingenvironment within the
hospitalworked againsta care pathwaystructure:
Nursesdon t have an over-inl9atedview of their skills...1 rememberbeing tralned to do all the things Astedin the carepathway. Managerial duties have beenpushed down the gradesand this has displacedthe therapeutic role.
Yet other respondentsnoted that althoughthey had agreedto use the care pathwayduring its development,following implementation it enabledthem to think about their work in different ways. For exampleKerry observed that many of the interventionslisted on the care pathwaywere %dealsof what we sl7ouldbe dolng'but were not a routine part of practice.For Kerry,being confrontedwith this conflict enabledher to questionher own practice.This would be a positive
266 feature of care pathwaydevelopment but only if it gave rise to improvedpatient care and this was not evidentduring this study.
The differencebetween the Ideals' and 'reality' of psychiatricpractice may be explained by the research approach and the way respondentswere asked to describe psychiatric care. Walton (2000) also observed that psychiatric care was describedas a 'fragmented'approach when data was collectedthrough
'impressionistic'and a lessstructured fashion. However, respondents in this researchstudy were askedto describepsychiatric care accordingto the structure of a care pathway.It appearsthat respondentsdeliberately exaggerated their work regardlessof the definedstructure of a care pathway.
Somerespondents identified that the working group and developmentmeetings led to nursesand other professionalgroups giving inaccurateaccounts of their roleand function and arguedfor a 'realitycheck to be Insertedtoensure that the discussionarose from a practicalrather than theoreticalposition. In a sense..
Georgewas applyinga criticalapproach to understandingthe theory-practice relationship.This view acceptsthe contributionsof both positionsin understandingthis complexrelationship (Carr 1986). George suggested that someprofessional groups exaggerated their roleand function due to the political natureand transparent structure of the carepathway procedure and that the
267 every day practiceof psychiatricwork !5ounds very benign'com pared to the rhetoricof evidencebased practice:
Peoplemake it up to maIntaintheir own posidonin the Trust. Thereis no doctor who sits down every weekand re-doesthe mentalstate examinationand the nursIngstaff do not have regularkeyý- worker sessionsto educatetheir patients,it wasall put in to make them look as though ffieyý-edoing something useful,
Supportingthe aboveexample, and describingthe approachas 'referringto a text-book'duringthe developmentof the care pathway,George reiterated the exaggeratedpicture of psychiatriccare. Steve illustrated this point further by usingthe teachingpackage of interventionsthat was includedwithin the care pathway:
The education process goes along but it becomes the whole hotch potch of nursing interventions, which are so varied that nurses are not even aware that ffieyýe doing it. The care pathway leads nurses into a false sense of role security In thinking they can do ffilngS.
In a sense,respondents have usedthe action researchcycle as a form of self- reflectionto understandthe difficultiesin constructingpsychiatric practice within a care pathway.George recounts some of his thoughtson how the role of the clinicianwas misconstruedand exaggeratedto fill the care pathway,but noted how this becameapparent following implementation. This observationcan be supportedby the researcher'sentry in his field notes becauseinspection of the care pathwayfound large parts were not being completed:
268 Everyonewas in an Ideallsticmode, Y can do that but peopledidn't know ,' how it wasgoing to re5ect on them when they tried to put it into practice becausepeople just carriedon doing exactlywhat they were doing before and the carepathway dIdn't reflect the care deliveredat the time.
Jude describedthe contentof the care pathway,as 'too ambitlous'and suggestedthat the processof developmentshould start with a simple representationof care. Followingimplementation, further parts of the care processcould be includedwithin the care pathway.This may reversesome of the exaggerated functions included within the care pathway but also enable a measuredresponse to changingpsychiatric practice. At no time during the working group processwas a stagedapproach to developmentadvocated by the respondents.
Ingrid claimedthat the contentsof the care pathwaywas a fair representationof
OT work but identifiedthat the type of patientswho were admittedonto the care pathwaywould not usuallyreceive the samelevel of input in her usualcare.
Again,this observationdemonstrated the inaccuratecontent of the care pathway:
We do what is written down, but the people you had on the care pathway, from my own experience, they are diffkult to ergagg. so I wouldn't have tried to engage them as much as I did.
269 in this sectionthree major problemsin developingthe care pathwayhave been
explored.In the first, respondentsfelt that a care pathwaypresented a too
simpleor over idealisedapproach to care.This was largelydue to the visibility of
psychiatricwork and how this dominatedthe less noticeableaspects of work on
psychiatricwards. Moreover,identifying the processof care was difficult for the
respondents. The role of the researcherwas to facilitate this process.This was achievedby uncoveringaspects of practicethat respondentsdid not discusssuch as when the psychologistbecame involved in a patient'scare or why patientsdid not receive community assessmentsat an earlier stage in the care process.This did lead to accusationsfrom respondentsof partialityin the collectionof data.
The researcherwas accusedof manipulatingthe developmentof the care pathwayby forcing cliniciansto say what they did for this particularclient group.
A secondproblem was that respondentsinserted delays into the care process.
Manyrespondents recognised this occurrenceand usedthe action researchcycle to illustrateand learn from their working group experiences.Psychiatric professionalsmay have inserteddelays into the care processto protect their role from increasedworkload or becauseof an inabilityto predict patient care. A third problemwas a respondent'swillingness to exaggeratetheir roleand function and this was presentedas a theory-practicegap deficit, Respondents may have done this to protect their role in responseto organisationalchange. A central element of the working group processwas the negotiatedcontent of the care pathway althoughthis led to an inaccuratepicture of psychiatriccare.
270 Nature of change environment
Turnover of staff
The nature of changemanagement programmes will producea variety of responsesfrom "enthusiasm'and "support'to 'reluctance"and'antagonism'
(Parsley& Corrigan1994). In this section,the effect of managerialchanges to the ward and communityteam and how this affectedthe developmentand implementationof a care pathwayis explored.Particular problems covered by this topic, reflective of the wider problems in psychiatric hospitals, include the lack of adequatenumber of staff to providethe minimumtherapeutic standards of care (RoyalCollege of Nursing1998).
Maintainingcontact and commitmentwith a ward team experiencinga low retentionof staff provedto be difficult. Both Simonand Stevespoke directly about the retentionof staff and how this influencedthe developmentof the care pathway.Such factors rangedfrom unstablemanagement structures across the ward and communityteam, low morale,disrupted education process and poor participationin a changeprocess. For example, a considerablenumber of the nursesinvolved with the projectwere moved onto other wards. This affected the relationshipbetween the ward, communityteam and the working group process.
271 Gilesspoke openly about his frustrationat the disruptioncaused to Vs`ward and
linkedthe changesexerted by managementas the cause:
At the stalt it wasa more receptiveenvironment and youV find it much easier,you wouldnt have nursesmo, ving on, you wouldnt have people sayingsorry Dn too busy to fill in your forms.As a result of clumsy managementchanges, five of the best nursesleft over night leavIng the place in what was effectivelya vacuum,there wassex on the floots, dope wasbeing smokedopenly, it was total chaos.
Stevealso spokeabout the importanceof havingan establishedward manager
prior to the start of the project. Stevefelt that the actingward managerwas not
alwaysacting in the best interestsof the projectand describedhim as !5tamping
his mark on the ward. Steveadvocated a stablemanagement structure in order
to establisha care pathway:
You'vegot a person who is anxIousto make a namefor themselvesand any researchis going to be subjectedto that.. carepathwaYs was being usedas a tool for the manageron the ward too improvetheir Own systemswhich are alreadyIn place.
For Georgethe ward experiencedan unsettledperiod by not havinga permanent
ward managerand this affectedthe levelsof motivationwithin the staff team for
developingthe carepathway. It wasconsidered that opportunitiesto display
leadershipand innovationwere not takenup by the actingward manager such as staff meetingsand supervisionarrangements. George even questioned whether the ward managerwas supportiveof the project.Throughout the
272 durationof the study, three different ward managerswere in post, each displayinga different style and approachto the project. In the researchers'field notes, it was recordedthat towardsthe end of the project,the third successive ward managerpaid only superficialattention to the projectwith little awareness of the variousstages of developmentor to the politicalconsequences for individualprofessional groups.
Ingrid on the other hand felt that the dynamicson the study ward had always been difficult leadingto the impressionthat it was a difficult ward to carry out research:
They'vebeen going througha lot of different changes,,but itý; always been a diffl`cultward, it wasnta stableplace or well receivedby the staff.
Peterwas the secondward managerin post during the project and he was candidabout the major organisationalchanges that were past and presentwithin the organisationand how this distractedattention from the project:
Thereý7 not beenenough stability on the ward,people moving, big changes,more impoltant consideratlons for peopleand energieshad to be in otherdirections. It wasa shameyou couldnt keepup the momentum at the beginning,because it felt vetyexciting and positive.
The problemwith staff turnover was the perceivedcompetencies of staff that later were to be employedon the ward. Georgedescribed the processas
273 I ýIunclering'themore able members of staffand replacing them with 'rejects
from around the hospital'.Other staff on the ward also registeredtheir intention
to leavethe ward. Georgespoke about this beinga particularlydifficult phase
becausethe processwas reliant on examiningrole functionand requiredinterest
from the new membersof staff. Whenthis enthusiasmwas not evident,it
contributed towards low morale within the team. This created a processwere
peoplewere continuallybeing trained to use the care pathway.
A particular difficulty for some respondentswas the lack of preparation time for
peopleto feel comfortablein implementingthe care pathway.This led to
increasedpressure on the remainingfew nurses.Jude stressed the importanceof
training all staff who were to be involvedwith the care pathwaysproject, but
also to havethe right type of staff for it to be viable.Jude felt that care pathways
should not be used if a hospitalrelied on agencystaff due to the poor levelsof
training and use in practice:
If all hadbeen trained to useIt, it wouldhave been more effective becausewhen I wasn"t around thIngs weren It getting done, it wasthe poorpermanent stafflng level you couldn't inform agency staff to be preparedin thesame way because there was no guarantee they would be therethe next day and then you ended up explainingit evety single day. Peoplehad tried to useit asa normalnursIng document and it 17adn It worked.
Stevefelt that the changesimplemented by managementwere a thoughtless action, which inevitablydamaged the processof engagement:
274 Managementdidn t have enoughforesight to see the implicadonsof pulling staff off Singletonward, but they'vetaken people Involved In the carepathway who weregenerally interested and enthusiasticand theyýe now on wardswere theyýe not involvedwith the carepathway process...how they expectedSingleton ward to engagewith this project Is beyondme.
Stevedescribed situations where manyagency nurses were being usedwho
were both unfamiliarwith care pathwaysystems and with the type of patient
eligiblefor the research,thus affectingthe viability of the project. However,
there was also unwillingnessfrom the agencystaff to becomeInvolved with the
research.Towards the latter end of the researchstudy, there was a difference
betweenthe peoplewho plannedthe pathwayand thosewho carriedit out.
Steve identifiedthe extra time and resourcesto educateand preparepeople for
the care pathwayprocess and observedthat the constantdecline of staff de-
stabilisedthe care pathwayprocess.
Kerry noted there was a great difficulty in implementingthe care pathway,in
part due to poor communicationchannels but also due to not havinga regular team of nurses.The problembecame apparent when on-calldoctors were called to assessthe patientand so eitherignored the carepathway components or made incompleterecords within it, For Kerry, followingthe care pathwaywas
I. impossibleandpotentially Atlglous'withoutthe full team knowinghow and where to documentclinical information. This finding is in contrastto that of the
275 literature.Hall (2001) for examplesuggested that communicationpatterns were improved with a care pathway and this prevented the chancesof litigation cases from occurring.
Respondentshave identified factors present in other studies documenting the problems in implementing clinical guidelines (Hadorn etal 1996). For example,
Cotton & Sullivan (1999) found that hospital doctors were too busy to carry out the guideline and were influenced by negative opinions from their peer group.
Hospital nurses expressedconcern over the lack of training. These factors were presentin stablechange environments. Some of the problemsidentified by the respondentsmay be due to the amount of extra paperwork involved in carrying out the care pathway. De Luc's (2000) study of implementing a maternity care pathway found many problems with the documentation, particularly the amount of time requiredto completeit. De Luc(2000) usedthe criticalincident techniqueto discoverthat respondentsperceived the care pathwayto offer a no more useful source of information than the currently used paper systems.
In this sectionsome of the problemsin developingthe care pathwayin this researchenvironment have been explored. For many respondents,the rate of staff retentionfrom a full complementof nursingstaff to one that relied on agencystaff createdmany problems. The major issuewas one of enthusiasmfor the projectalongside the difficultiesof preparingstaff to implementthe care
276 pathway.There were manyrespondents who felt the problemsof staff retention were due to managerialstaff intervention. Other respondentsfelt that the problemsof staff enthusiasmwere evidentbefore any managerialintervention. It seemsunlikely that thesefindings would be a featureof all staffingcomplements in London hospitals but if this was the case, it would be difficult to develop care pathways within this changing staff environment.
'Wejust couldn't be bothered'
The preceding parts of this chapter have reviewed the occurrenceof a low retentionof staff and attentionis now focusedon someof the perceivedeffects of this staff movement. Morale and enthusiasmfor change are important for new changeinitiatives to be successful.How these factors influenced the processof developingand implementingthe care pathwaywill be explored.
The differencein moralefrom the start of the projectto the end can be illustrated by the willingness to undergo an internal critique of practice. Peter describedthe nursingstaff as 'fairlYkeen to explorePractice'and willing to improvecare processes.However, these positiveaspirations for the research study quicklyturned into negativeviews when suddenchanges were madeto the staff complement.Steve felt that the environmentrequired a stablecomplement of nursingstaff for effectiveengagement with the study. Moreover,as suggested
277 by George,the moralefactor led to disciplinesnot !selling themselvesduring the development process:
M7 difficult for peopleto say what they do at the best of times but for somethingthat is cost eff7ciencybased, each di5cipline would want to sell themselvesto the highestto have20 pagesdedicated to just what they do on the carepathway to showhow much the hospitalneeds them, but peoplecouldn t be botheredto take ownershio.
Mike expected Peter who was the acting ward managerto promote the project
'constantly'and this lack of effort turned into a potential barrier to generating interest. However, it may have been difficult for Peter to maintain motivation given the staff turnover on the ward. For Peter, attentions were directed towards
practicalward managementissues such as ensuringthe ward nursingduty was
'covered'although he did acknowledgethe difficulty for people to participate in the research study. Primarily this was due to people experiencinga wavering sense of morale, which led them to feel insecure in their role, and so it was
ldifflcult for them to achieve the basics, let alone extra research activity,
Simonwho was a clinicalpsychologist described how the projectstarted with considerableenthusiasm and then stoppedand attributedthis effect to the lack of interest from clinicians and the absenceof support from the Trust as a whole:
Thingshave beensliding, and sinceI've only ever receivedone note about oneperson, I've just beganto think well, is itjust fading out The wardhasn t backedcare pathways for a second.The whole organ1sation
278 has to be persuaded.There was a lot said, say 6 monthsago, when these meetingswere happenIng, and then they stopped.
The problemsin implementingthe care pathwayalso stemmedfrom the lack of
co-ordinationbetween the wardand the communityteam. This processwas
coupledwith the small numberof individualswhom had investedthemselves Into
the researchstudy. This createda dynamicwhere someindividuals were
engagedin the implementationand somethat stood as passiveobservers on the
project. Buchanan& Huczynski(1990) note that this may be due to a lack of
trust in the changeinitiative and certainlyquestions the approachtaken by the
researcherto engagethe ward and communitystaff, Mikedescribed the team as
'fragmentedand lackingin real interestand this led to the care pathwaynot
being adequatelycompleted. Moreover, Mike felt the study participantswere
consciousof other politicalfactors occurring in the hospitalreferring to the
'clumsymanagement changes'that had taken on such importancefor the staff in the hospital.
Mikecommented on the level of insecuritythat cliniciansfelt on the ward and how this adverselyaffected their involvement.For example,Mike perceivedWyn who was the generalmanager to be unappreciativeof staff efforts and how a
'blameculture /permeated the organisationfrom 'top to bottom. This led to staff feelinginsecure and reluctantto adoptnew change initiatives and an attitudeof
Yetsjustdo the basics"leadingto a maintenanceof past work patterns.
279 Anotherrespondent suggested that peoplefailed to engagewith the project becauseof the absolutelevels of low moraleon the ward, which createda sense of apathyfor usualcare practices.George identified that membersof the team rejectedthe extra demandsof the care pathway:
Ifpeople arent enthuslasticabout theirjob the leastpossible route to existenceand eventuallaziness, People: ý enthuslasmjbstdied vety quicklyand felt they dont do it (carepathways) on other wards,why shouldI do it here.
In a further exchange,George spoke about how the care pathway documentationwas incompleteleaving large parts of the care patientsreceived unaccountedfor. Informationwas not being documentedabout why an interventionor outcomewas given or achieved:
Variancesweren t being recordedand it didnt reflect why the care wasn't carriedout. If the patient was too disturbedto do the educationon the med1cation,do it at a later date, but that wasnt done no record waskept of that and it wasa caseof blankpages and laziness.
Lookingback over the implementationphase, Zeb attributed many of the problemsof developmentto the unstableinfluences on the wardand suggested that the project should be re-establishedat a more appropriatetime. However, havingsufficient numbersof staff was no guaranteefor ward motivation:
280 At the beginnIng,Singleton ward looked vely stablebut the b19killer factor was the level of unrest.It wasextremely dIfficult to predict how bad that would of got. Youneed new nursescomIng on to the ward with a fresh approach,theyý-e not institutionalised,Jtý; very easy to settle into an air of apathyand new nursesdo that very quIckly.
Mirrenobserved that staff felt too cle-moralisedto engagewith newways of
working.Additionally,, there was a perceptionthat clinicianswere subjectto high
levels of past change and that any further change was going to bring about
resistance.This affectedthe lack of commitmentof the nursingstaff to the working groupsand the numbersof nurseswho attendedevidenced this. Nurses also felt demoralisedbecause of colleaguesmoved by 'management'andothers who were leavingto take up other positionsin the Trust.
Georgeoffered a broaderview by drawingon how the Trust managednew innovationsand staff morale.For George,this resultedin resentmentin engaging with a researchproject that was going to enhancethe reputationof the Trust.
The major factor for Georgewas the feeling of a senseof depreciationand lack of supportfrom the wider organisation.George described psychiatric work as a
'thanklesstask'and indicatedthat nursesfelt sensitivetowards this when the organisationundervalued their work:
Peopleare less keen to be involvedin something,wh1ch is extra to the m1nimumthat they can get away w1th.If we can't feel as valuedmembers of staff, then weý-e hardly going to developthe future of nursIng for Hackney-peopleinvolved will get nothing from doing it and weýe doing the Trusta fa vour.
281 However,not all participantswho engagedwith the researchproject experienced
a senseof low morale,although they recognizedit within the wider workforce.
Mike and Bill perceivedthe researcheras makinga certaineffort to engagethem
particularlywith the researchproject. For example,Mike felt that he was
informedmore about the objectivesof the researchstudy comparedto others. It could be that respondentswho experienceda low senseof moralemight be less inclinedto engagewith a researchproject. Moreeffort would be requiredfrom the researcherto involvethis potentialgroup of staff with the developmentof a care pathway.
Other respondentscommented about the one-waynature of researchstudies where the actual participantsgained little benefit from engagement(Fryer &
Feather1994). Mikespoke about his perceptionsof why respondentsfailed to engagewith the projectand recognised that peopleperceived it as a 'research project'which was Mort term!
Whatdo we get out of this becausethis isn't going to be on-goinglike CPA.If carepathways was comingIn people wouldsee it on a long term basisand lead to greater investmentbut it wasjust research.
The nature of changeaffects peoplein different ways.The intention at the start of this researchstudy was to identify a ward and localitythat was both 'hlghly staffed'and motivatedto examinepractice. The researcherpurposefully spent
282 time securingthe commitmentfrom all staff. Other factorsidentified by participantswere the confusionof usingcare pathwaysalongside usual care processesand peoplebeing too busyfor developmentalwork.
In this particularresearch study, there was a suddenchange in ward personnel.
This createda periodof disengagementand disinterestfrom the project and this was also exhibitedby feelingsof low morale.There was also some referenceto feeling undervalued by senior managementwithin the Trust and somestudies have found that when peoplefeel unappreciatedthere is a reluctanceto collaborate and take on new roles and responsibilities(Davies 2000). In this sectionsome of the problemsin securingthe role of the participantsin developinga care pathwayhave been reviewed.The followingsection will focus on the role of the facilitatorand the use of changemanagement strategies.
Managerial impact upon empowering process
Paradox ofpo wer
The processof usingaction-orientated procedures to securerespondent engagementwith the study will now be reviewed.As will be shown,respondents overtly and covertly usedcoercive management strategies to ensurecompliance and dominationover professionalgroups and clinicians.The Intentionwas to use actionorientated research methodology within a collaborativefashion, and as far as possible,this strategywas pursued.As detailedin previoussections, the
283 environmentchanged considerably, impacting on the moraleand interestwithin the researchstudy. Respondentswanted to take control of the project by influencingthe researcherto makepeople comply with the care pathway structure.
Georgeperformed a key role in developingand implementingthe care pathway from its conception.Even during the first consultation,George wanted to covertly ensurerespondents complied with the actionsof the researchstudy and the researcher.Primarily,, George wanted to introducethe care pathwayin a way, which would prevent role erosionfor psychiatricnurses. Tina spokeabout
!5elling'the proposedresearch strategy to the ward and communitystaff. This was in contrastto the views of the researcherwho pursuedengagement and empowerment:
Notbein9 seen as havinglimited clinicalcredibility or some academic whoseusing the ward to get a PhDand belng convincedthat you ýe committedto improvingcare, being carefulon how we sell it as Improving care.
Meyer(1993) attemptedto use a bottom-upapproach at the start of her study into developingpatient centredcare on a surgicalward but found circumstances in the field to dictatea top-downstyle. For example, an ultimatumwas given to the ward manager,from the senior managers,to either supportthe project or leave.Similarly, both Wyn the senior managerand intermediarymanagers such
284 as Tina wantedto coercepeople into beingpart of the researchstudy. The researcherfelt uncomfortablewith this position,but similarlyto Meyer(1993) had little choicein pursuinga compromisedcollaborative research process.
Both Georgeand Tina were providingthe researcherwith Importantinformation to successfullyengage the respondents.However, their Intentionswere to secure compliance.The surprisingfinding was that Tina wantedthe facilitatorto be autocraticin the managementof the project and that she would !5upport this way in all of tl7emeetings" George readily accepted that participantshad been coercedinto taking part in the project:
It has been coerdonbecause people were injdallyafraid to commit themselvesto somethIngthat goes agaInsttraditional individualised care and potentiallyproving themselvessurplus to requIrementsfor the hospitaland thatý;a scary thought,
The intentionsat the start of the researchstudy were to let the participants decidethe contentsof the care pathway.However, major stakeholdersin the processwere reluctantto concedethis ground to fellow colleagues.George felt that the role of the facilitatorshould be to externallyexamine practice and for this then to be endorsedby a groupof professionals.George argued that this would be a more successfulmethod of creatingthe care pathway.Pat advocated for a facilitatorwho would 'force'peopleinto complyingwith the demandsof the
285 care pathwaystructure and say, 'youýedoing this andyou must changeyour
waysof working.
The OT departmenthad beenvery cautiousabout engagingwith the researcher
throughoutthe study. Derrinspoke about how the care pathwayhad been
developed in a highly political context and how she perceived general
managementas somehowsplitting the voice from the OT department:
Therehas beenpressure on 0T from managementto cut back our resourcesand this project has workedthat agenda,but Helenand myself have known eachother for years,if we didn't have a good relationshioit wouldhave been divisivewith two messagescoming out and this research was exploitingpotential differencesIn workingrelatlonships.
AlthoughWyn who was the generalmanager for the hospitalwas overt about
requestingOT to be involvedwith the project there was also a covert strategyto
somehowundermine the effect that OT playedin the whole packageof care.The
researcherhad also gainedthis impressionby informalconversations with Wyn.
At the time of the researchstudy, Wyn was in the processof taking management
responsibilityfor the OT department.OT's were unhappywith this development
becausethey suspectedthat the autonomyof the OT interventionswould be compromised.Wyn hadstated to the researcherin a furtherinformal contact that he thought OT's 'werea wasteof time on Me wardsand d7eysl7ould be part
of the numbersýWyn was referringto a desirefor OT'sto be part of the
286 complementof ward nursingstaff. Derrinwould be correctIn her perceptionof
managerialcontrol by senior nursingpersonnel over the OT discipline.
Evenat the end of the project, for Jude there was an acknowledgementthat you
need to havea recognisedfacilitator of the project who would commandrespect
from all disciplines.A personemployed within this role would add legitimacyto this task:
You need a facilitator who will chase people up to ensure that they comply and you ha ve to ensure that there is a system in place to monitor that. If Jtý;theiriob People won't think, who is that nurse telling me how to do my job and they wouldjust accept him.
Followingthe processof implementinga care pathwayin a specialhospital for
mentallydisordered offenders, McQueen & Milloy(2001) also found that they
neededto developa 'co-ordinator'to ensureclinicians implemented the care
pathway.A personwith 'great access'to professionalgroups was advocatedand the nurseward manageradopted this role. The difficulty would be ensuringthat other professionalgroups accepted the remit of this role and as demonstrated within this study, clinicianswere resistantto examiningroles and functions.
Both Georgeand Peterattributed the willingnessof nursesto engagewith the projectto the occupationalclass of the researcher,and the trusting relationship that had been establishedover the years by the researcherworking for the
287 hospital.Paradoxically, this relationshipwith the Trust led to some respondents
to disengagewith the researcherand the project:
It was a nursIngled thIng and we thought we could trust you but for othersyou were beingpald by the Trustand they w111have accessto the Andingswhen it"s published. People have been carefulabout disclosingtoo much information,so to limit awarenessover what they do but this is not a criticismbut you need to be awareof your agenda,your agendais not too positive about Ors or psychologIstsand you are pro-carepathways.
Other informantsagreed with this perception,but wishedto capitaliseon this position.For example,Tina adopteda defensivestance towards the management of the project where 'carepadmays wouldbe seen as a nursinginitiative, not a
d7ing' This domination medical . position reflects one of control and over other disciplinegroups. However, the researcherdid not supportthis positionand activelyengaged with a wide group of peopleto be part of the project.
In an actionresearch study investigating the developmentof an advancednurse practitionerin dementiacare and treatment, Rolfe& Phillips(1995) noted that the researcher also wished to change practice. However, the direction of change was supportedby the researcherand so in effect, shapedthe final outcomeof the project. Respondentsin this researchstudy may have perceivedthe researcherto be exertinga dominantrole in the carepathway project, although this was not a consciouslyengineered role.
288 Somerespondents did not perceivethe researcheras havinga dominant
influence.This finding mirrorsthat of the literaturewere qualitativeapproaches
havethe potentialfor informantsto feel as though they are being listenedto and
influentialin the representationof the ethnographicaccount (Patton 1980).
Simonfor examplefelt that the researcherwas likeableand this led him to
engagewith the project:
ftý; by chance we get on, and I've done more for you than I might 17ave done, but i& to your credit that you've been persistent and pleasant that you've actually got somewhere against the odds because the organ1sadon has not supported you.
Somescholars have noted the importanceof the interpersonalskills of the interviewerto gain compliancewith the study objectives(May 1989)and similar to Simonabove, Giles engaged with the researcherbecause of the amicable relationshipbuilt up over time. Gilesalso spokeabout the constraintsof his job impactingon the role he playedin the researchstudy. Gileswas honestin his appraisalof his role in developingand implementingthe care pathway:
You'vebeen so charming and persuasive, but I've got enough on my plate without you coming around wanting me to write it all down, fortunate/Y the paper work has been kept to a precious minimum for me and all I do is sign and agree with thlngs,,and theyýe written down on paper, and so I've got away with it.
In this section,the perceivedrole of the facilitator in managingthis research study has been explored.Action orientatedmethodology aims to empower
289 participantsto changepractice (Webb 1989),attempting to draw peoplefrom all
perspectives.However, evidence from this particularcontext conflicts with this
perspective.Respondents wanted to coerceparticipants into working with care
pathwaysand for somediscipline groups such as nursing,to take ownershipof
the project. A perceptionof professionalcoercion may have led cliniciansto feel
uncomfortablewith the developmentof a care pathway.
Managerial styles
Approach used by the researcher
It is widely reportedthat cliniciansare more receptiveto developmentsif they are involvedin their developmentand this typically meansusing a bottom-up approach(Kennedy 1996). In this section,it will be exploredhow the researcher was able to adhereto this ideal but also adaptedthe style to matchthe local needsof the researchcontext.
The need for the facilitatorto be perceivedas both a !5peclalist'and available for consultationis importantfor the developmentof care pathways(Hainsworth et al. 1997). Zeb was able to confirmthis view when the researcherattempted to engagewith the communitystaff. The researchermade several visits to the communityteam and attemptedto securetheir involvementthroughout the researchstudy althoughthere was only partial success:
290 Get the communV staff to see you as knowledgeableat the Initial stages becausethen theyll feel they'veinvested something in it and trust you becauseif your not Involvedthen you tend to think well its not golng to work and then it becomesa self fulfillingprophecy of why should we listen to him,
Somerespondents were very clear about the way individualsshould be
Ynstructed'toengage with the researchproject and activelysupported autocratic changemanagement styles. For example,Zeb wanted 'instructionin writing from
the Trust boardtelling cliniciansto participatewith the researchstudy. This departsfrom other studies,which encourageparticipative decision-making processes(Broome 1980). Other respondentshave taken a mixed perspective where both changestrategies should be used. Mike reflectedon his own contributionsand felt that opportunitieswere madeto 'describethe real world in tt7e the However,Mike the importance communityand restrictions'. still valued of gaining higher managerialsupport, which may force other cliniciansto be part of the project.
Degelinget al. (1998) found that if the hospitalmanagement culture was perceivedto have an organicorientation in involvingstaff in the developmentof initiatives(i. e. bottom-upand participative),more of the respondentswere gearedtowards accepting work control methods. However, this wasnot perceivedto be the casefor the staff working in the hospitalwithin this study.
For example,Mike felt that managementshould have addressedsome of the
'deeper'problemsoccurring within the organisationthat were makingclinicians
291 feel uncomfortablesuch as the levelsof poor motivationand disengagement
experiencedby the team. Reversingthese negativestaff attributeswould be vital
so as to enablestaff to positivelyembrace the work control methodscontained
within a care pathway.
Other respondentsrejected the callsfor cliniciansto decideon the content and
Implementationof the care pathway.Zac felt that the methodof change
managementadvocated in this researchstudy would have been more successful
if it was co-ordinatedby senior management:
You'vegot to have a lot of people who are in power in the organisatlon behindit and activelyengaged with you. Thereis a oreat dangerif the innovationis on the shouldersof one person,especially if they arejust sort of added to the ward as you have been.
Steveon the other hand commentedthat 'management'createdan unreceptive environmentand worked against clinicians wanting to engagewith the project.
Stevedescribed the processof 'managementcoming down in a heavymanner' and felt this worked againstempowerment and inclusion:
For Peopleto get involvedall opportunideswere made,It ý;fairly natural that people are going to feel wary aboutplacIng them5elves on the line due to the nature of the Trustand how Wynmanages people.
Both Zac and Steveacknowledge the need for supportfrom senior management of the Trust. However,it is the nature of the supportthat appearsimportant.
292 Bond etal. (2001) observedthat if care pathwayswere Introducedat a ward
level, without a firm strategicoverview from senior management,they tendedto
fail. Supportfor care pathwaysfrom all levelsof the organisationwas required for the tool to be successfullyimplemented.
Mirrencommented that the nursingstaff on the ward felt lalienated'bythe perceived'managerialpresencein the working groupsand suggestedthat some meetingsshould have been reservedjust for the nursingstaff on the unit. Mirren was critical of the way the working group attractedits membershipwho she perceivedas '17avingnoffiing to do wiffi tl7eward. Althoughthis impressiongives some insight into the fractiousculture of psychiatriccare, it did leave respondentswith the impressionthat some membersof the group were more important.Mike on the otherhand was unconcernedwith non-nursingdisciplines such as membersfrom the HealthAuthority attendingthe working group althoughattributed this to the role insecurityexperienced by some disciplines.
Mikefelt that Zac from the HealthAuthority would providea more informedview of the care team and how it shoulddeliver care for peoplewith schizophrenia.
This was also the intention of the researcher.By includingas many cliniciansand interestedparties as possiblein the projectit did leavepeople with the perceptionthat their voicewas less importantcompared to other participants.
293 For some respondents,an approachwas requiredthat would serveto empower
professionalgroups. Peter asserted that the role of the group was to make
peoplefeel as 'equalpartners"andto 'makethe ride aspleasantaspossIble'In decidingthe content of the care pathway:
I like the idea of actionresearch and olevelopIngIt In practice, the laboratoryas the workforce,you wouldnt 17ave as much successcoming in with a readymade package that had been researchedsomewhere else. Youbf get a lot more resistance.
Mirrencommented that if managementbecame too dominant,clinicians would only pay lip serviceto implementingthe care pathway.This may have beenthe case, becausevery little of the care pathwaywas implemented.The significance of this exampleis that the circumstancesof the ward would not have responded well to any managementstyle given the nature of care pathways:
Beingvely authoritariandoesn t meanyou ýe going to increasemotivation the few implementingthe or complianceespecially over past months.. carepathway was on a losingpath from the start becausepeople just got so despondentand angry, 'management telling us whatto do; they couldnIt be botheredwith a researchproject.
Jude felt that both approacheswere necessaryto complementall sectionsof the workforcealthough acknowledged that someclinicians were adverse to change:
If it comesfrom top to bottom, not g1vingpeople the chOICe.PeOPle will respondnegatively because overall they dont like chan-0e.
294 Ingrid felt that the developmentof the care pathwaywas hinderedby not having a patient representativeon the working group. Ingrid wantedto discussthe client's perspectiveof what they wantedto includeIn a care pathway.Much has been noted on the needfor usersto be representedat the strategiclevel in planningservices (Health Advisory Service 1997) althoughthis failed to occur in this study:
It doesnt involve the client and they wouldhave to be involvedin the developmentand implementationof it, Youcould do it with people who had comein a numberof times by lookingat the recordsand talk to them when theyý-emore stable.
The action-orientatedapproach to developand implementthe care pathwaydid not lead to full participation,although some respondentspersonally liked the researcher.In other words,there was a limit to people'sinvolvement without the presenceof a managerialdirective. Simon likened the positionto 'lookingat
4 videoinstructions.
Putting the care path way together has had almost no Impact yet, except for a few meetings. It will if they refer someone and then Ill stalt analysing it properly. It ý; like video instructions for changIng channels, I glance at them and then when I really need to do It,, 1747get out the book and start sweating and say what the hells this all about.
Respondentsidentified that the working group processmay have placedpressure on peopleto structure care into a more standardisedfashion. However, Steve offereda different impressionof the working group processin that it afforded
295 the chancefor peopleto determinethe directionof the care pathway developmentproject:
Opportunitywas made to get peopleinto the workIngparty and once in, the if yo0-e yo0-e part of arenaas much as everybodyelse .. people donIt want to takepa4, it leavesthem with fewer optlons.
Steve also felt that when professional groups refused to attend the working groups,the researcherwas limited to individualdiscussions with members outsideof the working group. However,this compromisedthe input from disciplinegroups and Stevefelt it was allowingdisciplines to make it 'too easyfor the processto be compromised.Steve questioned whether there was a lack of informationat the start of the researchstudy althoughanother respondent confirmedthe view that sufficientopportunity was madefor individualsto be involvedwith the research.Linking this point to the generalapathy towards the introductionof a researchprogramme, Jude noted:
A// of the peopleinvolved had severalmeetings before it statted, they all acceptedto use it, some of them tried to use It, and others didnt bother. Theydidn t take it seriouslybecause it-2; research and they dont see it as somethingtheyve got to follow.
Thedifficulty in securingthe involvementof the participantsfor the research study was evident by the numberof sessionsthat the participantsrefused to attend.The researcherexperienced difficulty In contactingthe variousindividuals and for the viability of the project, the researcherneeded to securethe role of
296 the generalmanager to ensurecompliance with the overallobjective of the
researchstudy. Somerespondents have beencritical of this move,whilst others
such as Stevefelt that it was the only way forward. Disciplineswere 'holdingoutf
until their stancewas 'shunted'alongby managersin the directorate.
For Derrin the role of the OT was negotiated to fit the structure of the care pathway.The fieldworkdiary chartedhow much of the content of the care pathwaywas negotiatedwith individualdisciplines. Derrin recognisedthat her reactionshad changedfrom negativityto acceptanceof the care pathway,in responseto the empoweringapproach taken by the researcher:
Wehaven t compromisedon makingdecisions before the individual/S seen, we didnt get pushedinto that, it's been negotiated,we've perhaps put more structure to it than wed wanted,but that will do no harm and weý-e happy with the end result.
Action researchhas the potentialto fuel a senseof empowermentin making decisionsabout care, but alsoa positivefeeling generated from beinginvolved in these decisions. For example, Hart & Bond's (1996) action research study into improvingstandards of care found ward managersto feel ýositive`abouttheir roIeandape rcepti on 'that they might be able to influencethe courseof e vents wherebefore they had beennegative. In somerespects, this wassimilar for
Derrinand the role of the OT. Perceptionsof the OT were held to be negative prior to and during the researchstudy. Followingimplementation, some
297 participantswere able to experiencean enlightenedperspective of the role of the OT.
The aims and objectivesof the projectwere complicatedby the fact that the researcherwas followinga researchagenda alongside the Trust's alms of attemptingto implementa care pathway.Management intervened to ensurethat disciplinesengaged with the projectto form a care pathwaydocument. All respondentsdid not acceptthe role of the researcherin attemptingto createthe conditions for receptive change. Key informants wanted to coerce participants into developingthe care pathway.Additionally, the researcherneeded to coerce respondentsto achievethe objectivesof the Trust. Takinga broaderperspective, the respondentsdiscussed the nature of changeusing autocraticand inclusive managementstyles. A rangeof viewswas elicitedsuggestive of supportfor both approacheseither separatelyor together.This twin style approachappears to have been most appropriatewithin this particularcontext
Conclusion
In this chapter,three areasappear important for the developmentof a care pathway.In the first, respondentsidentified those aspects of practice,which appearedmost visible to describeand illustrateon a care pathway.This had the effect of displacingthose aspectsthat were least visible such as therapeutic contactor 'bein9 wit/7psychiatricpatients. By identifyingthe visible parts of
298 psychiatricpractice, it gave respondentsthe impressionthat it representedthe totality of psychiatriccare. It was only through the processof Implementation that respondentsidentified that large parts of care were not includedwithin the care pathway.The secondmajor difficulty identifiedwas for respondentsto identify and insert care delaysin the care systemthat preventedpsychiatric work from being carriedout at certaintimes. The most commonreason was due to the patient'sillness and being unableto predictsymptom control. Bureaucratic problemssuch as the interfacewith housing,supported living and benefits agencieswere also identified.The inabilityto accesssuch servicesforced respondents to insert a delay mechanism Into the care pathway. The final difficulty in developingthe care pathwaywas the extent to which respondents exaggeratedtheir role and function.This had the effect of displayinga gap betweenthose areasof practicetaught in collegeand those skills practisedon a psychiatricward.
The three problemareas identifled above haveall been characterisedby a processof negotiationand coercionwhereby clinicians debated their role and functionto fit the confinesof a care pathway.For many respondents,the developmentsof the carepathway laid baretheir'visible' role in psychiatriccare.
Thismay have contributed to themeither constructing delays or exaggerating their role and function. Both coursesof action would leadto problemsof matchingthe care pathwayto clinicalpractice. Attempting to introducea
299 potentiallychallenging structure like care pathwayswas able to draw out this distinction.
Analysingthe context of this researchstudy was crucialto understandingsome of the perceptionsheld by respondentstowards a care pathwayfor practice.In this researchstudy, respondentsviewed a suddenchange In ward personnelas a negativefactor for the developmentof a care pathway.This factor is important given that recruitmentand retentionof psychiatricstaff is a constantproblem acrossthe UK (Audit Commission1997) and so the issuesidentified in this study would have relevance for the uptake of care pathways in other hospitals.
Changesin staff personnelalso led to feelingsof low motivationand poor engagementwith the researchstudy. Thesetwo elementsmay well have contributedto the unwillingnessof participantsto be more honestor awareof their role and function and its representationon a care pathway.
The final sectionhas lookedat how the changeprocess for the developmentand implementationof a care pathwaywas facilitated.Organisational change theoristshave positedthat changeshould be targeted at many levels
(organisational/ individual)(Moss Kanter etal. 1992) althoughin this study, it was directedat staff working on the ward and in the community.Participants in this study expressedpositive views about authoritarianand bottom-upchange managementstrategies. Alongside this, key informantsidentified the role of the
300 facilitatoras forcefullycoercing participants to engagewith the researchstudy.
In some sensethe researcherwas torn betweenthe objectivesof the research study and organisationalobjectives. Ultimately the approachused within this studywas reflectiveof the particularcontext and relationswith the participants.
301 Chapter Seven
Macro issues impacting on development & implementation
Introduction
In this chapter,the way managerialpolicy in the NHShas shapeda movement towardsthe acceptanceof care pathwayswill be discussed.In the first section, the way in which professionalgroups identified the variousmanagerial techniquesused in practiceare discussed.A care pathwayhas been identifiedas a tool to extend this managerialagenda. It will be describedhow respondents displayednegative views about managerialtechniques, but then paradoxically advocated managerial techniques within practice.
Muchhas beenwritten about evidence-basedpractice (Sackett et al. 1996)and how this shouldform an integralpart of practice(Department of Health 1996).
Carepathways make great use of evidence-basedpractice but the deficitsin knowledgefor the buildingof a care pathwayhave not been rigorouslyexplored, especiallyfor unpredictablestates such as schizophrenia.In the final section,the perceptionsheld by respondentstowards evidence-based practice and experientialpractice for peoplewith schizophreniawill be described.
302 Business ethic within the NHS
Presence of a managerial agenda
The way respondentsdiscussed business like practiceswithin the care process will be discussedas one of the main themesin this chapter.Some have argued that NHSresource allocation has alwaysbeen dominatedby a cost benefit relationship(Maxwell 1995). For example,the Introductionof the Resource
ManagementInitiative in 1986 involvedprofessional groups in the management of health care and its effectiveand efficient distribution(Perrin 1988). Other examplesinclude the internal market placingresponsibility on health authorities to both assesshealth needsand purchaseservices (Madhok 1999) and the care programmeapproach (CPA) attempting to placea definedstructure on care
(Departmentof Health 1995b).In this study, many respondentswere concerned with the costs,effectiveness and outcomesof care.
Somerespondents who provideddirect clinical roles rejected the structureof care pathwaysin the initial discussiongroups by suggestingthat it was too
'managerial'andthat their role was to care for patients.Nurse's that occupied managerialpositions were more in favour of work control methodsto reduce clinicalvariation. To somerespondents this createda senseof tension.Linda spokeabout the nurse'srole in managingpatient care and referredto the wider politicalimperatives to reducethe costs of care:
303 Den r, actices are cost based now, we ý*ebelng told to look at different ways of cutting back the number of nursing staff that we have on the ward, Jtý; purely lookIng at the financial implications, k2; not ConsIderingthe patientý; needs.
Clinicianshave becomemore awareof the needto justify the level of
expenditurein health care (Richards& Lockett1996). This has led respondents
to suggestthat they are 'budgetconsclous'and that it is part of their role to
identify skills and needsas part of a 'resourcejustification'process. Possibly, this
may have influencedsome respondentsto becomeinvolved in the research
study. For examplePat could foreseea nursingenvironment with 'oneRMN to
hand out medicationand then a handful of unqualil'lednurses looking alter the
bask needs,iM; a cheapway of dolng the samejob. Althoughnot an accurate
appraisalof psychiatriccare, Pat was consciousof the tensionbetween cost
pressures,effectiveness and job security.
Thetensions of deliveringan effectiveoutcome, and of moreimportance, the
personwho judges this outcomeare apparentfor all areasof health care. For example,Firth-Cozens (2001) has identifiedthe different stakeholdersfor a
patient who has suffereda stroke and demonstratedthat all have different but ideal outcomes.Problems in agreeingoutcomes for peoplewith chronic schizophreniahave also been found (Meltzer 1997). The preoccupationof 'costl dominatinghealth care has also led respondentsto questionthe beneficiaryfrom
304 this situation.Giles contrasted the perspectiveof the purchaser,provider and
consumerof care:
Bestpossible to a mother of a schIzophrenicmeans he sits pleasantlyat the dinner table and conversesspontaneously with h1sfamlly, for the patient he sits upstairsin his bedroomand doesn'ttalk to anyone,that he S7happy eatIng without the voiceslaughIng at h1mlfor the hospital managerhe ý;on the cheapestdrug available,just to shut him up.
This view appearsunfairly critical of the hospitalmanager. It seemsmore
probablethat Gileswas simplyquestioning the humanmotive for measuring
efficiencyin the service.Like von Otter (1991), Gilesfelt that the applicationof
market principlesdistorted the value of health care, leadingto a cynicalsituation
betweenthe clinician,,patient and relative:
You'vegot a rec1pefor a perverseset of Incentivesthat will lead to corruotion,disInterest, lying and knowing that homeo-saplensare the grubby dirty httle ape that it really is, it liesJust to pay the mortgage.
In this example,the tension betweena businessstyle care systemand the
cliniciansdesire to deliver a patient focusedsystem has been illustrated.The
NHSis dominatedby a 'value for money'orientation and this pervadesthe
planningand provisionof health care. Althoughit is unlikelythat Giles'sview of cliniciansis correct,it is moreprobable that Gilesis reflectingthis particular
monetarydominated ethos but in a cynicalfashion.
305 Policymakers have attempted to developa more effectiveservice by
emphasisingevidence-based practice (Department of Health 1996) and this has
impactedupon some parts of clinicalpractice. Simon for examplequestioned the
effectivenessof some psychologicalinterventions:
You can'tjustify having therapies wh1chall empIrIcal research suggests don t work. Why should we give someone three years therapy when they've found out that 10 sessionsIs just as effective,
Hospitalbased organisational systems have emerged to better managenursing staff resourcesand over the years have includedtask allocation(Berry & Metcalf
1986), team nursing(Waters 1985) and primarynursing (Manthey et al. 1970).
Somehave arguedthat the organisational-basedchanges have led to a greater scrutinyover the quality of care (Black 1992).All systemsshare the aim of deliveringa more structuredcare process.Respondents have identifiedthat a care pathwaywould extendthe managerialcontrol over health care. For example
Georgesuggested that the roleof the in-patientcase manager, who wasto ensurequality and checkon the deliveryof care was comparableto the role of the chargenurse using primarynursing. George spoke about ld7ed-ingup, pushingdown, you'vegot to do th1s'andso managingstaff in order to deliver healthcare.
In an earlier interview,George described how he reviewedcase notes on a weeklybasis to ensurecare was being deliveredand outcomesachieved. The
306 methodwas depictedas an informalsurveillance mechanism to monitor
performanceand quality of care. However,George mentioned many difficulties with this techniquesuch as the informal natureof the role and emphasison singlediscipline review:
We need to get proper team meeting and structure, with far more effective sharing of team views because itý; still a nurse only plan of care, my role is never to look at what other disciplines do, there is no overall coordInation of care.
Someresearch has shownthat cliniciansexpress negative attitudes towards the businessculture of the NHSand prefer to highlightthe caring aspectof their role
(Flynn 1992). HoweverTina was very positiveabout the businesslike nature of the NHSand felt that joining the nursingprofession was to work towards improvingthe health service.This view from a nurse managerreflects that of other managersin health carewho have internalisedthe principlesof general managementin their work (Austin& Dopson1997):
TheIncestuous old culture that anythingfinancially driven Is dirty was rife before the new breed of managersarrived to removethe complacency and wastagewithIn the health service, we need to support that and make sure It impactson practice.
Georgehas supportedthis perceptionbecause in his third interview he Identified that the health servicewas gearedtowards managinglength of stay by claiming that purchaserswere requestingclinicians to Yustifyresources'forpatients to
307 receivehospital care. This has becomeknown as bed managementand George identifiedthis task as a typical nursingfunction of acute hospitalcare. Similarto the Wings of a Government report, Better off in the Community (House of
CommonsHealth Committee 1994), George also recognisedthat the interface betweenthe ward and the communityservices was not operatingas efficientlyas possibleleading to a wastagein hospitalresources. The essentialpoint beinga greater accountabilityon the part of the clinicianon the deliveryof costly resources:
Purchaserý7don t care that schizophrenicsare individualswho respond differently to treatment,all they want to know is how many daysstay do they need to buy for that patlent and we should endeavour to meet that becauseit backsup on the rest of the systemif someparts are not working.
The developmentof a care pathwayaims to standardisecare (Petryshen&
Petryshen1992). Derrin identifieda sourceof conflict in working towards pre-set patient outcomesbecause the valuesof OT lay with individualisedcare. This examplesupports some of the literaturethat has identifieda clinician's reluctanceto work towardsa businessculture of health care, which valuesthe principlesof short hospitalstay (Bray 1999) and reaffirmedmedical dominance in organisingpsychiatric care (Lego 1992):
Thecare pathway is for the purchasersand costingand auditing, but we are here for the patients becausewith a carepathway the patient has to
308 comeand fit in with the servicerather than the other way aroundbecause this wouldharm patient care,not improveit.
This OT respondentmay be preservingher role againsta managerialintention to
standardisethe role for a care pathway.Derrin has arguedthat the needsof the
patient should be foremostto the needsof the organisation.This defensive
strategy has been seen in Ardvern's (1999) study where an attempt was made to
changethe function of a day hospitalfor dementiacare. The staff group stated that patient care would suffer if the day hospitalchanged its function. Placingthe
needsof the patient abovethat of the organisationis a powerfulstrategy that
has been used by respondentsin this study.
A further way in which clinicianshave felt pressuredto managehealth care has
beenthe increasingemphasis on coordinatingdiscipline groups through the CPA
process.Peter noted the current structureof the ward team and how it could
benefitfrom greatercohesion. The centralelement was the needto monitorthe roleand functionof all teammembers:
Theproblem Is ensurIngthat disciplinesare providing what theyý-e supposedto provide and workingtowardsJoIntly agreed goals... if the OT is involved,she I/ come to the CPAand ward round but we are limited becausewe don't feed into the 0 rs, its ad hoc, thereý; no stradfled structure or control over what they do.
Mikefor exampleperceived that the role of the nurse had becomedominated by
managerialtasks:
309 There is a lot of work in the office, getting staff for the shIlTs,fillIng out forms,,dolng supervision, coordinating the shIlt, wrItIng out reports,. sorting out bed state, wh1chare more managerial and v1sibleto theIr managers. A lot of nurses feel safe with that; you V find a lot of nurses in the offl"ce,because when theyýe out there on the ward, theyýe not entirely sure what they should be dolng,
Other studieshave found psychiatricnurses to congregatein the ward office and
this spatialdislocation from the psychiatricpatient may be a feature of greater
control over the managementof care (Hall 1996).In Hummelvoll& Severinsson's
(2001) study into psychiatrichospital care the emphasiswas on effectivecrisis
management,quick diagnosisand treatment and reducinghospital stay.
Respondentsidentified some parts of the care process,which were inefficient, and in need of managementchanges. Steve usedthe exampleof the ward
round, which was the mainforum for discussionand decisionmaking in
psychiatrichospitals. Steve described the wardround as a Waltingcame for somethingto happenand for the person to get well'asopposed to apIanned managementof care.This point was particularlyrelevant for patientswith chronicschizophrenia given the observedapathy of the staff groupson the study ward.
Georgedescribed the presentmanagerial structures as retrospectiveand repetitiveas opposedto outcomesfocused. George again usedthe exampleof
310 the ward round and describedit as 'backwardlookIng'and 'damagelimitation sesslons'withlittle attentionto coordinatingcommunity resources:
Wardrounds are like a running commentaly,vety unstructured,ltý; rare that you I/ And a desIgnatedperson attached to that careplan. We'vegot patients for over 6 monthsand psychiatricsymptoms were dealt with long ago but their socialsituation is still being dealt with.
Both Steveand Georgehave identifiedthat further managementchanges were requiredto improvethe co-ordinationof resources.It seemsto be the casethat both these respondentshave internalisedthe drive to find the most effective ways of managingresources.
Throughoutthe courseof this researchstudy, the researchercollected numerous and varied accountsof the managerialstructures that were usedwithin patient care systemsand usedto best effect to ensurea transfer of care to community services.The aim hasnot beento be exhaustive,but to demonstratethat these systemswere operationalwithin the NHS.Respondents have identifiedthat
%costs','effectiveness' and 'efficiency'dominated working practices.Some respondentsfelt that it was their duty in comingto the professionto identify and extinguishaspects of inefficientpractice. Other respondentswere less positive aboutthe changesand promotedthe needsof the patientabove the interestsof the organisation.However, respondents also identifiedexamples of managerial systemsto extendthe organisationand control of resourcessuch as effective
311 ward roundsand using prospectivegoal planning.An Issuethat has not been addressedin this sectionbut identifiedby some respondentswas how clinical informationwould be best managedto makegreater use of resources.In all, it has been observedthat businessstyle principleshave beenwidely appliedIn mental health practice.
Extending managerial structures through a care pathway
Mentalhealth policy has arguablybeen extendedto providegreater control over both the patient (Burns& Priebe1999) and care processes(Department of
Health 1990). Respondentsreadily identified care pathways as complementing this managerialagenda and as a mechanismto improvethe overallquality and managementof care.
One of the frequentlyreported benefits of care pathwaysis their perceivedfocus on costsof care(Velasco, et al. 1996)and howa carepathway would illuminate deficienciesin the service.During one of the first interviews,George suggested that for cliniciansto disregardthe costsof care were 'livingin a self-deluded world-'andexpressed an exclusionaryattitude towards professionsand interventionsperceived to be of little value:
Themodel of the NHSis a buslnessstyle and the maln thing is to spend your money wisely.Care pathways are going to identify where the moneyý;needed and whereits being thrown away and if people aren't
312 dolng theirjobs properly the Trusthas a right to say your servicesare no longer required.
This view may have beeninspired by the attemptsof the care pathwayto stanclardisethe processof care and assignthe most appropriateresources to the clinicalobjective. It could be arguedthat clinicianshave taken on boarda greater sense of accountability for the outcomes of care. In doing this, clinicians have attemptedto build in productivitymeasures (Shaw 1997)such as effective bed management.However, Seedhouse (1994) has positedthat cliniciansare ethicallyresponsible to ensurethat resourcesare appliedin a cost-effectiveway and so this senseof accountabilitycould exist regardlessof a managerial intention.
Nursingdocumentation has been usedincreasingly in casesof litigation (Young
1994)and untowardincidents. George noted the potentialof the care pathway as a Namlng tool'in these cases.However it may makeclinicians more accountablefor care deliveryand possiblyreduce the numberof untoward incidents.The problemwould be gainingacceptance for care pathwaysif certain occupationalgroups such as nursesand doctorsfeel vulnerablein caring for certaintypes of patients.
At the start of the researchstudy, the researcherattempted to gain support for the project by giving publishedcare pathwayliterature to the respondents.Some
313 respondentsreferred to this literatureand Identifiedthe managerialfocus of the care pathway.Tina focusedon the ability of the care pathwayto improveon the current systemof measuringoutcomes and emphasisedthe importanceof determiningappropriate skill mix:
ltý7a way of measuringoutcomes and how effectiveinterventions are changIngthe serviceto meet the demand the serviceat presentIs not co- ordinatedto get a control'onoutputsý
Pat describedthe current systemof managingpatient referral in community teams and suggestedthat a care pathwaywould act as a trigger to monitorthe referral processand so removesome of the delaysin the localityteams:
If locality assessmentsfall to takeplace for whateverreason, then we have a time frame in whicha secondassessment needs to be attended too, and Jtý7notjust left in the duty basketfor the next duty worker.
Simonspoke about how a care pathwayshould offer a greater rangeof psychologicaltherapy for patients,irrespective of the costsinvolved:
Thereshould be sets of standardsin practice, wh1chinclude, as the Governmenthas said long ago and if carepathways encourages that, it wouldbe a good thIng but it contradictsfundamental issues like patients' rights and innovationin practIce.
One of the benefitsof a care pathwayis to comparedifferences between the quality of care in variousprovider units (Arkell 1997). Reflectiveof a view from
314 the HealthAuthority, Zac recognisedthe pitfalls In doing this such as differences
In the socialeconomic composition of the boroughsand lack of evidenceIn
procedurealthough he did recognisecertain benefits:
Carepathways can be developedin a qualityperspective rather than a contractmechanism perspective. It will identify current diffIcultlessuch as beds being blockeddue to lack of a vallabilityof accommodation.
Other respondentssuggested that a care pathwaywould extendthe structureof
CPAto improvethe co-ordinationand evaluationof care. However,this position
fails to take accountof the stated intentionsof CPA(discharge preparation)
within Governmentpolicy. Steve differentiated between the two structures:
Carepathways would take more interest in what'sgolng on whilst the person is in hospi(alsuch as buildingreladonshlps,, attending gtoup4, compliancew1th medication.
Robsupported the useof a carepathway to set out the sequenceof eventssuch
as when a patient shouldbe allocatedto a communityworker, setting out when
assessmentsshould be completedand how quicklythe key-workershould visit the patient during this assessmentexercise. However, similar to other
respondents,the completionof these taskswas alwaysbalanced to the individual
needsof the patient.
315 It is clear In the previousexamples that respondentsperceived a care pathwayto extend and Improvethe managerialcontrol over health care and this has been found in other studies(McQueen & Milloy2001). Respondentswere positive about the desireto co-ordinate,achieve targets and attain best practice.The terms and principlesincluded within these statementsquoted aboveresonate with the processesof generalmanagement (see chapterone).
A fundamentalissue within mental health is the cohesionbetween different disciplines,departments, sectors and agencies.One of the most problematicto overcomehas been the demarcationbetween the hospitalstructure and communityteam. This has been highlightedin many untowarddeath inquiries
(Ritchieet al. 1994). Zeb spokeabout areasthat were presentlyuncoordinated such as multi-discipli nary note keepingand 'responsetimes"for meetingclients in line with the socialservices requirements and the patient'scharter. It was arguedthat a care pathwaymight add greatertransparency and Improved working towards predetermineddeadlines. Further, for some kind of action form to includethe categoriesof accommodation,benefits, and compliancewith medication:
if weýe seriousabout this ideaof a seamlessservIce, then we needto havea centraladmInistrative system thatý; uniform within the wardand the localityand that couldbe achievedwith a carepathway. Care is alreadystandardised through the CPAtiered system and the requirements for certainpeople to be involvedand timescales and care pathways would addmore substance to this.
316 For Georgethe processof makingdecisions was unplannedwith little predictable sequencebut he arguedthat a care pathwaywould add greateraccountability to care:
Carepathways will provide the nurse and patient with a better expectation of what should happen,where and when,presently, its very much a case of relying on whatý;going through that primary nurseshead at the time when they write out the careplan and make decisionsa carepathway will make clinicianstied to performancemeasures.
The difficulty in being both a clinicianand managerwithin the care pathway frameworkwas illustratedby Pat.The benefitsof greater managerialcontrol could be to the disadvantageof other areas:
Somebodyelse standing outside of the carepro v1slonwith very little hands-on,may well be in a better position to monitor and press the right buttons and makesure the right things happenbut it:ý wherethat human resourcecomes from becauseits addinga secondlayer of bureaucracy.
Respondentsidentified that a care pathwaymay be able to reducelength of stay althoughthis was not alwaysseen as a positivefeature. The pressingpoint was to be able to manageresources in an efficient way, even if this meant patients wouldbe dischargedbefore it wastherapeutically desirable. However, Zac suggestedthat a care pathwaymight be able to 'ensurepeople received approprzatetreatment at the right time, In the right place and at the fight cost.
The questionis whether a care pathwaycould fulfil any of these functionsfor
317 psychiatricpatients given the inabilityto determinethe exact content of the care pathway.
Bond et al. (2001) exploredthe perceptionsof implementingcare pathwaysfor orthopaedicpatients across six hospitalsites in the UK. Evidencewas found to suggestcare pathwayswere usedas a tool to reducelength of stay or waiting times for surgery,to improvecare processesand outcomes,and to ensure greater managerialcontrol over work processes.Respondents in this study also identifiedcare pathwaysas a mechanismto maximiseresources, through a more co-ordinatedlength of hospitalstay. However,there is no conclusiveevidence to suggestthat a care pathwaycan reducelength of stay (Hale 1997). Other respondentssuggested that a care pathwaymay improvethe quality of care. De
Luc (2000) notesthat the ability of a care pathwayto Improvethe quality of care has been a major feature of their successin the UK.This would be Important giventhe greaterconsumer voice in healthcare and the demandfor a more transparentand responsiveservice.
The policyof the NHShas beento improveon the ability to managestaff resources(Department of Health 1998c)and respondentsidentified this aspectin manyinformal and taped interviews. Moreover, it wasobserved that a care pathwaywould serveto advancethis managerialagenda by removingcostly delaysin the care system,offering a greater range of therapies,identifying
318 expensivebed blockingpatients and linkingclinicians to performingcertain
duties.Other respondentshighlighted the organisationalstructure of CPAand
how a care pathwaywould improvethe functioningbut extend managerial
controlover certainareas. Some respondents noted the disadvantagesof care
pathwaysfor managingpsychiatric care such as respectingpatient choice,
funding of innovationand preoccupationwith cost and perceivedcontrol over
clinicalpractice. Others questioned the additionallayers of bureaucracywithin
the systemof care. Ultimately,a care pathwayhas been recognisedas a tool to
extend the managerialagenda over health care, albeit with both negativeand
positiveviews for practice.
I. Bhybrother watching" .W Manyscholars have notedthat cliniciansperceive a lossof control over clinical practicealongside a processof continualscrutiny with the advent of care pathways(Gibson & Heartfield1996). This factor may be importantfor the developmentof care pathwaysin psychiatricpractice. Work control methods were perceivedto be lesseasily defined compared to physicaldisease conditions.
In this section,how respondentsindicated a strong reluctanceto work within an explicit managerialframework will be explored.
Manyrespondents perceived the intent to developthe care pathwayto arise from within the 'managementSide'of the organisationas opposedto a set of
319 researchobjectives. For example,Peter suggested that 'managementwouldn't have this golng on if there wasnt a savingto be had. AlthoughPeter voiced little oppositionto this, he did not acceptthe primary reasonfor carryingout the study, which was principallyto explorethe factors importantfor developmentof the care pathway.
A perceptionof managementinfluence over the study led some respondentsto reflect on why cliniciansdid not want to get involvedwith the project. Duringone interview, Mike perceivedthe care pathwaystructure as being directly managed and conspiredfrom the 'officesof management'asa further attempt to monitor the work force:
With Wyninvolved people felt., this Is anothermanagement thing handed down and peopleare very reluctant to get involved,we've got enough structuresIn place now, CPA,contacts, and theyý-eseelng carepathways as an extra duty to keep an eye on us.
Manystudies that havedescribed the developmentof a care pathwayidentify the importanceof involvingall professionsin the process(Dunn etal. 1994) although this was problematicfor this researchstudy. Someparticipants were content to havetheir role and function determinedby a care pathway,although this was not the casefor the wider team. Bill gave many reasonswhy the team felt threatenedby a care pathwaysuch as the increasinglevel of managerial
320 surveillanceover patient care, increasingpaperwork, and the Infancyof care pathwaysfor practice.
Similarsuspicions were alsovoiced by a SeniorHouse Officer who felt that a care pathwaywould placetoo much of a managerialfocus on health care. However,
Kerry concededthat it would prescribea basicminimum for practice:
If we could have thosestructures but not to the extent that you had to sIgn every time you did it, and you felt you werebelng watchedin every thing you did.
As demonstratedin previoussections, respondents have identifieda greater managerialscrutiny over what they do and one could arguethat the processof action researchhas enableda consciousawareness of this process.However,, action research'implies that the group belng researchedare powerlessuntil empowered'(Banister1995: 119). Previousextracts have demonstrated that respondentsshowed some awareness of managerialcontrol prior to the developmentof a care pathway.For exampleZeb suggestedthat workerswere reluctantto attend the working groupslargely becauseof awarenessof past and current managementinspired changes. Moreover a working group processthat uncoveredunder-performance from staff members:
M7 about the less confident,less experiencedworkers who will think, itý; a way of finding me out or show them to be a bad worker.
321 Ingrid attributeda clinician'sreluctance to engagewith the project by drawingon
the generalperception of managersin the hospital.For some people,the actions
of some managersmade them appearcynical about the workingsof the Trust
and a perceptionthat 'managementwere looking after themselves'asopposed
to supportingclinicians:
Thereý; an underlyingparanoid element to everybodyworking around here, and wary of who wantý;to know...care pathways was such an if unknownquantity that it was vlewedw1th a huge amount of suspicion... Jtý7difficult to identify what you do, the easlestoption is not to be involved at all.
All disciplinegroups did not hold this perspective.For example,from a nursing
perspective,George attributed this view to the level of contactthat patientshad with them. However,this finding is unsurprisinggiven the relative power of
medicallydominated hospital structures (Turner 1987):
Mediclneand nursingare the two securestprofessions around because wardsare 24-hour nurse staffl'ng.Doctors are essentialfor the treatment of the client and so they'vegot nothing to fear.
In this sectionrespondents have discussedhow they perceivedthe care pathway to extendthe managerialfocus and control over mental health care and included the impacton generalcare systems, length of hospitalstay and the overall efficiencyand effectivenessof care. Primarily,respondents felt that current
servicearrangements provided for sufficientmanagerial surveillance over
322 clinicianactivity. A care pathwaywould extendthis surveillanceactivity. Some
respondentsfrequently asserted that it was Ng broffier keepIngan eye"onthe
workforcein taped and informalinterviews. Some respondents also felt the
initiative was supportedby managementand acceptedit as the usualmilieu of the reformedNHS. Also includedwithin this sectionhas been the suggestionthat the research was ill received becausethere was too much organisational change occurringwithin the organisation.Clinicians felt detachedfrom playinga positive
part in these changes.
Somerespondents argued that the externallyImposed 'managerial agenda'has changedthe working mentalityof psychiatricprofessionals. Respondents support this observationby identifyingstructures to manageresources rather than be therapeuticagents. However, some respondentsexpressed positive opinions about the managerialfocus on health care and felt that part of joining the health
professionwas to eliminate Wastein health provision.Alternatively some
respondentsplaced the centralityof patient care abovethe needsof the organisation.
Evidence guiding psychiatric practice
Professional versus the cleaner
In this secondtheme, the relationshipbetween evidence-based practice and the
expressionsof the evidencefor peoplewith schizophreniawill be exploredand
323 Includethree centralcomponents. The first detailsthe various responsesthat cliniciansgave to underpinningpractice with evidence.The seconddiscusses how clinician'sexperienced difficulties in identifyingevidence. In the final part, the way respondentsdescribed the processof clinicalexperience guiding psychiatricpractice will be explored.
The Governmenthas activelypromoted evidence based mental health practice
(Departmentof Health 1998c,1999) althoughsome haveasserted that the majority of health care is of uncertainbenefit to patients(Baker 1998).This leaves a whole gulf of practice where clinicians are operating within a system that is subjectiveand ultimatelyresponsive to individualways of working. For example,Kerry felt that a care pathway ýainfully'showedthe failings of being able to predictthe processof psychiatriccare:
We dontkno w enoughabout schlzophreniaand thereý; all these new drugs comingon the market and it seemsa shamenot to use them, becausewe have not got any Idealdrugs.
In a further exchange,Kerry commented about the adventof new technology such as PositronEmission Technology (PET) scans to 'betterdiagnose the schlzophrenlabefore it becomeschron1c but we dont evenhave the scansto do this'. Kerryacknowledged the infancyof this diagnostictool for practiceand its current limitationsbut also how and In what ways the knowledgewould be used
324 to best effect. For example,PET scans are not a routine part of practicewith their use restrictedto researchsettings.
Gilesquestioned the researchbase, specifically examining the types of studies carriedout for peoplewith schizophreniaand suggestedthat cliniciansbelieve this body of knowledgerather than acceptthe futility of what they do and proposedthat we are all ýIayingthe game!
The types of research are nonsense, you can t control as effectively for the canons of science and you V rather believe that than the false control... 80 to 90 916of what gets written is flawed. If you accept that then the whole edifliceon what soclety is built,, science, mates paying your mortgage comes crumbling down, so cliniclans hide behInd these edifices.
The processof developinga care pathwayled some respondentsto think that care practiceswere basedon experiencewith little referenceto evidencebased practice.The researcheralso observedrespondents to experiencea senseof futility with the researchbase for schizophrenia.This factor appearedto partly supportthe use of the care pathway.For example,respondents suggested that the care pathwaycould label those interventionssupported by evidenceand so highlightother areasfor future development.However, this factor also acted as a barrierfor peopleto engagewith the developmentprocess. Respondents would arguethat the limited amountof evidencecounter balancedthe rationalefor a care pathway.In many respectsthis is true becausethe care pathwaywas observedto show little reflectionof psychiatricwork.
325 There were some respondentssuch as Georgewho offered such a negative
opinionof the evidencebase for schizophreniathat he describedthe ýquess-work'
like nature of current treatmentapproaches such as medicationand nursing
care:
Thereare numerousaccounts of literatureportraying medication as ineffectivefor large numbersof Peoplewith schizophrenlabut we all assumedthat what we did wasbeneficlal, otherwise just closethe whole place down, what is there lett to offer.
The suggestionthat psychiatricpractice is basedon a 'myth'or a 'beliefthat
whatpeople do Is effectivewould not be accurategiven the knowledgeon how
and why systemsof care are knownto work. For example,medication does offer
relief for large numbersof peoplewith schizophrenia.Moreover although the
preciseeffect of ward psychiatricnursing is unknown,the importanceof
psychiatricnursing to providethe careand managementof patientsis crucialand
unchallengedin modernhospital care. What has been challengedis the lack of
therapeuticintervention between nurses and patientsand this problemhas been
identifiedfor the last thirty years (Altschul1972, Higginset al. 1999).
Derrindiscussed the quality and quantity of the researchbase for OT and
describedit as 'narrativeas opposedto 'testing'interventions.Derrin attributed
this problemto the unpredictability of mental health problems:
326 Thereisn ta lot of e v1denceinto OT in Psychlatryand what we can work from becausethe nature of psychlatricOT Is less definedcompared to OT in physIcalconditlons,, ltý; much easlerto measurewhat differencean Or makeson the outcome.
Stevefelt that the structureof a care pathwayenabled psychiatric care to
becomemore evidencebased by acting as a researchstructure for the future.
Steve locatedhis argumentwithin the larger structureof the NHSdriving
evidencebased practice, but acknowledgedthe perceivedpaucity of researchfor
nursing practice.Steve used the exampleof the educationalinterventions
includedwithin the care pathwayto demonstratethis point:
How much evidenceis there for educationalInterventlons? We ý-e working on an assumptionthat if you tell the patient more about their medication, theyll be more agreeableto taking it, but thIs is subject to all matter of personalblases such as valuesystems and clinlcaljudgmentand wejust don't know enoughyet
Additionally,Steve perceivedthat the lack of knowledgeabout interventionsfor
peoplewith schizophreniaexcluded them from a care pathway.An important
point is that if 'mile-stones'were set, then it assumedthat interventionshave
been provedto work and this was far from the case.Steve maintained the worthwhile benefitsof developinga care pathwaybased on local practiceas opposedto evidence-basedpractice such as helpingto clarify what cliniciansdo.
However,there were somedisadvantages noted such as potentiallyreducing
interventionsthat could be includedwithin the care pathway.This had the effect
327 of minimizingthe interpersonalrelationship between nurses and patientsas a
central part of care:
Losingtoo much individualityIn those micro-structures,for professlons like nursingJtý7 all we have, eachprofession hasn't got that evidence basedpractice to put fotward and people don't know what to discardand what to keep in.
Lydeard& George(1996) suggestthat professionalswill resort to clinical judgment in the absenceof evidence.One avenuewould be to wait until more
evidenceis forthcomingwere it could be developedin a more coordinatedway.
Somediscipline members have been open to this lack of evidence,but only with
repeatedinterviewing did the researcheruncover it. For example,Simon
identifiedproblems for psychologicalresearch into schizophrenia,such as the
differencesin diagnoseswithin and betweendifferent countriesand poor use of
robust designsand researchinstruments. Simon feels that the quality of the
researchwould needto improveto establishcausal relationships. In the working groupsthis was deniedduring discussionsabout the role and function of a
psychologist.Although Simon recognised the lack of evidence-basedpractice to supportthe inclusionof psychologicalinterventions within a care package,he was adamantthat patientsshould be given therapy.
Simonidentified other problemsfor researchpractice and psychologysuch as the illusionthat evidencebased practice existed. Simon perceived that the drive for
328 evidencewas a cover for reducingthe amountof psychologicalinterventions that could be performedfor peoplewith schizophrenia.This argumenthas also been deployedfor reducingthe availabilityof medicalinterventions under the guiseof
%scientiflcmedicine'(Dent 1999):
Evidencebased practice for psychlatfyIs a misnomerand its dangerous,it looks impressive,but all Jt2;doing is savingmoney. Weý-e treating evidenceas thoughJtý; jbst given and not debatableandpeople have been fighting like hell over findings, we must be given time to find the evidence.
A huge diversityof opinionon how peoplewith schizophreniarespond to psychologicaltreatment existsand provideslittle directionfor practice.For exampleMike providedan exampleof working with a patient who sufferedfrom a delusionto illustratethe level of inconsistencyin using nursinginterventions:
P, #-,n viously itsaid ignore the delusion,now ffieyýe saying tty and work with the delusion,There ý; so much variancewith schlzophrenla,people reactionsand thereý; not going to be a treatmentof cholcefor each Individual,iM; all hit and miss.
During his first interview,Giles was open about the limited knowledgebase of psychiatry,which would ultimatelyaffect the content of the care pathway.Giles identifiedthe processof makingpredictions such as levelsof dangerousness, suicide,response to drug treatment and suggestedthat psychiatristswere not particularlywell 'armedto makepredictions"and questioned why he shoulddo it
329 given that the patientwill stay on his caseload. For Giles,Yust carry on looking
after h1mand see wherehe ends upý
Giventhe perceptionthat little can be predictedfor mental health, Gilesalso
suggestedthat clinicalaudit not only displayedthese inadequaciesbut leadto a
disinterestto monitor practice:
Weare lookinginto an abyssof unceltaintyand a reminderof our own impotency,the uselessnessof our treatments,by and large, nature and TempusFugee work as effectivelyas we can, Youdon t want to work In a system that is going to remind you of how uselessyou are.
In a further exchange,Giles admitted that evidencefor drug treatment was
inconclusivebut he still performedthis role and advocatedits use within the care
pathway:
Thispatient is on 75 milligramsof HaloperldolDecanoate weekly for her delusions.If the delusionshaven't gone after three months.,IM; Increase it to a 100 and see what happens.Of causeit won't make any difference but we've done somethingto put off the moment of reckonIngfor another few weeksand get on with the other 1500patients.
When evidencefor practiceis lackingit possiblyexposes the underpinning knowledgeof a professionalideology. Simon illustrated this by lookingat the conflict betweenthose cliniciansthat advocatedpsychoanalysis and cognitive
behaviouraltherapy:
330 Whenthe different factionsquestion the evIdencebase, it will exposethe cracksbecause there is vely little. Wehaven't got to a stage where we can say CBTis the best and put it into standard1sedpackages.
Duringthe developmentof the care pathwayrespondents were askedto build the treatment grid using interventionswith referenceto evidencebased practice.
However,clinicians were not alwaysable to providethis and discussedtheir reasonswhy. RepeatedInterviewing and closecontact between researcher and informantdetailed that some parts of psychiatriccare were not supportedby evidence.This could be due to the availabilityof finding or translatingthe evidenceinto practice.Many respondents have notedthat the care pathway identifiedareas for future researchsuch as on-goingmedication treatment and the effect of nursinginterventions.
Manyrespondents have notedthat very little evidencehas been found to support psychiatricpractice. This assumptionis incorrectgiven the evidencefor psychologicalinterventions and medicationmanagement (see chaptertwo). If these statementswere to be taken at face value, the developmentof a care pathwaywould be severelyaffected. This finding displaysthe importanceof havingpeople involved with the project who are aware of the interventions supportedby evidence.In this study, psychologists,psychiatrists and nurses were amongthe professionsinterviewed and contributedmost to the evidence presentedwithin this section.It clearlydisplays a lack of awarenessfor the
331 evidencesupporting interventions and if this was representativeof staff within
psychiatrichospitals, it would questionthe care given to psychiatricpatients.
We V like but? ' to use evidence .. There has been a greater professionalawareness to developa culture of
researchand developmentwithin the organisation(Department of Health 1991a)
and this may havespurned clinicians to expressthe wish to practiceto this Ideal.
In this section,it will be describedhow respondentsacknowledged the
importanceof usingevidence, and reasonsfor not doing so are explored.
Cliniciansexperienced a pressureto work towardsdelivering outcomes based
practiceand this was mainlyfrom within the organisation.
Gilessuggested that from a theoreticalperspective, it was ideal to measure
mental health outcomes,but countersthis with the need for joint outcomesfrom
all stakeholdersin care.This is particularlypertinent to the care pathwaywith its driveto makeclinicians more accountable for the total careprocess. Giles also offered positiveinterest towardsstandardised outcomes, but questionedif a
linear care pathwaywould be able to representthe complexityof mental health care:
Weset the carepathway up as the oracleto which we all go, managers, cliniciansand patients but we"Ve all got to agree that the oracleis correct, and that meanswriting the correctnumber of boxesand arrowsso that iM; flexible to reflect an effectiveapproach to treatment.
332 Simonlikened the searchfor outcomesin working with patientswith schizophreniaas ;vIoneers working at Me cutting edge'and usedthe following powerful metaphorto emphasisethe importanceof experimentalwork within psychology:
Thepsychology discipline is in itý; infancyfor it to be subject to r1gorous analysis,there are only a set of pioneersaround out there lookIngfor gold, well a bit of metal woulddo actually,a tin can, out there in the mountains we canIt set up a mine yet we are more like scouts.Is ffils a mountaln worth even lookingat for business?
Derrin spokeabout externalGovernment pressures forcing OT to adopt outcomesbased practice, but again drew parallelswith the psychologydiscipline in not havinga sufficientlyprepared research base. Similar to other respondents,
Derrinwould like to incorporateoutcome measures into her practiceand made the point that 'Ors believethat what they do was eftective'and it was just a caseof demonstratingthis:
Politicalforce within the NHSdriving this mantra of standardisedcare and we are being askedto look at outcomemeasures. We ýe not as far along it as some other professions,because of the inadequateresearch base and researchtraining but webf like to do Jt but it ý;useful to have standards becauseservices that arent monitoredbecome sloppy and theyýe vital if you want to offer the best service.
For example,Simon reflected on the differencebetween psychological services in the UK and the US.Simon felt that servicesin the USwere dominatedby an
333 Insurance-basedsystem, which restrictedpsychological services for peoplewith
schizophrenia.Simon refused to allow his work to be subjectto this 'excluslonary
pressure'.This indicatesthat psychologicalwork can be deliveredIn an
autonomousway, regardlessof organisationalobjectives.
Somerespondents spoke about the nature of outcomemeasurement and used this as a potentialbarrier to the developmentof a care pathway.However, there
is a problemof determiningthe causallink betweentreatment processesand outcomes(French 1995). This problemis compoundedfurther when a variety of
professionalsare involved in the process of care (Long 1994). In the working group, Zac echoedthe problemsin measuringmulti-disciplinary outcomes and determininghow and in what ways different interventionslead to different types of outcomes.Although discipline groups recognisedthe difficultiesIn measuring outcomes,clinicians stressed the importanceof usingthem and alignedthis to the evidencebased practice movement. Rob elaborated on the roleof the locality teamin workingtowards outcomes and howthis couldbe usedas a vehicleto persuadeclinicians to use a care pathway:
Measureoutcomes in a way that meanssomething to cliniclans,there will be resistancefrom people who are anx1ousabout outcomes,but if theyý,e seen as definInggood quality care, it wont be Impossibleto sell.
334 Ingrid identifiedsome positivebenefits of measuringoutcomes for OT such as raisedstaff moraleand effectivepractice but cautionedthis with the fear that if outcomeswere difficult to find, OTjobs would be taken out of service:
57*11caff , will acceptit if its explainedto them and not used to cut funding....when posts are becomingvacant theyý-enot belng filled, there is a feeling that we need to justify ourselvesto survive.
The views representedabove appear to be reflectiveof the wider national agendato improvingin-patient services. Howell & West (2000) describethe work of the In-patient Networkwho found respondentsbroadly positive about introducingevidence-based interventions in to practicethrough care pathways.
There was an acknowledgementthat psychiatricservices were inadequatebut respondentswere unsurehow to bring about changeor to accessevidence for practice.
Althoughclinicians identified with the needto worktowards outcomes, little emphasiswas placedupon it within clinicalpractice or within the working group process.Similar to the sectionin chaptersix exploringdelays in the care process,
Stevestated that cliniciansfailed to build enoughcreative processes into a care packageto measureand checkclinical progress. In some respectsthis protected cliniciansfrom working towardsoutcomes with the patient. Moreover,it was impossibleto judge if the outcomesidentified in the care pathwaywere met becauselarge parts of the documentwere Incomplete.
335 Derrin also acknowledgedthe importanceof using outcomesfor the OT discipline,but recognisedsome of the constraintsthat the disciplinecurrently experienced.For examplethe OT departmentcarried out meetingsto searchfor outcomesbased practice although this was limited due to not havingan academicbase to supplyanswers to measuringoutcomes in psychiatry.
However,not all disciplinegroups experienced this managerialpressure to the sameextent. Gilesidentified a sourceof financialpressure, but temperedthis with the assertionthat there was no monitoringand performancemechanism:
The only restraint is finandal, 'no you cant prescribe this drug without permlsslon from the pharmacy; there are no standardised attempts to ensure you provide the basic minimum, Jtý;down to us as clin1dans.
Peteridentified a financialpressure to standardiseoutcomes, but gearedthis towards maximisingoutputs from various professionalgroups. This tendency howevercan lead to professionaldegradation:
it gives the opportunityto quantify what the different disciplinesdo in a totally financialway to get cost effective work from them.
Simonpreferred to view his internalwork motivationas gearedtowards finding the best and most innovativeway of working:
336 Dn interestedin finding out whatý;the best way of workIngwith people, here let we negotiateit with the psychiatrists and say us have a try..-a Andingof practIcethat care has to be indivIduallydeveloped for each personbut Jtý;not dominatedby Imposedways of workIng,or )/Oumust meet this outcome. itý;Just not done.
The needto work towardsevidence based practice forms the bedrockof a care
pathwayalthough identifying evidence for inclusionhas been difficult in this
research setting. Problems range from having sufficient evidence to set
outcomes,acknowledging the infancyof professionsto !5earchlng'for outcomes,
determiningwhat interventionsto use and how they affect the outcome.Some
cliniciansidentified that they felt pressuredinto workingwith outcomesthrough
organisationalstructures such as ward rounds,management directives and
determiningfinancial balance over therapies.The use of a care pathwayhas also
addedto this pressure.Other respondentshave not perceivedthese pressures
and continueto follow their own treatment methods.This displaysa lack of
parity acrossthe professionsand supportsthe observationthat some professions
felt morevalued than othergroups.
Experiential learning & practice
The difficultiesin working towardsevidence based practice and using outcomes
have been abundantlydemonstrated in the sectionsabove. The Importanceof
this final sectionis the acknowledgementthat some professionalsjust do not
know why they do things and rely on clinicaljudgement, intuition and
experience.The relevanceof intuitive and experientialforms of knowledgeand
337 practicehas becomewidely creditedin the nursing(Benner 1984) and professionalliterature (Schon 1983). The challengewould be to representthis form of decision-makingand practiceon a care pathway.
Gilesfelt that his role and function could not be 'written down on paper"and openly admittedthat he works on !5ubjective 17uncl7es'and !5uggestlon" developedthrough years of experience.Eason & Wilcockson(1996) have consideredthat decisionmaking of this kind should not be seen as irrational,but rather as a seriesof actionsthat occur in responseto past learningexperiences.
Barker (2000) argues that these experiential learning episodes are'personal truths'which contrastwith the evidencefrom controlledtrial research.It may well be the casethat Gileshas a realisticview of psychiatricpractice. Giles acceptsthat 'uncertalnty'isa fact of psychiatricpractice and that much certainty has an illusoryquality. Moreoverthis positionsupports the Ideathat understandingpractice is a form of knowledgethat maybe unableor undesirable to transform into protocols(Crook 2001).
Similarthoughts were echoedby Kerrywho summedup her experiencesof medicalpsychiatry and the abilityfor it to be presentedon paper.one of the maindifficulties for Kerrywas the complexityand heterogeneityof the disorder and the theoreticalbasis of psychiatryas opposedto factual guidelines:
338 Psychiatryis more complicatedfor a causalrelatlonshlo and dedding the interventlonsto cure it becausein eachcase you've got to considersoclal aspectsand what exactlyhas made them relapseand declslonsare totally subjective.
Manyof the problemsin developingthe care pathwayarose from the lack of researchbased evidence. Reflecting on his role as a psychologist,Simon was specificin one interviewwhen he appliedthis to his work with Volces'andthe range of interventions:
Theyý-eso new and only really being evaluated,itý; too early to standardisecare becausewe haven'tgot an empiricalbasis, we operate on best practIce,developed through experlence.itý; personalto me and my work w1ththe clients.
Gileshas arguedthat specifictraining for psychiatristshave been so varied that no one way of working can be determined.This leadsto a mixture of approaches groundedin experience.In his view, cliniciansresponded to problemsby referringand comparingnew clinical problems to the knowledgegained through clinicalexperience. This has becomeknown as hypothetico-deductivereasoning
(Higgs Mones 1995).
For Kerrythe processof medicaltraining also influencedthe nature of decision- makingin clinicalpractice but insteadof the hypothetico-deductivereasoning identifiedabove, referred to the existenceof gut Instinct.Agut feeling' approach to makingdecisions has been identifiedin the psychiatricnursing literature (Rew
339 1991) but unlike somewho celebratethis form of practice(Cutcliffe 1997), Kerry
felt this was her only alternativegiven the lack of knowledgeIn treating people
sufferingfrom schizophrenia:
If peoplegot trainedright from the beginnIngto use evIdence,it would becomesecond nature, but everyonehas got a different experienceand so you go on your instinctson what worksand what doesn't.
The examplessuggest that different professionalgroups develop clinical
decision-makingprocesses from experience.This finding is relevantfor greater
understandingof the clinicaljudgement processfor treating peoplewith schizophreniabut also illustratesmore clearly how professionalsmake decisions.
However,it may also lead to potentialbarriers to integrationas professionals
professto havetheir own methodsof arriving at decisions(Buckingham & Adams
2000). As previoussections have detailed, this is conceivablegiven that interventionsand outcomesare not easilyidentified.
Mikesuggested that the processof psychiatryhas arisenfrom a baseof experientiallearning as opposedto scientificfact and more emphasisshould be placedon the experientialskills of professionalgroups. Mike useda powerful metaphorto illustratethis point:
Clinicalskills have been honed down over hundredsof years that the professioný7 been in existenceand we need to be more honestabout what do is that has the has we can ...a nurse a creature swaln out of water and
340 Into evolved thIs ruthlesseffl"cient caring machine .. our trainIngm1sleads us that we are able to predict carefor schlzoPhrenlcs.
Simonsuggested that someaspects of clinicalpsychology for patientssuffering from schizophreniawere not supportedby evidencebut basedon experiential practice:
It stifles experientlalwork becausesomeone ý; got to do the Innovatlon, becausepatients may not receivesome interventionsjust becausethey haven't been tested and that is ludicrousbecause we wouldend up dolng nothing with them.
In the absence of evidence for practice, Derrin emphasisedthe interpersonal nature of her OT work developedthrough the uniquelearning experience and personalityof the clinician:
UsIngthe hiddenqualities,, the therapeuticuse of self and that comes from experience,itý; somethingyou learn whenyou ý, e training, and through modelingpeople who work well with patients.
An argumenthas also been madethat becausepsychiatric professionals were unableto say with certaintywhat they do it did not equal a positionof not doing anythinguseful at all. Gilessuggested that psychiatricskills was groundedin experiencewhich did not alwaysrequire a soundrationale for it to be seenas important:
341 If I was to developschIzophrenla, and you stuck me In a room with peoPle ., who have no experienceof what to do Withffils hallucinatIngperson, I m1ghtha ve an OK time for the first few m1nutesbut that person will pack up and go home.Itý7 a bit like sendingsoldiers Into battle and not knowinghow to fire a gun. Youmight not know what the war is about, but you still need the soldiersto fight it.
In this sectionviews have beenexplored on the nature of experientialpractice.
Many reasonswere put forward for not being able to standardisecare such as the 'newnessof the interventionsfor practiceand Insufficientknowledge about the aetiologyand diseaseprogression of schizophrenia.An argumentwas presentedthat it was satisfactoryto use intuitive forms of practice,although for care pathways,such forms of knowledgewould needto be open to Inspection and ultimate description.As previouslyexplored, this has been difficult for respondents.
Somerespondents have disclosed to the researcherthat they basetheir practice on individualjudgment because they wantto just carryon with theirjob and maintainthe !5tatus quoý This may explainwhy clinicianswere reluctantto engagewith the researchstudy and awareof the frailties of their knowledgefor clinicalpractice. Some clinicians even suggestedthat they had no idea why some patientsimproved and that practiceand judgment were basedon ýuess-work.
This maylead to the questioningof the needfor qualifiedstaff if muchof psychiatryis basedon ýuess-work'or a re-evaluationof what is taught to mental
342 health practitioners.Clinicians involved in the researchstudy havedisclosed that appliedknowledge has beengained from clinicalexperience.
This analysiswould not claimto be representative,however it doesquestion the evidencebased practice movement that is supposedlyguiding mental health services.Evidence based practice assumes that evidenceexists to be discovered and that it is indisputable.It makesassumptions that clinicianswill know how to accessit, apply it and for the recipientto agreeto it. Somestudies have shown that cliniciansare open to the idea of evidencebased practice but do not have the skills to use it correctly (Carey & Hall 1999). This analysis has uncovered positiveassertions of wanting to use outcomesand evidencebased interventions,but this is temperedby the need for time to carry out the research,parity acrossthe professionsand use of all scientifictraditions to conductresearch. Clinicians value the use of training to help them clarify outcomes,but the questionis whetherclinicians would be willingto replace individualisedwork with standardisedoutcomes. Evidence from this study suggeststhis not to be the case.
Conclusion
In this chaptersome of the managerialissues impacting on the developmentand implementationof a care pathwayhave been explored.Many of the respondents identifiedthat the originsand purposeof the care pathwaywas to exert
343 managerialcontrol over the care process.However, most respondentstalked of a managerialcontrol over their care processesprior to the Introductionof a care pathway.This supportsstudies that have identifiedthat cliniciansare becoming more concernedover managerialissues (Dopson & Waddington1996). The central analysishas uncoveredevidence of these ideasin people'sperceptions and observationswhen askedto developa care pathway.Recent Government initiativessuch as managerialstructures and evidence-basedpractice provide greater pressureforcing professionalgroups to exercisecontrol over resources dispensed.Some respondents in this researchstudy wanted to extend their managerialremit over health care and for this to includecross-professional workingwithin a care pathway.Government policy has been strident in placing quality as the priority (Departmentof Health 1998a)and an argumentcan be madethat a care pathwaystrengthens the managerialagenda in heath care. It was frequentlyasserted that a care pathwaymade clinicians conscious of being continuallymonitored.
In the final section,respondents discussed the amountand quality of evidence that would support a care pathway.Respondents identified that they could list
'bestPractice'to go into a carepathway and mostrespondents would agree that very little evidencecould be identifiedto underpinpsychiatric practice. However, positiveviews were expressedabout the importanceof outcomesbased practice and some instanceshave been discussedwhere respondentshave tried to
344 Identifythe difficultiesin both accessingand Implementingevidence based
interventions.In the absenceof research-basedpractice, respondents have
identifiedexperiential practice, which appearsto be basedon practicebased
learningand clinicalexpertise. These findings would challengeany suggestion that hospitalcare packagesfor peoplewith schizophreniaare basedon evidence-
basedpractice or whether clinicianshave a sound rationalefor providing
psychiatriccare.
345 Chapter Eight
Implications for psychiatric services
Introduction
This discussionchapter will draw togetherthe main findingsof the study and how they relate to the wider Governmentagenda of more integratedcare and the impacton professionalideologies and inter-professionalcare. The
NationalHealth Service (NHS) has been steadilymoving towards collaborative inter-professional health care to improve the quality and cost effectiveness of healthcare outcomes(Department of Health 1999).The developmentand implementationof care pathwaysfor peoplesuffering from schizophreniamay complementthis quality agenda.Following a reviewand summaryof the previouschapters this final chapterwill attempt to discussfive major issues:
* Cancare pathwaysproduce a more effective managementand change
processfor psychiatricservices?
* What do these findings meanfor psychiatricnursing?
* How may care pathwaysaffect multi-disciplinaryteam (MDT)working? a In what ways may care pathwaysshape education and training?
9 Couldthe treatment of schizophreniabe any different using care
pathways?
A final part of the chapterwill discussthe benefitsand drawbacksof the approachand researchmethods used within this study.This critical synopsis reviewssome of the difficultiesin carryingout the researchwithin the study
346 setting.The latter part of the sectiondetails further areasfor researchand
development,which could be appliedto widen the knowledgebase for care
pathwayresearch. A numberof recommendationsare also madefor
managerialand clinical practice.
Main findings
The developmentof a care pathwayfor peoplediagnosed with schizophrenia
has illustratedquite clearlythat professionswere lockedin debateregarding the individualisednature of psychiatriccare and treatment. Other respondents
perceivedthat care and treatment could be standardisedsuch as the
procedureof admissionor the applicationof the care programmeapproach.
Both the researcherand respondentsconstructed this dichotomyinto an
individualised-standardisedcare continuum.Elements of care could be standardisedsuch as the dischargeprocedure but developingpatient relationshipsand knowingthe patient was a highly individualisedprocess.
Respondentsmay have arguedstrongly for care to follow an Individualised care conceptionso to protect the uniqueidentity of their role and function.
The intention being only that professionalgroup could carry out the
Intervention.This possibleexplanation would not be Inconceivablegiven the inter-professionaldifficulties observed in teamworkstudies (Beattie 1995).
Alternativelysome respondentsargued that care shouldfollow a standardised frameworkand this could be explainedby the firm politicaldrive to manage care more closely.For examplethe Departmentof Health(2002a) has
347 recentlyannounced that certainoperations will cost a standardtariff with the assumptionthat health providersare able to standardiseand controlthe methodof deliveringcare.
The developmentof the care pathwayalso demonstratedthat respondents were not alwaysclear of the rationalebehind their interventionsor those of other professionalgroups. This was aptly demonstratedwhen respondents attemptedto implementthe care pathwayinto practice.Inspection of the care pathwaydemonstrated that large parts were not implemented.Respondents also acknowledgedthat their representationof what they did was sometimes optimisticand openlyacknowledged their lack of knowledgeof why certain interventionswere knownto work. Uncoveringthis perceptionrequired a certaindegree of trust and opennessfrom respondentswithin the research process.
It could be that respondentswere unclearof their role, function and interventionsbecause the nature of hospitalcare was and still remainsill defined.This is further complicatedbecause of the aetiology,disease progressionand outcomesof schizophreniabeing equally as contentious.
Althoughrecent guidanceon the prescriptionof medicationfor schizophrenia has been produced(National Institute for ClinicalExcellence 2002), there Is still a wide range of activity that is variableand poorly understood.For examplefurther work is requiredon understandingthe purposeof admission to hospitaland identifyingwhat the outcomesof admissionshould be for a
348 persondiagnosed with schizophrenia.Respondents may have been unclearon explainingtheir role becausethey may never haveconceived their role to fit within the confinesof a care pathway.This possiblyled to respondentsbeing criticalof the roleof the variedprofessional groups although the studydid demonstratethat someunderstanding of role occurredthrough developing the care pathway.
Respondentsmay have been unclearon what they did becauseof the training and preparationto work with peoplediagnosed with schizophrenia.Evidence collectedfrom reviewsof the training of the psychiatricprofessions does point to a requirementto specificallyaddress this issuebut alsoto look at training a different type of practitioner.For example,the ImplementationGuide for hospitalcare identifiesthe role of Support,Training and Rehabilitation workersto offer a different type of role for hospitalcare (Departmentof
Health2002b). Respondents,particularly nurses were criticalof professions such as occupationaltherapy and psychologyand this demonstratesa sense of vulnerabilityin their perceptionsof the nursingrole. Equallyit may demonstratea misunderstoodrole of mental health professionsin the care of peoplewith schizophrenia.
Findingsof this study also demonstratedthat the processof changeis complexand fraught with difficultiesthat may be outsidethe control of the researcher.Particular problems encountered in this study relatedto staff changesand poor morale.This affected both the developmentsof the care
349 pathwayin terms of engagementwith the project, but also of more importance,the Implementationof the care pathway.This was an unexpected occurrencewithin the project and led to participantshaving Insufficient knowledgeto implementthe carepathway into practice.This findingwould have relevancefor similarhospitals experiencing a fluctuatingcomplement of staff.
The role of the researcherin facilitatingthe changeprocess led to respondentsoffering both positiveand negativeviews. Somerespondents perceivedthe changeprocess to be a managementInspired objective whilst others recognisedthat they were able to contributeand shapethe agendafor change.The dual role of the researcherin being both a project managerand a researchermay havecontributed towards the perceptionof ever increasing managementcontrol.
In sum, the findings indicatethat the developmentand implementationof a care pathwayled to a rigorousdefence and articulationof the view of individualisedcare. Carepathway development did producevarious responses on the perceivedrole of professionalgroups within the contextof the multi- disciplinaryteam. However, these findings must be seenwithin the change context locally but also within the wider politicspermeating the NHS.The followingsection will now apply these findingsto the managementof psychiatricservices.
350 Management of psychiatric services - political imperative
In this sectionit will be consideredhow a care pathwaywould extendthe
managerialremit over psychiatricservices. This will be consideredIn relation
to the Governmentagenda of reformingmental health servicesto ensure
greater quality and control over psychiatricwork. The processof changing
psychiatricpractice will also be consideredand includethe developmentof
evidencebased practice, integrated care, managingcorporate risk and
enhancingthe role of the user in psychiatriccare.
A repeatedargument throughout this study has beenthat there Is Increasing
control over the managementof health personneland what they do (Edwards
1998),and secondly,how and where the client Is managed(Chan & Rudman
1998). Respondentsreadily agreed that a care pathwaywas more alignedto
the needsof the healthservice manager as opposedto a clinician.
Commissioningauthorities may be positivetowards this developmentbecause care pathwaysmay facilitateimproved service agreements. A care pathwayis designedto ensurethe patient receivesthe most effectiveInterventions and satisfiesthe outcomeswithin a time-limitedtrajectory (Rietz et al. 1997) althoughin this study, it was not possibleto managethe workforceIn achievingthese serviceaims. Respondentswere able to Identify the relationshipof a care pathwayto both the local needsof the servicein managingresources, but importantly,convergence with the wider
Governmentagenda of more integratedcare.
351 Convergence of appeal
Followingcompletion of the study, further advancementof policy has detailed
a greaterdegree of control over the provisionof health care (Departmentof
Health 1997).The Governmenthas identifiedthat variationsexist between
the way mental healthservices are providedand integratedacross the UKand
has put forward a seriesof measuresto placethe quality of care Into the
centre of health care planningand provision.Under a systemof clinical
governance,Chief Executivesof health care organisationswill needto
demonstratethat they and individualclinicians have systems to audit the quality of patient care (Department of Health 1998a). The Government has
produceda mental health NationalService Framework (NSF) (Department of
Health 1999) setting standardsin five areas: health promotion;primary care;
accessto services;focus on seriousmental illness(SMI) and the reductionof
suicide.A Commissionfor HealthImprovement (CHI) (Departmentof Health
1998a)will monitor adherenceto the standards.Respondents readily identifiedwith the influenceof past managerialstructures on health care and perceiveda care pathwayto be a natural extensionof this agenda.A care pathwaycould be usedto introduceother managerialstructures but as demonstratedwithin this study,respondents were not alwayspositive if it was perceivedto conflict with individualisedpatient care.
A NationalInstitute for ClinicalExcellence (NICE) has been establishedas a specialhealth authority to provideauthoritative and prompt guidanceon therapies,treatments and clinicalguidelines to the NHS.Following a periodof
352 review,new treatmentsand healthtechnologies will be proclaimedas a
nationalstandard and be includedwithin NSFs(Department of Health 1998a).
Systemsneed to be devisedto incorporateand demonstrateNICE guidance
(Littlejohns1999) and a care pathwaymay servethis need. In this research study, respondentswere unableto identify those tiers of interventionsthat were evidencebased and most appropriateto Introduceto the clinical encounter.Respondents could not agreeon best practicewhich would be the forerunnerto evidencebased interventions and so the usefulnessof a care pathway appears limited in this respect.
The Government'sstated appealto improveclinical accountability for the way professionalspractice their work demandsa major attitude changefor mental health practitioners.Targeting groups of disorderssuch as schizophreniaalso addsconvergence of appealfor the use of care pathwaysas a tool to co- ordinateclinical governance. A care pathwaymay enableNHS Trusts to co- ordinatethe use of clinicalinformation to exert maximuminfluence on the patient'sproblem and providebest use of clinicalresources (NHS Executive
1998). However,there were many problemsin developingthe care pathway, the most important beingthe inability of cliniciansto say what they do for this clientgroup. Moreover, each professional group has felt threatenedby having their role and function displayedwithin a transparentframework. Although the researchprocess did lead to a reappraisalof role function, the processof carryingout psychiatricwork was not greatly changed.
353 Assessingthe quality of care has beenexplicitly discussed In the NSFand was
widely recognisedas importantby the respondentsin the researchstudy.
Respondentsquestioned whether a care pathwayadded a too greater
emphasisof 'big brother'and a questioningof the workforce.However, this
perceptionof surveillanceis likely to be extendedunder clinicalgovernance.
The aim is for the processof care to be clearlymapped out for easeof audit.
Respondentsidentified that a care pathwaymay makethe professionalmore accountablefor their performanceand so rectify deficiencieswithin the service.However, inspection of the care pathwayfound large parts incomplete suggestive of greater deficits in care than was expected.
The recentchanges to the NHShighlight increasingInternal and external managerialcontrol over how clinicianspractice. The advent of the NSF heraldsa movementtowards reducing clinical variation and towards standardisedcare, monitoringthe quality of care and openingup a new era of clinicaltransparency and managerialscrutiny (Department of Health 1998b).
A care pathwayworks within these parameters,but as discoveredwithin this researchstudy, care pathwaysare perceivedto be politicallymotivated to
'control'the workforce.A perceptionof control manifestedIn manyways such as the care pathwaypreventing individualised work, challengingprofessional boundariesand addinga greater scrutinyover the rationaleof care. In this study, respondentsoffered negativeviews of a care pathwaywhen they thought managementstaff of the organisationwas directinga care pathway.
354 Linking primary and specialist services
The managementof illnessepisodes spreads far wider than the ward or communitysetting and a care pathwaycould be usedto Integrateall the different agenciesand professionalsinvolved (Hunter & Fairfield1997,
Edwards1999). For example,the interfacebetween primary and secondary care could be bridgedwith a referral route and specifiedaction plansfrom the
GeneralPractitioner (GP) to a communitymental health team. This would enablea greater degreeof control over accessto specialistpsychiatric servicesand may preventunnecessary use of expensivehospital beds. Lang et al. (1997) discovered that GPs were particularly concerned with poor communicationbetween primary and specialistservices with unclearroles and responsibilities.Respondents appreciated the advantagesof linking primary and specialistmental healthservices such as improvedcommunication, allocationof communityworkers and quickerdischarge from hospital, althoughthe tool was unableto demonstratethese featuresof integrationin clinicalpractice. Arguably the processof managingservices across different agenciesis too ambitiousfor a care pathwaygiven the lack of ability to manageservices in one care area.
Control over corporate risk
Careand treatment negligenceclaims are increasingin the UK and a care pathwaymay be a vehicleto guard againstcorporate litigation risk to the organisation(Ellis 1997).The care pathwaymechanism prompts the clinician to act when the patient is not conformingto the confinesof the care pathway
19;IZ F.0f (Pearsonet al. 1995). Hyamset al. (1995) found that clinicalguidelines could be usedto both preventand pursuecases of litigation. For example, organisationsthat developcare pathwaysfor ambiguoustreatment conditions like schizophreniamay be moreable to demonstratea consideredview In the courts.The oppositecase of providingcare with lesstime to considerthe possibilitiesmay be lesseasy to defend.Alternatively, the courts may demonstratethat two different psychiatristsprovided alternate types of care for the samediagnosis. However, in this researchstudy there was little evidenceto suggesta care pathwaycould reduceclinical variation and may actually increase the risk of litigation becauseclinicians were largely unaware of how to apply best practice.
Manynurse respondentswere critical of the blame-culturewithin health care and felt nurseswere too often identifiedas the culprits in medicaland nursing negligencecases. However, this must be balancedwith the fact that psychiatricnurses are the largestgroup of staff havingthe most face-to-face contactwith the psychiatricpatient (Thomas1997). A care pathwaymay introducea sharedperspective to managinghealth care risk for all of the team but be unsuccessfulin reducingnegligence cases.
Refocusing practice; the evidence based culture
Broaddirections have been laid down within the NSFfor the future developmentof mental health services(Department of Health 1999).The developmentof a care pathwaywould aim to includethose aspectsof care
356 deemedbest practice(Ellis & Johnson1999). RespondentsIdentified that the developmentof a care pathwaywas a dynamicprocess which would aim to includean ever increasingnumber of evidencebased interventions. However, respondentscould neither identify evidence-basedpractice nor describe psychiatriccare accuratelyfor inclusionwithin the care pathway.Following the processof implementation,respondents identified that parts of the care pathwaywere 'optimisticand 'unachlevable'.It could not be assumedthat a care pathwaywould facilitatethe developmentof mentalhealth servicesas determined within the NSF.
Assumingthat suitableevidence based interventions could be found for changingpsychiatric practice, it would involvea large elementof training the staff to use and evaluatethese new interventions.For examplerespondents identifiedthat usinga rating scaleto measuresymptoms and outcomesof carewas an improvementon the unstructuredmethod of assessment previouslypractised. As part of the preparationto implementthe care pathwaywithin this study, clinicianswere trained to use the Brief Psychiatric
RatingScale and the Healthof the NationOutcomes Scales. Many of the nurseswere positive about their newskills but their applicationIn practice wasnot widespread.Wider Implementation of the carepathway would require further and on-goingtraining commitmentsfrom the organisation.The use of care pathwaysmay be a possibletool to demonstratethis on-goingeffort for evidencebased mental health care (Dykes& Wheeler1999). Howeversimply
357 includingmore moderntypes of interventionswithin a care pathwaywould be no guaranteefor their use within psychiatricpractice.
A caseof not using interventionssimply for not being supportedby evidence may deny patientsa potentiallytherapeutic intervention. Steve, Mike and
Simonput similararguments forward for not standardisingcare. They felt that only standardisedcare could be supportedby evidence.This has possiblyled to the suggestionthat the care pathwaywas unrepresentativeof hospital care. For example,some care pathwaysfrom the UnitedStates do not include the role of a psychologist for in-patients with schizophrenia(St. Elizabeth
MedicalCentre 1995).Within this study, there was little provisionof OT or psychologicalcare for those patientswho followedthe care pathway.The bulk of the care pathwayreflected the role of medicaland nursingstaff in managingthe patient episode.It may well be the casethat psychologicaland
OT care could be providedas an exceptionrather than the norm. However, somestudies have identifiedthat psychiatricpatients value the'talking therapies'following their illness(National Institute of Health 1994). Moreover, the dangersof such a conclusionmay leadto a disintegrationand lack of involvementof the MDTin caringfor the psychiatricpatient. A rationalisedor
'reduced'service may be the end result of practicenot consideredto be
'evidencebased' by NICEor by care pathwayanalysis.
358 Managing morale
The NHSrecords a variableturnover of nursingstaff (7% to 36%) and high
rates of 'leavers'results in skill and knowledgeattrition, low moraleand
retentionof poorlytrained and motivatedstaff (Audit Commission1997). The
impactof job dissatisfactionhas been identifiedas a major sourceof stress
for nurses(Farrington 1997) although the link betweenstress and
absenteeismis not clear (Matrunola1996). It has beenargued that a care
pathwayincreases work satisfaction(Newel 1994)and leadsto a level of
perceivedcontrol over the nature of psychiatricwork. However,findings from
this study identifledconsiderable conflict both within and acrossthe
professionsduring both the developmentand implementationphase of the
care pathway.Although recruitment and retentionof staff remainsa particular
problemfor psychiatricservices a care pathwaymay compoundthe problem
and be unableto conserveon this vital humanresource.
A positivecorrelation has beenfound betweenincreased levels of control,
autonomyand work routinesLe. protocolsin patient focusedcare (see
chapter 1) with reducingstress in the nursingrole (Jenner1998). However, this studyfound repeated examples of roleconflict as respondentsgrappled with contentiousissues in decidingthe contentof their work.Some
respondentsexpressed concerns over their ability to exercisecontrol in the
provisionof care. Levelsof moraleon the study ward compoundedthe
problem.Because care pathwaysare so new to the current systemsof care, they demanda working environmentand staff group that will accommodate
359 the featuresof a new system.It remainsuncertain whether organisational systemscould be better managedto enablecare pathwaysto give higher levelsof autonomyand control to cliniciangroups.
D'an for the Realignment of care consumer
Greateremphasis has been placedon the role of the consumeras an interactiveagent in the planningof care (Neuberger1999). However, problemsstill remainin their actual involvementand patientsunderstand little of the treatment direction (Spicker et al. 1995). A care pathway is an attempt to makethe processof care transparent.Users of servicescan determineif the contentsof the care pathwayfit their expectations.This may challenge the dominant'paternalistic' provision of care and embracea new era of a self- critical public.There was someappreciation of these factorsfrom Ingrid, but on the whole, the care pathwaywas interpretedas a mechanismimposed on the workforceand the patient.As a further step towardsinvolving the user of care, some care pathwayshave includedpictures or imagesof the care deliveryepisode (Burngarner & Evans1999). This may be usefulfor inner city areasthat cater for a patientwhere Englishis a secondor poorly understood language.
Someresearch from the care pathwayliterature analysinggeneral adult conditionshas found that patientsscore higher on care satisfaction.Patients valuedthe prescribedpattern of care so that they knew in advancewhat treatmentto expect (De Luc 2000).This may enhancepatient participation
360 and knowledgeabout the service.Users may prefer to have care given on an
Individualbasis as advocatedby the respondentsIn this researchstudy.
In this sectionit has beenconsidered whether a care pathwaywould extend
managerialintentions over healthcare. Basedon the evidenceof this study,
psychiatricpractice is a poorly understoodand appliedbody of knowledge.It
appearsunlikely that a care pathwaywould greatly extendthe agendafor
improvedquality of care or to reconfigurepsychiatric work to encompass
evidencebased practice.
A care pathwaymay lead to a greater appreciationof the factors contributing
towardsrisk and the value of the consumerin planningcare, althoughbe
ineffectivein managingservices across agencies. Although respondents
perceiveda care pathwayto extendthe managerialgaze over psychiatric
work, the suggestionthat a care pathwaywould lead to a more managed
servicehas not been upheldin this study.
Psychiatric nursing
There is a perceptionthat psychiatricnursing must follow an Individualised
perspectivein caring for peoplewith schizophreniaon hospitalwards
(Brooking& Ritter 1992) and this was highlightedby manyof the respondents
in the researchstudy. It was claimedthat peoplepresent with Individual
'needs'which requirean individualresponse from a clinician.it could be
arguedthat care pathwaysrepresent the antithesisof an Individualised
361 approach,so long espousedby psychiatricnurses for the developmentof
therapeuticrelationships (Hill & Michael1996). It was a commonlyexpressed
view that care pathwayswould somehowdemean the interpersonalwork that
takesplace between a nurseand a patient.Others have suggested that care
pathwaysare intendedfor use in specificillness or treatment groupsand have
mechanismsfor trackingvariances (Schriefer 1995) and ensuringIndividual
correctiveaction (Robinsonet al. 1992).However, respondents only partially
completedthe variancesection of the care pathway.If the patient did not
conformto the care pathway,the stated interventionwas not delivered.On
very few occasionswas nursing care changed to address individual needs. So
in this regard, respondentsusing the care pathwayfailed to track variances
from the stated care plan and certainlyoverlooked any correctiveaction.
Other respondentsperceived that care could be standardisedfor some parts
of the patient'scare and treatment.One could argue that by followinga
standardisedprocess, the nursecould be better able to respondto the needs
of the client in a plannedway. Individualisedcare may lead cliniciansto be
reactiveto situations.Some respondents argued that the processof
standardisingcare led to a moreconsidered view on psychiatriccare.
Althoughthis may have beenthe case,it did not changethe way nurses worked. Psychiatricnurses continued to do the sameactivities even when
they advocatedthe benefitsof indiviclualisedcare.
362 Somescholars have argued that standardisationof nursingtasks reducethe potentialfor flexibility in working practices(Mangen 1982). It could be that the setting of standardsremoves the potentialfor nursesto Insertdelays into the care system,practice according to particularstyles or to hold firm views on the nature of nurse-patientrelationships. In this researchstudy nurses usedthe problemsof care delaysto preventthe setting of standards.The impactof clinicalgovernance and the NSFmay ensurethat psychiatricnurses work towards nationalstandards of care for patientswith a SMI (Department of Health 1998a).Professionals who favouredindividualised care generally opposedcare pathwaysand this could be the casefor other Government initiativessuch as clinicalgovernance and the NSF.
Discourseon professionalgroups has identifiedpsychiatric nurses to experiencea senseof disempowerment(Stein 1967) and reverencetowards their medicalcolleagues (Clarke 1991). Issuesof socialclass, information and power have been centralto this inter-disciplinaryconflict (Pilgrim 1983).A care pathwaymay work towards re-dressingthis balanceby identifying parts of the role, which have clear links with evidence-basedpractice. Although nurse respondentsin this study could find very little evidenceto supporttheir role and function, this may be due to poor researchtraining. Retsas& Nolan
(1999) usedthe Barriersto ResearchUtilization Scale (Funk et al. 1991) and found the most frequentlyidentified problemswere insufficienttime to access,interpret and implementresearch evidence. Similar to the findingsof
363 this researchstudy, this led to problemsin implementing'evidence' within
clinicaleffectiveness initiatives like care pathways.
Increasingamounts of researchare findingevidence to supportnon-
pharmacologicalinterventions (Drury et al. 1996a,b, Tarrier et al. 1999).If
these interventionswere included,a care pathwaymay lead to a gradual
realignmentof nursingstatus and role with other professionalgroups such as
psychiatristsand psychologists.There are two main problemswith this claim,
specificallyfor care pathwaysdesigned for schizophrenia.In this study,
nurses encountered a great problem in describing a comprehensive list of
interventionsused for patientswith schizophrenia.Moreover, nurses did not
havethe knowledgeon how to apply or appreciateevidence-based
interventions.Primarily, there would be the needto train psychiatricnurses to
use these interventionsand, possiblyof more difficulty, persuadingnurses to adopt these interventionswithin the confinesof a care pathway.As identified within this researchstudy, nursesmay be unableto answerquestions relating to evidencebased practice due to the Infancyof the researchbase (White 1997).
A more pressingproblem has beenthe adoptionof a humanisticethic installedinto nursingpractice (Thomas 1997) and nurseeducation
programmesthroughout the 1980's(Nolan 1993).A humanisticperspective valuesthe individualapproach to care and prefersto look at the totality of the patient'sneeds. Mental distress would be seenas a productof the
364 environment and inner psychologicalconflict (Barker 1989, Barker et al.
1997).Some have argued that this perspectivehas led to a rejectionof the
evidencefor a neurobiologicalunderstanding of mentaldisorder (Betemps &
Ragiel1994), which embracesboth the use of medicaland psychosocial
interventions.Within this study, the care pathwaywas designedfor people
with chronicschizophrenia and basedon the medicalclassification of
disorders.This ultimatelyinfluenced and confrontedcommonly held nursing
perspectives.Preparing psychiatric nurses on the possibleconflict and
confusionbetween a humanisticand medicalcare perspectivewould be
fundamentalto securingthe adoptionof a care pathway.
The nursingprofession has generateda body of knowledgeand skills that are
claimedto be uniqueto the discipline.Within the researchstudy, nurses
claimedto have developedunique areas of expertisespecific to the patients'
illness.This may havefuelled some of the antagonismtowards 'lettinggo'of certain nursingduties. It has beendemonstrated that nursesperceived themselvesto be 'over-worked"inboth the deliveryand managementof
psychiatriccare. A care pathwaymay begin to illustratethe amountof time and activity that psychiatricnurses could potentiallyspend with patients.This would confirm the conclusionthat past and contemporarystudies continually find that hospitalpsychiatric nurses disengage with psychiatricpatients and spendlittle therapeutictime with them (Johns1961, Higginsetal. 1999).A care pathwaymay enablepsychiatric nurses to improveon this important
365 deficitin care and also producea more robust mechanismof determining therapeuticcontact.
A care pathwaymay be able to identify periodsof time when psychiatric nurseshave beenengaged in activitiesthat are consideredimportant or not importantfor ward work. The problemis that nurseswere unableto describe their role and this raisesquestions over whether nursingcare is sufficiently formalisedfor ward nurses.This could be due to respondentsnot havinga sufficientawareness of their role and many nurse respondentsdemonstrated this. However.,this positionquestions whether it is appropriatefor psychiatric nursesto work on wardsor if peoplewith schizophreniabenefit from being admittedinto hospital.The developmentof the care pathwayhelped to identify nursingwork but also displayedlarge gapswhere nurseswere unable to say how they justified their role on psychiatricwards. This could explain why nurseswere so defensiveof an inclividualisedapproach to psychiatric care.
Likeother accountsof inter-professionalrivalry (Lyons1998), this study found evidenceof a rigid adherenceto professionaldomains and this may possibly preventclinicians from acceptingthe genericroles held by health care practitioners.The developmentof a care pathwayalms to identify common ground,generic working and clinicallyeffective interventions. This may have antagonisedsome of the respondentsbecause the approachgives little supportto professionalideological differences in its pursuitof efficient health
366 care. If psychiatricservices were to adopt care pathways,the nursing
disciplinewould needto suspendsome of the concernsof Inter-professional
rivalry that have beenso stronglyasserted.
Psychiatricnurses are the largestoccupational group in mental heath services
(Thomas1997) and therefore providethe bulk of the responsibilityto deliver
and co-ordinatethe processof care delivery.One could assumethat nurses
would have a greateroverview of the input from all professionsinvolved in
the patient'scare. Respondentsidentified that it is the nursingstaff that
largely co-ordinate this care through daily 'hand-overs'. ward rounds and the
CPAprocess. One could have expectedtherefore a greaterappreciation of the
roles and responsibilitiesof both the nursingstaff and other cliniciangroups.
As discoveredin this researchstudy, the developmentof the care pathway
provideda forum to re-examinethe role and function of all psychiatric
professionals.Although nurses were unableto capitaliseon this forum, future
exercisescould preparepsychiatric nurses to becomeadept at extendingtheir
practice into roles undertaken by psychiatrists and psychologists.This could
leadto an increasein role legitimacy,but may also strengthennegotiating
positionsfor parity of status, pay and conditions.
Somehave arguedthat nursesneed to developa stanclardisedlanguage to
reflecttheir input into the care planningprocess (Dean-Barr 1994) and this
has been put into practiceby the work of the North AmericanNursing
DiagnosisAssociation (McFarland & McFarlane1993). Jones (1997) argued
367 that a standardisednursing language would enablethe nursingInput to be
formallyrecognised by purchasingbodies and more visible to policymakers. It
could be arguedthat a standardisedconception of care illustratesa
consideredand formal view on the deliveryof nursingInterventions. This
would be in contrastto an Informaland ad-hocway of describingnursing
care, which is subjectto the interpretationsof individualpractitioners. A
standardisednursing language within a care pathwaymay also work towards
demonstratingthe contributionin improvinghealth outcomesalbeit
compromisingthe individualisedethic in nursingpractice. In this sense,a
form of discourse projects power (May & Fleming 1997) where the language
of standardisedcare supersedesthe implementationof individualisedcare.
Althoughclinicians may have beentaught to delivercare in an individualised
way, or as identifiedin this study, deliver individualisedcare accordingto the
practitioner'svalue system,a stanclardisednursing language would counter
and bring into line these alternativeways of working. Greaterconcordance in working to set outcomesof practicemay then be achieved.
The prospectof greater managerialcontrol over the workforcemay well have
influencedthe Trust to supportcare pathwaysresearch. This researchstudy gainedsupport from the Directorof MentalHealth Services, but there was
little supportfor the projectthroughout the organisation.This was recognised and affectedthe commitmentfrom professionalgroups such as medicaland psychologicalstaff. Dueto the power and autonomousstatus of medicalstaff
(Flynn 1992),the use of care pathwaysmay be more effectivein managing
368 psychiatricnurses that hold lesspower compared to their medicalcounter- parts. For example,nurses could be employedspecifically to providecare as determinedon the care pathway.The care pathwaycould specifymore clearly the skill mix requirementsfor ward staff and so control more efficientlythe costsand deploymentof psychiatricnurses. The problemwould be for psychiatricnurses to implementthe interventionsspecified by the care pathway.Nurse respondents were open and criticalabout the lack of training or supportfor implementingspecialised interventions on psychiatricwards.
Manystudies have found that psychiatricnurses experience stress in their work (Sullivan1993) but one of the main factors associatedwith 'burnout' is that to do with unrealisticexpectations of the nursingeffect on patient outcomes(Melchior et al. 1997). Burnoutis thought to consistof three parts: emotionalexhaustion, depersonalisation and reducedpersonal accomplishment(Maslach Mackson 1982).A care pathwaymay begin to redressthe third issuewhere nursescan developa more focusedand realistic awarenessof their effect on patient outcomes.This is particularlyso for those patientsthat may be slow to recoverfrom their illness.However, in this study, respondentsoffered unrealistic expectations of their rolein bothdelivering interventionsand being able to predict responseto treatment. Moreover, respondentsattempted to build in delaysand exaggeratetheir role on the care pathway.This may contributeto a perceptionof decreasingcontrol over clinicalprogress and so exacerbatethe effects of burnout in psychiatric nurses.
369 The practiceof psychiatricnursing would be challengedby the Impactof a care pathwayspecifically the gulf betweenIndividualised and standardised approachesto care. In this study, the care pathwaychallenged the Idealsof psychiatricpractice namely that of the therapeuticrelationship, the language of psychiatriccare and the assumptionthat a nurseknows what they do. If psychiatricnurses are unableto explaintheir role it beginsto underminethe rationalefor hospitalcare. The proposedbenefits of a care pathwayin focusingpsychiatric nursing have not been found in this study. It is questionableif a care pathwaywould reducelevels of burnout In staff or improvethe co-ordinationof psychiatricnursing for peoplewith schizophrenia.
MDT working
The literaturecontains a vast amountof researchinto how professions disputeterritorial roles betweenone another (Hugman1995) and how they extendtheir role into vacantoccupational territory (Jordanet al. 1999).A care pathwayhas been proposedto improveinter / intra professional communicationand team integrity (Musfeldt & Hart 1993).Mental health care is no exceptionand possiblymore complexin the potentialfor conflict not just betweenprofessionals, but also betweenprofessionals and users. For these reasons,most studiesstress the importanceof developingcare pathways through meetingsand consultationbetween key membersof the MDT
(Velascoet al. 1996, Barnette& Clendenen1996).
370 A frequentlycited benefit of psychiatriccare pathwaysis their ability to providedefinitive role functionsand work activity patterns(Dykes 1997a). In this study, the developmentof care pathwaysquestioned the appropriateness of certainclinicians to deliver interventions.This led to professionalgroups assertingtheir control over certaininterventions. Professional groups felt disinclinedto discusstheir role beyondsuperficial dialogue. Some respondentsidentified the lack of 'evidence'supportingthe role of the team, whilst other respondentsidentified that it was difficult to describetheir role and function.
There are advantagesto developinga care pathway.Firstly, it exposessome of the underbellyof MDTworking such as suspicionand the tendencyto
I:5capegoat'other professional colleagues. It also exposespower Imbalancesin the team, which may fuel disintegrationof the team structure.With repeated discussionabout one's role it may reducerole ambiguityalthough it remains doubtful whether it leadsto improvedMDT working. Respondentswere able to identify commonproblems for peoplewith schizophreniaalthough had great difficulty in listing interventionsand outcomesfor individualdisciplines.
The group were unableto identify interventionsand outcomescommon to the
MDT.This suggeststhat genericMDT working is In nameonly althougha small numberof respondentswere able to recogniseand respectboth similarityand diversityacross the professionalteam. Manyrespondents identifiedthat a care pathwaydid not deliver a more focusedresponse to care
371 and others suggestedit leadto further demarcationInto rigid professional boundaries.A more pressingconcern is that if the MDThad difficultiesIn explainingtheir role, it underminedthe rationalefor the spectrumof psychiatriccare for peoplewith schizophrenia.
Muchof the working group debatecentred on the needfor definitive professionaldomains of practicebecause it was felt that any movetowards the use of care pathwayswould dilute the role and function of certain professional groups. In this study the care pathway was synthesised from the researchand theory of a numberof health care professions.Government policy has suggestedthat servicesshould be designedto minimise professionaland geographicaldemarcations (Department of Health 1999). It would appearthat a care pathwaycould integratethe wider continuumof mental health care to include,as the NSFhas suggested,housing, benefits and employmentagencies (Department of Health 1999). Howeverparticipants were unableto describein clearterms the admissionroute Into hospitaland the subsequentinvolvement of the communityteam. It would appeartoo difficult to integrateand representa far broaderapproach to care as detailed withinthe NSF.Respondents in this researchstudy were positive about the movesto recognisethe diversityof mental health care althoughthe team was unableto detail the complexityof multi-agencyservice configuration.
The roles of different psychiatricprofessionals share many similarities
(SainsburyCentre 1997)and respondentsobserved that teams provide
372 unnecessaryduplication of psychiatricwork most notablythat of assessment and care planningduties. For example,the researcherobserved that nursing staff assessedthe samereasons for admissionas the admitting doctor.A care pathwaycould be usedto economiseon limitedresources and also protect the patient from being over-assessed.However, respondents would comment that they thought their individualassessment was importantfor the planning processand refusedto limit this role in placeof other professionalgroups. A care pathwaywould beginto challengeparticular views but gainingconsensus of opinionand streamliningwhat does occursfor psychiatricpatients was incrediblydifficult in this researchsetting.
In this study, somedata on how MDT'sre-conceptualise their work within care pathwaystructures have beenexamined. The processcontinually questionsthe nature of interventionsused, the effectivenessand the appropriatenessof the professionalgroups who aspireto use them. The processby which health care becomepartitioned Into observablechunks and how MDT'snegotiate their work within a care pathwaywill undoubtedly producemany professional'turfwars. However,the prime factor that should fuel future researchand policyformulation is that the MDTwere unableto say how they work or what they do in great detail for peoplewith schizophrenia.
If this finding was to be representativeof all wards and communityteams it would questionthe provisionof psychiatriccare in the UK.
373 Education & training
There has beensome suggestion that current methodsof training mental healthworkers have been largelyineffective (Sainsbury Centre 1997)and this is inclusiveof psychiatricnurses (Tunmore 1997). This is largely because educationalestablishments have failed to deliver on the practicalneeds of the service.It has been assertedthat a care pathwaytype structurecould act as a frameworkto train a workforceto deliver care.The componentswithin the care pathwaycould determinespecific issues for inclusionwithin multidisciplinarytraining routes.The problemis decidingthe content of the frameworkand how near it comesto evidencebased practice. Some scholars have rejectedthe preparationof nursesfocusing on evidence-basedpractice.
For example,Gordon (1998) has arguedfor studentsto be exposedto practicesthat celebrateindividualised care. Respondentsnoted on many occasions,and for different parts of their role,,that evidencefor practicewas difficult to establishfor peoplesuffering from schizophrenia.This has relevancefor training psychiatricprofessionals to deliverevidence-based practice. The NICE will issue guidance on the types of interventions for certain patient groupsand it is not inconceivablethat guidancewould be issued within a care pathwaystructure.
Changingto care pathwayswould demanda compatibleworking culture where the team will work cohesivelyand collaborativelyin the pursuit of jointly agreedinterventions and outcomesof care. It is only recentlythat a skillscleflcit has been identifiedand addressedby coursessuch as the Thorn
374 Initiative(Lancashire etal 1997).It is to this end that servicesusing care pathwayswill require MDT'sthat are able to conceptualisecare within outcomes-based-language,articulate psychosocial interventions and havea greater understandingof the overall processof care. However,given the evidencesecured in this study it appearsunlikely that the MDTwould be able to achieveany of these objectives.
A care pathwaythat focusesless on outcomesbased practice and more on the processof care may be a more realisticstarting point for training psychiatric professionals. For example, a care pathway could track the various stagesof securingaccommodation for those patientswho habitually disengagefrom their housingand benefitsentitlements. This processcould then be taught speciflcallyto new employees.It may well be the casethat lesstime would be spent teachingprofessionals on issuesthat are not includedon the care pathway.Although this could producea highly skilled mental health worker, it would be at the expenseof a broaderapplication to mental health care.This could be evidencedwhen mental healthworkers chooseto go and work in different areasof practice.Mental health workers couldbe trainedto delivera largerproportion of taskscommon to professionalgroups. However,highly skilledand specialisedstaff such as psychiatristsand psychologistswould challengethe expansiontowards a larger genericrole for mental health workers.Although a care pathwaywould identify areasof genericpractice that could be Identifiedfor training material,
375 it was observedin this researchstudy that professionalgroups resistedany dilution in role.
If the contentsof a care pathwaywere taught to all the involved professionals,it might enhanceand focusteaching programmes on the most appropriatecare components.For example,some reports note that no single mental health professionhas beentrained to adequatelydeliver and manage psychiatriccare (SainsburyCentre 1997). Teaching professional groups to follow a care pathwaymay enableclinicians to follow commongoals of treatment for particulartypes of patientsand clinicalenvironments. The problemis makingsure that educationand training does not becometoo constrainedor dominatedby any one single care perspective.This teaching programmewould alsoconflict with an interactive,consciousness-raising approachto learningsuch as those advocatedby Freire(1972). This viewpoint makesthe assumptionthat studentswill simply learn facts from the educationalprogramme with no individualinterpretation or applicationto practice.It would be a retrogradestep for nurseeducation to simplyteach nursesthe contentsof the care pathway.Nurses require critical thinking skills to be ableto challengepractice and dominant care ideologies. The historyof nursingshows subservience to the medicalmodel (Nolan 1993) and giventhe fears of a medicallydominated care pathwayfrom within this study, the use of a care pathwayas an educationaltool must be viewedwith caution.
376 By its very nature, a care pathway itemises what the service requires professionalsto achieve.Respondents noted that it was very difficult to describewhat they do and when askedthis question,spoke only of the more measurabletasks. Teaching professionals how to care and treat people through the contentsof the care pathwaymay minimisethe hiddenskills of psychiatricpractice. Respondents noted many occasionswhen Yustbelng with the patient'was a meaningfulactivity. A care pathwayalso presentsthe imagethat care is a mechanisticactivity and that professionalshave control over the condition.As the contemporaryresearch data indicates,the predictability of health states such as schizophreniais poor (McGlashan1988) comparedto surgicalconditions such as total hip replacement(Gregor et al.
1996). Moreover,when respondentsobserved patients to proceedthrough the care pathwayit confirmedthe view that clinicalprogress remains largely unpredictable.
Beforea care pathwayis usedfor training purposes,further researchshould be performedto establishwhether health professionalsare content to follow this method.It may be found that it producesa too limited viewpointof patient care.This was certainlythe casefor the OT and psychiatrist respondents.They arguedthat the complexityof a patient'scare could not be splinteredinto a set order. It was advocatedthat treatment requireda multitudeof options unconstrainedby rigid practiceparameters.
377 In this section,it has beenconsidered whether a care pathwaycould Inform the future training of mental health professions.The nursing professionhas stated a commitmentto promotinginter-professional working (UKCC1992) althoughwhether a care pathwaycould deliver on this aim remainsdebatable.
Nurses,amongst other cliniciangroups were resistiveto identifyinggeneric practice.Quite possiblyboundaries will mergeto create a common professionaltraining althoughit remainsquestionable whether a care pathway would be the most appropriatevehicle to bring this about. In this study, respondents did not perceive care pathways to result in clinicians becoming less territorial or implement inter-professional collaboration at a level where it improvedthe quality of care patientsreceived. Greater purchasing authority to commissionhealth care educationwhich suppliessuitably qualified mental health professionalsto managespecific diagnostic groups fits comfortably with care pathways.However the recipientsof this educationmay be less positivewhen they attempt to challengecare or go on to work in different areasof mental health. In sum, movestowards a multi-skilledworkforce give little supportto individualprofessional ideologies and with this being such a stronglyasserted principle for the respondentsin this study, little use for a care pathwaycan be seenwithin this area.
Treatment and care of schizophrenia
The developmentof a care pathwayassumes that health professionalshave a degreeof certaintyover how patientswill respondto interventions.This has been indicatedby publishedaccounts of care pathwaysand the attempt to
378 Implementthe care pathwayin practice(Andolina 1995). However,for the diseasetype of schizophrenia,this may not be so easy.The problemsIn treatmentare in part due to the changingand complexpicture of its presentation,course and outcome(Johnstone & Lang 1994). By attemptingto developthe care pathway,respondents have identifiedthat the care of a patient with schizophreniais determinedby individualcircumstance. Process relatedactivities were easierto identify comparedwith outcomesbased practice.This may explainthe dominanceof processrelated care pathwaysin the literature (Lowe 1998). However.,some elementsof care could be standardised such as the admission of a client into hospital and planning for their discharge.
The diagnosticclassification of schizophreniahas come under intensecritique with many scholarsperceiving the label as a heterogeneouscategory with poor validity and reliability(Boyle 1990). Othershave considered the term schizophreniaessential for clinicalpractice. In one study Wing et al. (1998) expressedconcern that nurseswere particularlynegative in appreciatingthe importanceof the label in assessingand deliveringcare. Respondentswithin this studycould identify with peoplesuffering from schizophrenia,but preferredto identifycommon problems that affectedpeople with this diagnosis.In effect, the working group ignoredthe diagnosticlabel to focus on commonp robIemssuchas 'improving soclal functionlng'a nd !5ecuring accommodation'.Respondents argued that by focusingon commonproblems, mentalhealth care becamemore tangibleto plan and deliver.The use of 'lay'
379 terms may also reflect the sociallanguage of mental health that would be acceptableto all professionalgroups. Some respondents perceived the label of schizophreniato be representativeof a medicaldiscourse and felt uncomfortablein beingpart of a projectthat focusedheavily on 'symptoms' and ldiagnosls'.Therefore it may be more appropriateto designcare pathwaysfor groupsof patientsthat exhibit commonproblems as opposedto focusingon a diagnosis.
The pharmacologicaltreatment of schizophreniaplays a major role in managing the disorder (American PsychiatricAssociation 1997) and an importantpart in the care pathway.Greater promise has also beenfound with the newertypes of 'atypical'neuroleptic compounds compared to classical drugs (Franzet al. 1997,Tollefson et al. 1997), althoughfurther researchis required(Wolfgang Fleischhacker 1999). However,the processof developing the care pathwayinvolved a single responsiblemedical officer (RMO)and the medicationalgorithm was designedfrom his experience.It is questionable whether other RMO'swould agreeto implementthis medicationregime and this study demonstrateddifferences of opinion regardingthe predictabilityof schizophrenia.There appearsto be little consensusacross the medical professionfor followingset medicationalgorithms and this itselfIndicates the inabilityto predictthe treatment direction.A possibleway forward Is for all the psychiatristsin the local hospitalto agreeon medicationprotocols. These protocolscould then be includedwithin the care pathway.However, medical dominanceand independenceallows the professionto alter and change
380 treatmentto follow particularideas. The psychiatristrespondent supported
this when he suggestedthat ;osychlatrists follow what everpartIcularInterest
they have about the pathologyof the illness. The problemwith this practiceis the lack of accountabilityto both the patient and the organisation.A care
pathwaymay help to audit the prescriptionof medicationfor peoplesuffering from schizophreniaand show differencesbut may be ineffectiveIn ensuring psychiatristsstay within agreedprotocols.
Although there are no specific causative factors that can wholly explain the condition of schizophrenia, increasing evidence is pointing towards structural brain abnormalitiessuch as reducedgrey matter volumeand enlargedlateral ventricles(Zipursky & Kapur1998, Hafner 1998).Various tests can be performedto detect neurologicalchanges such as MagneticResonance
Imaging and PositronEmission Tomography (Travis & Kerwin 1997).Some respondentsidentified the possibleuse of these tests and a care pathway could indicatewhen these tests should be carriedout for the predictionof a more accuratediagnosis. For example,patients with bipolardisorders do not recorddifferences in grey matter volume (comparedto schizophrenia)
(Zipurskyetal. 1997). Furtherresearch may indicatethe most appropriate methodsof treatmentfor the differenttypes of disorderand these could be standardlisedon a care pathway.However, this advancementIn treatment remainsentirely speculativeand one that is not currently part of routine practice.
381 The developmentof the care pathwayprompted a generalawareness of the lack of milestonesin the treatment of schizophrenia.A preciseaudit of previousinpatient treatment for patientswith schizophreniawould be a further step towardsenabling the identificationof milestonesand outcomesof usualpractice. Developing and implementingmedication protocols would be more difficult as evidencedby the developmentof a care pathwayIn this study.The types of medicallanguage used to describepeople suffering from schizophreniaantagonised some respondentsinto rejectingthe content of the care pathway.However, the care pathwaycould be a mechanismby which to introducemore modernforms of detectionand diagnosisand so aid the treatment of schizophrenia.
In this section,issues relating to the management,configuration and training of mental health professionalshave been considered.A care pathwaymay havesome successin areassuch as makingcare practicestransparent.
Howeverthis is reliant on professionalsknowing what they do for peoplewith schizophrenia.In others areasa care pathwaymay offer false hopessuch as the increasedability to managepsychiatric care and professionals.The potentialof a care pathwayto shapeprofessionals to deliver care In a stanclardisedway maybe bluntedby the stronglyheld views on individualised care. A limiting factor in evaluatingthe benefitsof a care pathwayIs their infancyof developmentbut evidencefrom this study offers only a limited potentialfor psychiatricservices.
382 Limitations of the study
The researcherwill now identify a numberof different approachesthat could
be undertakenif a similarstudy was to be undertakenagain. The study
conclusionsalso identify a numberof differentlines of enquirythat would
inform the debateon care pathwaydevelopment and implementation.The
following sectionwill outline someof the mistakesencountered In carrying
out this study and suggestsome alternative research methods and
approachesfor future research.
The first intention of the researchdesign was to attempt to test a care
pathwaywithin a quasi-experimentaldesign for peoplesuffering from
schizophrenia.However, the difficultiesof developingthis type of designwere
apparentwhen the researcherattempted to apply this methodto the
particularcontext. Two of the major difficultieswere identifyingwhat exactly was being developedand secondly,organising the team to Implementthe care pathway.An actionorientated ethnographic research method was chosento best suit this researchsetting. However,the productsof such an analysishave beencriticised for producingsubjective 'impresslonisticdataf
(Mobley1997), 'trivlalgeneralisations'(Atkinson1990) and 'unrealistic
expectations'(Knaf]& Howard1984). Although both ethnographicaccounts
(Hammersley1992) and action researchstudies have as their goal to develop theory, it has not beenthe Intentionof this researchstudy to produce conclusiveexplanations or extend theory. Ratherto describethe processof
383 developingthe care pathwaywith the care team and bring to light the Issues as describedby the study participants.
Collectingfreely expressedperspectives from all respondentsproved to be a difficult process.For somerespondents, the researcherwas perceivedas a potentialthreat to their professionalculture. The researcherhad to adopt a progressiveentry procedureby taking a neutral positionto the many issues that were raised.This allowedthe researcherto graduallygain Insiderviews on the mechanicsof compartmentalisingthe variousroles and tasks of the team. Becker (1970) suggests that the researcher take a particular stand on a set of issuesand for these to be explicit during the courseof the research study. By doing this it clearlyshows any possiblemotivation for carryingout the research.This would have beenvery difficult for the researcherbecause co-operationwas requiredfor the working group processand for the implementationof the care pathway.Establishing trust and confidencefrom participantsand respondentstranspired through intensivecontact with the study site and close relationships with key informants.
Manyhave noted the needto involveall cliniciangroups In the development of the care pathway(Dykes 1997b). However,findings from this study suggestthat not all clinicianswere willing to engagewith the developmentof a care pathwayand compliancewith implementingthe care pathwaywas low.
This spannedacross all professionalgroups studied and it was difficult for the participantsto acceptthat it was a researchstudy centredon the use and
384 developmentof care pathways.This could be due to the perceivedthreat of a care pathwayin controllingwork processes.Alternatively, professions may have perceiveda care pathwayto breakdown tasks into a routine that could be performedby other professionalgroups. The researcherwas reliant on a few researchconfederates who were able to persuadeothers to engagewith the study. For example,George and Stevewere fundamentalto securing accessto the ward staff. For other participants,such as Gilesand Simonthe researcherdeveloped close friendships and so gainedmore involvementthan would be expected.For example,the researcherwould engagewith normal socialdiscourse and then weave in issuesrelating to the study. Opinions would then be noted down at the end of the working day.
The findings of this researchapproach corroborate some of the characteristics of action research,Namely, the processof action researchchanges in responsetoo organisationaland professionalpressure (Hart & Bond 1996) and the productsof action researchbeing determinedby all parties.The researcherintended to use an empoweringstrategy, but resortedto a top- down researcherled project managementstyle. The project raisedthe collectiveconsciousness of the workingsof psychiatricprofessionals and so In manyways fitted the enhancementapproach to action research(Holter &
Schwartz-Ba rcott 1993).Various questions were raisedsuch as W17at interventionsdo you use,at whattime and underwhat conditions for PeoPle with schlzophrenla'or'in what waysdo you Interact with other professlonal groups'.It could be arguedthat a far greater understandingof the role of
385 psychiatricstaff has beenachieved. However, the researchstudy has not
soughtto generateor test theory, rather to advanceand explicatea seriesof views regardingpsychiatric care pathways.In manyways, this researchstudy
usedan eclecticapproach to action researchusing whatevertools were appropriateat the time to carry out the study. For example,the researcher approachedthe site with a definedproblem (technical approach) but then workedon a seriesof tasks to empowerthe study participants(enhancement approach).This ultimatelyled to a perceivedclash of interest and may have fuelled disengagementand lack of interest with the researchprocess.
Althoughthe researcherappreciated the complexitiesand configurationsof organisationalculture (Meek 1988, Handy1993) and changeprocess management(Lewin 1958),it was unsurprisingthat the implementation process,ýqround to a halt'. For example,Zac identifledthat the research processwas 'on the shouldersof one person'.'The nature of a care pathway introduceschange to the culture of the organisationand so the processof changeshould have beentargeted at different levels.Moss Kanter et al.
(1992) identifiesthat changecan be targetedat both an Individuallevel and more globally,through the structureof the organisation.Further, the researcherunder-estimated the impact of examiningprofessional roles given the local politicaldifficulties within the Trust. The researchercould have used the Innovation ReadinessScale (Snyder-Halpern 1998) to determinethe ability of the organisationto partakein and supportthe study. On the part of the researcher,there was little appreciationof how far the Impactof care
386 pathwayswould revealthe sensitivitiesheld by professionalgroups towards this Innovation.However, the problemsof implementationwere also due to the instabilityof the changeenvironment, to the nature of care pathwaysand the poorlydirected change process. The suddenchange of staff at the start of the projectwas so unexpectedand dramaticon the successof developingthe care pathwaythat it ultimatelyled to the implementationphase of the care pathwayproject being discontinued.
The study could have been improvedif the researcherhad developedthe care pathway away from the study site. A research process could then collect views on the care pathwaybut alsotrack professionalthemes in Its development.Possibly the researcherwould not haveexperienced the poor level of engagementparticularly at the implementationstage of the study. In retrospectthe workinggroup processwas not sufficientlyhelpful to develop the care pathwayand more often led to professionaldegradation and confusionwhen describingroles and interventions.A working group may be more effectivewhen staff groupsare stableand feel motivatedto engage with a project describedin this study.
The researcherwas known by many of the hospitalmanagement and clinical staff and spendingtime on the ward at the start of the study provedto be successfulin pavingthe way to the larger study. Althoughthe researcher collectedonly initial impressions,it servedto clesensitisethe staff to the involvementof the researcher.Working group meetingswere establishedand
387 the researcherbecame active in the facilitationparts of developingthe care
pathway.At times the researcherchallenged some of the perceptionsof
psychiatriccare within the working groupsand this gave rise to the criticism that the researcherwas taking a biasedview. On one occasion,Simon accusedthe researcherof taking an anti-psychologistview In representingthe accountin the working group minutes.It may well be more appropriateto carry out action researchstudies with staff culturesthat are unknownto the researcher,although this would compromisesome of the benefitsof qualitative interviewing such as close proximity to the study issues (King
1994). Other difficulties occurred when the researcherwas over eager to collect informationabout people'simpressions of care pathwaysand the necessityto gain taped interviews.It becameapparent that 'endurance'and
%negotiation'was essentialin this particularstudy context.
It has often been noted that researchershave all to gain from carryingout researchat the expenseof the peoplewho give their time to answering questions and being studied (Fryer & Feather 1994). To some extent this is true of this researchstudy. The researchercarried out the study and left the organisationwith little contactwith the respondentswho he hadbuilt firm relationshipswith. Althoughthe researcherexpressed warm thanks to the participantsthere was a feeling that peoplehad beenassembled for the explicit purposeof studyingthem during this socialexperiment. However, the
Organisationas a whole gaineda great deal from the study. A different conceptionof psychiatriccare was developedwhich empoweredthe
388 workforceto questionpresent service provision. Punch (1986) would argue that a processof emancipationfar outweighsthe disadvantagesto potentially unwillingor exploitedparticipants. It led to membersof the hospitalstaff successfullybidding for further researchfunding to carry out additional researchinto care pathwaysand providedthe facilitator of the newly funded projectwith 'hands-on'knowledge on how to developand implementcare pathways.Johnson (1992) arguesthat researchersshould actively disseminatefindings in order to justify the researchprocess. The researcher had done this both before (Jones1995) and followingthe study (Jones1999).
Duringthe working group process,the researcherwould spendtime observingand listeningto conversationsand noting down issuesthat appearedrelevant to the study objectives.Although the working group meetingsoccurred at set times,there was little structureto the development of the care pathway.Decisions about implementingthe care pathway occurredspontaneously. This madebeing a systematicparticipant observer difficult and the researcherhad to capitaliseon unexpectedIncidents and issuesin the field. Archbold(1986) promptsthe researcherto acceptthese ambiguitiesand for preliminaryanalysis to re-focusthe researchprocess further. This led to an iterative processto occur betweendata collectionand analysis.
Muchcriticism has beendirected on the role of the researcherand the part they play in influencingrespondent's views (Paterson1994). This criticism
389 Impliesthat respondentsplay a passiverole in this exercisewhen experiences from this study found some respondentsto be confrontationalwith the researcher.Respondents would often contestvarious Issues relating to their role and function.These were usuallyprompted by naive questionsfrom the researcheror were a reactiveresponse to the occasionalbut unintentional brusquemanner by which the researcherattempted to gain accessto the variousdepartments in the hospital,and the communityteam.
The researcherwas enabledto carry out the study by the generalmanager of the Trust althoughthis createda set of problemsfor the researcherto developtrust with the respondentsand participants.Many of the staff In the hospitaland communityteam knew the researcherat both a professionaland friendshiplevel. However,respondents also identifiedthe study as being supportedby the managementof the Trust and felt uneasyabout divulging informationthat could,conceivably, be usedagainst them by the researcher.
One suggestionwould be for the researcherto ýuaranteesubject confldentiality'(Archbold 1986: 158) but this was problematicgiven the difficultiesin developingthe care pathway.In the field notes,the researcher recordedmany discussions with the hospitalmanager detailing various individualswho wereobstructing the carepathway project. As this studyhas demonstrated,this was necessaryto ensurethat the care pathwayproject was completed.The researcherexperienced disappointment however when the care pathwayproject had to be prematurelydiscontinued due to the eventuallack of engagementand the possiblenegative effect on patient
390 outcomes.For examplelarge parts of the care processwere left unaccounted
for thus placingboth the serviceand the patient at risk. This was an
unexpectedoccurrence and demonstratedsome of the pitfalls In carryingout this type of study, which is so dependenton engagementfrom staff. The senseof disappointmentalso helpedthe researcherto see more clearlythe dual role of both beinga researcherand a project manager.This was a sourceof stressfor the researcherbecause he was working to two sets of objectives.
Giventhat care pathwaydevelopment and multi-professionalcare Is under- researched,this led to the researcherasking questions that on reflectionwere naive and uninformative.For examplethe researcherspent time asking respondentsabout the characteristicsof usualcare. The findingsdo not representthe vision of more elaboratequestions such as how professionals negotiatecare pathwaysfor their own professionalprotection. This possibly illustratesthe lack of focus on the part of the researcherwhen he entered the researchsetting. Future researchenquiry may be more structuredin learning how specificoccupational groups respondto the Introductionof a care pathway.This may deliver servicebenefits for organisationswhen attempting to Implementa care pathway.
However,the study did collectdata on the more obviouspossibilities of care pathwayssuch as the effect of standardisedcare and an enhanced managerialperspective on care. Hammersley(1992: 70) identified !5uffi"ciency
391 of evidence'todetermine credibility and centralityof major researchthemes.
This researchstudy has demonstratedboth the occurrenceand diversityof the inclividualised-standardisedcare continuum,and for this to be significant for the potentialacceptance of care pathwayswithin psychiatry.This finding, althoughunsurprising, is extremelyrelevant given the movesto standardised care provision.
Qualitativeresearch has the potentialto amassconsiderable amounts of social data and selectingthe informationto includein the final analysiswas determinedby both pragmaticand ethical considerations.The researcher developedstrong relationshipswith key personnelin the hospital managementstructure and someof the confidentialinformation disclosed couldnot be includedin the final analysis.There was also the difficultyin estimatingwhether sufficientinformation had been collectedand if this would be detailedadequately to form interestingthemes for discussion.This resultedin the researcherpossibly carrying out too many interviewsand loggingconversations and observationsbeyond the needsof the research study.
The processof developingand implementingthe care pathwaywas through an action orientatedresearch process and the working group meetingscould have been presentedas singularcase studies or key events. Describingthe issuesthat were addressedin the working groups may have provideda clearerview of how and why the care pathwaywas developedIn this
392 particularway. Robson(1995) suggeststhat key events can illuminatethe contextof ethnographicresearch. However, it was importantto connectthe themesthrough the whole of the data set and provideinterrelationships betweeninter andintra professionalrelations across the studysite. Moreover, a considerableamount of datacollection occurred outside of the working group meetingsand this addedclarity to the developedthemes.
The presentationof ethnographicaccounts is often criticisedfor the tendency to omit detailedcontextual information concerning the environment(Garfinkel
1967) and method (Sandelowski 1986) In which issues were collected and how themesare linkedto one another (Keddyetal. 1996). However,unlike groundedtheory, this accounthas attemptedto demonstratelinks to the wider socio-politicalenvironment. Collecting this type of Informationhas resultedin data being soughtthrough numeroussources. Respondents may not alwayshave beenaware that they were divulginginformation, although they were all informedthat a researchstudy was taking place.For example the researcherwould listen to conversationsin the ward office or community team about the tensionsof integratedworking. On other occasions,the researcherwould collect information from socialgatherings where health professionalswould discuss cases and psychiatriccare. There has been some attempt to distinguishbetween overt and covert data collectionstrategies and how this informationhas contributedtowards the themes.The overallattempt howeveris to presentan accountof the issuesand processesthat the researcherand participantsexperienced during the time of the study.
393 Other research approaches
There is a paucityof researchinto the developmentof care pathwayswithin psychiatry.It is often assumedin the literature that care pathwaysare just
'produced'with consultationfrom clinicians.This study has exploredone methodof developingthe care pathwayand indicatesthe potentialfor different researchmethods and approaches.Moreover, the researchapproach describedin this study started from a positionof limited knowledgeon how to implementa care pathwaywithin mental health servicesand more informative lines of enquiry could be usefullyfollowed.
The care pathwaycould have beendeveloped in Isolationfrom the study ward and subsequentlyimposed on the staff groups. By applyingLipsky's (1980)
!5treet level bureaucracy;the researchercould explorehow staff groupsre- order the componentsof the care pathwayto suit their own needswithin the organisation.Alternatively, the care pathwaycould have been developed through a Delphistyle study. The Delphitechnique aims to gain consensus arounda set of issuesthrough an iterative process(Linstone & Turoff 1975).
Thisapproach could be adaptedto showincremental changes across the professionalgroups or whetherdifferent professional groups develop and agreethe outcomesof care pathwayin similar ways. For example,many respondentsin the study commentedon the possibleadvantages of creating the care pathwaywithin the confinesof their own professionalgroup.
394 Whilstthe study has detailedthe variousissues, there has been no attempt to quantifythese views acrossthe professionalgroups. The Issuescould be assembledinto a Likert scaleto assessclinician or manager'sperceptions of the changeto care pathways.Applying this type of researchmethod may provideknowledge on the "readiness'ofcertain hospitaland community
Trusts to adopt the use of care pathways.For organisationswishing to apply care pathways,the use of this researchmethod may enablechange protagoniststo target those areasmost susceptibleto change.
The researchstudy could have usedexpert panelsor focus groupsto develop the care pathwayas opposedto the clinicianson the ward and community team. Alternatively,a purchased'of-the shelf care pathway(Andolina 1995) couldbe customisedto matchUK health care policy and practice.This may have produceda more Informedcare pathwaybut one which was unacceptableto the staff group. Comparingthe two care pathwaysdeveloped in different ways may provideknowledge on how best to implementthem In practice.
A researchapproach that ascertainedthe viewsof serviceusers In both developingand beingcared for andtreated with a carepathway would extend the knowledgebase for serviceuser involvementIn the UK. Althoughonly sevenclients were admittedonto the care pathway,the study findingswould have benefitedfrom a more informedview on the serviceusers' perceptions of the positiveand negativeeffects of care pathways.Some studies have
395 found that patientsrecord a greater level of care satisfactionIf they know the expectedhospital treatment plan (Courtneyetal. 1997,Weiland 1997).
Howeverthis study addedlittle to the knowledgeon how In-patientswith schizophreniawill progressalong a carepathway, If outcomeswill be achievable,or if communityresources such as suitablesupported housing could be effectivelymobilised. Future implementation studies may be interestedin identifyingthe'hidden costs'of care (e.g. awaiting housing) when patientsremain in hospitalbeyond clinical need.
Giventhe difficultiesin establishingtrusting relationshipswith certain respondents,more informedand less constrainedviews may have been gainedfrom the use of a respondentdiary. The diary techniquehas been usedextensively in health research(Verbrugge 1980, Hickey etal. 1991) and could be usedto chart the developmentalproblems as a concurrentactivity in the workinggroup process. Intensive interviewing used within this study producedretrospective accounts of care pathwaydevelopment, often collectedweeks and monthsfrom the actual experience.The diary method may reversebias inherent in the researcher-respondentrelationship and In the recollectionof events. Rosset al. (1994) suggeststhat respondents recordevents that are typical of the observedeffects. Alternatively, respondentscould be encouragedto recorda diversityof casesto illustrate the extremesof care pathwaydevelopment and Implementation.
396 The majorityof studieshave employed quasi-experi mental designsexerting varyingdegrees of control over the samplingprocedure, independent variable and use of statisticaltests of significance(Cook 1998). Campbelletal. (1998) suggestsa publicationbias towards those studies that reportpositive results for carepathways. Future research studies need to employa randomised controlledtrial (RCT)to test the effects of a care pathway.Health technology assessmentchampions the RCTto evaluatethe effectivenessof new treatment methods(Stein & Milne 1998). However,the problemsof conductinga RCTmay be difficult to reversedue to the practicalproblems of control group contaminationand randomisationof staff / patientsto deliver the experimentaleffect. For examplemany wards are situatedwithin close proximityto one anotherand to a certain extent, staff work acrossdifferent wards. Comparingthe effect of a care pathwayon wards locatedIn different hospitalswould be compromisedby differencesin ward culture.
Recommendations
In this sectionthe researcherwill briefly examinesome recommendationsfor the commissioningof services,practice and future research.It Is Importantto reflectthat a greatdeal of politicalchange has occurred from beginningthis study to the end and so in someways the future for care pathwaysand their applicationhas been laid out. Carepathways for examplehave been Identified
as one of the strandsin the commissioningand deliveringservices within the
reformedNHS (Department of Health2002a).
397 Commissioning agencies
The abolitionof HealthAuthority structuresand a devolvedcommissioning serviceto a PrimaryCare Trust (PCT)herald a significantshift In front line care deliveryand control.A PCTwill be able to provideservices withln the primarycare area but also link up the secondarycare servicesthrough a care pathway.Likewise a PCTwill commissionand 'performancemanage' secondarycare servicesto ensuretargets are met. A care pathwayhas been identifiedas a vehicleto carry out this function.
A commissioning agency could also use a care pathway to shape education and training for specifictypes of disordersor services.This type of training may sit outsidethe traditionalmake up of professionalgroups. The deliveryof caremay focus more on the interventionsthat are usedas opposedto the professionthat is traditionallycommissioned to provideit. A care pathway may help to reshapethis agenda.
Managers of care
Respondentsidentified a care pathwayas a tool to checkon the delivery of
Interventionsand whether progress was being made to reachagreed upon outcomes.Although this was not particularlyrecognised as a positivefeature for their applicationin psychiatriccare by clinicians,a care pathwaywould havewider managerialrelevance. Recent legislation has calledfor greater controlsover the way hospitalsmanage the care episode(Department of
Health2000). Hospitalservices will needto demonstratethat they havetools
398 to managevariations that occurwithin diagnosticgroups. Localservice
managerswill thereforehave a greaterability to spot and rectify variations and so ensurecosts and quality of care are met. Althoughthe numberof
managersinterviewed for this study was very small, a care pathwaywould offer a managerof servicesmany worthwhile benefitssuch as controllingthe workforceto deliver health and socialcare outcomes.
A care pathwaymay enablea managerto redesignservice delivery to meet pre-setoutcomes of care. In this study respondentswere able to demonstrate that large parts of the care processcould be brokendown and reassembled within a care pathwaystructure. Although respondents offered both negative and positiveopinions on this process,it does offer a different mechanismto manageservice delivery.
Future research
Futureresearch should build on the qualitativeunderstanding of how a care pathwaycan be developedand the different optionsfor this. For examplethe researchercould developa care pathwayand then presentto psychiatric professionswith a viewto collectingdata on changingthe carepathway. A researchprocess would possibly be moreinformed by havinga clearresearch questionsuch as how and in what ways professionschange the care pathway to fit their practicerequirements. Alternatively a researchstudy could begin to explorethe patientsexperience of following a care pathway.
399 A researchstudy would needto be mindful of the environmentIn which the care pathwaywas going to be implemented.The researchermay wish to examinehow different professionsin a more quantifieddimension experienceda care pathwaybeing put into practiceand examiningany variations.For example,it may be found that it Is only when nursevacancies becomeunstable does the implementationof a care pathwaybecome problematic.
It is importantfor future researchto be cognisantof the complexitiesof changemanagement. On reflection,this researcherwas na*fveIn his awarenessof managingthe changeprocess within the project and so much more could be exploredin future studies. For example,future researchcould lookat differentstyles of implementationsuch as carepathways Implemented by cliniciansto those implementedby managementstaff. Data could then be collectedon the outcomesof implementationsuch as complianceIn the staff groupsin using the care pathwayand comparingthis to the successIn meetingthe outcomesfor patients.
Psychiatric professionals
Respondentsin this study did experiencea senseof greater understanding over what they did but also an enhancedview of the role of others within the team. This would haveclear benefitsfor themselvesand the patientsthey serve.It would help them also to seek out the evidenceto supporttheir ways of working and generallyrespondents were positiveabout acceptingthis
400 responsibility.Respondents spoke highly of what they did and a care pathway
could be usedto teach them althoughnot at the expenseof diminishingthe
individualisedconceptions of care. Muchmore needsto be done to demystify
the nature of care pathwaysif they are to be acceptedby clinicians.
Conclusion
This study has been able to demonstratemany difficultiesin developingand
implementingcare pathwaysand indicatestheir introductionto psychiatric
care is premature.In many respectsthere is a lack of knowledgeto support
the full spectrumof psychiatriccare and treatment.A care pathwayalso leads
to conflict and tensionwithin the MDT.The observationsand interviews
collectedfrom the respondentsare' unique to the study context, but their
relevanceto the businessof psychiatryis profound.Respondents were
involvedin an exercisethat departedfrom traditionalcare practicesand so
challengedtheir conceptionsof careand treatment. The useof a standardised
protocolconflicted with the way clinicianshave beentaught to provide
individualisedpatient care.
Governmentcommitment towards clinical protocols, investment In information
technologyand a modernisationof mentalhealth services has added stimulus
to finding new ways to deliver quality mental health care.The relevanceof
care pathwaysfor practiceshares many of the aspirationsof the Government
legislationsuch as the searchfor quality, equity of servicesacross the UK and
a curtailmentof variablepractice. Respondents were able to Identify how a
401 care pathwaymade MDT working more cohesiveand the managementof care
more accountablealthough psychiatric care was not changed.As someof the
findingsillustrate, respondents have been guidedto these views by the
managerialagenda pursued over the lasttwo decades.
This discussionhas pulledtogether the main problemsand barriers encounteredin constructinga care pathwayfor the In-patienttreatment of schizophrenia.The main obstaclesencountered In this study reflectedthose describedin the literature: professionalresistance to exposingpractice; concerns about the mechanistic nature of the care pathway and its threat to individualisedcare; inter-professionalrivalry and defensivenessover roles and functions;above all, absenceof informationon interventionsand outcomesto inform the pathwaycomponents. A numberof recommendationsfor practice, managersand researchhave also been made by drawingon some of the researchfindings but alsothe widerpolitical context within the reformedNHS.
A critical synopsishas been providedon the researchmethods used and approachtaken within this study. Limitationsof the study highlighteda numberof differenttechniques that couldbe employedfor future research.It has been the generalargument that care pathwaydevelopment and implementationresearch should be carriedout usingethnographic principles within an action researchprocess. In the light of expectedand unexpected eventsoccurring within the study, a researchstrategy that was adaptableto a changeableset of circumstanceswas important.The use of qualitative
402 methodshas been usefulgiven the absenceof qualitativestudies exploring the contextualchanges for psychiatriccare pathwayswithin NHSTrusts. It is suggestedthat the approachesused within this study could inform future studiesin care pathwayresearch.
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468 Appendix 1
469 Multi-disciplinaryCare Pathways for In-patientswith Schizophrenia Framework For Use
Summaly i) The care pathway is a single multi-disciplinary documentation package given equal legal status as usual care / progressnotes. ii) The care pathway is completed by all care providers. iii) The care pathway replacesindividualised discipline notes. Only care pathway documcntation can be used for this pilot project. iv) All patient and processinformation to be written in the care pathway case note folder.
Description of use 1) The care pathway has 5 pre-identified problems commonly associatedfor in-patictits with schizophrenia (>3 ads. 3 yrs.); disturbed psychotic state which may result in the patient becoming a danger to self or others; poor knowledge about illness process, symptoms & access to psychiatric services;poor compliance with medication; deficits in social and occupational functioning; problems in securing discharge arrangements.
2) Problems,interventions and outcomesnot identified hereare chartedand deliveredby exception.They arewritten on the'Problems,Interventions & OutcomesNot CoveredBy The CarePathway form. It 3) The problemsidentified are commonto all professionalgroups. All professionalgroups work towardsresolving these problems by deliveringpre-specified interventions.
4) Eight groupsof interventions(categories) have been identified; assessmenton admissionand throughoutlength of stay(LOS); teachingon admissionand throughout LOS; discharge planning;psychosocial interventions; risk assessment& safetyin hospital;Mental Health Act; medicaltreatmentPage Is on admissionand throughout LOS; occupationaltherapy & interventionsthroughout LOS.
5) The CPRMs,IPCM or allocatednurses (those aware of the principlesof carepathways) will judge whetherto makea daily entry into the 'multi-disciplinarynotes' section. Allocated nurses who are unawareof the principles of carepathways must makea shift-by-shiftentry on the daily progressof the patient.As far as practicable,pilot patientsshould be allocatedto RNs who are awareof the principlesof carepathways. *
6) The careprovider using this carepathway would not includeinformation contained in the care pathway.Example the CPRNwould not write in the MDT notes:Me patient hasa BPRSscore have little insight into illness ý of ...... the patient appearsto their and reasonsforadmission
7) Eachdiscipline follows the carepathway and completesthe interventionsas prescribed. If the interventionis completed,the provider signsthe documentand dates it. For example,on PageI of the carepathway, if the CPRNcompletes the admissionTrontsheet' within 2 hoursof admission,s/he signs their namein the 'completed'column and insertsthe datein the'date'
page I (CPRN-care pathway registerednurse IPCM-in-padent casemanager, RN-registered nurse; OT-occupational therapist;SHO-senior house officer, RMO-responsiblemedical officer, LW-locality worker) Multi-disciplinaryCare Pathways for In-patientswith Schizophrenia column.If the interventioncannot be completed,the provider looks at the variancetracking codes,selects the appropriatecode and insertsit into the variancecolumn. The provider completesthe variancetracking sheetby insertingthe date,written note on the variation, its code,action taken, signature and designation.For example,if the CPRN can not completethe admissionTrontsheef because the patient is too aggressive,the CPRN insertsa variancecode for the patientbeing aggressive (A8) in the 'variance'column. S/hethen goesto the variance trackingpart of the folder, and completesthe variancetracking form. It could read, "unableto undertakeassessment because the patient was too aggressive"for the 'variation!part, and "will re-assessin 4 hourstimefollowing medication" for theaction taked part. Later, if the interventioncan be delivered,the provider signsand datesthe interventionto indicateit hasbeen completed.If on subsequentattempts, the interventionis still unableto be delivcrcdýit is recordedon the variancetracking form.
8) It is the responsibilityof the IPCM (chargenurse / other mentalhealth professional) to monitorthe overall delivery of multi-disciplinaryinterventions within the carepathway (additionalproblems added) and for outcomesachieved. This may occur on a weekly basis (moreif necessary).This will provide an up-to-dateretrospective and concurrentaudit of what needsto take placefor outcomesto be achieved.
9) Eachdiscipline follows the carepathway and auditsthe patientsprogress to seeif the patient achievespre-determined outcomes of care.The documentationprocedure for point 5 is applied here.
10)Care pathway documentation replaces daily note keeping.If changesin the patients conditionoccur and arenot coveredwithin the care pathway,this informationwould be documentedin themulti-disciplinary notessection!. Examples may include:suicide attempt, physical/verbal aggression,absconsion, changes in levelsof observation,changes in activity plans,alterations to psychologicalinterventions.
11) If the patientis transferredto BevanWard (PsychiatricIntensive Care Unit) or any othcr acuteadmission ward, the carepathway is terminatedand usual care documentation uscd.
Organisationalchanges to- implement care pathways 1) 1 IPCM and 2 CPRNs have been identified for this pilot. Identified patients to follow this care pathway should be admitted by I of these threeýkey personnel (if unavailable, another RN should complete the documentation). At the next available opportunity, the CPRN should check the documentation and update as specified on the care pathway. Roles for the OT, Psychologist, RMO, SHO have also been locally agreed.
2) All admittedpatients (max. n--8) who fit the criteria for carepathways will be allocatedto one of the 2 CPRN groups.To ensurethe correctbalance in groupnumbers, as I trial patientis admittedinto a CPRNgroup, a patientfrom that group will be allocatedto a non-CPRNgroup.
page2 (CPRN-carepathway registerednurse IPCM-in-padent casemanager, RN-registered nurse;OT-occupational therapist;SHO-senior house officer, RMO-responsiblemedical officer, LW-locality worker) Multi-disciplinaryCare Pathways for In-patipntswith Schizophrenia(Copyright)
3) To ensureCPRN / IPCM cover,annual leave will be plannedin advance.For pcriods of annualleave, no additionalpatients will be admittedonto the pilot project.
4) 2 LWs havebeen identified to casemanage the 8 prospectivepilot patients.All patients admittedonto the carepathwaywill, be allocatedto an LW within the first week of admission.
5) Therewill be 1 centralisedcollection of documentationnotes and these will be storedin the nursingoffice. Care pathway documentation will be identifiedwith a stickerlocated in the middleof thefolder stating that the patient is on a carepathway. The patient will alsobe identifiedby lookingat theward office patient information board. They must not be removed fromthe ward area.
6) Nurseswho administerprescribed medication to pilot patientsmust be careful to recordall refusalscct on the reverseof the medicationchart. This informationwill be usedfor variance trackingpurposes.
7) Either the IPCM or the CPRN should attend weekly managemcnt,,%, vard and CPA rounds and complete the care pathway for pilot patients.
't
3 (CPRN-care IPCM-in-patient RN-rcgistercd OT-occupational page0 pathway registerednurse casemanager, nurse; therapist;SHO-senior house officer; RNIO-responsiblemedical officer, LW-locality worker) a
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