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City Research Online City, University of London Institutional Repository Citation: Jones, A. (2002). Perceptions on the development and implementation of a care pathway for people with schizophrenia. (Unpublished Doctoral thesis, City University London) This is the accepted version of the paper. This version of the publication may differ from the final published version. Permanent repository link: https://openaccess.city.ac.uk/id/eprint/7585/ Link to published version: Copyright: City Research Online aims to make research outputs of City, University of London available to a wider audience. Copyright and Moral Rights remain with the author(s) and/or copyright holders. URLs from City Research Online may be freely distributed and linked to. Reuse: Copies of full items can be used for personal research or study, educational, or not-for-profit purposes without prior permission or charge. 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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

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