Collaboration and Partnerships in Mental Health Care (Male Acute ward)
This essay discusses the issues that arise for the service user, carers, nurses and multidisciplinary team involved in the process of collaboration. The discussion highlights the potential difficulties of working collaboratively and the possible ways of overcoming these difficulties, considering how collaborations can be achieved through, for example, assessment (APIE), care planning, therapeutic risk taking, relationship building, cultural awareness, amongst others. The discussion also includes discussion of relevant legislation and policy.
The essay also includes examples from practice in mental health nursing (male acute ward) to illuminate the discussion, considering, for example: what exactly is meant by a user partnership and how would one be identified; whether user partnerships are possible in health and social care and, if so, what are the possibilities and parameters; the nurse patient relationship, and whether it is a partnership; what the tensions are between each party, giving examples of the circumstances under which these may come to the surface; what aspects of care users of health services can participate in; what the obstacles to nurse-patient relationships are; what nurses can do to encourage partnerships; and what the interdisciplinary issues are regarding partnership working.
The issues that arise for the service user, carers, nurses and multidisciplinary team involved in the process of collaboration
As will be shown in subsequent sections of the essay, there are many issues that arise when thinking of successful partnerships, in terms of how partnerships can be best facilitated and enabled, the factors that are necessary for successful partnerships (such as communication and trust, amongst others) and the obstacles that need to be dealt with, and controlled, in terms of facilitating the basis for successful partnerships.
Potential difficulties of working collaboratively and the possible ways of overcoming these difficulties
There are, as shall be seen in subsequent sections, many potential difficulties with partnership working, in terms of individual difficulties with communication and powerstruggles, and other, more institutional obstacles, such as a lack of training in partnership working, for example, that can lead to difficulties in implementing such ways of working. These potential difficulties will be discussed in more detail in subsequent sections of the essay.
Relevant legislation and policy
As outlined by McQueen (2000), the reformed NHS service (through government initiatives such as those outlined in Department of Health, 1989, 1990 and 1998) have meant that those patients receiving care under the NHS framework are now encouraged to take an active part in the decision-making process with regards to their treatment and care, with a view to improving their health and well-being (see McQueen, 2000). These reforms have been endorsed by the main professional bodies for healthcare workers, such as the UK Central Council for Nursing, Midwifery and Health Visiting, meaning that these reforms are now a practical reality in terms of patient care under the NHS framework (see McQueen, 2000).
What is meant by a user partnership and how would one be identified?
As discussed by Dowling et al. (2004), partnership working has become central to British social welfare, and healthcare, policies since New Labour came to office. The issue of partnership working is nowhere more fundamental than in the overlap between health and social care, with partnership working being stressed in many different sectors, but definitions of success of such partnerships being disagreed, and, indeed, the effectiveness of joint working between the NHS and social services being called in to question (see Cameron et al., 2000; Cameron and Lart, 2003; Dowling et al., 2004).
In general, partnership working is taken to mean the situation in which partners, who are normally independent bodies, come together, cooperating to achieve a common goal (Dowling et al., 2004). This definition covers nurse-patient relationships and other common partnerships in health and social care, such as partnerships between nursing staff and other health professionals or between health professionals and social workers, for example.
User partnerships can generally be identified when a service user (i.e., a patient) is actively involved in their own care in a cooperative effort with nursing staff, for example, to achieve a common goal. In the male acute mental ward setting, this could mean, for example, the nurse and the patient working together to achieve successful control of their mental health problems, with user participation being the communication of feelings and emotions, for example, when trying different medications or combinations of medication, for example. To identify this as user participation, the patient would need to be actively involved in their own care, in ways that will be described in the subsequent sections of this essay; identifying successful user participation is, generally, measured in terms of the outcomes of this participation.
Are user partnerships possible in health and social care and, if so, what are the possibilities and parameters?
As concluded by Lelliott (2000), in a study using concept analysis to determine the parameters of successful patient participation, partnerships are possible in mental health care provided that what patients are requiring from the service they receive is clearly understood. The possibilities for nurse-patient partnerships in health care are many and varied, with nurse-user partnerships shown to improve management of health problems (Cahill, 1996).
The nurse-patient relationship: is it a partnership?
As Cahill (1996) explains, there are many forms of nurses and patients working together: patient partnership, patient participation, patient collaboration and patient involvement, all of which are subtly different, and require different modes of communication, critical thinking and approaches to patient care. Under the definition of partnership already given, the nurse-patient relationship, under the new dictates of the NHS Plan has, by its nature, to be a partnership. How this partnership is played out in practice, however, depends on the particular situation, in terms of the ease of facilitation of such partnerships due to the willingness of both parties to come together in a partnership and the presence of any obstacles that might be present to prevent a successful partnership from occurring.
What the tensions are between each party, giving examples of the circumstances under which these may come to the surface?
The tensions apparent when considering user participation in terms of the nursepatient are many and varied. Some nursing staff, for example, do not want to relinquish power, as they see it, to patients and some patients they meet can be very pro-active about directing their own care, leading to automatic tensions over the right to administer care. For example, in the case of an acute mental health ward, patients may be under the impression that they are lucid and able to make their own decisions, leading them to feel confident that they can determine their own care, but nurses in this situation, through their experience, might be wary of conceding power to the patient, leading to a conflict in terms of what medication should be administered, for example, or the amount of counselling that is considered necessary, for example. User partnerships are particularly sensitive in acute mental health ward settings where patients still have the right to be autonomous and to be involved in their own care, but where, at times, they are not mentally capable of such intervention. This can obviously lead to tensions between the patient and their nurse and between different nursing staff involved in the patients care.
What aspects of care users of health services can participate in?
As outlined by Cahill (1996), patient participation is limited by the severity of the illness presenting, the organizational structure, the amount of knowledge, and the ability to express this knowledge that the patient has, and the patients own desire to participate in their own care: some patients are not interested in being active participants in their own care and actually derive satisfaction from being passive and subjecting themselves to a situation in which they believe ‘nurse knows best' (see, for example, Muetzel, 1988).
In terms of the aspects of care that patients (service users) can be involved in, ideally, nurse-patient partnerships should involve the patient at all stages of care, including diagnosis (through proper questioning, and testing, to elucidate the diagnosis), treatment (such as deciding what medication is best for them), and after-care. As such, ideally, nurse-patient partnerships would include the patient in every step of the care pathway, with the obvious caveats placed on this by the obstacles to patient involvement in an acute mental health ward setting, as will be discussed in later sections.
What are the obstacles to nurse-patient relationships?
As Coulter (1999) identifies, there are many issues that provide obstacles to the nurse-patient relationship, including the need for nursing staff to provide full information to patients in terms of enabling patients to be in a position to make decisions regarding their own care (see, also, May, 1990). This becomes an issue when nursing staff are working under pressure and without adequate support, for example, when they are working long hours, alone, or without correct supervision. Under these circumstances, although it would be ideal that nursing staff are in a position to educate their patients regarding the choices they have for their treatment and care, it is difficult to see how such in-depth communication can be achieved. Thus, lack of access to good quality information to support decision-making on behalf of the patients is one very real obstacle to valid nurse-patient partnerships (see Coulter, 1999). Decision-aids can help in this process (see O'Connor et al., 1999) although, whilst these can reduce decisional conflict through improving knowledge, they have little effect on patient satisfaction and a variable effect on the decisions and the outcomes of the decisions made.
What can nurses do to encourage partnerships?
In terms of encouraging partnerships, it must be recognized, firstly, that a partnership is based on some fundamental attributes, namely, that a relationship must exist, that there must be a narrowing of the appropriate information between the nurse and patient, using suitable modes of communication in different situations and contexts, that there must be a surrendering of the degree of control by the nurse, that there must be a degree of engagement at an intellectual level between the nurse and the patient, at all stages of the relationship and that there must be a positive benefit gained from the partnership (see Cahill, 1996). For patient partnership to be established, patient participation is first needed, with patient involvement and collaboration being encouraged in order to lay the foundation for successful partnerships (see Walker and Avant, 1988; Cahill, 1996).
In terms of encouraging partnerships, and encouraging the success of these partnerships, all concerned need to be involved at each and every stage of the partnership, from assessment, to goal setting to planning, implementation and evaluation (Cahill, 1996). This requires a great deal of trust between the members of the partnership, and requires that the nurse abnegate some degree of power and control over the treatment decisions of individual patients, according to the decisions of the patient (see, for example, Quill, 1983; Cahill, 1996).
As McQueen (2000) makes clear, the forming of a successful nurse-patient partnership is dependent on the nurse engaging with the patient on an interpersonal and emotional level. There are many successful ingredients of a successful nurse-patient partnership, including forming a relationship of trust, feeling like part of the family and providing enriching experiences through providing a holistic approach to caring (see Mok and Chi Chui, 2004). Other studies have suggested similar routes for encouraging successful partnerships, namely ‘being there', ‘being concerned', ‘establishing trust' and ‘facilitating transition', all of which encourage the establishment and maintenance of a relationship with the patient which will allow for the successful addressing of their mental health problems (see O'Brien, 2000).
Hosany et al. (2007) explore the relationship of nurses with acute mental health patients, finding that in order for partnerships to be successful, an atmosphere of engagement needs to be fostered, through solution-focused therapy, an approach that aims to shift the focus of interactions away from concentrating on an individuals problems and weaknesses to focusing on a proactive identification of their strengths and weaknesses and what can be achieved through utilizing these strengths and weaknesses.
Ryles (1999) focuses on the concept of empowerment and how it is necessary for nurses to empower patients in order to foster successful partnerships, in order that care can be administered on a fully individual basis, taking fully in to account the patients needs and feelings and, through this, ensuring the possibility of maximal success of their care.
Tee et al. (2007) extends this idea, showing how user participation in mental health nursing requires a co-operative effort regarding decision-making, which is free of inhibiting factors, such as stigmatizing and paternalistic approaches and making clinical judgements on the basis of diagnosis alone. Atmospheres that encourage successful partnerships are those in which users expertise regarding their own condition is respected and where belief is communicated to the patient regarding their potential to get better (Tee et al., 2007).
There are some tools that nursing staff can use to facilitate successful nurse-patient partnerships, including assessments, care planning, therapeutic risk taking, relationship building, cultural awareness, amongst others, all of which can be used to develop an understanding of the patient and to develop ways in which to connect with the patient, in order to begin to form a relationship built on partnership.
Thus, there are many factors that are fundamental in terms of nursing staff ensuring user participation is a positive force for their patients, not least enabling patients to feel they are able to participate, engaging patients in their care, through empowerment, and transmitting positive messages to their patients, so that the patients believe in the power of the partnership and, through this, in their potential to recuperate.
What are the interdisciplinary issues regarding partnership working?
As McQueen (2000) makes clear, the forming of a successful nurse-patient partnership is dependent on the nurse engaging with the patient on an interpersonal and emotional level, yet these requirements of nurses roles, under the patient partnership framework of the new NHS, are not, as yet, embodied in the dictates of clinical practice nor in education and research related to nursing. As such, there remain many issues to be addressed at basic levels with regards to partnership working, between nurses and patients, but also between nurses and other healthcare professionals and healthcare professionals and other professionals, such as social workers, for example.
As shown by Huxley et al. (2008), healthcare workers and social workers, for example, often have widely differing ideas as to what constitutes a variety of mental health problems and whether how these problems relate to eligibility decisions for social care, for example. These findings led Huxley et al. (2008) to suggest that health professionals need training in order to make decisions about social assessments and eligibility determinations, something that is of particular relevance to nursing staff in acute care wards, who often have to make assessments as to when a patient is ready to leave this care setting, for example.
Conclusion
Due to the changes in the way in which the NHS delivers care its patients, who are now regarded as service users with the right to intervene in their own care, partnerships between healthcare professionals and patients are fundamental in ensuring the success of patient care. This essay has looked at the fundamentals of such partnerships, finding, for example, that there are many factors that are fundamental in terms of nursing staff ensuring that user participation is a positive force for their patients, not least enabling patients to feel they are able to participate, engaging patients in their care, through empowerment, and transmitting positive messages to their patients, so that the patients believe in the power of the partnership and, through this, in their potential to recuperate. There are, however, many factors, especially in acute mental health ward settings, that obstruct such facilitation and the development of such partnerships. Often, due to the prevailing conditions, especially in acute mental health ward settings, the ideal of nursepatient partnerships, and collaborative working, is thus, at times, just that: an ideal and not a practical reality.
