Introduction
Recent publications by the Mental Health Commission (2005, 2008) highlight the need for our mental health services to provide recovery-focused care that empowers service users to ‘take control’ of their own recovery. In this person-centred approach, working with their assigned care co-ordinator (or key worker), service users are proactively empowered to define what recovery means to them as individuals, and to accordingly formulate and drive the implementation of their needs-based care plan (Mental Health Commission 2008). Moreover, the role of mental health services is to support service users in fulfilling their potential in all life domains – from their well-being to their participation in social and community activities, education and employment (Mental Health Commission 2008; Byrne & Onyett Reference Byrne and Onyett2010).
A Vision for Change (Department of Health and Children 2006) recommends the provision of integrated, recovery-focused care that is delivered in the community, primarily by multi-disciplinary Community Mental Health Teams (CMHTs). As detailed in the guidance papers from the Health Service Executive (HSE) National Vision for Change Working Group (HSE National Vision for Change Working Group 2012), this can be achieved by providing a continuum of integrated services (see Fig. 1). Moreover, the Mental Health Commission has developed the evidence-based Quality Framework for Mental Health Services in Ireland (Mental Health Commission 2007). This non-prescriptive framework has eight themes, 24 standards and 163 criteria that can be applied to all mental health services, and it aims to place service users at the centre of care through quality, recovery-focused service delivery (Mental Health Commission 2007).
Fig. 1 Continuum of care from Community Mental Health Teams (CMHTs) (HSE National Vision for Change Working Group 2012).
A prerequisite for such integrated, recovery-focused care is effective teamworking within CMHTs. However, achieving this is dependent on environmental, structural and process factors that interact with each other as teams develop over time (Byrne & Onyett Reference Byrne and Onyett2010). Building on guidelines from the Mental Health Commission’s Teamwork in Mental Health Services in Ireland (Byrne & Onyett Reference Byrne and Onyett2010), this paper aims to highlight how to best manage these factors in order to facilitate effective teamworking and recovery-based care in CMHTs. First the stages of team development are outlined. It then considers the factors that influence teamworking and some potential interventions that may realise effective teamworking. Finally, it explores ways to evaluate if teams are working effectively.
Stages of team development
Tuckman’s (Reference Tuckman1965) group development model describes four stages of team development: forming, storming, norming and performing. During the forming stage, new teams establish provisional ground rules regarding their nature and purpose. During the storming stage, team members reveal their personal goals for the team and there may be some ‘jockeying for position’. During the norming stage, formal and informal intra-team conflict resolution strategies are established, potentially leading to increased cohesiveness. Finally, during the performing stage, the emergent solidarity and shared understanding among team members allows them to focus on ‘getting the job done’ (Farrell et al. Reference Farrell, Schmitt and Heinemann2001). Teams ideally progress through these stages but regression can also occur, for example when there is a change in team composition (see Fig. 2). Teams may encounter difficulties associated with each stage of development, and ways to manage these are detailed in Table 1 (Byrne & Onyett Reference Byrne and Onyett2010).
Fig. 2 Stages of team development (Tuckman Reference Tuckman1965).
Table 1 Problems and management strategies at each stage of team development (Byrne & Onyett Reference Byrne and Onyett2010)
Team environment factors
The choice of care model is often hotly contested among team members from differing disciplines who may compete to assert the primacy of their preferred model and the superiority of their associated interventions (Singh Reference Singh2000). However, this competition and subsequent choosing of a particular ‘professional’ model (e.g., the biopsychosocial model) (Clare Reference Clare1976) is time poorly spent, as it does not satisfy the diverse needs of service users (Byrne & Onyett Reference Byrne and Onyett2010). What is required is an integrative and flexible ‘recovery’ model that:
∙ Recognises the need to ‘develop a tight bundle of relevant responses congruent’ with those of service users (Heginbotham Reference Heginbotham1999).
∙ Empowers service users to reclaim ownership of their own life story (Owens & Ashcroft Reference Owens and Ashcroft1982) and ‘take action’ in resolving problems (Mental Health Commission 2008).
∙ Defines recovery not as total remission of symptoms or cure, but as supporting service users in fulfilling their aspirations as socially included citizens (Byrne & Onyett Reference Byrne and Onyett2010).
∙ Highlights the necessity of ongoing therapeutic input and the need for significant teamworking and collaboration between different agencies so that all service users’ needs are addressed (World Health Organization 2005).
∙ Rejects the ‘sick role’ of service users, instead valuing their voice and expertise (Slade Reference Slade2009).
To best influence the adoption of a ‘recovery’ model by team members, mutual respect and understanding of each others’ preferred assessment and treatment models must be fostered (McHugh & Byrne Reference McHugh and Byrne2012). While this can be facilitated by ongoing training, it is optimally developed early in professional training when professional identities are still ‘forming’ (Mental Health Commission 2008).
In terms of current environmental changes, the HSE Service Plan 2012 includes the appointment of over 400 mental health professionals to professionally complete existing CMHTs (HSE National Vision for Change Working Group 2012). This is much needed as the latest report by the Vision for Change Monitoring Group (Vision for Change Monitoring Group 2012) has estimated that 1500 posts in CMHTs across Ireland have yet to be filled, due in part to the HSE recruitment embargo and the Public Service Moratorium. This has led to a lack of development of recovery competencies in service delivery (Vision for Change Monitoring Group 2012). Nevertheless, although the HSE Service Plan 2012 represents a considerable environmental change that may temporarily disrupt the everyday functioning of teams, it also provides an opportunity to boost the capacity of CMHTs and re-orientate services towards a recovery-orientated community care model (HSE National Vision for Change Working Group 2012).
Another influential and evolving environmental factor within CMHTs is the reporting structures in place. In an effort to implement the recommendations of A Vision for Change (Department of Health and Children 2006), reporting structures are being reformed. Singular Area Mental Health Management Teams (MHMTs), one per Service Area, are replacing all existing mental health management structures. Consisting of a business manager, clinical psychologist, director of nursing, occupational therapist, service user, social worker, and chaired at least initially by an executive clinical director, these teams report to the HSE Area Manager who then reports to the Regional Director of Operations or, if appointed, a National Director of Mental Health Services (see Fig. 3) (Mental Health Commission 2008). The effectiveness of each Area MHMT will largely depend on their functioning well as a team and the extent to which they work effectively with other mental health structures (e.g., Approved Centres). However, the proposed National Mental Health Service Directorate (Department of Health and Children 2006) has yet to be put in place and the uncertainty surrounding plans to do so may adversely affect teamworking (Vision for Change Monitoring Group 2012).
Fig. 3 New reporting structures (HSE National Vision for Change Working Group 2012).
Team structure factors
Team structure factors which provide a framework for team processes include the level of service user involvement, governance structures, model of clinical responsibility and skills mix (Byrne & Onyett Reference Byrne and Onyett2010) as well as team leadership style (Byrne et al. Reference Byrne, Lee and McAuliffe2006) Table 2 below highlights how some of these factors relate to teamwork, and how they might be managed to realise improved teamworking.
Table 2 Team structure factors, their impact on teamwork and recommended actions
Team process factors
Team process factors determine how tasks and interpersonal dynamics are handled and how teams transform inputs into outputs (Byrne & Onyett Reference Byrne and Onyett2010). These factors include the referral pathway, the process of work, workload distribution, communication, supervision and training (Byrne & Onyett Reference Byrne and Onyett2010).
Referral pathway
The referral pathway (see Fig. 4) determines the service user’s journey into a CMHT. Ideally, it should be clear, integrated, and easily navigated (Byrne & Onyett Reference Byrne and Onyett2010). This can be achieved through the rigorous application of inclusion criteria and team member agreement on the extent of the referral net (i.e. who the team can accept referrals from) and the number of access points (i.e. who on the team can accept referrals and bring them to the team meeting) (Byrne & Onyett Reference Byrne and Onyett2010).
Fig. 4 Referral pathway (Byrne & Onyett Reference Byrne and Onyett2010).
Process of work
This is an iterative cycle that determines how referrals are processed internally (see Fig. 5) (Byrne & Onyett Reference Byrne and Onyett2010). It involves the ongoing review of clinical progress after initial assessment and involves decisions concerning the assignment of a care co-ordinator (or keyworker), referral back to source, outgoing referrals and care plan suitability (Onyett Reference Onyett1998).
Fig. 5 The process of work (Byrne & Onyett Reference Byrne and Onyett2010).
Workload distribution
Workload distribution in mental health teams is often based solely on quantitative data (e.g., how many cases each team member is responsible for). However, this method of measuring workload does not take into account many other factors including caseload complexity, report writing and supervision responsibilities, and meeting and travel commitments (Byrne & Onyett Reference Byrne and Onyett2010). Sole use of administratively convenient but limited data may lead to workload inequities and team member burnout, anger and envy (Lankshear Reference Lankshear2003). To avoid such negative repercussions and to maximise fairness and balance, team members need to openly discuss all of the above factors as well as each members competency set (McHugh & Byrne Reference McHugh and Byrne2012). Moreover, if a team has an excessive number of open cases with no additional capacity for taking on new cases, it either needs to reconfigure how it works to free up some capacity for taking on new referrals and/or make representations to its Area MHMT regarding the recruitment of extra staff (with the appropriate competencies) (McHugh & Byrne Reference McHugh and Byrne2012).
Communication
Communication, both informal and formal, in a CMHT takes place both internally and externally to the team. This needs to be both open and honest as it determines how well all of the other team processes link together (Salas et al. Reference Salas, Stagl and Burke2004; Byrne & Onyett Reference Byrne and Onyett2010). To enable such openness, team leaders and members need to promote an atmosphere of psychological safety whereby all can voice their honest opinions without fear of ridicule or rebuke, and there is a focus on learning from mistakes rather than apportioning blame (McHugh & Byrne Reference McHugh and Byrne2012). Moreover, conflict resolution strategies need to be in place to ensure disputes are resolved in a pro-active manner, thus minimising the possibility of escalation (Byrne & Onyett Reference Byrne and Onyett2010). When communicating with service users and others, the language used needs to be as jargon-free and understandable as possible (McHugh & Byrne Reference McHugh and Byrne2012). The need to improve such communication has been highlighted in a recent survey (n=79) that reported service user dissatisfaction with their communications with a Dublin-based community mental health service (Hill et al. Reference Hill, Turner, Barry and O’Callaghan2009).
Supervision
Supervision in CMHTs can take the form of clinical supervision and/or peer consultation (Byrne & Onyett Reference Byrne and Onyett2010). Its primary purpose is to provide support and a safe place for learning based upon evidence-based practice (Fleming & Steen Reference Fleming and Steen2003) but it can also have a monitoring function (Byrne & Onyett Reference Byrne and Onyett2010). Peer consultation values the team as a resource and can take place in team meetings or on a one-to-one basis, often between disciplines (Byrne & Onyett Reference Byrne and Onyett2010). In contrast, clinical supervision typically does not span disciplines (British Psychological Society 2001) given that it is an intra-disciplinary process, and because the supervisor needs to be trained in the areas of work being supervised so that she/he can be held accountable for that work (Byrne & Onyett Reference Byrne and Onyett2010). Hence, some disciplines may have to arrange supervision external to their team. Whatever form it takes, supervision for CMHTs should perhaps take place on ‘neutral ground’ or away from the workplace – a study of community mental health nurses (n=260) found that the latter was associated with improved rapport, skills development and ability to reflect (Edwards et al. Reference Edwards, Cooper, Burnard, Hanningan, Adams, Fothergill and Coyle2005).
Training
Training needs to address teams’ knowledge and skill gaps related to recovery-based care planning. This can be achieved by the inclusion of modules relating to understanding and empathising with service users’ needs, and modules that advocate the empowerment of service users to enhance their own care (McHugh & Byrne Reference McHugh and Byrne2012). Ongoing training and continuing professional development need to address both team-specific competencies (e.g., skill sets and responsibilities) as well as multi-disciplinary needs such as communication and conflict resolution strategies (McHugh & Byrne Reference McHugh and Byrne2012). There are various outlets for such training including Dublin City University’s (Irish College of General Practitioners 2011) module on Team-based approaches to supporting mental health in primary care settings and the online training portal HSELanD (McHugh et al. Reference McHugh, Byrne and Liston2012).
Evaluating teamwork
As effective teamworking has been evidenced to be associated with higher quality of clinical care and positive service evaluations by primary care service users (Bower et al. Reference Bower, Campbell, Bojke and Sibbald2003), its evaluation within CMHTs should be prioritised. Furthermore, given that effective teamwork is a prerequisite to recovery-orientated care (Byrne & Onyett Reference Byrne and Onyett2010), service evaluations need to explore if effective teamworking is evident and whether service users are in receipt of quality recovery-orientated care.
Effective teamworking
To evaluate baseline teamworking effectiveness, team members can complete the 25-item Mental Health Team Development Audit Tool (MHDAT) (Byrne & Onyett Reference Byrne and Onyett2010; Roncalli et al. Reference Roncalli, Byrne and Onyett2013). Both convergent and divergent MHDAT data sets can be used as teamwork intervention points. For example, there may be differing perceptions of who does what within a team which would necessitate discussion about an agreement on team member role definitions. Data from the MHDAT could be supplemented by data from other scales including the Team Participation and Team Functioning scales (Alexander et al. Reference Alexander, Lichtenstein, Jinnett, Wells, Zazzali and Liu2005). Moreover, to evaluate the leadership skills displayed across CMHTs measures such as the Psychological Safety and Team Learning scales (Edmondson Reference Edmondson1999) could be completed. Given that work satisfaction is often associated with staff retention and resultant quality of service provision, team members could also be asked to complete work satisfaction questionnaires such as the Minnesota Satisfaction Questionnaire (Weiss et al. Reference Weiss, Dawis, England and Lofquist1967).
Evaluation of recovery-orientated care
To evaluate the extent to which a CMHT is providing quality recovery-orientated care, service user outcomes can be measured. For example, service users could complete the 60-item Pillars of Recovery Service Audit Tool that was developed in the Irish context (Mental Health Commission 2008) or the Developing Recovery Enhancing Environments Measure (Dinniss et al. Reference Dinniss, Roberts, Hubbard, Hounsell and Webb2007). However, as these measures are quite lengthy, other non-recovery-specific yet global outcome measures such as the 5-item Work and Social Adjustment Scale (Mundt et al. Reference Mundt, Marks, Shear and Greist2002) and the 12-item Health of the Nation Outcome Scales (Stewart Reference Stewart2009) could be used.
The HSE’s ‘Enhancing Teamworking Project’ is being rolled out with a focus on improving teamwork effectiveness and the degree of recovery-oriented care in our mental health services. Evaluation of this project may also incorporate qualitative feedback from team members and other relevant stakeholders (see Fig. 6).
Fig. 6 Enhancing Teamworking Project.
Conclusions
This paper describes ways to manage environmental, structural and process factors that contribute to CMHT work effectiveness and ultimately to the provision of recovery-based care, as CMHTs develop over time (see Fig. 7). Environmentally, a recovery rather than a ‘professional’ model of mental health needs to be adopted and tight reporting structures are required. Structurally, meaningful service user input and a focus on shared capabilities is needed, as well as trust-invoking leadership, collaborative governance and distributed responsibility. Regarding process factors, teams need an easily navigated referral pathway, a regularly reviewed work process, equitable workload distribution, a ‘psychologically safe’ atmosphere of communication, a focus on peer-orientated supervision, and recovery-orientated training. In the journey towards effective teamwork, a good starting point for CMHTs is to ask ‘How are we now functioning as a team?’ Here, as used in the HSE’s ‘Enhancing Teamworking Project’, team members would benefit from completing the MHDAT (Byrne & Onyett Reference Byrne and Onyett2010; Roncalli et al. Reference Roncalli, Byrne and Onyett2013).
Fig. 7 Steps towards effective teamwork in a recovery context. CMHT, Community Mental Health Team.
