International Journal of Mental Health Nursing (2006) 15, 19���28 doi: 10.1111/j.1447-0349.2006.00400.x �� 2006 Australian and New Zealand College of Mental Health Nurses Inc. Feature Article Multidisciplinary team working: Collaboration and conflict Adrian Jones1,2 1North East Wales NHS Trust and 2North East Wales Institute of Higher Education, Wrexham, Wales, UK ABSTRACT: The aim of this paper is to report on findings identifying some of the difficulties encountered by the multidisciplinary team in the development and implementation of a care pathway for patients diagnosed with schizophrenia. Policy direction has shifted towards greater team working and blurring of professional boundaries. Moreover, there is greater need to deliver care according to set standards and for patients to reach particular outcomes of care. Care pathways are relatively new for psychiatry and will potentially uncover tensions within the team. Data were collected by partici- pant observation and semistructured interviews over a period of 12 months on an acute psychiatric unit. The care team developed the care pathway and the process of development and implementation was observed through action research. Cross-sectional indexing was used to analyse the data, and themes were developed using interview and observational data collection methods. Clinicians argued strongly for clear role boundaries but also defended their perceived control over health care from other professions. The findings indicate that designing a care pathway for people with schizophrenia may produce conflicting perceptions from the team. Conflict may arise through professions being unwilling to accept plurality over roles, which may hinder progress in meeting the needs of patients. The findings also counter the impression that care pathways can be implemented with little impact on the team. KEY WORDS: hospital care, multidisciplinary team working, schizophrenia. Blackwell Publishing AsiaMelbourne, AustraliaINMInternational Journal of Mental Health Nursing1445-83302005 Blackwell Publishing Asia Pty Ltd? 20061511928Feature ArticleMULTIDISCIPLINARY TEAM WORKINGA. JONES Correspondence: Adrian Jones, Llwyn-y-Groes Psychiatric Unit, Croesnewydd Road, Wrexham, Wales LL13 7TD, UK. Email: adrian.jones@new-tr.wales.nhs.uk Adrian Jones, PhD, BN (Hons), RMN. Accepted June 2005. INTRODUCTION A modern psychiatric service is now comprised of a large array of services and mental health nurses form the corner stone profession. Understanding how nurses and other mental health professions work together is funda- mental for successful care delivery. Policy has sought to map out targets for setting up the different types of teams with hospital care forming the central hub within the wider whole system of community-based services (Bowles & Jones 2005 Department of Health 2000 2002). The role of a care pathway to help structure care has also gained prominence in clinical practice, with their use being cited as good practice for managing the care epi- sode of patients with complex psychiatric presentations (Department of Health 2002). It is argued that a care pathway would structure and define how professions deliver their care, but centrally to this study, display the underbelly of interprofessional rivalry. POLICY BACKGROUND The UK National Health Service (NHS) has undergone huge reform with major investment to fund different ways of working, principally in community settings, namely home treatment, assertive outreach and early interven- tion teams (Department of Health 2000). Similar reform has also taken place for acute inpatient care documented in the Policy Implementation Guidance (Department of Health 2002). A number of recommendations were high- lighted, namely, system change in the way different

20 A. JONES �� 2006 Australian and New Zealand College of Mental Health Nurses Inc. sections of mental health services interlock and commu- nicate patient need. More specifically, the Policy Imple- mentation Guidance noted recommendations for how inpatient care is to be organized and emphasized the value of the multidisciplinary in working together. Assumptions were made that professions will work together in the pursuit of patient goals and to highlight this way of thinking, training was advocated to increase skills in assessment and therapeutics. Within the UK increasing attention is being paid to how professions work together, but also to widening the debate in terms of expanding the different types of professions and workers who are to be employed within mental health services. For example, roles have been identified for support, time and recovery workers (Department of Health 2002) to spend dedicated thera- peutic time with patients. This new role undertakes work that was once delivered by mental health nurses and occupational therapists (OTs). The challenge will be introducing new roles and ways of working into the acute hospital setting, particularly their integration into the mutidisciplinary team (MDT). Importantly, it has been recognized that the NHS requires change management systems to enable both existing and newly developed professions and worker groups to integrate cohesively. Some have argued that inpatient nurses continue to practise from a custodial role with little tolerance for plurality of roles (Gournay 2005). Work has been undertaken to find out different ways for training inpatient nurses so that their time and interven- tion can become therapeutic and patient-focused (Clarke 2004). Improvements have been recorded in the way nurses spend larger amounts of time in therapeutic engagement (Bowles et al. 2002) and supporting inpatient nurses to connect their involvement within the whole system of acute inpatient care (Bowles & Jones 2005). The work carried out by consultant psychiatrists have been identified as a key driver for change so that new and innovative models of care delivery can be achieved (Department of Health 2004). Against this policy back- ground, we have the concept of care pathways, which have, as their aim, to clearly demarcate out roles and responsibilities for clinical staff. Importantly, the NHS has supported the use of a care pathway to reform clinical services (Department of Health 1998). CARE PATHWAYS FOR PEOPLE WITH MENTAL HEALTH PROBLEMS There are many definitions of a care pathway, but one that is commonly cited, is that of a paper-based document that lays down the expected problems, interventions, and out- comes specific to a diagnostic group or disease (Jones 2001). It is not the intention of this paper to carry out a literature review but to give the reader an appreciation of the types of studies carried out within the context of mental health services. There have been numerous stud- ies undertaken to evaluate how care pathways have been developed, and their effects on health-care outcomes. From one review of 200 studies, positive results have been recorded in terms of clinical and financial outcomes of care (Van Herck 2004). Such positive acclaim needs to be treated with caution, as the level of rigor and control within the studies was notably poor. Specifically for mental health, care pathways have been developed for people with comorbid learning dis- ability and mental health problems (Buxton et al. 2004) those patients in receipt of care in clozapine clinics (Chave et al. 2004) and low secure psychiatric units (Baker et al. 2002). Mynors-Wallis et al. (2004) have car- ried out a controlled trial to test a care pathway designed for people with schizophrenia in acute psychiatric care. The care pathway detailed 45 standards, 21 pertaining to assessment and the remainder for treatment. Over a 6- month period, 46 patients were recruited into the exper- imental group and 30 patients received usual care. Although staff reported generally positive views on the benefits for patient care, no statistically significant find- ings were reported on length of stay or clinical symptom outcomes between the experimental and control groups. Patients who followed the care pathway were no more likely to receive higher standards of care compared with the control group. The authors reported that the standard of care was very high prior to the introduction of a care pathway, thus insinuating that a care pathway may be effective in improving care on poor functioning wards. A major limitation of the study lies with the authors report- ing no difficulties in defining the care to go into the pathway from the MDT perspective or in how the team perceived the care pathway to standardize their contribu- tion to care. Van Herck (2004) has noted very few studies report on how care pathways are developed, and in particular for mental health, very little qualitative research has been carried out examining their impact on team dynamics. Jones (2001) has reported on some of the initial problems in developing a care pathway such as the over-reliance on diagnosis and how this ���medicalises��� the hospital process. Jones (2003 2004) has also reported on the negative per- ceptions that people hold on the value of evidence sup- porting the care of people with schizophrenia and the reluctance for them to standardize aspects of their care.