Effectiveness of Multi- Professional Team Working (MPTW) in Mental Health Care

Transcription

1 National Institute for Health Research Service Delivery and Organisation Programme Effectiveness of Multi- Professional Team Working (MPTW) in Mental Health Care Michael West 1, Beverly Alimo-Metcalfe 2, Jeremy Dawson 6, Walid El Ansari 4, Jon Glasby 5, Gillian Hardy 6, Ginny Hartley 3, Joanne Lyubovnikova 3, Hugh Middleton 7, Paul B Naylor 3, Steve Onyett 8, and Andreas Richter 9 1 Lancaster University 2 University of Bradford, School of Management 3 Aston University 4 University of Gloucestershire 5 Health Services Management Centre, University of Birmingham 6 University of Sheffield 7 University of Nottingham 8 Onyett Entero Ltd/University of the West of England 9 University of Cambridge Published October 2012 This project is funded by the Service Delivery and Organisation Programme Address for correspondence: Michael West Queen s Printer and Controller of HMSO This work was produced by West et el.

2 Address for correspondence: Michael West, Professor of Organizational Psychology C42 Charles Carter Building Lancaster University Management School Lancaster University LANCASTER, LA1 4YX This report should be referenced as follows: West M, Alimo-Metcalfe B, Dawson J, El Ansari W, Glasby J, Hardy G, et al. Effectiveness of Multi-Professional Team Working (MPTW) in Mental Health Care. Final report. NIHR Service Delivery and Organisation programme; Relationship statement: This document is an output from a research project that was funded by the NIHR Service Delivery and Organisation (SDO) programme based at the National Institute for Health Research Evaluations, Trials and Studies Coordinating Centre (NETSCC) at the University of Southampton. The management of the project and subsequent editorial review of the final report was undertaken by the NIHR Service Delivery and Organisation (SDO) programme. From January 2012, the NIHR SDO programme merged with the NIHR Health Services Research (NIHR HSR) programme to establish the new NIHR Health Services and Delivery Research (NIHR HS&DR) programme. Should you have any queries please contact sdoedit@southampton.ac.uk. Copyright information: This report may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NETSCC, HS&DR. National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre University of Southampton Alpha House, Enterprise Road Southampton SO16 7NS Disclaimer: This report presents independent research funded by the National Institute for Health Research (NIHR). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and not necessarily those of the NHS, the NIHR or the Department of Health. 2

3 Criteria for inclusion: Reports are published if (1) they have resulted from work for the SDO programme including those submitted post the merge to the HS&DR programme, and (2) they are of a sufficiently high scientific quality as assessed by the reviewers and editors. The research in this report was commissioned by the SDO programme as project number 08/1819/215. The contractual start date was in April The final report began editorial review in October 2011 and was accepted for publication in September The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The SDO editorial team have tried to ensure the accuracy of the authors report and would like to thank the reviewers for their constructive comments on the final report documentation. However, they do not accept liability for damages or losses arising from material published in this report. 3

4 Executive Summary Background Multi-professional team working (MPTW) has increasingly become an important feature of the organisation of work in all sectors. When decisions and actions made by multi-professional teams are based on the perspectives of all members they are generally of higher quality than those made by single discipline teams and individuals acting alone. While the potential value of multi-professional teams may be clear, there is evidence that organisations often have difficulty in realising the benefits. In particular, little is known about the factors influencing the effectiveness of MPTW in the context of adult mental health care in the community. Aims The overall aim of this research was to identify the principal factors that ensure MPTW is effective in delivering and improving mental health care for service users. The research explored the following factors: team task design; team effort and skills; resources; organisational supports; team processes including objectives, reflexivity, decision making, task focus and conflict; leadership processes; and outputs comprising team member satisfaction, inter-team working effectiveness, innovation and overall team effectiveness. Specifically, this research aimed: 1. To identify facilitators and inhibitors of effective MPTW, including leadership, team processes, organisational support and context-specific factors including structures and processes driving and guiding the work of CMHTs. 2. To develop and test diagnostic tools for measuring MPTW processes and effectiveness and the organisational processes and supports for MPTW. Effectiveness is here defined as the extent to which teams fulfil or exceed the requirements of their key stakeholders, including the team members themselves, and particularly focused on meeting the needs of service users. 3. To provide practical guidelines that can be easily adapted to develop MPTW and thus make a positive difference to team work in adult mental health care, and thereby to the quality of care for service users. 4

5 Methods This was a three stage project. The aim of Stage 1 was to establish the characteristics of MPTW effectiveness from the perspectives of key stakeholders (service providers, users and carers) for use in a quantitative questionnaire measure of MPTW effectiveness in CMHTs. Stage 2 involved a large scale survey (incorporating the Stage 1 measure) of 135 teams in 11 NHS Trusts examining team inputs, processes, leadership, organisational support, resources and team effectiveness. Stage 3 involved in-depth ethnographic studies of 19 of the teams involved in Stage 2. Results Stage 1 Working with stakeholder groups, including service users, the research team developed a measure of MPTW effectiveness. The CMHT Effectiveness Measures is a 20-item questionnaire that assesses seven key domains of effectiveness identified in Stage 1: improved service user well-being, creative problem solving, continuous care, inter-team working, respect between professionals, responsiveness to carers, and therapeutic relationships with service users. Stage 2 The use of the 100 item Aston Team Performance Inventory (ATPI) and 20 item CMHT effectiveness scale across 135 teams revealed that CMHTs generally reported lower levels of resources, organisational support, achievement of goals and managerial praise for performance than other NHS teams. CMHTs reported higher levels of task focus, participation in decision making, constructive debate, focus on quality and discussion of errors. There were relatively high levels of trust, safety and support and relatively good communication. Early Intervention teams appeared to be the best functioning of the teams in the sample and Generic CMHTs the worst. Key predictors of CMHT effectiveness were practical support for creative and innovative approaches to providing care for service users; team participation in decision making; regularity of meeting; and trust, safety and support among team members. Team leadership was also a strong predictor of effectiveness. Having the right mix of skills and a high level of effort was characteristic of effective teams, as was having a well-designed team task (autonomy, task relevance, a complete task, feedback on performance). 5

6 For older adult CMHTs, the resources available was the most important predictor of effectiveness. For all team types, organisational support was an important predictor of inter-team working. An absence of conflict within teams was another very important factor in effective team working. Stage 3 The ethnographic studies and observation of team meetings revealed that shared decision making was a genuine feature of many CMHTs, but it depended on team type and leadership. The quality of team processes was variable but generally positive and supportive climates were typical of most teams. Features of effective teams were the resources available to the team, particularly staff availability. The most effective teams had the time to plan care, the right mix of professionals, and positive inter-professional attitudes. Less effective teams were often hampered by targets, bureaucracy, staff turnover, staff shortages and inflexible ways of working. Positive attitudes to change and honest, open, trusting team relationships were characteristic of the most effective teams. This climate extended to carers and service users with such teams active in promoting carer involvement. The most effective teams also sought out ideas for new and improved ways of providing high quality care. Their inclusiveness extended to other teams and agencies with which they had to interact to ensure high quality care. Leaders played a crucial role in this. Many of these findings are not new in relation to our knowledge of teamwork generally and in healthcare in particular, but how they manifest in the context of mental health care provision is. They have significance particularly in their implications for practice. We describe recommendations below in priority order. 1. Clarify purpose and function of CMHTs. Clear specification of purpose and team objectives is a cornerstone for good team design. When these are clear, team members can shape and develop clear roles and ways of working interdependently and effectively. Where local needs assessment reveals a need for a more generic service, particular attention will need to be given to clarifying team objectives. 2. Provide good leadership Good leaders continually clarify vision, purpose and team objectives and help team members clarify their individual roles and objectives. They also manage the organizational context; negotiate for appropriate resources; lead inter-team cooperation and manage change effectively. They have an engaging leadership style; ensure time and space for away days and reflection space; manage meetings effectively; and manage intra and inter-team conflict; they involve users and their supports; and value diversity within teams. The findings reveal 6

7 the central importance of honest, trusting and respectful relationships at all levels: between users and team members, between team members, between team members and their managers, and between team members from different teams. 3. Actively manage team composition and processes. Team members knowledge, skills, experience and, as importantly, values and attitudes, must fit well with the demands of the team task. Team processes should also be designed to ensure that practitioners receive constructive and useful feedback, through clinical review meetings, peer support, supervision and appraisal. Diversity within teams is an asset where there is a norm of positive attitudes to the value of diversity for team innovation and effectiveness. Of most importance is ensuring information on outcomes and experience of end users continuously informs team improvement. 4. Promote inter-team working. This involves having structures and processes in place that reduce inter-team conflict, as well as protocols for transfer to other teams that promote cooperation. Organizations must encourage inter-team meetings, and promote strong, positive identification with the wider aims of the organisations. 5. Ensure reflection and adaptation Teams require opportunities for reflection in order to develop their skills, improve their processes and continuously improve their productivity and the quality of care they provide. They should have sufficient autonomy to innovate within safe boundaries. Leaders should help teams to create space for reflection on team objectives and processes. Such time must be defended and factored into considerations of team capacity to meet local demand. 6. Hold effective team meetings We recommend that all mental health teams ensure their meetings are effectively chaired and structured around a clear written agenda tightly linked to team objectives. Service for users should be the central theme of most meetings. The usefulness and effectiveness of meetings should be regularly reviewed. Conclusions It was clear throughout this research that those who work in CMHTs are both compassionate and dedicated in their commitment to working with service users to deliver high quality care. The strategy and supports provided by the Trust within which teams work plays an important part therefore in the teams ability 7

8 to deliver and continuously improve care for service users. Leadership in this domain, as in all others in health care, is critical. Investing in developing good leadership in health care teams is important if CMHTs are to achieve their potential. Many teams are working in very challenging and, at times, dispiriting situations. With targeted interventions, indicated by the findings from this report, much can be done to support them in their work, thereby improving care for service users. 8