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Title: Care co-ordination for people with severe mental illness
Author: Simpson, Alan.
Awarding Body: University of Brighton
Current Institution: University of Brighton
Date of Award: 2004
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Aims: This thesis explores the factors that facilitate or restrict the ability of Community Psychiatric Nurses (CPNs) in their role as care co-ordinators within multi-disciplinary Community Mental Health Teams (CMHTs) to meet the needs of people with severe mental illness. Methods: A multiple case study of seven CMHTs within one NHS trust in England, incorporating a focus on 15 CPNs and 15 services users with severe mental illness over 15 months. Methods included interviews and questionnaires with CPNs and users every three months; participant observation of over 70 CMHT and related meetings; interviews with team members, managers and carers; and a review of relevant literature and documentation including CPN patient files and care plans. Analysis was guided by grounded theory and involved constant comparison and 'pattern analysis' within and between cases. Difficulties using a 'pure' grounded theory approach are discussed. Progressive focusing on emerging concepts allowed a working hypothesis to be developed. Findings: Inter-related factors resulted in CPNs feeling that they provided 'limited nursing'. Specific demands of the care co-ordinator role and developments associated with multi-disciplinary working combined to reduce direct contact with service users. This impacted on the CPNs' ability to provide appropriate evidence-based psychosocial interventions to users and carers. The effects of 'limited resources' were explored and served to further exacerbate this tendency towards 'limited nursing'. CPNs identified the benefits of the care co-ordinator role but there was a 'lack of flow', or genuine expectation that the requirements of the CPA and the care co-ordinator role would be acted upon. Differences between more or less harmonious CMHTs revealed the importance of team structure, procedures and leadership. Absence of these factors led to the emergence of historical inter-professional suspicion and tensions. CPNs and team managers were often 'undermined' and teams became 'unsafe', inhibiting communication, the disclosure of information and effective care co-ordination. 'Remote and invisible' senior managers and an organisational culture of 'defensiveness' further curtailed the potential effectiveness of teams and CPNs. Results were considered and discussed in relation to several theories of social and group interaction and negotiation. Conclusions: The inherently flawed design and implementation of the CPA and insufficient funding of mental health services undermined the operation of this form of case management. Failure to acknowledge and address underlying inter-professional tensions and the existence of organisational defensiveness further reduced the ability of ePN care co-ordinators to provide effective coordinated care and interventions that might help prevent relapse and encourage social integration. The findings may partly explain reports that suitably trained mental health staff fail to provide psychosocial interventions in clinical practice and that there is an apparent association between CPA case management and increased inpatient bed use in England.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available