Care co-ordination for people with severe mental illness
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.