Balancing professional and team boundaries in mental health services: pursuing the holy grail in Somerset

The overcoming of professional boundaries to collaboration in patient care has become one of the goals of mental health service policy in England over the past 25 years, predominantly through the creation of community mental health teams. However, research has shown that these boundaries have been slow to come down, and some commentators have pointed to the benefits of appropriate boundaries. This paper introduces a theoretical framework, which seeks to categorise boundary activity in organisations and then examines the boundary activity of professional groups and community teams during the integration of mental health and social care service provision in one locality in the southwest of England. The paper identifies the ways in which this integration impacted on boundary activity and draws out the messages for mental health policy and practice that emerge.     

Electrical impedance tomography: so close to touching the holy grail

Electrical impedance tomography is a new technology giving us lung imaging that may allow lung function to be monitored at the bedside. Several applications have been studied to guide mechanical ventilation at the bedside with electrical impedance tomography. Positive end-expiratory pressure trials guided by electrical impedance tomography are relevant in terms of recruited volume or homogeneity of the lung. Tidal impedance variation is a new parameter of electrical impedance tomography that may help physicians with ventilator settings in acute respiratory distress syndrome patients. This parameter is able to identify the onset of overdistention in the nondependent part and recruitment in the dependent part. Electrical impedance tomography presents a big step forward in mechanical ventilation.In a previous issue of Critical Care, Blankman and coworkers provide new results that may change the mechanical ventilation paradigm [1]. Over the past 25 years, the use of computed tomography (CT) for clinical evaluation of thoracic diseases has rapidly gained in popularity and CT has become firmly established as an important research and diagnostic modality [2]. CT yields cross-sectional images of the lung, allowing virtually all intrathoracic pathological conditions to be evaluated. In particular, CT has played an important role in improving our knowledge of the pathophysiology of acute respiratory distress syndrome (ARDS) and in determining the morphological and functional consequences of different manoeuvres commonly used in the therapeutic management of this syndrome [3]. Gattinoni and colleagues’ [3] and Rouby and colleagues’ [2] trials of CT have definitively changed our meaning of ARDS, but this remains research; CT still needs patient transfer to the department of radiology, CT still needs radiation, and CT is still static imaging. In fact, physicians are still blind at the bedside.Electrical impedance tomography (EIT) is a new technology giving us bedside lung imaging that may allow lung function to be monitored at the bedside. Several applications have been studied to guide mechanical ventilation at the bedside with EIT. Positive end-expiratory pressure (PEEP) trials guided by EIT are relevant in terms of recruited volume or homogeneity of the lung [4]. Setting the ventilator to avoid alveolar derecruitment, loss of aeration, is crucial both in anaesthesia and in the ICU [5]. In ICU patients with ARDS, however, looking for alveolar recruitment is insufficient. In ARDS patients, even the normally aerated lung is not a healthy lung and overdistention may occur [6]. Overdistention, with or without hyperinflation, is defined as an excess of alveolar gas compared with lung tissue. Very probably, 90 % lung aeration (corresponding to CT attenuations of -900 Hounsfield Units or less) is the threshold that separates inflation from overinflation. If inflation of healthy lung regions during mechanical ventilation is safe (but useless), hyperinflation-induced overdistention of nondependent lung regions may be harmful and is probably a major issue in mechanical ventilation, responsible for ventilator-induced lung injury [2].If surrogates of recruited volume have been extensively described in the last decade (with EIT, bedside functional residual capacity, dynamic compliance, lung echo, and so forth), the visualisation of overdistention remains CT’s prerogative. Lung overdistention is therefore a long-running story between myth and fact.In the late 1990s, pressure–volume curve analysis was identified as a good surrogate of the recruitment–overdistention relationship [7]. Unfortunately, results were disappointing. Indeed, recruitment is a continuous phenomenon that may occur after the upper inflection point, and overdistention may appear before this point [8]. More recently, studies with lung ultrasound showed the possibility to quantify the recruitment, but with a subjective analysis and the inability to measure the overdistention [9].Blankman and coworkers used a new EIT parameter, tidal impedance variation, to find the ‘best’ PEEP, which is regarded as minimal lung collapse and minimal overdistention in order to prevent ventilator-induced lung injury [1]. During a decremental PEEP trial, they have shown that intratidal gas distribution is able to identify the onset of overdistention in the nondependent part and recruitment in the dependent part. Looking for lung overdistention at the bedside, in addition to recruited volume, looks like the holy grail for physicians dealing with ARDS over the years. Because alveolar recruitment is a continuous phenomenon during lung inflation, and because keeping the plateau pressure below 30 cmH₂O with a reduced tidal volume does not protect all patients from overdistention [10], taking into account overdistention during PEEP trials is a crucial issue. These preliminary results obtained in postcardiac surgery patients are therefore a big step forward in mechanical ventilation. Obviously this study has several limits. The most important, in our view, is that this study was performed with postcardiac surgery patients. ARDS after cardiac surgery is known to be really diffuse with a homogeneous loss of aeration. But even this limit is not a real issue. We shall have to perform the same study with different ICU patients. The proof of concept is done, and that is most important.EIT is probably a revolution in mechanical ventilation. Even if EIT devices moved from research laboratories to ICUs, this revolution is ongoing [11]. The results of this study are one more proof of EIT’s ability to change the paradigm of mechanical ventilation, but obviously not the last. An increasing use in the clinical setting can be forecast in areas other than lung aeration/lung collapse. As the perfusion-related changes in thoracic impedance are about one order of magnitude smaller than the changes induced by ventilation, it is much more difficult to extract information on stroke volume, cardiac output, or lung perfusion. Notwithstanding, separation of cardiac-related and ventilation-related EIT signals is not impossible, as shown recently [12]. Ventilation–perfusion monitoring continuously at the bedside for ICU patients during PEEP trials, prone positioning, or recruitment manoeuvres may be the next step – and yes, this will be the holy grail!     

Chronic inflammation in peritoneal dialysis: the search for the holy grail?

Mortality and morbidity in chronic kidney disease (CKD) patients are unacceptably high. The annual mortality rate due to cardiovascular disease (CVD) is approximately 9%, which, for the middle-aged person, is at least 10- to 20-fold higher than for the general population. Classic risk factors for CVD are highly prevalent in CKD patients, but they cannot fully account for the excessive rate of CVD in this population. Instead, it has become increasingly clear that nontraditional risk factors, such as systemic inflammation, may play a key role in the development of atherosclerosis. It is well established that inflammatory markers are very powerful predictors of high CVD morbidity and mortality not only in the general population, but particularly in CKD patients. Signs of a sustained low-grade inflammation, such as increased levels of C-reactive protein (CRP), are present in the majority of stage 5 CKD patients, even in patients in clinically stable condition, and they are also commonly observed after the initiation of dialysis therapy. Dialysis therapy--hemodialysis as well as peritoneal dialysis (PD)--may itself contribute to systemic inflammation. Local intraperitoneal inflammation can also occur in patients treated with PD. These local effects may result in a low-grade inflammation, caused by the bioincompatibility of conventional glucose-based dialysis fluids, to intense inflammation associated with peritonitis. Given these circumstances, it is reasonable to hypothesize that strategies aiming to reduce inflammation are potentially important and novel, and could serve to reduce CVD, thereby lowering morbidity and mortality in patients with CKD. In this review we provide information supporting the hypothesis that systemic inflammation is tightly linked to the most common complications of CKD patients, in particular those on PD, and that local inflammation in PD may contribute to various related complications. The aims of this review are to discuss the reasons that make inflammation an attractive target for intervention in CKD, the particular aspects of the inflammation-CVD axis during PD treatment that are likely involved, and possible means for the detection and management of chronic inflammation in PD patients.     

Assessing risk: professional perspectives on work involving mental health and child care services

The assessment of risk is central to work with families where parental mental health needs and child care concerns coexist. This article reports on the findings of three interprofessional focus groups which examined professionals' experiences of working with such families. Specialisation and differing thresholds and codes were identified as factors which contributed to difficulties for practitioners and families and scepticism was expressed concerning the feasibility of a key worker system for this group. The issue of psychiatric diagnosis evoked ambivalent responses and was both valued as offering direction for planning interventions and seen as a means of labelling and excluding individuals from services. The focus group participants were aware that assessing risk placed families under considerable pressure, but practitioners themselves also appeared to experience an emphasis on risk as restrictive.     

Assessing risk: professional perspectives on work involving mental health and child care services

The assessment of risk is central to work with families where parental mental health needs and child care concerns coexist. This article reports on the findings of three interprofessional focus groups which examined professionals' experiences of working with such families. Specialisation and differing thresholds and codes were identified as factors which contributed to difficulties for practitioners and families and scepticism was expressed concerning the feasibility of a key worker system for this group. The issue of psychiatric diagnosis evoked ambivalent responses and was both valued as offering direction for planning interventions and seen as a means of labelling and excluding individuals from services. The focus group participants were aware that assessing risk placed families under considerable pressure, but practitioners themselves also appeared to experience an emphasis on risk as restrictive.     

Cases for change in mental health: partnership working in mental health services

This article examines our current state of knowledge about partnership working between health and social care in UK adult mental health services. Drawing on a narrative review of the literature commissioned by the National Institute for Mental Health, this paper focuses on 43 documents from the review which discuss partnership issues. After exploring the rationale for partnership working, potential barriers and possible ways forward, the paper identifies gaps in the existing literature and discusses the implications of the review for current health and social care policy.     

Time-limited psychotherapy in the community mental health team

A community mental health team is offering clients short-term focal psychotherapy in the local area. Many clients find the team's base easier to attend than a central unit, and, with good communication and co-operation from other health-care professionals, the relevant clinical nurse specialist is able to make good progress, as indicated by the case study described here.     

Primary mental health workers in child and adolescent mental health services

BACKGROUND: The interface between primary care and specialist services is increasingly seen as crucial in the effective management of child and adolescent mental health (CAMH) problems. In the United Kingdom, a new role of primary mental health worker (PMHW), has been established in order to achieve effective collaboration across the interface through the provision of clinical care in primary care settings and by improving the skills and confidence of primary care staff. However, little is known about the development of this innovative role in service contexts. Issues raised during the early stages of implementation may have important implications for the preparation and development of professionals who undertake the role. AIMS: The aim of this paper is to report on a study that examined key issues in implementation of the PMHW role in six health authorities in England. METHODS: Case study evaluation was conducted, using thematic analysis of 75 qualitative interviews with key stakeholders from different professions (e.g. PMHWs, general practitioners, health visitors, psychiatrists and service managers) and representing different sectors (primary care, specialist services and community child health services). FINDINGS: The study identified three models of organization (outreach, primary care-based and teams). Each was associated with different advantages and disadvantages in its effects on referral rates to specialist services and the development of effective working relationships with primary care providers. Problems associated with accommodation and effective integration of PMHWs with specialist services, and tensions caused by the two different roles that PMHWs could undertake (direct clinical care vs. consultation-liaison) were common across all sites. CONCLUSIONS: The PMHW role is an important development that may go some way towards realizing the potential of primary care services in CAMH. The implementation of new roles and models of working in primary care is complex, but may be facilitated by effective planning with primary care providers, clear goals for staff, and a long-term perspective on service development.     

Mental health: integrated network and family-oriented model for co-operation between mental health patients, adult mental health services and social services

Background. Co‐operation between mental health care units and the social services is important in the case of people with social problems who also suffer from mental health problems. However, participation of patients and their families in the treatment process, and co‐operation between them and the professionals, are also important. Communication between the professionals, patients and their family members, and the professionals is a crucial factor for co‐operation. Aims and objectives. The aim of this study was to elucidate the experiences and importance of co‐operation for the patients. The data consisted of interviews with 22 mental health patients who were also clients of municipal social services. Method. The grounded theory approach was used, focusing on the informants’ experiences of the integrated network and family‐oriented model for co‐operation. Results. The findings indicate the importance of the participation of patients and their social networks in psychiatric care or the treatment process. Meetings should be characterized by open and reflexive discussions with all participants’ points of view being included, so that fruitful co‐operation is possible. However, some negative experiences were also reported, all of which were connected with the professionals’ behaviour. Conclusions. Trust and honesty are essential elements in relations between professionals and psychiatric patients, but it cannot be assumed that they will develop naturally. It is the professionals’ responsibility to adjust their behaviour so that these elements can be created in a mutual process between patients and professionals. Multidisciplinary teams are a necessity in family‐oriented co‐operation between psychiatry and social services, and in a satisfactory caring process. Relevance to clinical practice. Nurses’ work is often individually oriented and nurses are ruled by routines in their work. The mental health caring process should be seen as a shared process between the patient, his/her human environment and professionals for which nurses need skills to their interaction with patients and their social network.     

Reflective practice and team teaching in mental health care

AIM: To develop and test new approaches to professional education that would address issues of team capacity and readiness to learn, thereby strengthening the ability to practise reflectively. METHOD: The time out and the debrief approaches to team training in core competencies were piloted with ten care teams in the north west of England. Pre- and post-training measures of competency were obtained to assess the effectiveness of the training. RESULTS: The results show that competence measures taken after attending the programme were significantly higher than those taken before training. Self-assessments and manager assessments supported this, indicating that the training had a positive effect on the overall capability of practitioners. CONCLUSION: The findings suggest that the innovative educational process created in this study could be used to support the structures of reflexivity and thoughtful practice. This educational process could be used to support practitioners to fully embrace work challenges.