Joint Working

Author: Ken Barlow RMN, BA, CPN Cert, CertEd

Joint working is patently not a new concept for most CPNs. There has been a gradual move toward collaborative involvement in care over many years, arguably driven by cost saving efficiencies initially but also by altruistic influences surrounding the nature of client needs and the development of multidisciplinary provision.

For 30 years or so, successive governments have sought ways of encouraging collaborating between the many agencies involved in mental health care in the community including clients and carers. For purposes of this guidance paper, however, joint working can be defined as: ‘the acting together of two or more people from the same or different agencies and/or involving client/carer, with the same aim of delivering a service that could not be offered to the same degree by one person alone’.

Multidisciplinary approaches have massive implications for service structures, procedures and operational processes, which cannot be explored here in any detail. This paper will concentrate on the basic essentials of joint working with a clinical emphasis, from a CPN practice perspective.

Role clarification
Joint working presents a number of problems and opportunities. CPSs need ot know how to convert the former into the latter. One of the keys to this is to recognise the need to adapt roles to different situations and as expressed needs demand. It is just as imprtant to clarify what the CPN role is not, in given circumstances, as much as what it is.

If a CPN and team colleague undertake a joint visit it is important to establish in advance why the visit is joint, what the purpose of the visit is, who will adopt which role and when this might be changed. Good communication skills are vital to the smooth transition of roles during a joint visit.

An appropriate venue for the session needs to be established. Not all visits will be at the client’s home. For instance, seating arrangements, a mutually agreeable time, and who is the nominated key worker are all issues which need consideration in establishing the mechanics of the joint session.

There are also factors to be taken into account regarding the blurring of traditional professional boundaries.
For example should you, as a CPN, be happy to help fill in a housing application form, while your social work colleague is busy taking down details of the client’s medication if this is how the session works out?

A precise, heavily prepared script or plan is not recommended. It may well appear contrived, figid and, to some people, suspicious in nature. Too rigid a preparation can court disaster in the event of spontaneous unexpected occurrences.
It is usual, and common courtesy, to inform clients and/or carers that a joint visit is being planned and unless there are specific reasons for withholding such information, who will be undertaking what aspects of the visit. The involvement of clients in care planning is now far more common. Their informed consent to joint working should be sought with the reasons behind the decision to joint working being clearly explained. Beresford and Trevillion (1995) emphasises the essentiality of trust and sharing in the collaborative relationship with the client.

Justification
Joint working can be seen as an expensive option in terms of using scarce resources. It is suggested that CPNs refer back to the original definition at the top of this paper before opting for joint working. The key component of the definition which should help guide decision making in this respect is that part which says, ‘delivering a service which cannot be offered by one person alone’. The following are suggested as criteria against which to gauge the need for joint working or not.
Therapeutic activity is raised.
Safety aspects indicate a strong recommendation.
Specific skills are brought to bear.
Introduction or transfer activities are required.
Legislative or structured care needs are indicated.
Casework supervision is indicated.
Supervised training needs are indicated.
Local, specific or unique conditions exist.

Values
Joint working is based upone three basic values, namely trust, sharing and good faith. CPNs working with colleagues from other disciplines need to be sure that there is a commonality of value systems which forms the basis for a working philosphy upon which to base practice. The following issues are felt to be essential to good joint working
Trust
Respect
Autonomy
Risk Taking
Self-awareness
Tolerance

The opportunity to openly discuss these issues in a non-threatening and nurturing atmosphere should always be encouraged. When Peck & Norman linked these practice based issues in a multi-disciplinary setting, the results made for fascinating reading.

Team working
CPNs working in structured or semi-structured community mental health teams (CMHTs) are arguably in a more advantageous position, because they are more familiar with their colleagues and their uique working methods. While this familiarity can bring its own problems, it does alleviate some of the more common obstacles faced when considering joint working with a colleague who may be a virtual stranger in a ‘hands on’ clinical situation.

Multi-disciplinary teams are growing in numbers around the UK. Many CPNA members will no doubt be members themselves. For them, the opportunity for joint working could not be more available. One of the keys to success in establishing and then maintaining CMHTs lies in the commonality of agreed values, philosophy, aims, priorities and working structures whilst at the same time encompassing and broad approach to the balancing of local needs against available service provision. (Onyett et al and Ovretviet)

The importance attached to the differences between teamwork and collaboration as suggested by Loxley (chapter 4) is echoed in the fascinating work of Peck & Normal. These authors concluded that successful teamwork was dependent upon the various disciplines involved and could not be prescribed, contrived or directed by managers or policy makers. It is suggested that joint working can be the mortar which binds the structure of the CMHT through its teambuilding processes.

Joint training
Any discussion of joint working and teamwork, should not exclude the concept of joint training. The two go hand in hand.
The utilisation of knowledge, a constantly changing crucible of social change, is something with which all CPNs should become familiar. Acquiring, processing and using knowledge is essential, both from a sociological perspective and in terms of professional development. To understand this paradigm better, CPNs are urged to read Drucker and Sorrell-Jones & Weaver for well presented arguments about ‘The Knowledge Worker’.

Governments are beginning to move forward the process of joint training in a more structured manner although it is recognised that massive obstacles lie in the path of such developments. In Scotland, The Scottish Executive has recently published detailed proposals for education, training and lifelong learning for all NHS staff in Scotland, ‘Learning Together’. This paper leans heavily toward joint training and collaboration as a basis for organisation, service delivery and clinical practice.

Some would argue that this not before time. In 1995, Couchman commented: ‘The integration of all education for healthcare professionals into higher education should facilitate inter-disciplinary developments’ (Page34).

The inclusion of clients and carers in developing training curriculae is gradually becoming more welcomed - see Reid & Dewan and Simpson. This is an aspect of training in which CPNs should be encouraged to form a bridge between clients’ needs, skill development and curriculum planning on the basis of common core, inter-disciplinary training.

It may be argued that the place for a fuller debate regarding joint training should lie elsewhere. But most CPNs involved in its practice will testify to its value as a learning tool and the need for it to be addressed when formulating policy.

Recommendations
CPNs do not function in a professional vacuum. Whether they are members of a structured CMHT or a loosely formed inter-professional network or even a specialist team, all CPNs have a need to liaise closely with fellow professionals. The opportunity for joint working and the benefits that this can offer should not go ignored. Some of the key elements to successful joint working can be summarised thus:

Clarification of role in specific situations (both can change).
Involvement of clients/carers in the joint working process.
Consider the appropriateness of joint working.
Commonality of core values and philosophy of care.
Valuing the concepts of teamwork and team building.
Collaborative training including the input of clients and carers.

Finally it is recommended that CPNs gradually acquire familiarity with joint working. Like any new experience it can be threatening and strange, so seek help and guidance from more experienced colleagues.

References

Beresford, P. & Trevillion, S (1995) Developing Skills for community care: a collaborative approach. Addershot, Arena.
Crouchman, W (1995) Joint education for mental health teams. Nursing standards, November *, (10) 32-34.
Druker, P (1994) The knowledge worker. The Atlantic Monthly Magazine, November 1994.
Loxely, A (1997) Collaboration in health and welfare; working with difference. London, Jessica Kingsley.
Onyett, S; Pillinger, T & Muijen, M (1995) Making community mental health teams work: CMHTs and the people who work in them. London, The Sainsbury Centre for Mental Health.
Ovretveit, J (1993) Co-ordinating community care: Multi-disciplinary teams and care management. Buckingham, Open University Press.
Peck, E & Norman, I (1999) Working together in adult community mental health services: Exploring inter-professional role relations. Journal of Mental Health 8 (3) 231-242.
Reid, J & Dewan, V (1999) More than a learning experience. London, Mind.
Simpson, A (1999) Creating alliances: The views of users and carers on the education and training needs of community mental health nurses. Journal of Psychiatric & Mental Health Nursing. (6) 347-356.
Sorrell-Jones, J & Weaver, D (1999) Knowledge workers and knowledge intense organisations. Part 1-3 inc. JONA Vol 29, nos 7/8/9/10; July/Aug-Oct 1999.

Ken Barlow is a CPN working with care of the elderly in Dumfries and Galloway