Department of Clinical Psychology, Radboud University, Nijmegen, and Gelderse Roos Institute for Professionalisation, Wolfheze
Gelderse Roos Institute for Professionalisation, Wolfheze
Gelderse Roos, Arnhem, The Netherlands
Correspondence: Professor Giel Hutschemaekers, Gelderse Roos Institute for Professionalisation, Postbus 27, 6870 AA Renkum, The Netherlands. E-mail: g.hutschemaekers{at}degelderseroos.nl
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ABSTRACT |
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Aims This study examines the collective sense of the profession about the relationship between patient characteristics and the contribution of tasks by disciplines.
Method An adapted RAND appropriateness method was used. Eighty-six professionals judged 77 case descriptions of psychiatric patients on the contribution to diagnostic and treatment tasks of eight selected disciplines.
Results In two multi-level models the variance explained by the judges' characteristics was 3.7% for diagnostic tasks and 4.5% for treatment tasks. The variance explained by the patient characteristics was zero for diagnostic and 0.5% for treatment tasks. The variance explained by the indicated disciplines was 36.8% for diagnostic and 12.6% for treatment tasks.
Conclusions The collective sense of the profession on the contribution of psychiatrists to mental healthcare is unambiguous but not related to patient characteristics. It seems to be based on an a priori ranking order of disciplines.
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INTRODUCTION |
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More agreement may help governments in workforce planning and mental healthcare institutions to organise a more appropriate distribution of tasks. This may be especially important when setting up new forms of collaboration, e.g. between mental health and social care (Exworthy & Peckham, 1998). Increased clarity may also help patients in their search for the best equipped professional for their problems. Although the assignment of patients to professionals in mental healthcare often depends on pragmatic arguments such as availability, and on traditions at institutional, local or even national levels (Hutschemaekers & Neijmeijer, 1998; World Health Organization, 2001; Druss et al, 2003), most professionals believe that their decisions are related to the task to be performed and the patients' problems.
The current pilot study was designed to outline this collective sense of the profession of the relationship between patient characteristics and the tasks to be performed by psychiatrists and other professionals.
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METHOD |
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The indicators
The selection of indicators (patient characteristics) for the construction
of case descriptions was performed by an expert team of eight experienced
clinicians, one from each of the selected disciplines. In a Delphi procedure
consisting of two rounds, the experts reached agreement on eight different
patient characteristics as indicators for the distribution of tasks between
various disciplines. The selected indicators (with the number of categories in
parentheses) were: diagnostic classification (9), severity (3), level of
social/role functioning (4), comorbidity (5), treatment history (7), stress
factors (4), suitability for treatment (4) and reason for seeking help
(9).
A case description was constructed by the unique combination of the different categories of each indicator. Using these indicators we were able to describe the broad range of mental health patients between the ages of 18 and 65 years who are usually seen in psychiatric wards, community mental health services and private practices. Descriptions of forensic psychiatric patients and those with severe substance misuse were excluded. A typical case description is a patient with moderate depression with a comorbid personality disorder who has not received prior treatment, who has a sufficient level of social role functioning, with chronic stressors, poor suitability for treatment and striving for symptom reduction.
By permutation of all the patient characteristics it was possible to generate 544 320 different case descriptions. In order to reduce the judgement task to a manageable size we used orthoplan (SPSS, 1998). Orthoplan produces an orthogonal array of indicator combinations. This reduced the number of combinations to 77, while guaranteeing that the indicators were equally distributed in this sample and the effect of each indicator still could be evaluated. However, one disadvantage of this procedure is that interactions between patient characteristics and other variables cannot be analysed systematically.
The recruitment of the judges
We recruited the judges from the disciplines that were selected for the
indications. The members of the expert panel assessed the following selection
criteria for the judges: they must be working in mental healthcare, have
experience with the processes of indication/assessment and treatment planning,
and be representative and authoritative members or opinion leaders of their
professional group. Each member of the expert team invited at least ten
members of his/her professional group to rate the model cases, taking into
account variation in work setting, years of experience and gender. In total,
102 professionals were invited to participate in the panel of judges, from
which 86 (84%) agreed to participate (10 or 11 respondents for each
profession). Non-response was not selective for setting, experience or
gender.
The judgement procedure
We asked the judges to rate each case description on the defined
indications: the contribution of the eight selected disciplines to diagnosis
and treatment. The judges had to rate the contribution of their own and seven
other disciplines to these two tasks for the 77 case descriptions. Each task
was rated on a five-point scale as follows: 1, no contribution; 2, small
contribution; 3, partial contribution in collaboration with other disciplines;
4, considerable contribution; 5, complete contribution (no other disciplines
required). Each judge had to give a total of 77 ratings (case descriptions) on
8 disciplines and 2 tasks, amounting to a total of 1232 judgements. The actual
number of usable judgements was 104 422 (99%).
Analysis
Because the design of the study was nested, we had to perform multilevel
analyses of variance. Figure 1
shows how this nested data-set was constructed from the judgement procedure.
According to the way the data-set was constructed, we had three levels in the
analyses: the indications that were judged (level 1), the indicators in the
case descriptions (level 2) and the judges (level 3). Subsequently the fixed
variables were added as follows: first the characteristics of the judges, then
the various indicators, and finally, at the lowest level, the disciplines in
the indications being judged. Each subsequent model started with the
significant variables of the previous model. Two separate analyses were
carried out for the two dependent variables, i.e. ratings on the contributions
to diagnostic tasks and to treatment tasks. Because almost all variables (see
Fig. 1) were variables at a
nominal level, we had to construct dummy variables for the various
categories.
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RESULTS |
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In the multilevel model for the judgement of the diagnostic tasks, the significant judge characteristics (shown in Table 1) explained 3.7% of the total variance, the indicators did not explain any variance at all and the fixed variable disciplines in the indications explained 36.8% of the total variance. In the multilevel model for the judgement of the treatment tasks, the significant judge variables explained 4.5% of the total variance, the indicators explained 0.5%, and the disciplines in the indications 12.6% of the total variance. This means that the ratings that were given on the contribution of diagnostic and treatment tasks were mainly influenced by the ideas about the disciplines under judgement, were less influenced by the characteristics pertaining to the judges and were almost independent of the characteristics given in the case descriptions.
Both models show signs of interaction effects. The diagnostic model
improved slightly after adding the significant indications
(2=107, d.f.=24), although the indications did not explain any
variance. Table 2 shows in the
last model (the indication model) an increase of the random variance on the
level of indicators from 0.18% to 0.21%, which may be due to some interaction
effects between discipline and the case characteristics.
We conclude that, contrary to our expectations, neither the ratings on the disciplinary contribution to diagnostic tasks, nor the ratings of the contribution to treatment tasks were primarily associated with the indicators in the case descriptions. In order to explain this unexpected result we returned to the raw data.
The disciplines that were judged
Figure 2 shows the mean
ratings that the judges gave to the different disciplines for the contribution
to diagnostic and treatment tasks. There is a clear ranking order between the
various disciplines for both tasks. The psychiatrist is considered to have the
highest contribution in both tasks, and the non-verbal therapists and
pedagogic workers the lowest. Psychiatrists, for example, received a mean
rating of 4.14 for diagnostic tasks, indicating that psychiatrists were almost
always seen as being capable of performing all diagnostic tasks without the
aid of other mental health professionals.
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An example of an interaction effect that may have occurred is shown in Fig. 4: the contribution to treatment by each discipline for three diagnostic categories, schizophrenia, mood disorder and interpersonal problems. First, we see the main trends as shown in Fig. 2: psychiatrists were rated as having the highest contribution and social pedagogic workers the lowest to treatment tasks. Second, a smaller trend is apparent, indicating that the average contribution of disciplines changes with the severity of the problems of the patients. The contributions of the social pedagogic worker, the psychiatric nurse and the psychiatrist increase with the severity of the diagnosis. The contributions of the non-verbal therapist and the social worker are more or less the same for all three diagnostic groups. The contributions of the clinical psychologist and the psychotherapist decrease with the severity of the diagnosis. This pattern corroborates our suggestion of an interaction effect.
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DISCUSSION |
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Limitations
It is possible that these unexpected results are at least partly an
artefact of the study design. In the judgement procedure the
operationalisation of the dependent and the independent variables was crucial.
The dependent variables were limited to the contribution of professionals
towards two tasks: diagnosis and treatment. More tasks might have led to more
differentiation between disciplines. Also the choice of eight broad
disciplines may mean that not enough room was left for the nuances of
sub-specialties and also that the indicators in the case descriptions may not
have been specific enough to allow clear judgements.
In addition, we do not know the extent of the influence of the way the tasks were rated. The categories of the five-point scale anticipated a double judgement on the part of the judges: they had to give an absolute judgement on the contribution of a specific discipline to diagnostic and treatment tasks as well as giving a relative judgement (the appropriate contribution given the contribution of other disciplines).
Although we cannot exclude the fact that other operationalisations would have led to other results, the large difference between the explained variance by the three main factors - judges, indicators and indications - is so overwhelming that we doubt whether this main result of the study would have changed with other study criteria. In addition, as we cannot compare our results with results from other studies, we can only consider, with some caution, the possible implications of our findings.
Agreement on the tasks to be performed by psychiatrists
The results show that the judgement of the contribution towards care by
eight professional groups is quite transparent. Almost all of the random
variance was on the level of the indications. Among the fixed variables
disciplines in the indications explained most of the variance.
Psychiatrists hold the position of always having to carry out the most
important role, whereas the contribution of pedagogic workers is seen as quite
modest. Psychologists should make a substantial contribution to diagnostic
tasks whereas psychiatric nurses have a substantial role in treatment tasks.
The main conclusion of this study is, therefore, that the collective sense of
professionals concerning the tasks of various disciplines is defined and very
strong.
Lack of agreement on the shop floor remains
The agreement concerning the distribution of tasks between psychiatrists
and other mental health professionals was not expected, considering the
differences in task distribution between disciplines in the mental healthcare
institutes (Hutschemaekers &
Neijmeijer, 1998). Nor does the agreement fit with the competition
between professional unions and related professional struggles
(Abbot, 1988; Herrman et al,
2002).
It is possible that the current procedure of judgements may have decontextualised and depoliticised the judgements of tasks where the immediate risk for the position of their own discipline was not taken into consideration by the judges. It is also possible that the competition between disciplines has less to do with diagnostic and treatment tasks than with other tasks, such as team coordination or case management (Sainsbury Centre for Mental Health, 1997). Finally, our data do not indicate the ideal composition of mental healthcare teams (number and numeric proportions of disciplines) or the way such a team should function (Hutschemaekers & Neijmeijer, 1998). Further research is needed to explain the lack of agreement on the shop floor, and the strong agreement found in this study.
Images of professions
The most unexpected finding of this study is the lack of clear
relationships between the assigned contribution of disciplines to diagnostic
or treatment tasks and the different indicators in the case descriptions. It
is hard to understand on what other sources professionals have relied in this
judgement procedure. Perhaps these sources consist of more or less generalised
images that professional groups have of each other. If this is the case, our
data provide insight into the nature of these images. First, given the lack of
specific relations with patient characteristics, we may assume that these
images are not very specific. Second, these images do not seem strongly tied
to specific clinical settings. The large differences between the distribution
of disciplines in the field of work are at least not reflected in the ratings
of the judges. Third, and most astonishingly, professional groups only
partially differ in the images they have of each other. Their ratings show
that they use one broad set of shared images. These images therefore fit what
is called in social psychology a cultural value or a social presentation
(Moscovici, 1984).
Power or expertise?
In this study we aimed to provide more clarity on how the contributions of
aligned tasks between psychiatrists and other disciplines are seen. Although
we feared a lack of agreement due to professional competition, we actually
found strong agreement, probably also due to a lack of specific images on the
expertise of disciplines in relation to the needs of patients. How, therefore,
should these results be interpreted? One possible interpretation is that the
distribution of tasks has to do more with responsibility or power than with
specific expertise, simply because most interventions in mental healthcare can
be performed by several disciplines. This would imply that there is only a
moderate link between disciplines and specific expertise. Another
interpretation is that psychiatrists as well as the other professionals in
mental healthcare have insufficiently learned to recognise and use the
specific expertise of other mental healthcare professionals. An example of
this specificity could be the distinction between generalists and specialists.
In general healthcare, for example, more distinction is made between
interventions in primary care and interventions in specialised healthcare.
If indeed a lack of recognising and using differences is a viable explanation for the results presented here, a conclusion of this study could be that professions in mental healthcare should focus more on differentiation. This would mean that psychiatrists, as well as other professionals, should focus more on their core competencies in relation to specific patient groups.
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Clinical Implications and Limitations |
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LIMITATIONS
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Received for publication June 16, 2004. Revision received November 16, 2004. Accepted for publication November 24, 2004.
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