Vrklevski_whole_thesis.pdf (10.11 MB)
Professional roles and identity in public mental health services : the multifaceted interaction of belonging, attachment, power and activities
thesisposted on 2023-05-28, 08:51 authored by Vrklevski, LP
Deinstitutionalisation of the mentally ill formally commenced in Australia in 1992. People with mental illness were discharged into the community in great numbers. Consumers of public mental health services are a complex and challenging cohort. These consumers require assistance in psychiatric, psychological, relationships, accommodation, psychosocial, vocational, and legal domains. This called for new models of care and different work practices for mental health clinicians. Case management and multi-graded positions were implemented. Multi-graded positions on community mental health teams have led to blurred boundaries and role overlap between psychiatry, nursing and allied health professionals. Blurred boundaries can result in role conflict between professions, as well as a loss of professional identity and feelings of disempowerment. This study addressed the question: what is the role of allied health in the future of public mental health services? In examining this question, this research explored two intertwined issues. First, the impact of Mental Health Service (MHS) multi-graded positions on the strength of professional identity, perceptions of power across disciplines, and the perceived impact this has on patient care was considered. Second, the study investigated whether public mental health services are meeting the needs of consumers. Specifically, the study identified which needs are being met, which needs are not being met and what activities and skills are required to meet these needs. A unique contribution of this research has been the theoretical development and testing of a new and robust model of professional identity. The four-factor model, called the Four Factor Model of Professional Identity (4FM-PI), recognises professional identity is a multi-factorial and multi-dimensional construct. The four factors that contribute to strength of professional identity are; belonging (tribal theory), attachment (role theory), power (organisational hierarchy) and activities (discipline specific and generic). The setting was a large metropolitan MHS comprised of three inpatient facilities with 270 inpatient beds. There is a 12-bed step-up, step-down unit based in the community to assist with transitioning to or from inpatient care. About 3000 people receive inpatient care annually. There are also five community mental health centres that provide over 128,000 non-admitted occasions of service for more than 14,000 people. The MHS is staffed by about 700 clinicians. Participants were drawn from the five largest disciplines - nursing, occupational therapy, psychiatry, psychology and social work. A mixed methods design was employed. An on-line survey was administered and consisted of four psychometric measures: the Demographic Data Questionnaire (DDQ), the purpose ‚Äö- designed and empirically derived Mental Health Activities Checklist (MHAC), Professional Identity Scale (PIS) and Power Questionnaire (POWQ). Data was analysed using inferential statistics. In addition, semi-structured interviews were conducted. Hour-long interviews were held asking participants: to describe their role; which professional group they were most and least similar to; how role clarity can be achieved; if the needs of consumers are being met; and, in the future, what is required to meet the needs of consumers. Interviews were transcribed and thematically analysed. Across the five professions, 320 staff elected to complete the survey, for a 44% response rate. The average PIS scores for each discipline were Social work (PIS= 4.40), Psychology (PIS= 4.48), Occupational Therapy (PIS= 4.54), Nursing (PIS= 4.58) and Psychiatry (PIS= 4.62). Even though psychiatrists reported the highest average PIS score the difference between disciplines on strength of professional identity was not statistically significant (p=0.69). There was a weak positive correlation (r=0.230, n=320, p <.0001) between PIS and time spent on discipline specific activities (MHAC). There was a weak positive correlation (r=0.359, n=320, p <.0001) between PIS and Power. Even though inpatient staff had higher average PIS (˜í¬¿=45.77) and Power (˜í¬¿=4.11) scores than community staff, PIS (˜í¬¿=44.80) and Power (˜í¬¿=3.98) the differences were not statistically significant. There were 20 semi-structured interviews conducted. Ten staff members from both inpatient and community services participated, with four from each of the five professional groups. The questions in the semi-structured interview were designed to allow participants to describe their experience of working in the mental health service alongside other professional groups. The investigation confirmed role overlap between psychiatry, nursing and allied health is beneficial and enables a shared understanding. Mental health professionals need skills and abilities that are varied, similar, flexible and adaptable. However, multi-graded or generic positions can limit the ability of the team to address the full range of consumer needs. Empirical testing confirmed the theoretically derived 4FM-PI model of professional identity. Belonging, attachment, power and activities interrelate and reinforce to shape perceptions, attitudes and practices of one's own and other professions. This is a new and unique contribution to the empirical knowledge base. The study confirmed that the service was meeting consumer needs across three domains. The first domain was in psychiatric intervention: consumers were provided with medication, and regular psychiatric reviews. The second domain was housing: consumers were found accommodation despite shortages of suitable low-cost housing. The third domain was in adherence to legislative and regulatory standards in the delivery of care: consumers were managed appropriately under relevant legislation. The study found that there was a range of needs across medical and social dimensions the service was not meeting. These needs were predominantly in the area of psychological and psychosocial interventions. To address these unmet needs, the study identified that discipline specific allied health skills are required now and into the future. Alternative models to care coordination could and should be explored to address the unmet needs in the psychological and psychosocial domains. In summary, future services needed to offer more holistic mental healthcare provided by professionals with discipline specific skills and focus.
Rights statementCopyright 2019 the author Chapter 2 appears to be the equivalent of a pre-print version of an article published as: Vrklevski, L. P., Eljiz, K., Greenfield, D., 2017. The evolution and devolution of mental health services in Australia, Inquiries journal, 9(10)