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Developing practice in school health services – Aiming towards equality in a multidisciplinary team

Clinical Social Worker, PhD, Nic Waals Institute, Lovisenberg Diakonale Hospital, kari.langaard@lds.no

Educational Therapist, Oslo University Hospital, k-olai@online.no

Senior Researcher, PhD, Centre for Child and Adolescent Mental Health, ruth.toverud@r-bup.no

  • Side: 28-42
  • Publisert på Idunn: 2014-03-19
  • Publisert: 2014-03-19

Development of accessible mental health services for youth is an important objective in many Western countries. In Norway, increased collaboration among professionals from community health services and speciality health services is considered as vital to reach this aim. This article addresses processes of working together among school nurses and professionals with background in speciality health services. A Participative Action Research (PAR) project provided the context of collaboration. The aim of the project was to develop counselling for youth with psychosocial problems in school health services. The research group included four school nurses, two mental health professionals and the researcher. Through joint reflections based on the practitioners’ case-work, the intention was to draw on knowledge from the two fields of practice: school nursing and mental health. By analysing the process in retrospect we found that conditions that hampered collaboration were initially connected to insecurity, doubt and different opinions among the practitioners. Throughout the project lack of time resources was an important challenge. Conditions that facilitated collaboration could be clustered around the two main themes: first, to give place for expression of doubt and different opinions and second, to share practice experiences. The discussion reflects upon how these issues might inform how health workers with different professional backgrounds can develop practice together.

Keywords: Mental health, participative action research, practice development, primary health services

Recently, there is an increased concern for the mental health status of young people in Western countries. Several studies show that both boys and girls report mental health problems that severely influence daily functioning (Costello, Egger, & Angold, 2005; Costello, Foley, & Angold, 2006; Roza, Hofstra, van der Ende, & Verhulst, 2003). In this situation, making mental health counselling easily available to those in need of support is considered a vital task in many countries.

Adapting well to the aim of accessibility, school based health services are regarded as an important avenue of intervention (Brindis et al., 2003; Davis, Montford, & Read, 2005; Gustafson, 2005; Ministry of health and care services, 2003). As part of young people’s daily environment, the services are available to youth that otherwise would not have received necessary support. Targeting all youth, the services have the opportunity to be perceived as not stigmatizing. A review of the literature, however, reveals that both counselling practice and working conditions of practitioners are in need of development and improvement (Bullock, Libbus, Lewis, & Gayer, 2002; Denehy, 2002; Hootman, Houck, & King, 2002; Svebak, Jensen, & Gotestam, 2008; Vought-O’Sullivan, Meehan, Havice & Pruitt, 2006). According to Keller and Ryberg (2004), school nursing practice is characterized by a constantly changing environment and a chronic state of uncertain resources. The services are usually staffed by school nurses who work alone, part time. The continuous threats of the withdrawal of scarce resources make working conditions even more difficult. Simultaneously, they have to handle a wide range of questions and problems presented by the adolescents; varying from simple requests about headaches or contraceptives to complex psychosocial difficulties.

To target the discrepancy between the daily state of affairs and what is desirable, a Participatory Action Research (PAR) project was established at two upper secondary schools in Oslo, Norway, in 2005. The project continued for three years. Prior to the project, the first author, with professional background from speciality mental health services, conducted a pilot project together with the school nurses at one of the schools. The aim was to support the school nurses in their work with youth with psychosocial problems. The pilot project promisingly demonstrated how school nurses and mental health professionals together could develop their competence in mental health counselling in the context of school health services. Similar experiences are reported in the literature. Flaherty et al. (1998) state that working in schools, counsellors, psychologists, social workers, nurses and psychiatrists have a unique opportunity to address the mental needs of youth. They continue: «To deliver effective services, treatment modalities that have heretofore been used in clinics must be adapted for use and evaluated for effectiveness in school settings» (p. 420). In line with these experiences, the follow-up project was based on an assumption that the development of mental health consultations should build on competence from both the field of school nursing and mental health services. School nurses have implicit knowledge of what might be helpful through consultations with troubled youth in the context of school health services. Mental health professionals are educated and trained in mental health consultations, but in another context than school health services. The practice of counselling in school health services, however, need to be anchored in the context of health promotion and performed in ways that focus on the adolescents’ resources and active participation.

The concern of the present article is to elaborate on processes of collaboration among health workers from primary health services and speciality health services. According to The Norwegian Government’s Coordination Reform (Ministry of health and care services, 2009), increased cooperation across the two levels of health services, is crucial to improve services. How to develop this particular kind of collaboration raises many unanswered questions that need to be further elaborated. Some barriers to cooperation, however, are highlighted in the literature. Flarethy et al. (1998) note that even if there is no argument to be made against interdisciplinary collaboration in school services, the history of school personnel working alone implies an important barrier to cooperation. Another barrier highlighted by the same authors concerns group dynamics. Some professionals have more power entailing education, tradition and public reputation. They assert that questions of status and authority which is common to all organizations, may pose significant obstacles to interdisciplinary cooperation. The mental health professions’ history and traditions may represent their own kind of obstacles. The Norwegian child psychiatrist Nic Waal, who influenced the development of mental health services for children and adolescents for several decades, expressed her view on how professional status might influence the dynamics in a multidisciplinary team when she returned from London in the thirties: «It was easy to detect that the structure of the child psychiatric team usually was quite hierarchal...the child psychiatrist preceded over the team as the white godfather, the psychologist was the angel somewhat down the ladder and the social worker was climbing as best as he could at the bottom, humbly performing practical social work at the mercy of god psychiatrist» (Waal, 1969, p. 127). Although the structure of multidisciplinary teams to day is characterized by increased equality among members, power entailing professional status is still present.

The Norwegian action researcher, Tiller (2007), affirms that the rule of reciprocity and equality is one of the most important stabilizers when practitioners develop practice together.

«If the participants’ recognition of each other’s professional and social significance is lacking, a breakdown will soon occur», he says (p. 56). However, although equality is viewed as desirable and necessary, in real world practice it is difficult to perform. Experiences from the pilot project also suggested that tensions and contradictions entailing different professional positions inevitably will emerge among the participants.

Theoretical perspectives

Practice development through joint reflections

The project was based on an assumption that knowledge used in action should be grounded in daily experiences. The wide range of problems in school health services demands a kind of counselling that recognize uniqueness, uncertainty, complexity and instability that characterize such practices (Schön, 1983, 1987). This stance contrasts an instrumental practice that focuses on method and techniques. Another basic idea that underpinned the project, was to develop practice «from within» by active involvement of the practitioners themselves. Several action researchers claim that inviting practitioners to reflect on their own practice will make them more sensitive to the complexity of situations that practitioners face in their daily work (Teram, Schachter, & Stalker, 2005; van Manen, 2001). According to Kemmis (2006), this kind of action research can be described as «a practical form … that aims to inform the (wise and prudent) practical decision-making of practitioners» (p. 95). The work of Donald Schön can be placed within this kind of action research. Schön (1983) asserts that a key characteristic of psychotherapy and other forms of counselling is the dynamic and open ended processes which occur among the participants. Such practices are characterized by the reflective activity of the practitioner, her reflection-in-action. A reflective practice should be developed by the practitioners reflecting on how they act in concrete situations, reflection-on-reflection-in-action. Different issues can be reflected upon: the practitioners’ feelings, actions, thoughts, and also how the practitioner positions herself and how contextual conditions influence practice. A particular kind of reflection highlighted by Schön, is frame reflections. What the practitioner attend to, how a phenomenon is named, depends on how the situation is framed. He says that conflicts among professionals often can be traced back to different frameworks within which a phenomenon is interpreted.

Knowledge development through joint reflection gives priority to people’s experiences. Heron & Reason (2006) assert that the development of a reflective practice is based on «people examining their own experiences and action carefully in collaboration with people who share similar concern and interests» (p. 149). This kind of knowledge development highlights the importance of equality among the practitioners. The experiences of each participant, independent of professional background or other attributes, is at the heart of interest.

The significance of communicative space

In this theoretical perspective, the concept communicative space is vital. Building on Jürgen Habermas’ theory of communicative action (1984), Kemmis (2006) claims that «a communicative space is constituted as issues and problems are opened up for discussion, and when participants experience their interaction as fostering the democratic expression of divergent views» (p. 103). Kemmis underscores the importance of creating a climate that promotes each participant to articulate his or her genuine meanings. He states that the legitimacy of knowledge claims and what to do, will be proportional to the authentic engagement of those concerned. According to Kemmis, using PAR to develop knowledge, the legitimacy of theories depends on equality in participation of those involved. The quality of theory development will be hampered if some voices are silenced. Consequently, attention to the obstacles that get in the way of genuine dialogues is decisive (Wicks & Reason, 2009).

Aim and research question

The aim of this article was to explore processes of cooperation when school nurses and mental health professionals shall develop practice together. Which challenges can be identified and which conditions might facilitate collaboration?

Methods

A combination of PAR strategies and grounded theory methods provided the methodological approach. The PAR group included a total of four school nurses, two mental health professionals (the latter including the project manager), and the researcher. All participants had worked for 10 years or more in school health services, adolescent mental health services, or both. All were women whose ages ranged from the mid-thirties to the early sixties.

A common forum for reflection on practice was established, and the research group agreed on monthly meetings. The group shared the intention of developing counselling that gave priority to young people’s active participation in consultation sessions and change processes. The practitioners should present cases, then participate in joint reflection and arrive at a consensus about practices that were in accordance with this intention.

Data and data analyses

Transcripts from group discussions and our1 experiences as participating researcher and project manager provided the empirical basis. Four group discussions were audio taped and transcribed verbatim. Three of the group discussions focused on the practitioners’ views of the characteristics of this kind of practice. The fourth discussion focused on the members’ views of their own participation, and on the cooperation and climate in the group during the process. According to Dadds (2003), the study of practice through action research cannot be based on limited data sources alone. The participating researchers’ overall experiences also provide a legitimate data source. Hence, the findings are coloured by our experiences, reflections and discussions during the research process.

The transcripts were analysed by using grounded theory methods. The analytical process commenced by reading and re-reading the written material using the constant comparative strategy to acquire ideas about those issues that appeared to be particularly relevant to the participants (Strauss & Corbin, 1998). Constructivist grounded theory guided the analysis, which means that concepts are grounded in data, and then constructed by the researcher (Charmaz, 2006). The process proceeded from initial, open coding towards more focused coding building on emerging patterns in the data. Our interest in expanding the understanding of processes that emerged among the participants guided the analysis. Issues that led to high intensity and involvement were given special attention. This approach, termed «descriptive analysis», recommends looking for the strengths of the participant’s comments and opinions (Carey, 1995). The emerging issues were continuously discussed by the authors. The last group session, where the members reflected on their own participation and on the group climate, appeared to be of particular relevance in this sense. This transcript was therefore analysed more closely in a second step. At this stage the analysis was guided by theoretical sampling which «directs you where to go» (Charmaz 2006, p. 100). Theoretical sampling was used to determine the central dimensions that influenced collaboration.

Human subjects’ approval statement

The study was evaluated by the Regional Committee for Medical Research and approved by the Norwegian Data Inspectorate. It also received approval from the head teachers of the schools. The participants were informed verbally and in writing that they could withdraw from the study at any time.

Results

From the start of the project, until it was finished three years later, the research group had moved from a position characterized by doubt and insecurity to a position where the practitioners’ experiences of equality and togetherness had increased. Which conditions could be identified that did promote collaboration? The findings are structured around the following themes: first, to give place for expression of doubt and different opinions, and second, to share practice experiences. Conditions that hampered collaboration clustered initially around participants’ doubt and insecurity, and throughout the whole project around lack of time resources.

To give place for expression of doubt and different opinions

Our purpose for the group was that the practitioners should bring the uniqueness and complexity of «real-life» experiences to the group discussions and be open to joint reflections of their work. The practitioners, however, seemed reluctant to present concrete situations, and with some exceptions, the discussions were often held at a more abstract level. As we, (researcher and project manager), were eager to start work according to the project plan, the practitioners’ hesitation was an obstacle important to handle. Looking back, the practitioners’ hesitation could be linked to the unfamiliarity of this way of practice development. From the start they expressed uncertainty about reflection on practice as an approach to develop counselling. Some expressed doubts, while others more openly questioned how this way of developing knowledge could be practised. In the first group discussion, the practitioners expressed their thoughts in this way. Practitioner 1: «Who should decide what good practice is? The students might think differently from us. (This way of developing counselling practice) …is all too subjective…» Practitioner 2: «Maybe the students can answer a questionnaire …». Practitioner 3: «I wonder if you (the researcher) should present a model that we can use… or shall we rather just do our best, use our implicit competence? Then you can make a model at the end of the project». Practitioner 1: «What about validity? It is just subjective interpretations».

The practitioners address basic assumptions about knowledge and question whether this way of developing theory for practice produce reliable and valid knowledge. Some relate to an epistemological stance that considers validity of knowledge claims as neutral and objectively constituted. Others relate to an epistemological position that acknowledges the subjective and interpretive dimension in development of knowledge. During the research process tensions connected to the two positions appeared as doubt and insecurity among the practitioners. In the final group discussion, when the participants reflected upon their participation in the research process, the issue was addressed by one of the practitioners in this way: «We discussed: Do we believe in this project? What will come out of it? We had different opinions. We must not forget that. However, and that’s my point, I have a feeling that the objections led to a firmer grasp of the ideas. You get some bumps during the process, but I think it has been handled in a good way». This practitioner pays attention to how differences might lead to «getting some bumps», or in other words, how different views may threaten feelings of togetherness. On the other hand, the expression and negotiation of different views within the research group seemed to have strengthened this participant’s commitment to this way of creating knowledge.

To share practice experiences

Processes that strengthened feelings of togetherness and equality among the practitioners were also portrayed. One of the practitioners described it in this way: «When you work alone, you have no one positioned in the field in the same way as yourself. Then you sit talking to yourself, and you don’t get any response at all. To be together in a group has been very good, the best of it all». This practitioner draws attention to the meaning of sharing practice experiences as a basis for group discussions. She highlights working together as a prerequisite for the development of practice. The remark «to be positioned in the same way as yourself» might be understood as containing meanings related to equality, with no person being superior to the next. The process of working together, discussing and struggling with concepts seemed to have created a feeling of togetherness among the participants. How the feeling of togetherness had developed was further elaborated and also related to their multidisciplinary co-operation in the last group discussion. When the initial intention of learning from each other was brought up, one of the practitioners said: «I think that we have moved towards a more common way of practice. It makes us more unified to be aware of that ….» Researcher: «Can you elaborate on how this feeling of togetherness has developed?» Practitioner: «I think our group conversations have made us conscious of how we think about coping and resources. Certainly, we have done it our own way». This practitioner experienced that sharing practice and also sharing awareness of challenges, increased feelings of togetherness. She highlights diversity when it comes to action.

Lack of time resources

An important obstacle related to joint discussions concerned time constraints. While the progress of the project was a top priority for the researcher and project manager, the practitioners were worried about «stealing time» from the young people to discuss practice. This represented a dilemma for the practitioners as no additional resources were provided for this work. They expressed how this situation was experienced from their point of view: Practitioner 1: «During the discussions, I felt that there were expectations that we should participate more than we really wanted … it takes time, and you must do that work on top of your daily work». Practitioner 2: «It’s about time and all that kind of stuff. We are in the office and the telephones ring from morning till afternoon». The practitioners experienced expectations that were difficult to fulfil. As an unwanted consequence, some of the practitioners felt that they were forced to participate more than they wanted. The experience of getting short of time, was shared by all of the practitioners, and revealed a basic dilemma in practice development through joint reflection.

Discussion

I accordance with Donald Schön’s model on The Reflective Practitioner (1983) we want to focus the discussion on conditions that might promote togetherness and equality among the practitioners. This model recommends that practitioners engage in reflection- on- reflection- in- action, which means that the practitioners share practical experiences and participate in joint discussions about the practitioner’s actions in that particular situation. To decide what might be recognized as good practice, it is vital that the contributions from all the practitioners are included. Consequently, to establish communicative space that facilitates authentic dialogues is crucial to practice development.

We found that to acknowledge feelings related to doubt and insecurity about this way to develop practice was essential. These feelings could be related to different epistemological stances among the practitioners. Knowledge development through reflecting on practical experiences in a group context in a systematic way is rather seldom. Redmond (2006) asserts that the unusualness of this way of learning might influence participants’ readiness to take part in reflective work. Moreover, those who favour the dominant medical paradigm in health research also challenge the legitimacy of PAR (Koch & Kralik, 2006). Considering the power of the evidence based health care discourse in which our project was embedded, the insecurity, doubt and disagreements expressed by participants must be taken for granted.

Doubts might be fruitful as well as obstructive. Kesby (2005) confirms that to make the PAR approach genuine, it must truly enable multiple, critical voices and cooperation. Some of the practitioners affirmed that doubts and different views had strengthened their commitment to practice development through joint reflection. On the other hand, as Kemmis (2006) advocates, to make cooperation work, everybody must take an in- principal stance in participation. The participants must in spite of uncertainty, make a decision to contribute in a constructive way. Doubts and insecurity might occur, but the participants must be willing listen to each other and learn from each other. Hacker and Wessel (1998) propose that differences connected to frame of reference should be proactively prevented by addressing possible problems openly. One might assume that to make clear that differences in views is taken for granted and welcomed, will allow different opinions to be articulated more freely and contribute to the creation of authentic dialogues.

Kemmis (2006) expands the understanding of participation by highlighting different ways of contribution. He asserts that much advocacy of action research has been premised upon a group of persons willing to work together. However, after practicing action research in different settings, he argues that even if each individual must take an in-principle stand to participate, participation can be shaped in different forms; «… as a speaker or listener, at the podium or in the gallery….or even as the person who finds the discussion irrelevant and lips away by a side door» (p. 103). Hence, to recognize and welcome diversity in ways of participation might strengthen the genuine contribution of each participant.

To acknowledge that each practitioner must follow her own pathway can also be connected to how the practitioners share experiences. Although sharing practice experiences on a more abstract level strengthened feeling of togetherness, when it came to study practice more closely, the practitioners hesitated to take part. In the literature, the practitioners’ willingness to jeopardize themselves has been argued to be a prerequisite for the development of knowledge through reflection (Lindholm, Nieminen, Makela, & Rantanen-Siljamaki, 2006). However, reflection on practice is a deep and personal process. It involves the practitioners’ reflections on experiences in both professional and personal life domains (Neufeldt, Karno, & Nelson, 1996; Rønnestad & Skovholt, 2001). To make oneself visible to others might evoke ideas of being criticized in a negative way. The practitioners’ hesitation might be understood as a strategy to explore whether the group was safe enough for the members to jeopardize themselves.

Recognizing the nature of reflection, one might assume that the characteristics of the atmosphere in which reflections are embedded is of great importance. To create a group climate characterized by openness and safety is vital for all the members to expose themselves. Dadds (2003) addresses the emotional climate that promotes reflexivity and authentic dialogues: «We need to learn to apply positive skills of self-critique, with helpful and loving friends that do not turn critique into self-chastisement» (p. 271). Such an atmosphere must be developed over time.

Kemmis (2006) asserts that equality among the practitioners is a prerequisite for the validity of knowledge claims. Each participant must feel free to articulate his or her genuine meanings and legitimacy of knowledge claims and what to do will be proportional to the authentic engagement of those concerned. We found that equality across interdisciplinary boundaries developed through working together and struggling with the same concepts. These findings support Park (2006), who affirms that relationships characterized by equality develop through engaging in the same activities, experiencing the same things and taking part in the same culture. In a multidisciplinary team this issue entails some challenges. The very idea of teamwork is that each participant contributes with specific knowledge. Equality, however, must not be mixed up with «sameness». «Sameness» understood as «doing the same things», undermines the idea of multidisciplinary teamwork. The group as a whole share some basic principles for how to work. These principles are grounded in a common vision and constitute a theoretical framework within which the practitioners carry out their own practice, as one of the practitioners stated: «We have done it our own way».

One obstacle to the development of togetherness and equality among the participants, relates to territory. In our case, mental health workers entered the nurses’ territory. The relationship between practitioners from the field of school health services and mental health services is characterized by inequality in terms of professional power. For example, mental health professionals often act as supervisors and teachers for school nurses, but seldom the other way around. On the other hand, when practitioners from one field of practice enter into another field already «possessed» by another health profession, processes of protection of territory might emerge. Some fields, including school health services, are by tradition strongly identified with profession. It is, however, important to separate protection of territory from protecting practice forms. Protection of territory represents a barrier to collaboration, protection of practice represents a possibility to articulate ones experiences and reflect on it in a group. Flarethy et al. (1998) state that for school based multidisciplinary health centres to be successful both parties must move away from territorial stances and develop a shared vision. «All the involved professionals must take responsibility for generating an activism, energy and spirit»(p. 412). To overcome the obstacle that inequality in professional status represents, a common vision and a common framework is decisive; and even more important, a mutual recognition of each other’s significance.

We have, so far, highlighted conditions that might enhance the development of equality among the practitioners in the development of practice through reflection. Time constraints were a crucial obstacle to the development of authentic relations in the group. This finding supports the results from other PAR projects, where the importance of not underestimating material conditions is underscored (Fine et al., 2003; Kesby, 2005). Waterman et al. (2007) state that involving practitioners when using PAR in health-care research is one of the hardest tasks because even supportive participants might have other business to attend to. We learned that the institution, at an organizational level, must take responsibility for providing the time necessary for the practitioners to participate. On the other hand, van der Velde, Williamson and Ogilvie (2009) assert that from their experiences, financial stability alone is not sufficient to motivate participation. In line with this, Westhues et al. (2008) found that commitment to PAR meant that in spite of busy time schedules, the participants found time to participate in meetings. However, to be committed to practice development through reflection takes time and to secure sustainability, institutional anchoring and support is decisive.

This article has highlighted some dimensions that influence collaboration across professional boundaries in the development of practice through joint reflection. Reflection on practice is a long-term learning process, and an open, supportive and non-critical atmosphere is vital for genuine dialogues to take place. In an optimal situation the organization as a whole is engaged in creating contexts for learning, creativity and togetherness. Von Krogh, Ichijo and Nonaka (2000) articulate the meaning of institutional support in this way: «Knowledge enabling … relies on a deeper level on a new sense of emotional knowledge and care in the organization, one that highlights how people treat each other and encourages creativity — even playfulness» (p. 4).

In the light of this statement the institution’s readiness to develop, and maintain, communicative spaces where productive dialogues can take place, provide the basis for practice development through reflection.

Methodological reflections

To combine GT with a PAR strategy is contended to strengthen research results (Teram, Schachter, & Stalker 2005). Both approaches develop theory grounded in experience and GT methods are considered to strengthen analytical rigor (Dick, 2007). However, one important methodological problem concerns the participation tenet. In action research participants should be involved in every stage of the research process. People are regarded as co-researchers, not only as informants. To involve all participants in the analytical process is considered to strengthen the validity of knowledge claims (Heron & Reason, 2006). Also in GT to involve participants in the analytical work is recommended (Morse, 2007). In this study the analysis were conducted by the researcher, supervisor and the project manager. Though both the researcher and the project manager were active participants in the project, our positions were different from those of the practitioners. If all the practitioners had been included, other issues might have been focused on and the analysis might have been more detailed.

Another issue that should be reflected on is quality of data. The data were collected in 2005. This might weaken validity of the findings. Our experiences are, however, that how to promote equality and togetherness among the practitioners continue to be a decisive task. After the project period came to an end, a new PAR project that continued and even expanded our work, was established. Currently, multidisciplinary teams with practitioners from school health services and speciality mental health services supply several upper secondary schools. The practitioners continue to reflect on how they together can develop counselling that promotes health and well-being among youth. In these processes equality and mutual respect cannot be taken for granted, but must be highlighted and reflected on, over and over again.

Funding

The study was funded by the institutions: The Norwegian Foundation for Health and Rehabilitation, and Centre for Child and Adolescent Mental Health, Eastern and Southern Norway.

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1Throughout the article, ‘we’ includes the first author as a researcher participating in the team, the second author as research supervisor and the third author as project manager.

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