Mental Health Nursing: Case Study

In the contemporary rapidly-developing world, healthcare can be noted as one of the most challenging areas. Both quality and safety of care depend on a range of diverse factors, including patients’ demands and expectations, financial constraints, inappropriate access to services, workforce issues and the need to adapt and continuously improve patient-centered care (Gopee and Galloway, 2014). In this connection, the scholarly literature states that effective governance is essential to ensure high-quality care in both inpatient and outpatient settings (Asamani et al., 2016; Dickson, McVittie and Smith, 2020). This paper aims to examine the case study of a patient with emotionally unstable personality disorder and respiratory system issues, focusing on the role of leadership and interprofessional team collaboration. Using the evidence-based literature and personal experience, it is expected to identify the most suitable leadership styles and teamwork approaches.

In the given case, Mrs. B., a 35-year-old female patient, has emotionally unstable personality disorder and chronic pain. She returned from the leave to the hospital and was referred to the student nurse by a nurse in charge to monitor her vital symptoms. Mrs. B. was found unconscious in her room and resuscitated by the nurse in charge, while the Clinical Team Lead (CTL) was also present. This information was transferred to the Multidisciplinary Team (MDT, and when the student nurse noticed hypertension, high temperature and saturation, the Medical Emergency Team (MET) was called. Due to pain relief medication overdose, the patient was placed in the Intensive Care Unit (ICU). This case shows a lack of proper leadership and management to ensure a high-quality and coordination of care providers, which resulted in health complications of the identified patient.

In order to understand the changes that could be applied to the given case study, it is critical to pay attention to the links between Mrs. B.’s diseases and the role nurses play in handling them. The review of epidemiological information on personality disorder shows the “prevalence of personality disorder of between 4% and 15%” in North America and Europe (Tyrer, Reed and Crawford, 2015, p. 720). In females, this prevalence is higher, and people with personality disorders have higher morbidity and mortality rates. These findings mean that mental health care nurses should be more attentive to their patients to detect any symptoms and address them in a timely manner. For example, Paton et al. (2015) and Antai-Otong (2016) are consistent in the assumption that evidence-based care should be applied to such patients. The attitudes of nurses towards patients are critical: their emotional and behavioral responses impact therapeutic relationships, as well as care delivery processes and outcomes (Loader, 2017; Mack and Nesbitt, 2016). Psychoeducation and training of nurses is a viable way to enhance their knowledge and attitudes (Clark, Fox and Long, 2015; Dickens, Hallett and Lamont, 2016).

In this case study, it is clear that nurses and teams already have a certain set of knowledge and skills, as well as experience working in the mental health unit. However, as health care transforms, and the nursing profession develops, they need new areas of expertise and strong leadership to guide their actions. In particular, there is a need to develop their competencies, clinical thinking, nursing diagnostic skills, and communication (Cope and Murray, 2017). The above authors emphasize that management focuses on people doing their responsibilities, but leadership prioritizes making people adopt correct behaviors and attitudes. Considering a lack of coordination among various care providers to help Mrs. B., it seems that transformational and participative leadership styles are most pertinent to making mental health care more focused, timely and patient-centered.

Higher life span, expectations and lifestyle choices set an additional burden on mental health care of the 21st century. The World Health Organisation (2013) distinguishes between six dimensions of quality, such as accessible, safe, equitable, efficient, effective and acceptable to patients. The fundamental aspects of care quality are patient experience, patient safety, and clinical effectiveness. The challenges of keeping the condition of the given patient stable are associated with the last two aspects, which can be minimized through the theory of transformational leadership. According to this leadership style, a leader should encourage people to do more of what they initially considered possible, through the exchange of personal ideas, knowledge and expertise (Huston, 2017). While not trusting employees, the leader may never find out about their problems and receive critical information. The leader can create an enabling environment by developing open, two-way communication in which he or she transmits and obtains information. Such an environment can be formed via the presence of the leader in the working area and building relationships with the members of a team.

It is beneficial for a leader in nursing to monitor the implementation of tasks daily and regularly checks the progress towards the main goal. It is important to clearly understand where they can achieve success since only in this case, people learn to develop and consolidate successes to further improve (Tafvelin, Hyvönen and Westerberg, 2014). For example, once every three months, it is worth testing the level of competencies of employees with subsequent analysis. Negative information is usually a warning or a signal of danger, but sometimes it makes it difficult to choose the right direction and often slows down the movement to the goal. A nurse with the psychology of a loser sees the mistake as the end of a failed action, losing the target and feeling guilty (Tafvelin, Hyvönen and Westerberg, 2014). A transformational nurse leader can use different methods to create an environment conducive to staff support and open communication.

Speaking of the strategies, one way is to conduct informal rounds of patient care units and consult with nurses about the problems they face. Giddens (2018) stresses that by participating in such events, the leader shows interest in the nurse as a person and demonstrates attention to staff performance. The atmosphere of open communication can also be designed by exchanging information with nurses at meetings. Another way to create a trusting environment is to involve nurses in the sectors of the Nursing Councils where they can share their knowledge and experience, contributing to better patient care. By providing nurses with the opportunity to engage in this type of activity, the nurse supervisor helps them gain new knowledge and skills and shows confidence in their abilities (Giddens, 2018). Guided by the theory of transformational leadership, a leader nurse contributes to the maximum development of the potential of nurses, empowering them to share views and remain open to changes.

Democratic leadership style is another option that is characterized by the distribution of power and authority among the team members. In a democratically managed team, leadership functions are divided between employees and the leader, who is often considered the most authoritative actor (Sullivan and Decker, 2013). Such an organization promotes two-way interaction between the team and its leaders. Greater decentralization of power means the greater influence of employees on policy development, decision-making and the application of control systems. Among the most important characteristics of the democratic style of leadership, there are the delegation of authority and ongoing consultations on important issues. In such a team, communication flows are actively working in both directions. The leader unquestionably bears the ultimate responsibility, but, at the same time, actively delegates authority to other members of the team. Compared to the transformational style, this leadership style is marked by an active transfer of information both from top to bottom and vice versa (Sullivan and Decker, 2013). Due to the participation of nurses in decision-making processes, their involvement is at a high level in both leadership styles.

As nurses participate in the decision-making process within the framework of the democratic leadership style, they are more inclined to contribute to their implementation, creating the conditions for greater creativity and productivity. Employees also try to take great initiative – they are looking for new methods for accomplishing tasks to work more efficiently in less time and cost, which ultimately leads to productivity growth (McKeown & Carey, 2015). The team’s creative spirit creates conditions for the growth of the level of innovative ideas and technological solutions generated by the employees. The right to make mistakes and constant feedback give place to creative thinking. The process of consultations and participation in decision-making boosts personal interest and openness (Huston, 2017). The culture of democratic management is considered by giving employees a certain responsibility and setting positive, motivating tasks for them (Harris and Mayo, 2018). This approach allows employees not to be afraid to talk about problems and difficulties, as well as ask for help in solving them.

The critique of the democratic leadership style is related to the issue of time. Namely, the decision-making process in a team requires time that an employee could spend on his or her job (Saleh et al., 2018). It is clear that the collegial form is not suitable for every solution, and that it will be problematic in a crisis, when the speed of response is essential. In contrast, transformational leadership allows for making rapid decisions since it is the leader who guides others’ actions. On the contrary to transformational leadership, democratic leadership can engender a pseudo-participatory culture (Saleh et al., 2018). In those situations where the leader does not adhere to a democratic manner, but only pretends, a serious threat to the formation of a culture of pretense and double standards may arise in the team.

In a democratic management model, team members can function even in the absence of a leader. However, the absence of a leader can lead to completely opposite results in cases where employees are not accustomed to a participatory style and do not have self-organization skills, or have not yet managed to develop sufficiently mature views and skills-building horizontal connections (Fowler, 2016). Some studies note that in the short term, there is great productivity at the initial stage (Tafvelin, Hyvönen and Westerberg, 2014). However, this period is usually replaced by a rapid decline in productivity in a long period. The level of productivity in authoritarian-driven teams falls significantly below the level of productivity of teams with democratic and transformational styles.

The application of nursing leadership theories is often associated with considerable barriers. A lack of incentives, poor communication, clinical cynicism, and a low level of confidence can be mentioned. Griffith (2015) states that confidentiality is especially significant in terms of nursing as it proposes making sure that patients’ sensitive information is kept securely and shared appropriately. According to the latest Nursing and Midwifery Council (NMC) Code, nurses can “share necessary information with other health and care professionals and agencies only when the interests of patient safety and public protection override the need for confidentiality” (NMC, 2015, p. 8). The inter-professional collaborative practice implies systematic and integrative care, and nurses should be aware of the above principle when they work in a team. The right to confidentiality is inherent to all the patients, who can stay aware of the process of care, as far as the law allows (Griffith, 2015). In this case, sharing patient information can be regarded as one of the benefits of interprofessional collaboration, which contributes to informed decision-making.

As care providers, nurses, physicians, nurse leaders, managers, and other team members, tend to behave differently in working settings. Each of them possesses a unique set of skills, knowledge and experience, but some clusters can be used to classify these behaviors. DaCosta (2020) examines Belbin’s teamwork theory, according to which there are nine basic roles. A leader has a role of a Shape to guide projects or a Co-coordinator to align tasks and relevant persons. In case of Mrs. B., the clinical team leader can take one of these roles to overview and monitor the entire process of care delivery. Another group of roles includes a Completer-Finisher, Implementer and Monitor-Evaluator, who are responsible for some specific action or procedure (DaCosta, 2020). For example, the nurse in charge and student nurse should monitor the patient’s symptoms and timely call for their colleagues, if necessary.

Since little attention was paid to the dosage of medication, it becomes evident that the team’s coordination is insufficient. It would be better if at least one of the team members identified this problem and prevented Mrs. B.’s health complications. In particular, the so-called “doers”, registered nurses, physicians or nurse assistants, could note and report about this problem. In the context of Belbin’s teamwork theory, there can be Plant-Innovators, who offer new ideas and promote the implementation of innovations into practice (DaCosta, 2020). For example, a manager of the ward or a social worker can take this role and prioritize staff and patient education to stop the patient’s leaves. Team Workers and Resource Investigators are the persons who support others and communicate across the disciplines, such as the nurse in charge. Ultimately, an Expert-Specialist role is to be taken by a nurse consultant to provide the depth of expertise.

The teamwork theory that is applied to the given case study above shows that patient-centered care, comprehensive care delivery and closing communication gaps are the key benefits of inter-professional collaboration in care settings. As rationally argued by MacKian and Simons (2013) and Wilson et al. (2016), collaborative care reduces medical errors and improves patient health outcomes. It becomes easier to notice and understand mistakes and insufficiencies when serval care providers hold their responsibility areas and share valuable information. The recent study by Coventry et al. (2015) points to the positive impact of partnerships in psychological care delivery, which is expressed in the improvement of patients’ self-management of chronic disorders. In addition, the cooperation between various caregivers allows for starting treatment faster due to connectedness and timely response to the emerging problems (Wilson et al., 2016). It should also be stressed that it empowers the team members, who are invited to make recommendations and impact important decisions.

While inter-professional collaboration has a variety of advantages, some challenges should also be discussed. Among the most pronounced barriers, scholars list organizational, team-level and individual ones (Illingworth and Chelvanayagam, 2017). A lack of understanding and appreciation of others’ roles in a team and clearly-stated goals compose the main challenge at the organizational level (MacKian and Simons, 2013). There can also be resistance to cooperation, which is especially widespread between experienced and novice nurses, when the former does not want to share knowledge and skills with the latter. The policies accepted in hospitals can also impede the process of interdisciplinary cooperation (Illingworth and Chelvanayagam, 2017). In the given case study, the members of the team did not have clear instructions on how they should act in case of emergencies, which probably occurred due to leadership ambiguity. It would be better if the leader discussed this situation at the meeting so that the team would formulate and implement the guidelines to avoid similar cases in the future.

At the team level, the barriers to effective inter-professional collaborative practice include a lack of training, low professionalism of the team members, the absence of commitment to teamwork, conflicts and poor cooperation mechanisms. Beirne (2017) notes that individuals can also encounter prejudices, competition, a lack of trust and openness, as well as multiple responsibilities. It seems that the last three challenges are pertinent to the case of Mrs. B., which requires establishing a unified philosophy and developing a commitment to a common goal of high-quality care. These approaches inform inter-professional and multi-agency working, clarifying that all the team members should learn and recognize others’ contributions. According to a collaborative approach, the members should negotiate continuously to identify the roles, goals and practices (Dowell, Moss and Odedra, 2018; Watters et al., 2015). It is also critical to ensure that teams respect others’ knowledge and skills and support positive attitudes towards the nursing profession. The need to establish mutual trust and responsibility underlies successful collaborative tendencies and outcomes.

Proper communications promote building honest and transparent interactions in a team. The readiness for interprofessional cooperation can be defined as a personality quality that contributes to the productive integration of individual activities of professionals in solving complex, multifunctional problems (Watters et al., 2015). At the same time, from the perspective of the study, it is advisable to consider motivational readiness as a person’s readiness to transform his or her activity and change motives, when meeting with significant information that can affect such a transformation (O’Sullivan, Moneypenny, and McKimm, 2015). Based on the foregoing, readiness to change is a complex construct that contains in its structure not only communication but also cognitive, personal, and social components.

It is essential to note that the contribution of every team member is important for the ultimate goal achievement. The role of self in collective decision-making plays a key role to align personal and organizational stances. According to Watters et al. (2015), interprofessional increases the self-efficiency of a person in teamwork and leadership. In terms of the communication dimension, training leads to better staff performance and, consequently, result in improved patient outcomes. Among the main training needs, there is the ability to make informed decisions, effectively use evidence-based interventions, consider negotiation and consultation opportunities and shape a common understanding regarding care practices. Compared to a uniprofessional approach to training, interprofessional practices encourage the greater engagement of nurses and stimulate the interest in ongoing learning. Thus, communication, teamwork and leadership shape a triangle for effective interprofessional collaboration.

To conclude, it should be emphasized that a lack of strong and determined leadership, as well as poor team interaction, were the main causes of Mrs. B.’s health deterioration. The case analysis allowed for revealing that a range of professionals who were involved in care need to improve their awareness of others’ knowledge, skills and responsibilities. The patient had a medication overdose, leaves from the hospital, and had respiratory issues, and the failure to properly manage her condition points to the ineffectiveness of inter-professional collaboration. Transformational and democratic leadership styles were proposed to be applied by a leader to empower the team members to participate in decision-making and build interpersonal relationships. The examination of benefits and challenges to inter-professional team performance identifies the need to adopt a collaborative approach and focus on communication, which requires staff training, constant meetings, and open discussions.

Reference List

  1. Antai-Otong, D. (2016) ‘Evidence-based care of the patient with borderline personality disorder’, Nursing Clinics, 51(2), pp. 299-308.
  2. Asamani, J. A. et al. (2016) ‘Do leadership styles influence productivity?’, British Journal of Healthcare Management, 22(2), pp. 83-91.
  3. Beirne, M. (2017) ‘The reforming appeal of distributed leadership’, British Journal of Healthcare Management, 23(6), pp. 262-270.
  4. Clark, C. J., Fox, E. and Long, C. G. (2015) ‘Can teaching staff about the neurobiological underpinnings of borderline personality disorder instigate attitudinal change?’, Journal of Psychiatric Intensive Care, 11(1), pp. 43-51.
  5. Cope, V. and Murray, M. (2017) ‘Leadership styles in nursing’, Nursing Standard, 31(43), pp. 61-70.
  6. Coventry, P. et al. (2015) ‘Integrated primary care for patients with mental and physical multimorbidity: cluster randomised controlled trial of collaborative care for patients with depression comorbid with diabetes or cardiovascular disease’, BMJ, 350, pp. 1-12.
  7. DaCosta, J. (2020) ‘Insights for implementing change in healthcare’, British Journal of Healthcare Management, 26(1), pp. 20-26.
  8. Dickens, G. L., Hallett, N. and Lamont, E. (2016) ‘Interventions to improve mental health nurses’ skills, attitudes, and knowledge related to people with a diagnosis of borderline personality disorder: systematic review’, International Journal of Nursing Studies, 56, pp. 114-127.
  9. Dickson, C., McVittie, C. and Smith, M. C. (2020) ‘Being conductor of the orchestra: an exploration of district nursing leadership’, British Journal of Community Nursing, 25(5), pp. 214-221.
  10. Dowell, S., Moss, G. and Odedra, K. (2018) ‘Rapid response: a multiprofessional approach to hospital at home’, British Journal of Nursing, 27(1), pp. 24-30.
  11. Fowler, J. (2016) ‘From staff nurse to nurse consultant clinical leadership part 2: leadership styles’, British Journal of Nursing, 25(9), pp. 522-541.
  12. Giddens, J. (2018) ‘Transformational leadership: what every nursing dean should know’, Journal of Professional Nursing, 34(2), pp. 117-121.
  13. Gopee, N. and Galloway, J. (2014) Leadership & management in healthcare. 2nd ed. London: Sage.
  14. Griffith, R. (2015) ‘Understanding the code: working in partnership’, British journal of Community Nursing, 20(5), pp. 250-252.
  15. Harris, J. and Mayo, P. (2018) ‘Taking a case study approach to assessing alternative leadership models in health care’, British Journal of Nursing, 27(11), pp. 608-613.
  16. Huston, C. J. (2017) Professional issues in nursing. Philadelphia: Wolters Kluwer.
  17. Illingworth, P. and Chelvanayagam, S. (2017) ‘The benefits of interprofessional education 10 years on’, British Journal of Nursing, 26(14), pp. 813-818.
  18. Loader, K. (2017) ‘What are the effects of nurse attitudes towards patients with borderline personality disorder?’, British Journal of Mental Health Nursing, 6(2), pp. 66-72.
  19. Mack, M. and Nesbitt, H. M. (2016) ‘Staff attitudes towards people with borderline personality disorder’, Mental Health Practice, 19(8), pp. 28-32.
  20. MacKian, S. and Simons, J. (2013) Leading, managing, caring: understanding leadership and management in health and social care. Abingdon: Routledge.
  21. McKeown, M. and Carey, L. (2015) ‘Democratic leadership: a charming solution for nursing’s legitimacy crisis’, Journal of Clinical Nursing, 24(3-4), pp. 315-317.
  22. NMC. (2015) The Code. Web.
  23. O’Sullivan, H., Moneypenny, M. J. and McKimm, J. (2015) ‘Leading and working in teams’, British Journal of Hospital Medicine, 76(5), pp. 264-269.
  24. Paton, C. et al. (2015) ‘The use of psychotropic medication in patients with emotionally unstable personality disorder under the care of UK mental health services’, The Journal of Clinical Psychiatry, 76(4), pp. 512-518.
  25. Saleh, U. et al. (2018) ‘The impact of nurse managers’ leadership styles on ward staff’, British Journal of Nursing, 27(4), pp. 197-203.
  26. Sullivan, E. J. and Decker, P. J. (2013) Effective leadership and management in nursing. New Jersey: Pearson Prentice Hall.
  27. Tafvelin, S., Hyvönen, U. and Westerberg, K. (2014) ‘Transformational leadership in the social work context: the importance of leader continuity and co-worker support’, The British Journal of Social Work, 44(4), pp. 886-904.
  28. Tyrer, P., Reed, G. M. and Crawford, M. J. (2015) ‘Classification, assessment, prevalence, and effect of personality disorder’, The Lancet, 385(9969), pp. 717-726.
  29. Watters, C. et al. (2015) ‘Does interprofessional simulation increase self-efficacy: a comparative study. BMJ Open, 5(1), pp. 1-7.
  30. Wilson, A. J. et al. (2016) ‘Interprofessional collaborative practice for medication safety: nursing, pharmacy, and medical graduates’ experiences and perspectives’, Journal of Interprofessional Care, 30(5), pp. 649-654.
  31. World Health Organisation. (2013) Interprofessional collaborative practice in primary health care: nursing & midwifery perspectives. 

Appendix

NS622 CASE STUDY(ESSAY)

A 35 years old female patient who suffers from Chronic Pain and was diagnosed of Emotional Unstable Personality Disorder, returned on the ward from leave. For confidentiality reasons, this patient will be referred to as Mrs B.

The day had started with a handover session of three Registered nurses, two Healthcare Assistants and a second-year student nurse currently on placement on the ward. The nurse in charge delegated tasks and assigned the student nurse to monitor vital signs of Mrs B. On getting to Mrs Bs door, the student heard no response after knocking three times. She opened the door and saw Mrs B lying unconscious on the floor, the student nurse shouted for help and pressed the security bleep while the nurse in charge and the Clinical Team Lead (CTL) rushed into the room. The nurse in charge commenced resuscitation for ten minutes, Mrs B was eventually resuscitated and was placed on 1:1 observation monitored by the CTL to ensure that no adverse event occurs.

The nurse in charge advised the student nurse to conduct vital signs while she informed the Multidisciplinary Team (MDT), consist of Consultant, Manager of the ward, Physician and Social Worker of the incident. The student nurse conducted vital signs as instructed and found out that the vital signs of Mrs B were deteriorating. Her Pulse was 130, Saturation (SpO2) was 80%, systolic/diastolic was 197/80 and Temperature was 38.5. The student nurse sensed out that something was not right then called the CTL and the nurse in charge, both recalled their nursing skills, decide to call Medical Emergency Team (MET) and started to provide emergency aid. They changed the position of Mrs B and immediately got hold of a Physician who advised to give emergency aid to Mrs B. The MET gave clear instructions and active communication while the emergency aid was giving saved the patient from adverse event.

The MET arrived, and the student nurse recorded NEWS Score on Electronic Patient Records before the CTL handed over the vital signs results to the Team and took Mr B to intensive Care Unit (ICU) for a short period of time for further observations and was brought back on the ward after few hours. It was observed that Mrs B was suffering from respiratory and circulatory distress because of an overdose of pain relieve medication she took while on unescorted leave.

The MDT met and discussed on how to stop Mrs Bs unescorted leave and manage her mental and physical health on the ward.