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Collaborative working


This assignment will be based on collaborative working, it will be in two sections, section one will look at definition of collaboration and will then address the highlighted issues within collaboration such as a need for and applying inter professional collaboration between mental health service providers and the way they collaborate with service users and their families which is required by the Department of Health (DoH 1990/91 to 1999/1999a). Within this section will be a brief outline of issues that are relevant to the DoH such as policy initiatives that advocate collaboration within and between teams as well as other service providers.  Section one will also look at the barriers, difficulties and challenges that has been highlighted with the usage of effective collaboration workings between both multi professionals and service users.

Section two will hopefully show my own personal experience of collaboration through the critical summary of my reflections which i have used The Gibb's (1998) model of reflection (see appendices 1-3) this has been based on my learning experiences during the course involved client assessment and the implementation of their care and treatment packages.  Within this section the critical scrutiny   will involve re-examining my skills in working collaboratively with both clients and multi-disciplinary team (MDT), within the framework of mental health care, identifying areas for additional development. It must be prominent that the names of all persons contained within this part of the assignment are illusory due to confidentiality which remains in accordance with the Nursing & Midwifery Council (NMC 2008) The Code.

Part 1: Defining collaboration & outline of issues

The literal translation of collaboration from the Latin is ‘together in labour', whilst the dictionary definition of ‘to collaborate' is ‘to work with another or others on a project' (Chambers 1999). However, Clifford (2000 pp103) in re-iterating Henneman et al‘s. (1995) earlier argument stated that, in practice, the process of defining collaboration remained a “complex, sophisticated, vague and highly variable phenomenon”, which often resulted in inappropriate usage of the term, as issues relating to collaboration were (and still are) referred to using a range of terms, all intended to indicate broadly similar processes e.g.: ‘inter-professional/multidisciplinary', ‘inter-agency/multi-agency', ‘intersectional', ‘teamwork' & ‘co-operation‘. However, Hall & Weaver's (2001) conclusion that although both require people to work together (sharing information, knowledge & skills) in achieving common goals, inter-agency partnerships are created at a formal organisational level (service planning), whilst multi/inter-professional collaboration involves different professionals working directly to achieve service-user care/treatment, seems to sum up differences in concept/process & Barret et al. (2005) have concluded that in practice even if the composition of team(s) or group(s) varies, these indicate similar ideas of collaborative effort, which Hall & Weaver (2001) stressed required co-ordination in order to ensure that each professional's effort is acted upon and that each is aware of what the others are doing.

The move towards interagency (across health & social care boundaries), & multidisciplinary (within & between teams) collaboration, began with the shift in emphasis from institutional to community-based care, when it was felt that the demarcations and hierarchical relations between professions were neither sustainable nor appropriate (Barr et al. 1999 & Sibbald, 2000) & new ways of working that crossed professional boundaries, had to be found, to facilitate a more flexible approach to care delivery (Malin et al., 2002). Thus the promotion of inter-professional working in the delivery of healthcare has long been regarded by the DOH, theorists & practitioners as of great importance, in providing a better quality of service, as highlighted by the NMC (2008) and in UK government policy over the last two decades, at least. However Whitehead (2000), also highlighted the fact that one example of team working that was surprisingly neglected in the nursing literature of the time, was the partnership between client and nurse, which she argued should be regarded as part of the collaborative framework as well as in a team context.

Although, Whitehead (2000) highlighted the fact that client-professional collaboration was neglected in the (nursing) literature of the time, which she argued was an important element, it should be noted that this was not neglected by the DOH in their policy & guidance documents for all mental health workers & the DOH has consistently highlighted the need to collaborate with service-users &/or their family/carer. For example the Care Program Approach (CPA), its' up-date Effective Care-coordination (ECC) & the National Service Framework for Mental Health ({NSFMH}: DOH; 1990/1991, 1997, 1999/1999a) all specified the need for all service providers to work with their clients, highlighting the belief that such collaboration increased client satisfaction and improved client engagement. However, research by e.g. the Sainsbury Centre for Mental Health (SCMH 1998, 2003) & the DOH (e.g. 2006a) identified that neither the CPA or the ECC initiatives where working & there has now been a return to the original principles of the CPA (DOH 2008/9) in an effort to address problems & further emphasise the need for collaboration between service-providers & with service-users in providing evidence-based & agreed care/treatment packages.

The rationale for such policy stems from the recognized need to break-down organizational barriers between health & social-care services in particular to ensure that service-users received adequate care/support/treatment through integrated services (DOH 1997, 1998/1998a) & that they were involved in the planning & delivery of care (DOH  1998b). However, as the SCMH (2001/2002) identified in their ‘Keys to Engagement', such changes/initiatives required specific skills for mental health workers (see appendix 4), particularly if the targets of the NSF for Mental Health were to be achieved.  Based in this document the DOH (2004) identified core skills/competencies required by all mental health workers to work with each other & with service-users in achieving evidence-based outcomes & for nurses the ‘Values-to-action' document (DOH 2006b) further emphasised the need for such knowledge & skills/competencies in the application of an holistic approach based in the ‘Recovery Model'.

This document is further supported by the NMC's (2008) revised code which reiterates their consistent requirement that nurses should not only work with their peers, but also with other professionals and importantly with clients in developing their care-package & in relation to community mental health nurses (CMHN's) one role that was introduced through the NSFMH and ECC guidelines (DOH 1999/1999a) was that of the care-coordinator (previously key-worker), for the DOH acknowledged the CMHN's central position & suitability for this role (O'Carroll & Park 2007). Effective care-coordinator's, & all nurses, as with other professionals, must appreciate the roles of the other members of the MDT, and possess excellent communication & collaborative skills (Bonney. in Davis & O'Connor 1999, Hadland 2004, Stuart 2005), as emphasised by the DOH (2004, 2006), SCMH (2001) & NMC (2008).

However, as e.g. Hudson (2002), Hadland (2004) & Whitehead (2001) identified besides the benefits of collaboration, a variety of barriers exist, in relation to service-providers, hindering the developments of close collaborative relationships (see appendix 5)

However, given the above changes have been proposed to implement across professional common foundation programme of training of all healthcare workers to enhance inter-disciplinary communication (NHS Plan: in Lilley. 2001) & although these have been introduced (to varying degrees) within approved educational institutions, the DOH (2008) have now acknowledged that simply providing definitions & guidelines regarding the skills required for collaboration &/or for a particular role (e.g. the care-coordinator-Nb1) within the collaborative process, although it remains to be seen if their initiatives to address this will have a positive effect.

Relating to the role of the nurse as care-coordinator/key-worker, as long ago as 1984 Benner considered that, nurses played an essential role in the management of care of patients both as coordinators and educators, which in line with NMC requirements means that they e.g.: -

Ø Keep-up-to-date with the latest developments in care and local and National policies to ensure their practice conform to the standards of clinical governance

Ø Be central to the MDT to ensure that the patient is the focus of that care

This also means that nurses are required to persist in their attempts to actively engage all clients in the shared development or their care-packages, even when clients may be unable or unwilling (at least initially) to become involved (Thurgood 2004) for as the SCMH (2005) argued by 2015,not only should every patient have a comprehensive, tailored care plan, they should have taken the lead in determining how they want their needs to be met according to theNHS plan (1998).


Nb1:It should be noted that s/he is not one who simply follows an established ‘pathway' but someone who challenges existing practice and leads the way in developing new evidence-based clinically effective care (Seaman in Smith M: 1999:1998).

Part 2: Collaborative Skills (see appendices 1-3 for full reflections)

The following summarises my insights into my learning/learning needs regarding collaborative skills use relating to firstly my involvement in the collaborative assessment, planning & implementation of the treatment/care provided for ‘Jane', a patient within an acute forensic inpatient psychiatric unit (reflections 1-2) & secondly the collaboration between my mentor, the team & myself to achieve my set & mutually agreed learning outcomes whilst on placement.

· Reflections regarding Jane's assessment & care plan implementation. Before conducting the initial assessment with ‘Jane', under supervision, I was conscious of the requirements of the NSFMH & the then ECC guidelines (DOH 1999/1999a/b) that the assessment must be comprehensive in order for the MDT to develop an appropriate care package. I was also conscious that this required not only my use of effective communication skills with Jane, but also with the nursing and multidisciplinary team members (SCMH 2001, DOH 2004, 2006b). in order for the assessment data to be used as a basis for Jane's initial care-plan, which would allow for further assessment data to be gathered prior to her MDT review.

While both Barker (2003 & Stuart (2005) stated that psychiatric care requires the completion of an assessment of the client's bio-psycho-social status, Barker also asserted that the way in which an assessment is carried out and the methods used in the process make it a worthwhile exercise or largely a waste of time. Therefore I was conscious of the need to not only adhere to the ECC framework but also to the ‘Best practice competencies' guidelines for pre-registration mental health nurses (DOH 2006) and those of the NMC (2008) & guidelines for students. NMC (2009) I also found that the experience afforded me the opportunity of using in-depth & specialist assessment tools like the ‘START' Short-Term Assessment of Risk and Treatability (Mental health and addiction services online 2010)in further enhancing the basic ECC assessment framework a guide to areas requiring further discussion and as the START (see appendix 6) focused on risk pertinent to mentally ill offenders I found it useful & also discovered that it's use was being researched by this & other ‘special hospitals', for validity & reliability. This I realised was important an assessment & management of risk (to the patient &/or others) can never be 100% (Morgan & Wetherell 2004) & therefore valid assessment tools & collaborative in-put by the team & the patient should be fundamental to risk-management strategies, which should also involve positive risk-taking (DOH 2007, 2008). Even in the absence of identified risk this need for collaboration is further supported by specific National Institute of Clinical Excellence guidelines (NICE 2009) on care provision &/or treatment for a variety of client groups & specific disorders including: Schizophrenia which applied to Jane.

As indicated, the NMC (2008) also requires nurses to work with clients as partners; and there is widespread agreement that mental health service-users and their carers should be fully involved in care planning as this increases their satisfaction and engagement with services (Warner 2005, Rose 2003, SCMH 2009) This involves identifying their preference regarding care & the START facilitated this by identifying Jane's needs, as Jane's key-coordinator it was my (supervised) role to ensure that all due procedure was carried out regarding recording of the outcomes which also included the planning of therapeutic engagement. Record keeping, if accurate, topical & comprehensive facilitates collaboration with the team (NMC 2005)

Any assessment also requires that the nurse use her observation skills (Barker, 2003, O'Carroll & Park 2007, Stuart 2005b), which I feel  also facilitated my engagement with Jane in the process of deciding together and with the team the best potential strategies to facilitate development of her on-going care-package. Further, although I was aware of Jane's history & apparent paranoia, & despite an aggressive incident during this time (see appendices 1-2) I also realised that to work effectively with Jane that I needed to put my personal feelings aside (Stuart 2005b) and on further reflection, I feel that I was eventually able to therapeutically work with Jane in her on-going assessment & care-planning Theoretical knowledge and experience are required to make informed decisions in deciding a plan of action for patients (Stuart 2005a, NMC 2007/8, DOH 2004, 2006)

Further although we no-longer utilise the nursing process in statutory mental health services I realised that the ECC/CPA framework is based in the same principles & Wilkinson's (2007) argument that the nursing process promotes collaboration, remains pertinent, for when team members have an organised approach, communication is good, and patient problems are prevented. Similarly the ability to transfer/adapt knowledge and skills, especially communication skills, based in self-awareness, mutual-trust and understanding of each other's roles facilitates effective collaboration with different people in different situations (Hadland 2004, NMC 2008, Onyett 2004, Stuart 2005a/b) and are required competencies by the DOH (2004 2006). The (NMC, 2008) also make it clear that nurses must always act on what they believe to be the service-users best interests, and the Healthcare Commission's (2005b) core standards emphasise the need for employers to ensure that employees follow their professional codes.

As indicated MDT collaboration regarding Jane, began before the formal review meeting, however when I formally presented my initial and on-going assessment findings to the team, using guidelines from ‘The New Ways of Working programme' (DOH, 2005b), I encountered barriers to collaboration with Jane in this process, which were primarily due to legal and safety requirementsof the environment (Mersey Care Risk Management Policy and Strategy, 2007 DOH 2007) & I found that Jane was prevented from attending because the review was held in a non-secure area of the hospital. Although I understand the rationale behind this & although an advocacy service is provided for patients to overcome this, none was made available for Jane & I still feel that other strategies to overcome the problem should be developed, for as the SCMH (1998) & Rose (2003) identified this lack of patient involvement by services was an area of complaint by service-users.

Reflections on support for my learning: I feel that I was effective in utilising the skills outlined above in respect of gaining Jane's positive and collaborative engagement with me and the strategies agreed by the MDT. To help me develop my self-awareness and skills in relation to such issues, and those outlined above I found that keeping a reflective diary at this placement, was a crucial way of ensuring critical events that needed further review, to benefit my practice, would not be forgotten. Keeping a structured reflective diary facilitates further review (either alone or with a supervisor) of experiences from which the practitioner can learn & improve his/her practice (Gibbs 1998, Kirby & Hart 2004, Norman & Ryrie 2004) & throughout my experiences my mentor has proven to be a valuable resource, without whose support I feel collaboration with both Jane and the MDT would have been significantly more difficult. It is the responsibility of the student & mentor to work together in identifying learning needs & strategies to achieve them (NMC 2008 &2009)


In addition to my personal reflections and supervised experiences, which gave me the opportunity to better understand the roles of other team members and helped create a collaborative partnership between people with varying knowledge, skills and perspectives (Hornby & Atkins 2000, Nancarrow 2004), I feel that the opportunity for clinical supervision with my mentor has played an important part in my role development. Finally one specific criticism of the collaborative process I have concerns the lack of collaboration with families and carers, as their involvement I feel was actively discouraged, unless clients gave their permission for this (which I have found is not unique to this placement), with the only information given being visiting arrangements and telephone numbers. Although confidentiality & patient rights have to be considered (NMC 2008) (Mental health act 2009), I have found that they are never invited to the MDT meetings, Yet the DOH (e.g. 2005) state that to work effectively in partnership with service-users and carers, it is essential that we are able to form and sustain relationships and offer meaningful choice.


Critical incidents are snapshots of something that happens to a patient, their family or nurse. It may be something positive, or it could be a situation where someone has suffered in some way (Alphonso, 2007). The incident to be discussed took place at my current placement a medium secure psychiatric hospital. Any names mentioned are fictitious in accordance with the Nursing and Midwifery Counsel (NMC) Code of Professional Conduct (NMC, 2007).For the purpose of this reflection I will be using The Gibbs model (1988), cited in Burns and Bulman (2000) as it gives an opportunity to produce a structured account of the discussion, and clearly shows that true reflection in practice has occurred during its research.

During my management placement my mentor Alan assigned me as named nurse to a recently admitted patient (Jane), with the purpose of co-ordinating her care. I found this service user to be very difficult to engage with as she could become extremely paranoid and believed people could read her thoughts and interfere with her mind. Therefore she was very hard to engage with and very reluctant to disclose any information, this gave me limited information regarding her background at the start of the assessment process. Jane was also presenting with challenging behaviour and could become very verbally hostile. I did find her to be challenging overall and I pursued a different method of working with her whereby I made conversation and talked about other things not relating to her problems, to get to know her, it didn't take too long before I began to begin to build a therapeutic relationship with Jane. However when it came to undertaking the assessment Jane became quite withdrawn and guarded and did not fully engage with myself or my mentor. When we had completed the assessment and was back in the ward day area Jane became very hostile and began to shout at myself stating that I had stolen her thoughts and replaced them with files, Jane continued to shout and swear so staff intervened. However, we did complete the assessment but I felt disappointed that Jane did not interact well as I felt we had begun to communicate well with each other and had started to build a therapeutic relationship prior to undertaking the assessment. Using the information ascertained during the assessment and information I had gathered from Jane's clinical file, I also contacted Jane's social worker (Lynn) for any additional information, she assured me that she would make contact with Jane's family and feed back her finding at the MDT meeting. I also contacted Jane's consultant and informed her that I was leading Jane's care package and the plan that I had put into place in order to maximise the efficiency of the up and coming MDT review.


I learnt a lot from this experience, by analysing the critical situation; it is plain to see how bureaucratic style was effective in handling the situation. The following of procedures by staff was effective in dealing with the possibility of further hazards and ensured the safety of the patient and nurses (Palombara, 2006).

Utilising individual members of the multi- disciplinary team taught me the importance of inter disciplinary team working. The assessment, gave me the ability to gather information from Jane although the information was very limited. It would appear that an assessment of this description would not benefit from having a structured format, because the patient leads as much as the nurse. The support I received from my mentor, gave me the independence to organise the assessment in my own way, and I feel proud to be able to have achieved all the relevant information despite the difficult situation. I was able to obtain information which gave me great satisfaction. I feel I have the ability to fulfil the role of care co-ordinator and do things independently as well as collaboratively.I learnt from taking a leadership role that I was able to, think logically and will hopefully carry this attitude forward throughout my future nursing career. I learnt for the future to expect the unexpected and handle situations as they arise. I have learnt the importance of collaboration and support/supervision is paramount for one to achieve.

Appendix 2: Reflective Essay 2 (Implementation)


This reflection will be based on attending the MDT meeting and the outcome. For the purpose of this reflection I have chosen Gibbs (1988), as the model to help guide this process. This is an iterative model with stopping points, using these stopping points as headings; I will be able to reflect fully on the incident.

As indicated the NMC 2008 requires nurses to work with clients as partners, which involves identifying their preferences regarding care, and respecting these within the limits of professional practice, existing legislation, resources and goals of the therapeutic relationship. To facilitate this I had encouraged Jane to identify her needs, and to point out which were of greatest importance in her life. These were:-

To build a good relationship with her parents

To get out of hospital

To stop smoking

All information gathered from the initial assessment could now be discussed at Jane's (MDT) meeting.

Also in attendance was Jane's consultant psychiatrist, social worker, psychologist my mentor and myself. I explained to the team that Jane had wished to attend the meeting but due to the location of the meeting, security and hospital policies this was not possible. I discussed the aforementioned to the team, along with Jane's presentation over the past week.

The consultant was quite happy for the nursing team to continue with their assessment work, and made no alterations to her medication regime. The social worker had managed to make contact with Jane's family, she reported that Jane's family have expressed that they would very much like to build up a loving and positive relationship with Jane and would be quite happy to look after her when she has been released from hospital until suitable accommodation can be found for her close to the family home.

Once the meeting was completed I took the opportunity to thank the team for their support and help I also thanked my mentor for all the advise, help, guidance and support he had given to me. I felt that as a team we had developed a good package of care for Jane and also had helped to set in motion the chance for Jane to build a relationship with her family. However I was disappointed that Jane could not attend the meeting due to risk. I did speak to my mentor regarding this and he agreed with my thoughts.

On returning to the ward, my mentor gave me the opportunity to reflect on the situation before handing over the outcome of the ward round to the on duty staff and Jane herself, it was understandable that Jane was unable to attend due to security policy, and hospital protocol and this was something that I would have to explain to Jane and make her aware of.


Writing this reflection made me aware about how members of a team can provide support and how this can help to provide a much better duty of care to service users. Communication played an important part in this learning experience. I believe that in nursing the ability to work in a team is one of the key elements. Furthermore, Sully and Dallas (2005) go on to say the reasons that enhance effective inter- professional team work is the clear goals that are set by the team to make the significant differences for the patient. When the members are competent, committed and know the expected standards of excellence that also enhance inter-professional team work. Team work between nurses and multidisciplinary team is important.

Appendix 3: Reflection 3 (learning within placement)

This reflection will be on the nature of teaching and learning process within my practice placement. Some of the factors influencing a learning experience will be discussed and linked to known teaching and learning theories. Physical and psychosocial factors that affect the learning process will also be explored. To help facilitate this assignment, a reflective model (Gibbs model 1988) will be incorporated to discuss how I have achieved the necessary level of competence during the placement. To assist in the development of learning for future students, an action plan will be formulated from the issues recognised throughout this paper.

Any names mentioned are fictitious in accordance with the Nursing and Midwifery Counsel Code of Professional Conduct (NMC, 2008).

During the initial discussion with my mentor (Alan), I was able to express what learning needs I wanted to develop throughout my time on this placement. we agreed to be in close contact for the initial four weeks and also that I would work with Alan to ensure I had as much one-to-one mentoring as possible. This was extremely beneficial as he could track my progress and provide me with guidance during the weeks (Chow & Seun, 2001). At this point my learning was being promoted because he was skilled in student-led strategies. For example, he consistently explored my understanding of a task whilst providing support (Heron, 2001). I also felt positive about having the opportunity to develop a good relationship with him which is recognised as being beneficial to the learning process (Dix & Hughes, 2004).

According to Maslow (1971) the humanist theory of learning is concerned with feelings and experiences. My learning was definitely influenced by his positive attitude and manner, which, as suggested by Maslow leads to personal growth and individual fulfilment.

During my time on placement it was clear that Alan was creating learning opportunities, such as attending MDT meetings, taking the lead role as care co-ordinator and offering resources at all times. I also found he was able to explain tasks clearly and to answer any questions that I had. This is something typically favoured by nurse educators (Li, 1997).

My mentor was extremely approachable and would often demonstrate tasks with which I was unfamiliar, such as new assessments such as the START. Also if I was unclear on something he had asked me or if I did not know the answer to a question he had asked he would ask me to find out the information and then feed back to him. I found this an excellent way of building my knowledge.

Alan would consistently enquire about my existing knowledge on a subject or task which helped me to perform thorough self-assessment, and to re-examine what I had already learnt, Neary (2000) states that revisiting areas that have already been studied can enhance cognitive learning. This is associated with a major theme in the theoretical framework of Bruner (1996), who explains that learners are able to construct new concepts and ideas based upon their current or past knowledge. Feedback sessions were typically planned but were sometimes spontaneous. This was due to time restrictions and nurse workload. These unprompted sessions could perhaps be improved if they were more structured (Hinchliff, 1999). This is also supported by Quinn (2000) who believes that lesson planning is vital for learning because it ensures that all areas of learning are addressed, which results in higher productivity in terms of learning (ENB/DOH 2001).

Morgan (2002) states that it is vital that qualified nurses ensure students become part of the team, because this can be beneficial to their learning. In addition, the NMC requires that nurses support the development of student nurses. This was evident because each member of staff readily contributed to my learning experience through their willingness to share their professional knowledge with me (NMC, 2007).


My placement has been a positive and memorable learning experience. Primarily I learnt by observation and role modelling whilst utilising cognitive processes.Regular discussion is vital to ensure the learner is provided with some form of direction, as well as provide the opportunity to express any needs. Planned and structured teaching sessions are particularly beneficial to the learner because they enable the mentor to teach a session logically, and to maximise learning efficiency by utilising time effectively. Multidisciplinary team members with the same level of knowledge as the main mentor are also preferable. Additionally, factors influencing learning with regards to the physical learning environment are significant in the enhancement of learning for students, as stated in the action plan.