International Journal of Psychosocial Rehabilitation
Optimizing System &
The Shared Journey Project
Malachowski, B.Kin, BHSc OT, MRSc
(2009).Optimizing System & Patient RecoveryRediscover &
The Shared Journey Project.
Journal of Psychosocial Rehabilitation. Vol 13(2). 49-64
Cindy K. Malachowski,
B.Kin, BHSc OT, MRSc
Healthcare quality improvement initiatives have become a priority
issue across organizations and systems internationally. Ontario
is developing a strategic initiative to systematically improve the
quality of healthcare delivery. Mental health reform is of
Whitby Mental Health Centre has launched a quality improvement
initiative entitled "Rediscover & Recovery: The Shared Journey
Project". The objective of this project is to transform the
Centre's organizational culture and improve patient care by connecting
frontline clinicians with the values and beliefs inherent in the
recovery philosophy and interprofessional care.
The following paper offers a comparison of the shared values and
principles of the recovery philosophy and interprofessional care, and
will describe facilitators and barriers to their implementation.
The benefits of the project will be discussed, as well as
implications for rehabilitation practitioners.
Interprofessional Care, Recovery Philosophy, Quality Improvement,
Whitby Mental Health
Centre (WMHC), located in Central-Eastern Ontario, employs over 1,200
people and offers a range of specialized tertiary care mental health
programs for individuals living with mental illness (Whitby Mental
Health Centre, 2006). The Centre provides both inpatient and
outpatient services to approximately 2.8 million people residing within
the region. It opened as a mental health facility in 1919, and
management of the Centre was transferred from the Ontario Government to
a stand-alone public psychiatric hospital on March 27, 2006. A
culmination of recent developments has necessitated a significant
transformation of clinical care. The Centre’s divestment from
government governance to a public hospital, the international emphasis
on incorporating the recovery philosophy into best practices for mental
health (Allott, Loganathan, & Fulford, 2002; Davidson, 2007;
Farkas, Gagne, Anthony, & Chamberlin, 2005), the movement toward
interprofessional practice for clinical excellence (Akhavain, Amaral,
Murphy, & Cardone Uehlinger, 1999; Evetts, 1999; Infante, 2006),
and Ontario’s initiative to strengthen the mental health system (Local
Health Integration Networks [LHINs], 2008; Newman, 1998; Ontario
Ministry of Health, 1999) have set the stage to enable the enhancement
of clinical front-line care delivery at WMHC. These factors
have provided an opportunity to implement “The Shared Journey”, a
large-scale organizational change initiative that will improve the
quality of care provided by the centre. The purpose of this paper
is to explore the key factors that will impact the adoption of the
recovery philosophy and interprofessional care (IPC) within the current
healthcare climate in Ontario.
Internationally, there is
a movement to improve the quality of healthcare. The United
Kingdom has published a White Paper on healthcare reform and launched a
series of quality improvement initiatives (Thomas, 1998). The
United States has identified the need for safer, more effective
healthcare services and has made recommendations for system redesign
(Kohn, Corrigan, & Donaldson, 2000; Institute of Medicine Committee
on Health Care in America, 2001). In Canada, a review of the
healthcare system has resulted in recommendations for reform in order
to enhance the efficiency and sustainability of healthcare delivery
(Standing Senate Committee on Social Affairs, Science and Technology,
2002). Efforts to address local healthcare challenges have begun,
and in 2006 the province of Ontario developed the Local Health System
Integration Act and created fourteen Local Health Integration Networks
(LHINs) in order to plan, integrate, and fund healthcare services
(Local Health System Integration Act, 2006; LHINs, 2008). Mental
health and addiction services were raised as a priority issue across
all LHINs in Ontario. This is indicative of the importance
and priority that the province is placing on improving the present
state of mental healthcare delivery. The identification of mental
health services as a priority issue can be traced back to the first
wave of deinstitutionalization in the 1970’s, where neither the
healthcare system, nor the community was adequately prepared to meet
the needs of individuals living with severe and persistent mental
illness (Hartford, Schreker, Wiktorowicz, Hoch, & Sharp,
2003). The provincial government has since committed to the
reorganization and restructuring of services through mental health
reform. Hartford et al. (2003) provide a historical context for
mental health care in Ontario and illustrate that until the recent
development of the LHINs, mental healthcare system improvement has been
slow and changes have been nominal. The Central East (CE) LHIN is
addressing system improvement through their Integrated Health Service
Plan (Central East [CE] LHIN, 2008). This action plan has
identified key areas for healthcare improvement, and has included
specific objectives for mental health and addictions. The
following areas in mental health have been identified as a priority in
the mandate, and will have a significant impact on the type of care
that is provided within the region: service delivery, knowledge
exchange, interprofessional practice, and staff recruitment and
retention (CE LHIN, 2006). WMHC’s organizational change
initiative to embrace the recovery philosophy and IPC aligns seamlessly
with provincial objectives. The LHINs’ mandate for mental health
system improvement will be supported by the clinical transformation and
care provision changes at the Centre.
In order to improve the
quality of care provided at WMHC, the Centre has decided to model a
change initiative after the “Reconnecting to Care” project conducted at
the Baycrest Centre in Toronto, Ontario (Glouberman, Richards, El
Bestawi, Seidman-Carlson, & Teperman, 2007). The Baycrest
strategy was a deep change initiative for nursing services and
emphasized the importance of clinical competencies and the value of
direct care workers. It was initiated in response to the
challenge of maintaining a caring and positive work environment when
clinicians experience decreased morale. The work culture at
Baycrest was reflective of the attitude represented across many
non-acute healthcare settings, including the WMHC. Staff felt
that they were unrewarded and were trapped in a disconnected,
task-driven routine. In order to improve services, Baycrest underwent a
“renewal” process where patient care units at the facility were
systematically shut down for a period of four weeks. During this
time the staff was immersed in an educational program that resulted in
a more responsive, more alert, and more dedicated workforce.
After the intervention, staff also had a better understanding of their
roles, as well as an enhanced awareness of system and process
issues. A number of quality indicators revealed that the nursing
staff had improved their ability to relate to one another, their
patients, and patient families. As WMHC is looking to address
similar workforce and organizational culture issues, a similar process
will be adopted. However, the “Rediscover & Recovery: The
Shared Journey Project” will merge the concepts of recovery based
competencies and IPC with specific clinical skills and proficiencies
related to the field of mental health. To ensure the successful
implementation of this initiative, it is imperative that the
organization be prepared to create and sustain a change to clinical
expectations prior to anticipating transformation in frontline care
delivery. In order to set the stage for change and begin to
transform the organizational culture to improve the quality of care
delivery, WMHC must address the deeply entrenched values and beliefs
that underpin clinical practice at the Centre (Davies, Nutley, &
Systems: The Recovery Philosophy & Interprofessional Care
Instituting a new
organizational strategic directive through the implementation of The
Shared Journey Project will require the adoption of two approaches to
care at the WMHC: the recovery philosophy and IPC. This new
philosophical mandate will require personnel values and behaviour that
are significantly different from traditional healthcare delivery and
current practices at the Centre. Historically, mental health care
has employed a top-down approach dominated by an expert-driven model,
and interventions were based on deficiencies and incapacity (Swarbrick
& Brice, 2006). The “medical model” approach to care is based
on the absence of disease, pathology, compliance, and in essence
establishes a power differential between doctors and patients (Roberts
& Wolfson, 2004). In stark contrast, Anthony (1993) and
Deegan (1988) describe the meaning of recovery as a shift in thinking
from clinical pathology to a strengths-based approach; therefore,
instead of focusing on relief from symptoms, emphasis is placed on
building self-esteem and finding a meaningful role in society.
Deegan (1996) further describes recovery as providing opportunity for
choice; empowering people by allowing them to have a voice and taking
the time to listen to their story; allowing individuals to provide
input regarding service engagement; and by providing opportunity for
peer support, peer mentorship, self-help, and mutual support.
These concepts have attracted much attention and there has been a
movement internationally for system-restructuring in order to embrace
the recovery philosophy. Scotland (Scottish Executive, 2006) and
New Zealand (New Zealand Mental Health Commission, 2001) have
identified core clinical competencies and system indicators for
recovery. The United States have developed core concepts of
recovery and identified fundamental values and principles (Substance
Abuse & Mental Health Services Administration, n.d.). The
Canadian government has identified the need for a recovery-oriented
system reform, and has outlined a federal strategic implementation plan
and a national mental health strategy (The Standing Senate Committee on
Social Affairs, Science and Technology 2006). In 2002, the
Provincial Forum of Mental Health Implementation Task Forces published
a report calling for the recovery philosophy to be the foundation for
change in Ontario’s mental health system. Locally, the CE LHIN
will help deliver the mandate by improving access to mental health
services, reducing stigma and discrimination, enhancing safety, and
improving the effectiveness of services (CE LHIN, 2006). It is
evident that the recovery philosophy has gained international
acceptance and has become the prevailing philosophy for mental health
care delivery. The values and principles of recovery will create
a foundation for change, and will underpin clinical transformation at
WMHC. The Shared Journey Project will improve clinical care and
create partnerships between clinicians and patients that inspire a
sense of hope and empowerment, and ensure clinicians are providing
meaningful involvement and choice for patients.
The second component of
the Shared Journey Project will necessitate the adoption of IPC
practices. In their review of the literature, Rice (2000) and
Klein (2008) provide varying levels of evidence to support the
implementation of interprofessional care. Despite the lack of
strong empirical evidence demonstrating the effectiveness of IPC, there
is an abundance of publications that support its implementation to
enhance services. Evidently, the collaboration developed within
IPC teams is correlated with enhanced clinical outcomes, continuity of
care, decreased costs of providing care, improved job satisfaction, and
the promotion of professional identity. Interprofessional care
happens when teams comprised of various health care professionals
engage in equal participation to aid health care decision making
(Yeager, 2005). IPC occurs among and between healthcare
providers, and the ultimate aim is to create empowering partnerships,
teams, and organizations that are jointly responsible for services
(McWilliam et al., 2003). HealthForceOntario, a provincial
strategy to ensure high quality healthcare delivery, has recognized
that IPC may compensate for some of the challenges faced by Ontario’s
healthcare system, as well as result in overall system
improvement. On behalf of HealthForceOntario (2007), the
Interprofessional Care Strategic Implementation Committee has endorsed
IPC to increase access to care, improve outcomes for people with
chronic diseases, reduce tension and conflict among caregivers, enhance
use of clinical resources, aid the recruitment of caregivers, and
decrease rates of staff turnover. The LHINs have been identified
as enablers for IPC, and the CE LHIN is in the process of developing a
strategic plan to implement an interdisciplinary team approach to care
across agencies and across sectors in order to improve quality of care
and to provide more efficient, effective healthcare delivery (CE LHIN,
recovery philosophy and IPC share many of the same basic concepts,
which may facilitate their overall adoption into the workforce. Each
require strong partnerships between the clinical team, the patient,
family/caregivers, and the community; each require collaboration,
participation, and effective communication; and each can provide
enhanced quality of care and flexible services to meet the needs/goals
of the patient. Recovery and IPC necessitate a patient-centred
approach (Blickem & Priyadharshini, 2007; Schauer, Everett, &
del Vecchio, 2007) which not only encourages patient participation and
responsibility, but may help to reduce tension and conflict among
clinicians as they engage in more meaningful, focused interactions.
This will also impact patient safety as active engagement of all team
members will help to reduce errors and protect the health and welfare
of patients and staff at the Centre (Infante, 2006). At a system
level, recovery principles have demonstrated improved clinical outcomes
that will offer benefits to the patient, clinician, organization, and
ultimately the healthcare system as a whole (Solomon & Stanhope,
2004). Although many articles pertaining to IPC discuss similar
enhanced clinical outcomes, there is a lack of strong evidence to
support these claims (Rice, 2000). The implementation of the
recovery philosophy has resulted in better use of clinical resources
and transitioning services, which will reduce costs and improve flow of
patient care within and between organizations (Farkas et al.,
2005). The literature indicates that IPC has a similar impact on
patient flow and reduced clinical costs; however, these claims are not
grounded in empirical research and offer limited or mixed support (Reid
Ponte et al., 2007; Rice, 2000). Despite the lack of strong
empirical support for IPC, there are many underlying similarities
between the two philosophies that offer insight into the importance of
collaboration and competence for organizational and system
improvement. As a result, WMHC’s strategic directive to embrace
the recovery philosophy and IPC necessitates behaviour and value
changes in frontline clinicians to support the practice of partnership
on all levels: patient empowerment, teamwork and shared decision making
(Schauer et al., 2007; McWilliam et al., 2003). This will
translate into significant role changes and expectations as the
workforce deviates from the traditional medical model hierarchy and
adopts a more egalitarian philosophy. This change in practice is
important for optimizing patient care; however, the significant shift
in practice expectations also represents a barrier to successful
Challenges to Implementation
It is anticipated that
recovery and IPC components, values, and principles will help to guide
WMHC’s organizational transformation toward recovery-oriented
services. As with any large scale change initiative, significant
barriers exist. Challenges of implementing IPC are identified by
Powell et al. (1999) and can also be applied to the adoption of the
recovery philosophy as they share many of the same values and
principles. Barriers are identified as (1) personal factors, (2)
professional factors, and (3) organizational factors. The type of
relationships formed with colleagues, the distribution of power between
disciplines, and bureaucratic issues at an organizational level will
impact the acceptance of recovery and IPC.
competence, and confidence will have an impact on the way that
clinicians interact with their patients and with each other.
These personal factors and the concept of risk have important
implications for recovery and IPC as it may be a significant barrier to
embracing both philosophies. The recovery philosophy encourages
risk and risk taking in order to promote a patient’s personal growth
and development. Patricia Deegan, an individual treated for
schizophrenia, is an internationally renowned recovery advocate and
calls all professionals to “…embrace the concept of the dignity of risk
and the right to failure if they are to be supportive of us” (1996,
p.97). This is contrary to the traditional treatment of
individuals living with mental illness; historically the clinician was
viewed as the “expert” and made decisions on behalf of the patient who
was deemed incompetent as a result of their mental illness.
Roberts & Wolfson (2004) discuss the concept of risk from the
perspective of shifting from risk avoidance to risk-sharing in regard
to medication practices, a contentious issue between the medical model
and recovery approach. The medical model promotes compliance with
medication as a life-long necessity to prevent symptoms and/or
relapse. The recovery philosophy considers medication within the
context of the patient experience, and advocates for shared decision
making, choice and self-determination in regard to medication practices
(Deegan & Drake, 2006). Allowing patients to make their own
decisions and accepting the prospect of failure requires clinicians to
provide unconditional support to individuals, and acknowledges that
patients are entitled to make independent, informed choices.
Roberts & Wolfson (2004) state “…risks can be taken within safe
parameters and lessons learned from experience” (p.42). This
approach will facilitate a partnership that unites the expertise of the
clinician with the patient’s experience of their illness, and negates
issues of power and control. In a different context, the concept
of risk threatens the successful adoption of IPC practices.
Accountability issues have been raised as a concern in implementing IPC
(Evettes, 1999). Bronstein (2003) offers further insight into
regulation challenges of IPC as professionals share limited
understanding of roles, expertise, and scope of practice which can
result in tension, anxiety and conflict among care providers. IPC
team members may also experience role confusion and harbor feelings of
resentment when tasks or duties are shared among team members
(McWilliam et al., 2003). This contributes to the reluctance to
adopt IPC practices. Presently, Ontario does not allow for the
flexibility required to foster interprofessional collaborative care as
legislation is too rigid and focused on individual responsibility
(Health Canada, 2007; Thornhill, Dault, & Clements, 2008).
Consequently, clinicians who fear the potential liability and/or risks
related to the negligence of colleagues will be reluctant to adopt a
collaborative approach to care. As a result, individual values,
skills, and perspectives will have a significant impact on the
willingness to engage in change.
To illustrate challenges
on a professional level, the adoption of the philosophy has in part
been hampered by the tension between recovery and the medical
model. Despite evidence from longitudinal research demonstrating
that people can and do recover from long-term persistent mental illness
(Harding, Brooks, Ashikaga, Strauss, & Breier, 1987; Harrison et
al., 2001), the differences between the values and concepts of the
medical model and recovery stand in significant opposition to one
another. Numerous publications have debunked concerns and
perceived limitations to the adoption of the recovery model, but
reluctance to abandon the expert-driven model still exists (Davidson,
O’Connell, Tondora, Styron, & Kangas, 2006; Mountain & Shah,
2008; Samele, Lawton-Smith, Warner & Mariathasan, 2007). Similarly,
the medical model remains a barrier to the implementation of
interprofessional care. Locally, a recent Ontario Medical
Association (OMA) Policy Paper on Interprofessional Care (Hanna, 2007)
states that “physicians, having greater breadth of training and larger
scope of practice, should be the clinical lead in interprofessional
teams” (p. 3), and further recommends that “Physicians should be
compensated for their leadership and the indirect services they provide
in interprofessional team settings” (p. 7). This type of
professional elitism is apparent between all professional groups, as
inflexibility, rigid role separation, tradition, and vested
professional interest act as barriers to collaborative practice
(Roberts & Priest, 1997). As a result of the tension created
from entrenched power differentials, there is significant resistance to
adopt a practice that calls for an inclusive approach.
At an organizational
level, operational structure does not typically provide an optimal
environment for collaboration or recovery-oriented care.
Financial and budgetary decisions are often dependent on outcomes such
as length of stay and readmission rates. Recovery-oriented
services and measures require a shift in financial resources that
support the enhancement of quality of life, self-empowerment, and
hopefulness of patients (Sowers, 2005). These variables are much
more difficult to define and measure as a result of their subjective
nature. In order to embrace collaboration that supports both
recovery and IPC, organizational structure must adopt a clear policy
direction, performance criteria, and incentives that outline key
determinants of collaboration yet allow for flexibility (Ginsburg &
Tregunno, 2005). The importance of structure is reflected in
effective leadership and commitment across all levels of the
organization (Reide Ponte et al., 2007). At the heart of IPC, Ginsburg
& Tregunno (2005) describe a type of shared leadership between
frontline clinicians and management. This type of shared
leadership can also be applied in the recovery context and extended to
the patient, allowing individuals to take more of a leadership role
when making decisions about their care. Evidently, creating a
clinical infrastructure that fosters collaboration requires system
changes and amendments to current policies and procedures to promote
collaboration across all care providers.
Despite the many
challenges on personal, professional, and organizational levels, recent
attempts to bridge the gap between the recovery approach, IPC, and the
medical model have begun. As a result of efforts to strengthen
the recovery evidence base and establish the philosophy as a viable
approach to care, new measures and outcomes are being generated and
there is a movement to engage in quantitative research inquiries that
formalize and operationalize recovery dimensions (Anthony, Rogers &
Farkas, 2003). Attempts to find common ground between the two
philosophical approaches have encouraged clinicians to connect symptoms
with the specific meaning they have for the patient; to listen to
individual patient stories and experiences instead of just taking a
diagnostic history; and to reduce stigma and challenge clinicians’
assumptions about mental illness (Mountain & Shah, 2008). These
developments are particularly relevant for WMHC. A significant
challenge faced by the Centre is to abandon medical dominance and
embrace a collaborative practice that addresses both the physical and
mental health needs of individuals living with long-term, persistent
mental illness. IPC models offer insight into the type of
collaboration required to utilize effectively the clinical expertise of
various disciplines to meet the client’s needs during their journey of
recovery. Clearly, the redistribution of power and control, and the
inclusive nature of recovery and IPC will result in a significant shift
in values for all healthcare professionals as it will necessitate a
change in the way they view their role, their patients, and their
Creating a Shift in Culture
Today’s healthcare system
thinking has shifted from classic reductionism or top-down design,
toward nonlinear dynamics or a complex systems theory (Burns, 2001;
Suchman, 2001). This theory views the organization as a complex
and adaptive system that continually interacts with several
micro-systems thus evolving in response to multiple feedback loops
(Plsek & Wilson, 2001). The complexity of implementing
organizational change involves multiple variables that interact and
impact each other (Sturmberg, 2007; Suchman, 2001). It is relatively
easy to introduce new processes and procedures on a superficial level,
but creating change that will impact ingrained values and beliefs is
much more challenging and complex (Davies et al., 2000).
Resistance to change in organizations is well documented, and many of
the barriers to change have been identified in the literature.
Senge et al. (1999) describe change as a disturbance in balance, and
states that individuals resist change to maintain status quo or
comfort; others describe how change is frequently perceived as a loss
(Folger & Skarlicki,1999). Considering there are many
theories that offer insight into behaviour change, WMHC’s
transformational change initiative must consider multiple factors that
effect behaviour change.
In order to explain how
behaviour change occurs among healthcare professionals, various
theoretical perspectives have evolved. Grol & Grimshaw (2003)
provide examples of how theoretical constructs translate to
practice. For example, the cognitive theory offers an explanation
of behaviour change in the context of receiving knowledge and
information; adult learning theories attribute change to experience,
reflection, and discussion with colleagues; behavioural theories
contend that performance is shaped by feedback, incentives, modeling,
and reinforcement; and organizational theories explain change within a
system, process, and cultural context. Despite investigations
that attempt to identify standardized strategies that change or modify
clinician behaviour, specific knowledge translation tactics remain
elusive (Perkins et al., 2007). Deane, Crowe, King, Kavanagh
& Oades (2006) have investigated the failure of transfer of
training related to recovery oriented practice, and found that despite
policy implementation, support from management, and staff training,
there were minimal behaviour changes in clinicians. In their 2006
publication, Crowe, Deane, Oades, Caputi & Morland discuss the
friction between the recovery philosophy and the value system that
differentiates recovery-oriented care from traditional care models;
they conclude that staff attitude can be a barrier (or in some
cases a facilitator) to adopting implementation. Staff attitude
and perspectives are important considerations in developing strategic
change initiatives as both represent the culture of the
organization. They can also be applied when attempting to
understand barriers to change at an individual, group, or systems
level. To establish a change management process, it is apparent
that a baseline measure of values, attitudes, and beliefs must be
A critical factor in any
change management process is to determine the organizational culture
and readiness for change (Jones & Redman, 2000). In describing the
term organizational culture, Scott, Mannion, Davies, & Marshall
(2003) offer the following description:
It denotes a wide range
of social phenomena, including an organization’s customary dress,
language, behavior, beliefs, values, assumptions, symbols of status and
authority, myths, ceremonies and rituals, and modes of deference and
subversion; all of which help to define an organization’s character and
norms (p. 925)
A post divestment
cultural assessment survey has indicated that the majority of employees
at the WMHC exhibit significant concern about pay; lack of respectful
treatment; need to improve patient focus; tension between
union/management relations; lack of adequate staffing; decreased
morale; and inadequate leadership (HayGroup, 2007). In order to
devise a change management strategy additional workforce assessments
were completed. These assessments confirm that the current
environmental culture at WMHC resists change initiatives, that
frontline staff engage in bullying tactics, that there is a lack of
communication throughout the organization, and that employees take
minimal ownership for initiatives and have a “why bother”
attitude. (Deloitte, 2008). Many of the factors identified
by HayGroup and Deloitte are not unique to the WMHC organizational
culture and are well documented in the literature. Sovie (1993)
describes dysfunctional hospital cultures as organizations that engage
in turf battles, do not recognize staff accomplishments, have limited
concern about employee satisfaction, and do not regularly measure
quality of service. Perceived power imbalances, dissatisfaction,
frustration, internal competition, organizational change, and changes
in the composition of the work group are other variables that
contribute to dysfunction in organizations (Liefooghe & Mackenzie
Davey, 2001; Salin, 2003).
Many of the predominant
themes that emerged from the cultural assessments completed at WMHC can
be related to theoretical constructs of bullying. Bullying in
healthcare is a significant issue resulting from organizational
structure and power imbalances among/ between clinicians and/or
management and has been identified as a key factor in shaping
organizational culture (Bate, 2000). Absenteeism, high staff
turnover, decreased morale, loss in productivity, and a depersonalized
organization, are behaviours that have been identified as indicators of
workplace bullying specifically in healthcare (Hutchinson, Vickers,
Jackson & Wilkes, 2006). Turney (2003) provides evidence to
support both vertical and horizontal workplace bullying in the medical
profession. She describes workplace bullying that occurs between
professionals on the same level, and bullying caused by power
imbalances created by status attributed to certain professions.
Potentially, the shifting power among and between clinicians working
within an IPC team could initially heighten tensions and increase
animosity among the staff at WMHC, an important factor to consider when
developing a strategic implementation plan. Hutchinson et al.
(2006) argue that bullying can become normalized within an organization
and is strategically used to maintain order. This concept needs
to be considered when implementing change initiatives as the “push
back” from staff may result in rejection of the recovery and IPC
philosophies as it represents such a drastic change from current
practice. Many of the behaviours and values currently held by
staff are not reflective of those required for the successful adoption
of the values inherent in the recovery philosophy and IPC. Clearly, the
cultural context at WMHC will have a significant impact on the
successful implementation of The Shared Journey project. As a
result of organizational culture similarities, it is anticipated that
the Baycrest strategy will provide insight into successful techniques
that bring about significant organizational culture change at
Readiness and Implementation Strategies
As discussed earlier,
adoption of the recovery philosophy extends well beyond written policy
statements. Similar to any large scale change initiative,
preparation and process are critical success factors for implementing
the recovery philosophy and IPC initiatives. Organizational
change literature has established that workplace culture, leadership
and motivation are critical elements for any change process. However
recent evidence has also correlated the following variables with
successful change initiatives: the duration of the project and
benchmarking for success, the integrity of team members, staff and
leadership commitment, and the amount of effort the change demands from
staff (Sirkin, Keenan, & Jackson, 2006). This emphasizes the
importance of planning in order to embark on a successful
organizational change initiative. Grol & Grimshaw (2003) recommend
proper preparation to engage in a change process involving patient
care. Key steps include involving the relevant people; developing
a proposal for change that is evidence based, and feasible; studying
the main difficulties in achieving the change; and selecting a set of
strategies and measures at different levels (individual, team, and
organization) that are linked to identified problems. The importance of
defining indicators for measurement of success and monitor progress
continuously or at regular intervals is emphasized.
management strategies are critical considerations; however, approaches
specifically related to the recovery and IPC systems issues must also
be considered. Farkas, Ashcroft, & Anthony (2008) offer
specific strategies to facilitate the introduction of the recovery
philosophy within organizations. They recommend enabling a
culture of recovery through the implementation of values based
practice, obtaining commitment from staff and administrators, and
building capacity through staff skills training and knowledge
development. Anthony & Ashcroft (2008) offer strategies for
overcoming resistance to the adoption of recovery, including
encouraging all clinicians to participate in planning for recovery, and
integrating trained peer support workers to work alongside staff to
represent examples of hope and recovery. New developments are emerging
to address the challenges related to transfer of training and include
an emphasis on values-based interventions for clinicians (Crowe,
Couley, Diaz, & Humphries, 2007; Oades, Crowe, & Deane,
2007). Outcomes from their preliminary research should be
interpreted with caution as the evaluative tools used by Crowe et al.
(2006) are subject to sources of error, including bias in responding
and measurement bias as clinicians are likely to provide socially
desirable answers and may not have an accurate perception of the
recovery-oriented services they provide. The psychometrics of
each proposed measure, the Collaborative Recovery Knowledge Scale and
the Staff Attitudes to Recovery Scale, are compared with the Recovery
Attitudes Questionnaire (RAQ-7). However, the RAQ-7 does not
establish strong reliability as Chronbach’s alpha coefficients ranged
from .64 to .70, the low end of acceptable limits for research
(Streiner & Norman, 2003). Each measure establishes face and
content validity but fails to report on longitudinal validity, a key
indicator that changes in behaviour have been adapted over time.
This emerging research is encouraging; however, it reinforces the need
for stronger evaluative measurement tools to demonstrate transfer of
training. Clearly, disseminating the best methods to implement
change, monitor, and evaluate effectiveness is important for the
success of the Shared Journey Project.
Systems structures must
be adapted to support a new approach to collaboration and reinforce
change efforts. The new processes may include implementing new
policies, procedures, and strategies that recognize and reward
partnership efforts, and performance appraisals that recognize
partnership-building efforts (McWilliam et al, 2003). Strategies
for implementing IPC and expanding collaboration within WMHC include:
creating opportunity for interprofessional education, partnerships, and
relationship building (Bronstein, 2003); developing routine processes
for feedback, negotiation, and conflict management; and providing
opportunities for informal relationship building, encouraging a spirit
of fun, and inviting participation (Gerardi & Fontaine,
2007). Creating and sustaining a change in practice will require
strong leadership and a highly structured, organized approach to
implementation (Barrier, Anson, Ording, & Rogers, 2002).
Clearly, implementation strategies must also be sensitive to the
tensions between recovery and traditional pathological models if change
efforts are to be successful. The shared values and underlying
philosophical approach to recovery and IPC will act as enablers in
their implementation; each approach reinforces the values and beliefs
of the other.
The evolutionary nature
of healthcare will continue to have a significant impact on the
rehabilitation practitioner. In Ontario, healthcare system
changes coupled with mental health reform will drastically change the
demands and expectations placed on clinicians. With the
implementation of recovery and IPC the rehabilitation practitioner will
engage in a collaborative process with team members and patients within
a system that promotes and encourages all health disciplines to share
their expertise. Interactions with patients will transform from
an “expert” clinician approach to a partnership that includes the
patient as an equal participant in information sharing and decision
making. The rehabilitation practitioner will adapt to new
organizational structures, changes to professional autonomy, and new
approaches to teamwork (Ginsburg & Tregunno, 2005). In order
to engage effectively in IPC, the rehabilitation practitioner must
understand their full scope of practice and be competent in their skill
set (McCallin, 2006). The emphasis on teamwork and team
collaboration will require interpersonal skills, effective
communication, and ongoing reflective practice (Barry, 2007). The
rehabilitation practitioner will engage in shared leadership practices
with their colleagues, and extend shared leadership with their
patients. Assessments and interventions will be conducted from a
strengths-based perspective ensuring client centredness and effective
use of clients’ personal resources. Interventions will need to be
conveyed in a manner that is easily understandable for patients and
colleagues to ensure continuity of care and follow-through.
Documentation will encompass client’s strengths and resources instead
of focusing on symptoms and pathology. Clinical records will also
become a forum for all healthcare providers to “contribute their
personal and professional knowledge of the client on a regular basis”
and become “…an evolving collection of information about the client’s
holistic health status” (McWilliam et al., 2003, p.370). Patient care
will be provided by all disciplines working from, and contributing to,
the same plan of care. To support this type of collaboration from
a theoretical perspective, new models of IPC are being developed
(Bronstein, 2003; McWilliam et al., 2003). The rehabilitation
practitioner must show “respect for other disciplines, a willingness to
share information and listen to others’ opinions, and tolerate
disagreement” (Reid Ponte et al., 2007). As a result recovery and
IPC will support the LHINs mandate and mental health reform in Ontario,
while enhancing the role of the rehabilitation practitioner by
encouraging true collaboration.
Not only will clinical
practice be transformed, but the way that clinicians study and train
will also change. New approaches to interprofessional education
have been incorporated into academic training, and initiatives for
continuing IPC education have increased in recent years (Barr, 1998;
Roberts & Priest, 1997). A review conducted by the
Cochrane Collaboration has found a lack of strong evidence supporting
the effectiveness of current methods of inter-professional education;
therefore, new methods of teaching and instruction coupled with more
rigorous studies will also have an impact on the rehabilitation
practitioner (Zwarenstein et al., 2007). Collaboration among
professionals will be reflected in research initiatives as the
integration of different disciplinary perspectives will add richness
and depth to our inquiries (McCallin, 2006). Recovery research
will bring professionals together in an approach that expands
traditional notions of services, outcome measures, and standards of
evidence (Solomon & Stanhope, 2004). Best practice guidelines
will be enhanced as contributions across disciplines will promote
mutual understanding and better partnering (McWilliam et al., 2003).
In order to promote IPC,
Health Canada (2007) has called for legislative reform to address the
current practice of assessing negligence on the level of the
individual, and to develop a framework to better support IPC and
collaboration. This will provide opportunity for rehabilitation
practitioners to participate in a process that will restructure
regulatory policies and legislation, thus shaping the future of their
practice. As a result of recovery and IPC, the rehabilitation
practitioner will have to engage in reflective practice and maintain
ongoing assessment of values, both personal and professional, in order
to provide optimal care. The rehabilitation practitioner will
experience large-scale system changes and will have opportunity to
engage in a more efficient and effective process when delivering
healthcare to Ontarians.
Undoubtedly, we live in
an age of continuous quality improvement and healthcare system
advancement. Ontario’s initiative to strengthen the delivery of
mental health services can employ the shared values and philosophies of
recovery and IPC to provide effective, efficient services in the
future. In order to improve frontline clinical care, WMHC will
need to address organizational culture issues and engage in its own
recovery process prior to facilitating the recovery of individual
patients. A successful change initiative must assess workforce
readiness to embrace the recovery philosophy, a comprehensive change
management strategy, and a long-term sustainability plan that will act
as a catalyst for system improvement. Future research is needed to
better understand barriers when translating knowledge from policies and
procedures to behavioural changes in the frontline staff.
Strategic initiatives that help to ensure healthcare organizations are
ready and able to sustain changes must also be developed. The
shared values and beliefs introduced by recovery and IPC will
facilitate the development of newer ways of thinking, and may
contribute to yet another paradigm shift in our ongoing efforts for
system improvement in Ontario.
Amaral, D., Murphy, M., & Uehlinger, K. (1999). Collaborative
practice: a nursing perspective of the psychiatric interdisciplinary
treatment team. Holistic Nursing Practice, 13(2), 1-11
Loganathan, L., & Fulford, B. (2002). Discovering hope for
recovery: Areview of a selection of recovery literature, implications
for practice and systems change. Canadian Journal of Community
Mental Health, 21(3), 1-22.
(1993). Recovery from mental illness: The guiding vision of the mental
health service system in the 1990’s. Psychosocial Rehabilitation
Journal, 16(4), 11-24.
Anthony, W., &
Ashcroft, L. (2008). Addressing resistance to recovery:
Strategies for working with staff resistant to change.
Behavioural Healthcare. Retrieved May 18, 2008
Rogers, S., & Farkas, M. (2003). Research on
evidence-based practices: Future Directions in an era of
recovery. Community Mental Health Journal, 39(2), 101-114.
Barr, H. (1998).
Competent to collaborate: Towards a competency-based model for
interprofessinoal education. Journal of Interprofessional Care,
Anson, B. Ording, R., & Rogers, E. (2002). Culture transformation
in a healthcare organization. Consulting Psychology Journal: Practice
and Research, 54(2), 116–130.
Barry, K. J.
(2007). Collective Inquiry: Understanding the essence of best practice
construction in mental health. Journal of Psychiatric and Mental
Health Nursing, 14, 558-565.
Bate, P. (2000).
Changing the culture of a hospital: From hierarchy to networked
community. Public Administration 78(3), 485-512.
Blickem, C., &
Priyadharshini, E. (2007). Patient narratives: The potential for
“patient-centred” interprofessional learning? Journal of
Interprofessional Care, 21(6), 619-632.
(2001). Complexity science and leadership in healthcare.
Journal of Nursing Administration, 31(10), 474-482.
(2003). A model for interdisciplinary collaboration. Social Work,
Parliament. Senate. Standing Senate Committee on Social Affairs,
Science and Technology. (2006). Out of the Shadows at Last:
Transforming Mental Health, Mental Illness and Addiction Services in
Canada. Retrieved August 3, 2008 from
Central East Local
Health Integration Network. (2006). Integrated Health Service
Plan. Retrieved July 27, 2008 from
Crowe, T., Couley,
A., Diaz, P., & Humphries, S. (2007). The adoption of
recovery-based practice: the organization’s journey. New Paradigm,
Crowe, T., Deane,
F., Oades, L., Caputi, P. & Morland, K. (2006). Effectiveness of a
collaborative recovery training program in Australia in promoting
positive views about recovery. Psychiatric Services, 57(10),
O’Connell, M., Tondora, J., Styron, T., Kangas, K. (2006). The top ten
concerns about recovery encountered in mental health system
transformation. Psychiatric Services, 57(5), 640-645.
Nutley, S., & Mannion, R. (2000). Organizational culture and
quality of health care. Quality in Health Care, 9, 111-119.
Dean, F., Crowe,
T., King, R., Kavanagh, D., & Oades, L. (2006). Challenges in
implementing evidence-based practice into mental health services.
Australian Health Review, 30(3), 305-309.
Deegan, P. (1988).
Recovery: The lived experience of rehabilitation. Psychosocial
Rehabilitation Journal, 11(4), 11-19.
Deegan, P. (1996).
Recovery as a journey of the heart. Psychiatric Rehabilitation Journal,
Deegan, P. &
Drake, R. (2006). Shared decision making and medication management in
the recovery process. Psychiatric Services, 57, 1636-1639.
(2008). Whitby Mental Health Centre Cultural assessment: readiness for
change. Retrieved May 15, 2008 from Whitby Mental Health Centre Human
(1999). Professionalisation and professionalism: Issues for
interprofessional care. Journal of Interprofessional Care, 13(2),
Ashcroft, L, Anthony, W. (2008). The three C’s for Recovery
Services. Behavioural Healthcare, retrieved July 14, 2008 from
Farkas, M., Gagne,
C., Anthony, W., & Chamberlin, J. (2005). Implementing recovery
oriented evidence based programs: Identifying the critical
dimensions. Community Mental Health Journal, 41(2), 141-157.
&Skarlicki, P. (1999). Unfairness and resistance to change:
hardship as mistreatment. Journal of Organizational Change Management,
Gerardi, D., &
Fontaine, D. (2007). True collaboration: Envisioning new ways of
working together. AACN Advanced Critical Care, 18(1), 10-14.
& Tregunno, D. (2005). New approaches to interprofessional
education and collaborative practice: Lessons from the organizational
change literature. Journal of Interprofessional Care, 1, 177-187.
Richards, J., El Bestawi, M., Seidman-Carlson, R., & Teperman, L.
(2007). Reconnecting to care: A nursing initiative at the
Baycrest Geriatric Health System. Canadian Journal of Nursing
Leadership, 20(2), 40-50.
Grol, R., &
Grimshaw, J. (2003). From best evidence to best practice: Effective
implementation of change in patients’ care. Lancet, 362, 1225–30
(2007). Ontario Medical Association Policy Paper on
Interprofessional care. Retrieved July 16, 2008 from
Brooks, W., Ashikaga, T., Strauss, J., & Breier, A. (1987). The
Vermont longitudinal study of persons with severe mental illness, II:
Long-term outcome of subjects who retrospectively met DSM-III criteria
for schizophrenia. American Journal of Psychiatry, 144(6), 727-735.
Hopper, K., Craig, T., Laska, E., Siegel, C., Wanderling, J. (2001).
Recovery from psychotic illness: A 15- and 25-year international
follow-up study. British Journal of Psychiatry, 178, 506-517.
Schrecker, T., Wiktorowicz, M., Hoch, J., & Sharp, C. (2003).
Decades of Mental
Health Policy in Ontario, Canada. Administration and Policy
in Mental Health and Mental Health Services Research, 31(1), 65-73.
(2007). Enhancing Employee Satisfaction Together Survey. Cultural
assessment of the Whitby Mental Health Centre workforce. Retrieved May
15, 2008 from Whitby Mental Health Centre Human Resources Department.
(2007). Primary Health Care Transition Fund. Collaborative Care:
Synthesis Series on Sharing Insights. Retrieved August 19, 2008 from
(2007). Interprofessional Care Strategic Implementation
Committee. Interprofessional Care: A Blueprint for Action in
Ontario. Retrieved July 29, 2008 from
Vickers, M., Jackson, D., & Wilkes, L. (2006). Workplace
bullying in nursing: towards a more critical organizational
perspective. Nursing Inquiry, 13(2), 11-126.
(2006). Bridging the “system’s” gap between interprofessional care and
patient safety: Sociological insights. Journal of Interprofessional
Care, 20(5), 517-525.
Medicine Committee on Health Care in America. (2001). Crossing the
quality chasm: a new health system for the 21st Century. Washington
(DC): National Academy Press.
Jones, K., &
Redman, R. (2000). Organizational culture and work
redesign. Journal of Nursing Administration, 30(12), 604-610.
Klein, J. (2008).
Evaluation of interdisciplinary and transdisciplinary research: A
literature review. American Journal of Preventative Medicine, 35(2),
Corrigan, J., & Donaldson, M. (2000). To err is human: building a
safer health system. Washington (DC): National Academy Press.
Integration Networks. (2008). Engaged communities: Healthy
communities. Retrieved August 2, 2008 from
System Integration Act. (2006). Ministry of Health and Long Term Care.
Retrieved July 14, 2008 from
Mackenzie-Davey, K. (2001). Accounts of workplace bullying: The role of
the organization. European Journal of Work and Organizational
Psychology, 10(4), 375-392.
Coleman, S., Melito, C., Sweetland, D., Saidak, J., Smit, J., Thompson,
T., & Milak, G. (2003). Building empowering partnerships for
interprofessional care. Journal of Interprofessional Care, 17(4),
(2006). Interdisciplinary researching: Exploring the
opportunities and risks of working together. Nursing and Health
Sciences, 8, 88-94.
& Shah, P. (2008). Recovery and the medical model. Advances in
Psychiatric Treatment, 14, 241-244.
Newman, D. (1998).
2000 and beyond: Strengthening Ontario’s mental health system: Report
on the consultative review of mental health reform in the province of
Ontario. Toronto: Ontario Ministry of Health. Retrieved June 22,
New Zealand Mental
Health Commission. (2001). Recovery competencies for New Zealand mental
health workers. Retrieved August 18 from
Oades, L., Crowe,
T., & Dean, F. (2007). Collaborative recovery model: Moving
beyond ‘us and them’ in mental health. New Paradigm, June, 32-36.
of Health. (1999). Making It Happen: Implementation Plan for the
Reformed Mental Health System. Retrieved June 22, 2008 from
Jensen, P., Jaccard, J., Gollwitzer, P., Oettingen, G., Pappadopulos,
E., & Hoagwood, K. (2007). Applying theory-driven approaches
to understanding and modifying clinicians’ behavior: What do we know?
Psychiatric Services, 58(3), 342-348.
Plsek, P., &
Wilson, T. (2001). Complexity, leadership, and management in
healthcare organizations. British Medical Journal, 323(29),
Dosser, D., Handron, D., McCammon, S., Temkin, M., Kaufman, M. (1999).
Challenges of interdisciplinary collaboration: A faculty consortium’s
initial attempts to model collaborative practice. Journal of Community
Practice, 6(2), 27-48.
of Mental Health Implementation Task Forces. (2002). The Time is Now:
Themes and Recommendations for Mental Health Reform in Ontario.
Retrieved August 2, 2008 from
Reid Ponte, P.,
Gross, A., Winer, E., Connaughton, M., & Hassinger, J. (2007).
Implementing an interdisciplinary governance model in a comprehensive
cancer center. Oncology Nursing Forum, 34(3), 611-616.
Rice, A. (2000).
Interdisciplinary collaboration in health care: Education, practice,
and research. National Academies of Practice Forum, 2(1), 59-73.
Roberts, G., &
Wolfson, P. (2004). The rediscovery of recovery: open to all.
Advances in Psychiatric Treatment, 10, 37-49.
Roberts, P., &
Priest, H. (1997). Achieving interprofessional working in mental
health. Nursing Standard, 12(2), 39-41.
Lawton-Smith, S., Warner, L., & Mariathason, J. (2007). Patient
choice in psychiatry. British Journal of Psychiatry, 191, 1-2.
Salin, D. (2003).
Ways of explaining workplace bullying: A review of enabling, motivating
and precipitating structures and processes in the work
environment. Human Relations, 56(10), 1213-1232.
Everett, A., del Vecchio, P. (2007). Promoting the value and practice
of shared decision-making in mental health care. Psychiatric
Rehabilitation Journal, 31(1), 54-61.
Mannion, R., Davies, H., & Marshall, M. The quantitative
measurement of organizational culture in health care: A review of the
available instruments. Health Services Research 38(3), 923-945.
Executive. (2006). The Report of the National Review of Mental Health
Nursing in Scotland: Rights, Relationships and Recovery. Retrieved July
14 from http://www.scotland.gov.uk/Resource/Doc/112046/0027278.pdf
Senge, P. Smith,
B., Kleiner, A., Roberts, C., Ross, R., & Roth, G. (1999). The
challenges of profound change. Retrieved August 2, 2008 from
Keenan, P., & Jackson, A. (2006). The hard side of change
management. Harvard Business Review Online. Retrieved July 4, 2008 from
Solomon, P. &
Stanhope, V. (2004). Recovery: expanding the vision of evidence-based
practice. Brief Treatment and Crisis Intervention, 4(4), 311-321.
Sovie, M. (1993).
Hospital culture: Why create one? Nursing Economics, 11(2), 69-75.
Sowers, W. (2005).
Transforming systems of care: The American Association of Community
Psychiatrists Guidelines for recovery oriented services. Community
Mental Health Journal, 41(6), 757-774.
Committee on Social Affairs, Science and Technology. (2002). The
Health of Canadians – The Federal Role. The Final Report on the
state of the health care system in Canada. Retrieved August 2, 2008
& Norman, G. (2003). Health measurement scales: A practical guide
to their development and use (3rd ed.). Oxford, UK: Oxford University
(2007). Systems and complexity thinking in general
practice. Australian Family
and Mental Health Services Administration. (n.d.). National Consensus
Statement on Mental Health Recovery. Retrieved June 29, 2008 from
(2001). Error reduction, complex systems, and organizational
change. Journal of General Internal Medicine, 16(5), 344-346.
& Brice, G. (2006). Sharing the message of hope, wellness, and
recovery with consumers psychiatric hospitals. American Journal
of Psychiatric Rehabilitation, 9, 101-109.
Thomas, S. (1998).
White paper: New NHS modern dependable. Journal of Community Nursing,
12(7), retrieved July 9 from http://www.jcn.co.uk/default.asp
Dault, M., & Clements, D. (2008). Ready, set... collaborate? The
evidence says "go," so what's slowing adoption of inter-professional
collaboration in primary healthcare? Healthcare Quarterly, 11(2), 14-16.
(2003). Mental health and workplace bullying: The role of
power, professions and “on the job” training. Australian
e-Journal for the Advancement of Mental Health 2(2),
Health Centre. (2006). About Whitby Mental Health Centre.
Retrieved June 17, 2008 from
Yeager, S. (2005).
Interdisciplinary collaboration: the heart and soul of health care.
Critical Care Nursing Clinics of North America, 17, 143-148.
Reeves, S., Barr, H., Hammick, M., Koppel, I., & Atkins, J. (2007).
Interprofessional education: effects on professional practice and
health care outcomes (Review). The Cochrane Library, 4, 1-7.