Mental Health Nursing

Integrated care pathways: the ‘acute’ context 137
examined to identify variation in professional standards. This information is
used for both day-to-day clinical management and continuous quality
improvement. Over a period of time these data can be examined to establish
trends, develop action plans and improve practice. For example, Hall
(2000) found that group assessments by occupational therapists for those
newly admitted for dementia assessment were often not completed and
recorded as a variance. The variance in most cases was caused by high
levels of confusion associated with a recent change in environment. A
simple action plan was developed to ensure that this assessment was
offered on an individual rather than group basis in the future. This enabled
the occupational therapists to respond to the communication needs of the
individual and complete the assessment without the added stress of a
group-work situation. This is a simple but practical example of how variance
analysis reports and effects upon outcomes are discussed by a multiprofessional
team. From this process an action plan is developed and
practice reviewed.
Despite mainly favourable opinions of care pathways, many evaluative
case-studies appear weak in research design and statistical rigour. Research
into mental health care pathways in the UK in the future may be able to
exploit links to the mental health minimum dataset and the Health of the
Nation Outcomes Scales to aid evaluation. Whilst the literature does not
invalidate the concept of care pathways, quantitative studies would be
more widely accepted with the exposure of a control group which is absent
from many studies. Evidence to date is largely anecdotal and does not
enable conclusive evaluation of the effects of care pathways. There are no
systematic reviews of the use of mental health care pathways. Many studies
are deficient in statistical evaluation of cost reduction or effect upon
length of stay. Those which demonstrate a more rigorous statistical design
demonstrate only a small effect upon the use of resources and little effect
upon clinical outcome (Kwan-Gett et al., 1997; DeLuc, 2000). There are
few examples of trials without randomisation, single group pre-post, cohort,
time-series or matched-case control studies. Many favourable reports rely
upon narrative evidence, and an absence of rigorous analysis of data fails
to substantiate anecdotal claims. Irrespectively, interest in care pathways
remains high and gathers momentum, and therefore the potential benefits
of implementation continue to warrant rigorous evaluation.
Integrated care pathways: nurses and
practice development
Few would argue against the need for professional development and social
transformation in acute mental health in-patient services. Characteristics of