Why Is Better Mental Health Care So Elusive?
285
Jan Horsfall, PhD, Michelle Cleary, RN, PhD, and Glenn E. Hunt, PhD
PURPOSE. There are numerous barriers to
improving healthcare delivery. This article
summarizes contemporary theories and research
evidence to focus on ways to motivate change
within the hospital system to provide better
health care.
CONCLUSIONS. Understanding multidisciplinary
team processes, recognizing hospitals as systems,
and ascertaining the unit culture is a
prerequisite for leaders and policy makers to
improve mental health practices.
PRACTICE IMPLICATIONS. Finding ways to
deliver better health care to people with a mental
illness is a high priority, and nurses have a
central role to play in this pursuit of excellence.
Search terms: Culture, health care, mental
health organization, quality improvement,
system, team
First received November 4, 2009; Revision received January 5,
2010; Accepted for publication January 8, 2010.
Perspectives in Psychiatric Care Vol. 46, No. 4, October 2010
© 2010 Wiley Periodicals, Inc.
ppc_264 279..
Jan Horsfall, PhD, is a Research Officer, Research Unit,
Concord Centre for Mental Health, Sydney South West
Area Mental Health Service, Concord Hospital, Sydney;
Michelle Cleary, RN, PhD, is an Associate Professor
in Nursing (Mental Health), School of Nursing &
Midwifery, University of Western Sydney, Penrith South
DC; and Glenn E. Hunt, PhD, is a Senior Research
Fellow, Discipline of Psychiatry, University of Sydney
and Research Unit, Concord Centre for Mental Health,
Sydney South West Area Mental Health Service, Concord
Hospital, Sydney, New South Wales, Australia.
T he incorporation of new knowledge into clinical
practice has been slow, uneven, and at times resisted
(Davies, 2002; Garman, Leach, & Spector, 2006). Some-
thing is amiss when clinicians are faced with a plethora
of evidence-based practice data, clinical guidelines,
quality improvement initiatives, and research-based
implementation strategies, yet 30–40% of patients
report they do not receive the most appropriate care
(Garman et al., 2006; Grol & Grimshaw, 2003). Further-
more, research in the United States and the Nether-
lands reveals that up to one quarter of provided health
services are either not needed or are potentially
harmful (Grol & Grimshaw, 2003).
Although some healthcare providers may consider
this information false or not relevant to their own
practice, consumers, policy makers, and health
researchers inform us of unmet healthcare needs and
wasted resources (Cockram, Gibb, & Kalra, 1997; Grol
& Grimshaw, 2003). Doctors are often blamed for the
research-practice schism because many view them as
those with enough power to change practice and
ensure delivery of appropriate services. Others con-
sider that practice changes are only partly within
doctors’ purview as organizational factors determine,
to a large degree, patient safety and quality of
care (Garman et al., 2006; Grol & Grimshaw, 2003).
This raises the question: If medical specialists consti-
tute the most powerful group in health service
279
doi: 10.1111/j.1744-6163.2010.00264.x
Why Is Better Mental Health Care So Elusive?
organizations, then why are practice improvements
not more widespread?
Many researchers, theorists, and commentators
consider that change is more likely to be achieved by
intervening at the group level rather than targeting
individual practitioner decision-making (Garman
et al., 2006; Grol, Bosch, Hulscher, Eccles, & Wensing,
2007). In this article, we examine the role of groups
within organizations to implement change in deliver-
ing better health care in hospital settings. Careful
examination of the structure and components of these
groups and the way they interact provides insight as to
why today’s mental health care is so elusive, when so
much effort has been made over the years to improve
care and patient outcomes.
Levels of Hospital Service Delivery
Professional Teams
Teamwork is deemed to be necessary for continuity
of care, to improve quality of hospital care, lower mor-
tality rates, and decrease length of stay (Grol et al.,
2007). Teams have the following components and char-
acteristics: they share common goals, perform tasks
relevant to goal achievement, are interdependent
regarding work, have different roles and responsibili-
ties, and are parts of the same organizational system
(Kozlowski & Ilgen, 2006).
Team processes in mental health care are dynamic
and embedded within complex large organizations
that determine how members combine their resources,
and coordinate knowledge, skills, and effort to carry
out requisite tasks. Trust and psychological safety,
along with minimizing and managing team conflict,
are prerequisites for adequate team functioning. Team
functioning thrives on information sharing, good com-
munication, participative decision-making, and
dealing with new ideas, new practices, or new ways of
organizing treatment delivery (Garman et al., 2006;
Kozlowski & Ilgen, 2006). Team effectiveness emerges
from these processes. Over time, practices and routines
280
tend to regularize or ritualize; hence, “process begets
structure, which in turn guides process” (Kozlowski &
Ilgen, p. 81).
Effective teams are deemed to decrease costs,
decrease length of hospital stay, and improve patient
satisfaction, especially for those with long-term condi-
tions such as mental illness, stroke, or cancer (Grol &
Grimshaw, 2003; O’Neill & Silver, 2002; Shortell et al.,
2004). Some authors note that reducing admissions,
decreasing length of stay, and cutting costs are com-
paratively easy, but they do not address the diverse
and complex needs of people with long-term mental
illness (Mechanic & McAlpine, 1999). Shortell and col-
leagues (2004) found that teams who perceived them-
selves to be more effective and committed to quality
improvement actually made more meaningful changes
to improve the care of people with chronic illnesses.
Another assumed but intrinsic aspect of teams in
health services is that they are multidisciplinary: The
various professions involved enhance care by drawing
on complementary approaches and treatments; and
they simultaneously confer challenges by holding
viewpoints that not only differ but are also at times
contradictory. Size may matter, in that some teams can
be too small to be effective and others so large and
expensive they become difficult to coordinate to
provide cost-effective services (Shortell et al., 2004).
Organizations as Systems
Complexity theory, deriving from systems theory, is
an intriguing way of throwing light on organizations
and their potential for change. Given that health ser-
vices are increasingly more multilayered (vertically
and horizontally), it behooves us to consider them
holistically rather than dividing them into parts or sec-
tions. From a systems perspective, the whole is greater
than the sum of its parts; and whatever happens in one
part of the system has ramifications in other parts—
and also outside the system because of contiguity and
interconnectedness, which may not be apparent.
According to Kitson (2009, p. 220), “The essence of
Perspectives in Psychiatric Care Vol. 46, No. 4, October 2010
systems thinking . . . [is] seeing inter-relationships
rather than linear cause-and-effect chains, seeing pro-
cesses of change rather than snapshots” (emphases
added). One important insight from systems theory is
that attempts to improve a subsystem, even when suc-
cessful, can be detrimental to the system as a whole;
and attempts to radically change one subsystem can be
impeded by antithetical forces within the greater
system. This has ramifications for a mental health unit
within a general hospital when the mental health team
aims to implement an approach to patient care that is
not the norm in the larger hospital.
Conceptualizing the healthcare system in its
entirety is surprisingly difficult and confrontational.
Kitson (2009) points out that our mental model of
health care is mechanistic, technical, and rational, not
fluid, organic, and somewhat unpredictable. She adds
that this implicit model of health services-as-machine
is not congruent with actual complexities and is, there-
fore, unhelpful when considering how practice
changes may be created. A major consequence of such
a conceptual reconfiguration is that comprehensive
plans with detailed targets for subgroups rarely
improve health care (Grol et al., 2007), regardless of
governmental penchants for numerical improvements
for specific groups within a given timeframe (see
Bennett, 2008, for a recent Australian example). In con-
trast, it seems what is required are broad targets for
change, with autonomous actors within coherent effec-
tive teams developing their ways to improve patient
care (Grol et al.; Kitson, 2009).
Culture
Dynamic teams within interconnected health ser-
vices that constitute systems rather than aggregated
professionals, specialist bodies, or departments are not
the only ideas to help appreciate the difficulties of
changing clinical practice for the betterment of patients’
well-being; culture is another important consideration.
Organizational culture relates to the group’s internal-
ized assumptions, attitudes, understandings, and
Perspectives in Psychiatric Care Vol. 46, No. 4, October 2010
beliefs that are shared and overtly or subtly guide
behaviors and direct actions (Davies, 2002; Davies,
Mannion, Jacobs, Powell, & Marshall, 2007; Scott,
Mannion, Marshall, & Davies, 2003). Culture is shared
and accepted, and behaviors are both prescribed and
proscribed. Furthermore, it involves held-in-common
tacit knowledge: Such assumptions in health would
include those inherent in the medical model of disease
etiology, treatment, and prognosis. New members
absorb nonarticulated group viewpoints as well as
actively learn attitudes and understandings about the
nature of their work and how it is approached. As
Davies said, “They pick up—one way or another—on
how things are done around here” (p. 140).
One commonly used model for assessing and com-
paring working group cultures within organizations is
the competing values framework (Davies et al., 2007;
Quinn & Rohrbaugh, 1981; Scott et al., 2003). Within
this schema, there are four distinctive cultural types
that can be briefly summarized as: (a) clans that value
cohesion, participation, loyalty, and morale, (b) hierar-
chical groups that value order, rules, uniformity, and
predictability, (c) rational cultures that value competi-
tion, acquisition, productivity, and goal-orientation,
and (d) developmental approaches that value open-
ness, risk-taking, entrepreneurship, and innovation.
The first two types sit on one side of the vertical axis
indicating an inward focus on smoothing and integra-
tion. The last two types have an external orientation
with a focus on differentiation and competition. On the
horizontal axis, the hierarchical and rational cultures
draw on mechanistic procedures that emphasize
control and order, while the clan and developmental
cultures value relationship-based processes, flexibility,
and spontaneity (Davies et al., 2007). Initially, one
might assume that hospitals, in general, would fall into
the hierarchical quadrant valuing order, rules, predict-
ability, quashing conflict, and stifling individuality.
Some mental health facilities may strive (knowingly or
not) for the characteristics of the clan culture, valuing
interpersonal relationships, flexibility, cohesion, par-
ticipation, and constructively managing conflict.
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Why Is Better Mental Health Care So Elusive?
Gerowitz, Lemieux-Charles, Heginbothan, and
Johnson (1996) examined the role of top management
and team culture in hospitals and found that the clan
and hierarchical types were featured mostly in the
United Kingdom, developmental and rational in the
United States, and clan and rational types in Canada.
One important finding of their study is that “the domi-
nant culture of the hospital management team was
positively and significantly related to organisational
performance in the case of clan, open (developmental)
and rational cultures but only in the performance domain
valued by the culture” (emphasis in the original; Scott
et al., 2003, p. 109). Hence, clan cultures will have high
staff morale; rational cultures will gain competitive
advantage; and developmental cultures will be innova-
tive. What this means for hierarchical cultures is
unclear. It may indicate that the main outcome of such
a culture is a predictable workplace, with no clear ben-
efits for patients, employees, or productivity. Grol and
colleagues (2007) go so far as to state that hierarchical
cultures that emphasize formal structures and regula-
tions are negatively associated with quality improve-
ment objectives.
In general, organizational researchers consider that
culture and senior management are of central impor-
tance to improving hospital performance (Davies et al.,
2007; Scott et al., 2003). In large teams or units, presum-
ably culture is not monolithic, and subcultures of dif-
ferent kinds will occur (Davies et al., 2007; Scott et al.,
2003). Another likelihood is that only some work
groups exhibit a “pure” culture type. Within large hos-
pitals, there may be an assortment of cultures, some of
which will be antithetical to each other. For example,
the goal orientation of a rational subgroup will conflict
with the cohesive orientation of a clan culture; and the
desire for innovation within a developmental subcul-
ture will clash with the needs of predictability in a hie-
rarchical culture. On the other hand, productive aspects
of rational and developmental subcultures may offer
leverage to improve patient care (Shortell et al., 2004).
In summary, understanding multidisciplinary team
processes, recognizing hospitals as systems, and ascer-
282
taining the unit or team culture may all be required for
leaders and policy makers to improve mental health
practices. These perspectives overcome wishful think-
ing associated with the idea that one hero-professional
(health or management) can magically improve and
sustain better patient outcomes. It also skirts the
equally magical idea that people are rational, especially
those with some education in the physical sciences,
and even more particularly those who compete vigor-
ously to enter elite university courses. How though, do
these group-oriented ways of thinking—no matter
how astute or correct they are—help administrators
change group processes for the benefit of patients?
Individualism Versus Group-Based Strategies as
Agents of Change
Perhaps two insights can be gained from the explo-
rations of the authors previously cited and the plethora
of associated researchers and theorizers across a
number of disciplines. These points constitute two
sides of one epistemological coin. The first is that con-
ceptualizing health professionals within a hospital as
individual change agents is flawed, no matter how con-
gruent this is with western understandings of society
in general. The second is that human achievements
mostly arise from group activities; and even if we value
our discrete self, health professionals work in a milieu
with other individuals, including those who are not
physically present (policy makers, medical specialists,
family carers), and all can impinge on each other’s
practice.
Kozlowski and Ilgen (2006) emphasized the central-
ity of the group as the agency of change. They indi-
cated that workplace complexity in recent decades has
prompted management to push workers into nominal
teams, but cognitively, motivationally, and economi-
cally members see and feel themselves as separate enti-
ties and act within a personal–professional cocoon. If
we take the epistemological understanding of the key
importance of groups in hospitals seriously, then team
development, learning communities, expert facilita-
Perspectives in Psychiatric Care Vol. 46, No. 4, October 2010
tors, interprofessional learning, and involvement and
support from top management will be invoked (Grol
et al., 2007; O’Neill & Silver, 2002; Watkin, Lindqvist,
Black, & Watts, 2009).
Alternatively, if we take the centrality of western
individualism—in families, the education system, and
societies—seriously, what leverage do we have? Was
there ever an idea pertinent to safety, illness, or treat-
ment that arose in the last hundred years, no matter
how profound, that activated pragmatic health profes-
sionals to promptly make radical changes? Further-
more, if our mental framework for knowing ourselves
as humane individuals has developed among Europe-
ans over four centuries (Weber, 1976), how can we
relinquish such a deep long-term cultural assumption?
Individual Practitioners
If it is true that our presumptions about ourselves
are incontrovertibly individualistic in the same way
that the understanding of humanity within many
indigenous cultures is that of the group, tribe, or
family, then in the short term we may have to accept
this and temper our expectations of group-based
strategies for healthcare system change. Perhaps we
have to go back to whole individuals, that is, not view
health professionals merely as wilful and rational
actors.
Garman, Leach, and Spector (2006), respectively a
doctor, administrator, and nurse, consider the contra-
dictions involved in hopes for interprofessional col-
laboration and team work from the perspective of
personal–professional profiling. According to such
an analysis, doctors fit the following profile:
investigative–enterprizing motivation, favoring deduc-
tive reasoning, and having an education that empha-
sizes decontextualized facts that can be generalized.
Nurses reveal the following professional characteris-
tics: social–investigative motivation, desiring to care
for and practically help patients, and valuing and
emphasizing relationships. Health administrators have
the following profile: enterprising–investigative moti-
Perspectives in Psychiatric Care Vol. 46, No. 4, October 2010
vation, exercising control in their professional domain,
and desiring to influence organizational activities and
outcomes.
Considering these profiles, Garman and colleagues
(2006) concluded that health professionals are as likely
to “collide” as they are to “collaborate” (p. 839). The
most obvious point of convergence (especially for
doctors and nurses) is patient health. However, given
recent policy trends toward consumer-centered care,
doctors in particular have not spontaneously abrogated
their overall status as experts for patients’ benefits. As
with the previously discussed group approaches to
improving mental health practice, professional profil-
ing tends to omit or minimize the reality of medical
power; however, for significant change to occur in
practice, this will have to be addressed.
Implications for Nursing Practice
Finding ways to deliver better health care to people
with mental illness is a high priority, and nurses have a
central role to play in this pursuit of achieving better
outcomes. The following nurse-led project provides an
overview of a body of work we recently undertook on
psychosocial treatments for patients with a dual diag-
nosis. This example shows how better mental health
care has been researched by a psychiatric interdiscipli-
nary team.
We began by surveying consumers and carers to
ascertain the influence of substance use on psychiatric
patients’ needs, levels of anxiety, and caregiving
burden (Cleary, Hunt, Matheson, & Walter, 2008). We
then undertook a Cochrane review on psychosocial
treatments for patients with a dual diagnosis (Cleary,
Hunt, Matheson, Siegfried, & Walter, 2008). For this
review, a large number of nonrandomized controlled
trials and other evidence had to be excluded; thus, we
undertook a more inclusive empirical (Horsfall,
Cleary, Hunt, & Walter, 2009) and systematic review of
treatment options for these clients (Cleary, Hunt,
Matheson, & Walter, 2009a). The latter systematic
review included all trials that used a comparison
283
Why Is Better Mental Health Care So Elusive?
group, and a quality assessment was conducted so that
high-quality trials were given the greatest weight.
Another project undertaken on this topic was a
nationwide survey to ascertain the views of key mental
health stakeholders on clients’ problematic drug and
alcohol use (Cleary, Hunt, Matheson, & Walter, 2009b).
Certainly, not all mental health clinicians have ready
access to the types of psychosocial interventions rec-
ommended in the research literature, and many of the
quality studies reported in the dual diagnosis literature
are large, funded projects with highly selected samples
that may not translate to everyday practice on a local
level. Thus, we developed some guiding principles for
promoting dual diagnosis awareness in everyday clini-
cal practice (Cleary, Walter, Hunt, Clancy, & Horsfall,
2008). With the growing development of peer-support
networks in the mental health system, formal training
should be provided regarding the adverse effects of
substance use. Thus, we conducted educational work-
shops with caregivers and consumer workers to
increase their knowledge and confidence to support
people with a dual diagnosis. Workshops were evalu-
ated through pre- and postsurvey (Cleary, Hunt,
Malins, Matheson, & Escott, 2009).
The said examples show that psychiatric advanced
practice nurses can offer valuable advice, resources, and
guidance to incorporate new knowledge into clinical
practice. Educational interventions intended to change
clinical practice should employ a multilevel approach to
utilize new skills in practice settings (Sullivan, Blevins,
& Kauth, 2008). If change is to be effective in the health
system, the dynamic nature of the hospital system
needs to be considered from different perspectives.
Although change can be initiated at the ward level, to be
truly effective, other levels within the hospital system
need to be engaged for measures to be broadly accepted.
Conclusion
In summary, this brief exploration of teams, organi-
zations, systems, culture, and professional profiling
perspectives all raise further questions and need clari-
284
fication or confirmatory research. In other words, they
have reached a theoretical or practical impasse,
through which we have been unable to successfully
maneuver. Understanding why these bottlenecks exist
through systems analysis is one way to unravel the
complex relationship between health service culture
and healthcare provision.
Declaration of interest: The authors report no con-
flicts of interest. The authors alone are responsible for
the content and writing of the article.
Author contact: ghunt@mail.usyd.edu.au, with a copy to the
Editor: gpearson@uchc.edu
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