Abstract
Widespread organizational change in health care has occurred in Australia. This has been driven by the need to improve patient care and increase quality and effectiveness in service delivery. Refocusing service delivery has had a substantial impact on health care professionals. They have been required to adapt their professional frame of reference in order to respond to new models of care, new roles, responsibilities, and reporting relationships. New and expanded skill sets and competencies are required of staff to enable them to carry out the complex work roles that are characteristic of contemporary mental health services. The extent to which generic and discipline-specific work activities are required are largely unknown.
New organizational structures for integrated community based care of people with mental illness emphasize the importance of all the patient's needs [1]. To achieve this end, there has been the development of collaborative multidisciplinary and multi-agency working [2]. Working in multidisciplinary community mental health teams has required staff to change their customary work practices, ideology, and philosophy [3]. The patients they see have complex health and social care needs and require staff to address a broad range of problems often with little training, supervision or support [4]. Bland and Renouf [5] stated that the greatest potential for improving the effectiveness of multidisciplinary teamwork in mental health lies in marshalling the unique skills and perspectives of each profession in the service of the patients' wishes and needs. The process of case management is likely to be a common part of many new models of care [6]. Case management cuts across professional affiliations to place the patient in the community as the focus.
However, the generic skills required of the case manager may be seen to erode the specialist skills of mental health professionals such as occupational therapists and social workers. Tension between the generic and specialist roles is one of the main themes in current debate about the role of professionals in mental health care delivery [7–11]. They have experienced difficulties with defining their role in community mental health settings [3], [4], [10]. While the issue of generic versus specialist clinical roles has generated considerable debate, this debate has been limited by inadequate empirical data as to the actual work activity of professional groups. This is a matter of considerable importance, not just because it concerns the effective deployment of clinical resources in mental health care, but also because the training of mental health professionals must have reference to actual work roles and the skills required to perform those roles.
This paper presents one component of a larger study examining work activities and levels of burnout among occupational therapists and social workers. A description of this research has been reported elsewhere [12]. This aspect of the study sought to provide a clearer picture of work activity among two of the allied health professions with a prominent role in delivery of public mental health services in Australia. These two professional groups were selected owing to the limited research of their work activities in public mental health service settings. The aim was to quantify a range of generic and specialist clinical activities and to make comparison between the professions with respect to their generic and specialist roles.
Method
Participants
The State Department of Health provided a list of inpatient and community-based mental health services in the Australian states and territories. Senior social workers and occupational therapists in Australian public mental health services (with the exception of Tasmania and the Northern Territory) were contacted and asked to provide a list of staff who were interested in participating in this research. Potential participants were provided with information concerning the project either by mail or email. This was followed by distribution of the surveys to people interested in participating in the research. Non-respondents received two subsequent mailouts of the survey approximately four and eight weeks after the initial mailing. Occupational therapists and social workers working in Tasmania and the Northern Territory were not included due to the limited number of occupational therapists employed there.
Measures
The work practice scale is a self-report method of identifying work activities of mental health professionals. The items were compiled following a review of the literature and consultation with the university staff. The 77-item scale was investigated using factor analysis to assess the empirical fit of the work activity items. This analysis yielded four factors that met the loading criterion of 0.35. These four factors utilized a total of 55 of the 77 work activity items. These four factors were broadly consistent with the a priori subscales although there was some item reallocation. Consistent with the a priori determination, factors were titled: Senior Administrative, General Clinical, Specialist Clinical, and Community Development and were treated as subscales of the Work Practice Activities Measure. The 22 items that did not load on any of the subscales were excluded from further analysis.
The subscales generated by factor analysis were then investigated for reliability using Cronbach alpha as a test of internal consistency. Reliability for these four subscales was high (alpha = 0.84, 0.90, 0.92, 0.76, respectively). Items measure the following work activities that it could be expected these professional groups would be undertaking: administrative (12 items); general clinical (21 items); specialist clinical (18 items); and community development (4 items). Each work activity item is answered on a five-point response scale scored from 1 (not at all) to 5 (very frequently). Only two of the subscales are the focus of this paper. These were the general and specialist clinical work activities.
Respondents were also asked to provide details of their age, gender, work experience, and duration of employment in their current job. In addition, they were asked to provide information concerning the type of service or team in which they worked and location.
Results
Sample
The return sample consisted of 196 occupational therapists with a response rate of 78.1% and 108 social workers with a response rate of 74%. Most respondents were in the 20–30 years age bracket (44%). Seventy-six percent of the sample had worked in mental health for up to 10 years and in their current position for up to 5 years (79.9%). Women comprised 81.3% of the sample. The percentage of time spent by respondents providing acute care services was 70.9%, case management 69.2%, and extended treatment and rehabilitation 42.8%.
There were significant differences in the percentage of time spent by occupational therapists and social workers in the type of service or team in which they worked. Social workers spent a significantly greater percentage of time doing intake and assessment (t = 4.27, df = 302, p < 0.001), psychiatric crisis and treatment services (t = 3.68, df = 302, p < 0.001), and case management (t = 3.52, df = 302, p < 0.01. There was a significant difference in the percentage of time spent by occupational therapists working in rehabilitation services compared to social workers (t = 6.47, df = 302, p < 0.001). Ninety-six (31.6%) of respondents were from New South Wales, 75 (24.7%) from Queensland, 65 (21.4%) from Victoria, 39 (12.8%) from Western Australia, 27 (8.9%) from South Australia, and two (0.7%) from the Australian Capital Territory. One hundred and seventy-seven (58.2%) respondents worked in a capital city, 88 (29.0%) in a regional city or centre, and 39 (12.8%) in a rural or remote area.
Work activities
Generic clinical skills
It was possible to calculate a total score for generic clinical work activity by combining scores on each of the individual general activity items and a total score for specialist clinical work activity by combining scores on each of the individual specialist activity items. Both total subscale activity scores and individual item scores for occupational therapists and social workers were compared using t-tests for independent samples. Because there were multiple comparisons a more conservative test of significance (p < 0.01) was employed. The differences in work activities performed by the two professions are displayed in Table 1.
Differences in generic clinical work activities between occupational therapists and social workers
There were significant differences between occupational therapists (mean = 55.1) and social workers (mean = 65.8) (t = −6.1, df = 274, p = 0.000) for the general clinical subscale total scores and for a majority of individual items. In both the subscale total and the individual items, social workers reported performing generic clinical activities more frequently than did occupational therapists.
Specialist clinical skills
The individual specialist work activities carried out by occupational therapists and social workers were compared using t-test for independent samples. Again, because of multiple comparisons an alpha setting of p < 0.01 was used. The differences in work activities performed by the two professions are displayed in Table 2. There were significant differences between the two professions on all but three items.
Differences in specialist clinical work activities between occupational therapists and social workers
Since it could be argued that the specialist clinical work activities were biased towards occupational therapists, the average for the specialist clinical work activities for occupational therapists and social workers were calculated. The 22 items of the original specialist skills category on the survey and the two items (program coordination and helping patients with daily activities) that loaded into the specialist clinical skills after factor analysis were analyzed to determine which items were discipline-specific. These work activities were used to calculate the means for both groups.
Five items (specialist counselling, brief structured individual counselling, long-term unstructured therapy, couples/relationship counselling, and family therapy) were undertaken significantly more by social workers. Long-term unstructured therapy failed to meet the loading criterion and the remaining four loaded into the general clinical factor. There were no significant differences between occupational therapists and social workers in undertaking early intervention, psycho-education, and groups for patients with special needs (these items failed to meet the loading criteria and were discarded). Seventeen items were undertaken significantly more by occupational therapists, including use of activities with patients, activity analysis and grading of activities, and living skills training.
The mean total score for 180 occupational therapists was 2.5 (SD = 0.7) and for 107 social workers was 2.5 (SD = 0.8). They were not found to be significant (t = −0.4, df = 285, p = 0.670).
Generic and specialist clinical work for the sample as a whole
Mean scores for all respondents on items from both the general and specialist clinical subscales were ranked to identify those activities reported as being most commonly performed. Overall, respondents performed a greater proportion of generic clinical work activities than specialist work activities. Generic clinical work activities comprised the top six activities and accounted for nine of the top 10 activities.
Discussion
The findings reported in this study reveal that both occupational therapists and social workers are performing more generic than discipline-specific or specialist work. There were significant differences between occupational therapists and social workers in their clinical work profile. Even though both professions reported a high rate of generic clinical work, social workers reported a significantly higher rate of generic clinical work activities than did occupational therapists. Conversely occupational therapists reported a significantly higher rate of specialist clinical work activities than was the case for social workers.
In part the difference reflected the different work settings of the two professions. Social workers were more likely than occupational therapists to be working in acute services, intake and assessment, case management, and psychiatric crisis and treatment. These types of work settings involve high levels of generic work activities [6]. It is also notable that a number of the items that are commonly associated with social work practice such as arranging accommodation and arranging patient finances loaded onto the general clinical factor.
The work activities that were identified as being undertaken most frequently by social workers included supportive counselling, psychosocial assessment, links with community resources, family psycho-education, liaison with support networks and crisis management. These non-discipline-specific tasks relate to generic clinical and support work, which is a part of a case management role, crisis work, and intake and triage. Generic work activities undertaken most frequently by occupational therapists were similar to those undertaken by the social workers. These findings are similar to previous research examining work practice activities of Australian occupational therapists [9].
Occupational therapists carried out significantly more specialist work activities than social workers. Again, work setting was a factor as occupational therapists reported spending a greater percentage of their time working in extended treatment and rehabilitation than did social workers. These treatment settings have a strong focus on rehabilitation interventions and a more specialist approach to work assignment.
The types of specialist work activities carried out by occupational therapists were similar to those reported in previous studies that have examined the choice of interventions by occupational therapists [8], [9]. This was most evident in the areas of use of activities with patients, helping patients with daily activities, assessing occupational performance, activity analysis, and living skills training. The main type of specialist work activities carried out by social workers included program coordination and use of activities with patients. We found that compared with social workers, occupational therapists had a more specialist focus but this does not alter the main finding that generic clinical activity was more prominent than specialist activity for both groups. Based on these findings, we could anticipate that generic work activities would also predominate in the work activities of other professional groups such as nurses and psychologists.
In this study, it was evident that acute care and case management roles predominated and that this influenced work activity profile for both professions. This finding is in keeping with the report published on evaluating the National Mental Health Strategy where it was found that there was an emphasis on crisis intervention mode of service delivery [13]. In order to fulfil their new roles within the changing context of service provision, all mental health staff will have to adopt a different approach and attitudes, and acquire new knowledge and skills.
While acknowledging the specific competencies brought to mental health by the different disciplines, a set of core competencies required by mental health staff across a diverse range of practice settings needs to be considered. At present there is a mismatch between the outcomes of education and training programs being undertaken by occupational therapists and social workers and the skills they require in order to meet changing service needs. This has clear implications for all the key disciplines and the education and training they receive. There is a need to determine both the disciplinespecific and generic work activities being taught in university curricula and with ensuring that undergraduates have the right skill mix to work in a range of practice settings.
While it is clear that the larger part of the work practice of both occupational therapists and social workers revolves around a set of common tasks, it cannot be assumed that a workforce based on generic mental health workers would be a satisfactory substitute for the current multidisciplinary mix that characterizes Australia's mental health services. In addition to the generic work activities reported by participants in this study, there were a substantial range of specialist roles. More importantly, we do not know whether the specialist background of participants, whether occupational therapists or social workers, influenced the way they performed generic activities. It is quite possible that different professionals bring to generic roles specific perspectives and skills that make for a greater richness and diversity in the total service delivery mix than would be possible if the same roles were delivered by generic workers.
Limitations
Although the response rate was good, it is not known whether a response bias may have influenced the results. Response rate was calculated on participating sites and the underlying participation rate is lower. Unfortunately, it is not possible to determine the total number of occupational therapists and social workers employed in public mental health services in Australia therefore the true participation rate cannot be accurately determined. It is not possible to determine how non-responders would have responded to the survey and some caution is required in generalizing beyond the study sample. The work practices scale was developed specifically for this study and although initial reliability and factor structure was established, further work is required to confirm its psychometric properties.
Future research
Given that this study only surveyed two of the four identified core non-medical disciplines in mental health, further research in this area could be undertaken with other mental health professionals, for example nurses and psychologists, to determine the proportion of generic and specialist work activities they undertake. Research on additional samples is also required to ensure that the returned factor structure of the work practices scale is accurate. Given the finding of high rates of generic or common work roles, it is important to learn more about the way such roles are performed by clinicians from different professional backgrounds. This may require a more qualitative approach to the investigation of work activity and attitude.
Conclusion
The literature suggests that there are two distinct types of clinical work activities carried out by occupational therapists and social workers in mental health. One type involves generic work skills and the other disciplinespecific core skills. The findings from this study revealed that generic work activities are the primary work activities of both these professional groups. Given the direction of mental health policy and service development in Australia, it is not unexpected that generic work activities have become increasingly important. It is noteworthy, however, that some discipline-specific work activities were also identified as being frequently undertaken, especially by occupational therapists. This is an interesting finding as it highlights the fact that disciplinespecific skills still have a place in today's mental health service delivery models. The implications of these findings are that specialist skills remain important but that, given the expectations of service managers, it is necessary for occupational therapists and social workers to practice with a broad repertoire of skills. Professional training programs must prepare them for the generic as well as specialist roles they will be required to undertake.
Footnotes
Acknowledgements
We thank the occupational therapists and social workers who completed this survey, as well as Chris Foley for administrative support.