How can ways of working with others be developed to improve perinatal mental health care?

Systems thinking

Systems thinking theory illustrates how changing collaboration throughout the layers of an organisation can improve perinatal mental healthcare. Maternity services are made up of different teams that are interdependent, but not always successfully interconnected (Figure 1).

Systems thinking theory states that improvement requires change to take place throughout the system, including at individual, team and organisational levels (Ferlie and Shortell, 2001). However, this can be challenging, as strong leadership and effective interprofessional working are essential (Ferlie and Shortell, 2001). This model will be used throughout the article to demonstrate how changes in interprofessional working and leadership can enhance perinatal mental healthcare by connecting layers of a hospital Trust.

Partnership working

Hospital Trusts need to work in partnership with other healthcare organisations to improve perinatal mental healthcare. Partnership working occurs when organisations work across boundaries to develop trusting relationships that allow for joint working towards mutual goals (Carnwell and Carson, 2005). Approximately 20% of women will experience a mental health problem within the first year of childbirth; however, perinatal mental health services are inconsistent throughout the country (National Maternity Review, 2016). Partnership working between maternity services and mental health charities in the UK has been trialled successfully, demonstrating statistically significant improvements in women's wellbeing, social support and problem-solving skills (Steen et al, 2015). Nonetheless, recruitment of women with perinatal mental health problems appeared to be a challenge, and it was identified that: ‘better partnership working relationships needed to be developed with local maternity services' (Steen et al, 2015: 98). A lack of experience in working collaboratively can lead to barriers to partnership working, such as concerns regarding which organisation leads the venture and where the funding is sourced (Cameron et al, 2014). In addition, as there are four stages in partnership-building (Figure 2), creating a partnership takes time.

Hospital Trusts should commit to developing partnerships with other healthcare providers, such as charities, to improve training and services by using all available resources. This may be shown by the publication of a local directive that aims to enhance partnership working across organisational boundaries, or by the implementation of interprofessional training.

Interprofessional training

Maternity leaders need to devise interprofessional training methods to improve perinatal mental healthcare across the service. Lo (2011) stated that team training improved team performance by creating a safe and supportive environment for individuals to develop competencies and team behaviours. Surveys show that midwives desire more training on mental health problems, including how to care for women with mental health problems and how culture and attitudes can affect perinatal mental health and care provision (Noonan et al, 2018). Wriedt et al (2014) found that where training has been provided, health professionals had a greater awareness of:

Health professionals have been shown to appreciate interprofessional perinatal mental health training in the form of case studies and participant discussions, as both of these methods allowed for the exploration of different viewpoints by networking with individuals from varied disciplines (Wriedt et al, 2014). Health professionals also suggested that incorporating service user participation into training would benefit their learning by allowing them to reflect on personal experiences; however, organisations may find this a logistical challenge (Wriedt et al, 2014). Maternity leaders should devise a range of interprofessional training methods in partnership with mental health charities, incorporating case studies, participant discussions and service user participation where possible, to enhance staff education, encourage relationship-building and promote teamwork. Content should not only include education about various perinatal mental health conditions and how to identify them, but also how to care for women appropriately by taking into account cultural differences.

Communities of practice

Maternity leaders need to develop perinatal mental health communities of practice to enhance learning in this field and, by extension, patient care. Social learning theory suggests that there are four aspects of learning that can be embedded into communities of practice to enhance education, due to the connection between practical competencies and personal experience (Figure 3) (Wenger, 2013).

Wenger's (2013) hypothesis is complemented by Tseng's (2010) research on knowledge transfer, which concluded that organisations could improve their performance by generating new knowledge through the conversion of tacit knowledge (personal experience) to explicit knowledge (practical competencies) and vice versa. Some learning providers incorporate the community and practice elements, for example, through in-house, interprofessional training; however, the ‘shared identity’ (highlighting what a group stands for) and ‘meaning’ (reflecting on personal experiences) aspects can be lacking (Wenger, 2013). Where communities of practice have been set up to improve mental health services in Canada (Piat et al, 2016), there have been improvements seen in:

It can be challenging to incorporate a shared identity and meaning throughout a community of practice; however, one possibility is to incorporate these elements into interprofessional perinatal mental health training curricula with case studies, discussions and service user participation. These training methods may enhance shared identity through interdisciplinary discussions and meaning via the use of reflective practice when using case studies or service user experience (Wriedt et al, 2014). A second means to incorporate a shared identity and meaning throughout a community of practice is through digital media—for example, by developing a digital perinatal mental health community of practice on the hospital intranet—with contributions from staff in the mode of monthly newsletters, blog posts and forums. Maternity leaders should develop physical and digital communities of practice to enhance interprofessional learning in perinatal mental healthcare.

Collective leadership

Maternity leaders should employ a collective leadership style throughout their service to create a collaborative culture that fosters learning and improvement in perinatal mental healthcare (National Maternity Review, 2016). Collective leadership is required in modern healthcare organisations due to the increasing complexities that many patients face, requiring more co-ordinated and integrated care from various health professionals (The Kings Fund, 2014). However, most healthcare organisations still accommodate a transactional leadership style, where only people at the top of the hierarchy make decisions (McKee et al, 2013). By contrast, collective leadership is shared by all, thus promoting engagement, participation and innovation (Figure 4) (West et al, 2014). Cleary et al (2011: 632) concluded that collective leadership is ‘highly congruent with mental health nursing values’; nevertheless, there are many barriers to collective leadership such as (The Kings Fund, 2014):

Introducing a collective leadership style throughout maternity services may enhance collaboration, by empowering all staff to share new ideas on perinatal mental heath and build strong relationships with their peers. West et al (2014) provided a framework that maternity leaders could use to implement this leadership style effectively (Figure 4). Strategies may include posting surveys or feedback forms to patients and staff to hear their views, and encouraging staff to submit ideas for improvements via blogs or forums on the digital community of practice. A monthly newsletter could then communicate how suggestions have been actioned and could provide a reminder of the vision and goals of the organisation's perinatal mental healthcare service.