Organizing diagnosis: A multi-level study on the development and implementation of care pathways in Norwegian mental health services.

In 2015 the Norwegian Prime Minister Erna Solberg stated that innovation was needed in Psychiatry, and that Clinical Pathways (C P); standardised, evidence-based multidisciplinary management plans, which identify an appropriate sequence of clinical interventions, timeframes, milestones and expected outcomes, inspired by cancer medicine, were to be implemented in Mental Health Care. The assignment to develop and implement the different pathways were given The Norwegian Directorate of Health in January 2016.

RESEARCH QUESTIONS:

Part I. What reactions occurred after the decision to implement clinical pathways in Psychiatry, and how did these affect the process and final result?

Part II. a)What are the attitudes towards clinical pathway at Kronstad District Psychiatric Center, and how is this expressed in the clinic?

b)Does the standardisation of diagnostic practice and the recovery strategies that follow affect the technical and social dimensions of health professionals’ work in the psychiatric ward? In addition, in what ways do these changes affect diagnosis and treatment.

Part I “The idea of clinical pathway in psychiatry” Early on in the process, The Directorate of Health decided to involve participants from different parts of Psychiatry in the making of a C P. In addition to the work groups where they discussed the content, a tense media debate originated concerning the introduction of C Ps in psychiatry. The debate circulated around the appropriateness of standardization as innovation into the field of Mental Health Care. The process and this way of influencing the creation of a C P is what Fairclough term “technologization of a discourse”. Lamers & Barbour 2006 define institutions as constellations of formalized rational beliefs manifested in individuals’ organizing behaviors. As a result, some institutional forms and practices is considered legitimate while others become or remain illegitimate. When trying to understand how and why this is happening in the field of Psychiatry, one can look towards institutional isomorphism.

Part II “Understanding the implementation of clinical pathway in psychiatry

Barley & Kunda 2001 encourage researchers to “bring work back in”, - meaning to examine daily work practices inside the organizations. This is my focus in the second part of this PhD. Project where I will bring work back in at Kronstad DPS through an ethnographic study. The focus of this analysis is to establish a thorough understanding of how these clinical pathways affect the professionals’ work practice, and how this in turn influences the diagnosis and treatment for the patients involved. This will be done empirically by separating the collection of data into two separate parts answering different research questions. The first part concerns the stage preceding standardization and will present an outlook into work practices before the implementation of the standard mental illness diagnostic and treatment manuals. I will also provide an understanding of how health care organizations prepare for the change. Are there any resistance, and if so, where does it originate from and why, are elements I wish to have an outlook on. In addition I want to see how the changes are being led from the managers involved in the transformation process.

The second part will look specifically at the stages that take place during and after implementation. The main goal of this part will be to illustrate how the implementation potentially changes every day work practices.