People, interventions and context: a case study in theory-building

Commencing a series of long-overdue posts, here is a link to a final paper from the 3MDR project which I’ve blogged about in the past (see here, and here). This article, which draws on an unusually diverse range of data (researcher-assessed and self-report clinical measures; semi-structured interviews; physiological recordings; words used during therapy sessions; and subjective unit of distress scores), sets out to explore the complex relationships between people, interventions and context and how these interact in particular outcome typologies.

The paper was a long time in the making. Using a mixed methods approach, the various types of data brought together were initially analysed independently, before being subjected to an interpretation of how far these converged and diverged within a series of three therapy outcome typologies. Although the data relate to a relatively small number of therapy participants, the article makes its contribution by microscopically focusing on how different factors in different domains are patterned within different types of response.

Crisis responses paper

In February 2023, this new paper titled Review: Crisis responses for children and young people: a systematic review of effectiveness, experiences and service organisation (CAMH-Crisis) appeared in Child and Adolescent Mental Health journal. This reports on methods and findings from this study, which my colleague Dr Nicola Evans has led.

The journal asks for key practitioner messages, and these I’ve reproduced here:

  • Due to rising demand and increasing healthcare waiting times, more CYP present at mental health services at crisis point. To improve care, it is important to understand the types of mental health crisis services and how CYP and their families experience support at these facilities.
  • Findings from this systematic review indicate that CYP and their families are often unaware of available mental health services and how to access them. Children and young people should be involved in the development of public information about mental health services.
  • Mental health support needs to be provided through different mechanisms such as face-to-face appointments, text, email, or telephone via a direct line with round-the-clock availability.
  • Emergency departments (EDs) are often accessed at crisis point. EDs work well where care is provided in a calm and private environment by trained staff with experience in children’s and young people’s mental health.
  • Improving accessible community based early interventions with clear pathways to designated clinical services might prevent CYP reaching mental health crises.

Skellern Lecture and Lifetime Achievement Award 2023

The School of Healthcare Sciences in Cardiff University is hosting the 2023 Skellern Lecture and Lifetime Achievement Award evening, which takes place in the Glamorgan Building on June 15th. An Eventbrite link to book tickets to be there, in person, can be found here. Here, too, is the evening’s order of events:

A packed evening, for sure, with an invitation now to secure a place and to spread the word!

Keeping in Touch

Over a period of years, with Dr Nicola Evans and Dr Becky Playle I’ve been supervising Gavin John, whose doctoral studies have focused on (as Gavin himself puts it in his thesis), the ‘interventions and processes that promote or hinder children and young
people’s connections to their education, friends and families during periods of admission to
hospital for mental health care’.

Gavin’s research has built directly on the RiSC study (see here for an accessible summary). Following a viva at the end of 2022, in February 2023 Gavin officially because ‘Dr’: very many congratulations to him! For a direct link to Gavin’s thesis, the place to go is here. And, for flavour of what Gavin did in his research and what he found, here is his summary:

Background: Existing research has identified risks to children and young people’s (CYP)
connections to their friends, family and education during periods of inpatient mental health
care. However, to date there is a dearth of research on what interventions and processes
support CYP to maintain these connections.

Aim: To explore the interventions and processes that promote or hinder children and young
people’s connections to their education, friends and families during periods of admission to
hospital for mental health care.

Method: Case study methodology was used involving the generation of qualitative and
quantitative data in a single CAMHS inpatient unit. Three outcome measures relating to
mental health, friends, family and education were completed by adolescents admitted to
hospital for care and treatment of their mental ill-health (n=26). A subset of children and
young people (n=9), their caregivers (n=6) and health, social and education practitioners
(n=11) were interviewed, multidisciplinary team (MDT) meetings were observed, and policy
and procedure documents were examined.

Results: Demographic data were collected and results from three questionnaires indicate
participants were in the abnormal banding for the total difficulties score on the Strengths and
Difficulties Questionnaire (SDQ). Participants scored highest on the global scale and trust
and communication subscales in relation to mothers in the Inventory of Parent and Peer
Attachment-Revised (IPPA-R). Highest scores were recorded on the behavioural and
emotional engagement subscales of parts A and B of the Student School Engagement
Survey (SSES). Thematic analysis of interviews (n=26), observations and documentary
analysis of policy and procedure documents identified five themes: ‘Remote connections to
friends and family’, ‘Physical connections to friends and family’, ‘Peers in hospital’, ‘Impact
on families’ and ‘Connections to education’.

Conclusion: The study highlights significant barriers to children and young people
maintaining connections to their friends, family and education during periods of inpatient
mental health care. It identifies candidate interventions to help children and young people
maintain these connections.

CAMH-Crisis2

Crisis care for children and young people with mental health problems: national mapping, models of delivery, sustainability and experience is a new project funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research (HSDR) Programme, which my colleague Clare Bennett and I are jointly leading. The wider team includes Martin Elliott, Leanne Sawle, Aled Jones, Steven Pryjmachuk, Claire Fraser, Euan Hails, Iain McMillan, Nicola Evans, Mair Elliott, Rachael Vaughan and Aneta Taylor.

Our study builds on the now-completed Crisis responses for children and young people: an evidence synthesis of service organisation, effectiveness and experiences, led by Nicola Evans, about which I most recently wrote a post here. It also has a clear connection to the Developing a model for high quality service design for children and young people with common mental health problems project led by Steven Pryjmachuk, with which it shares aspects of study design.

Our new CAMH-Crisis2 study began in November 2022, and a summary of what we’re doing is here:

There has been a sharp and worrying increase in mental health problems experienced by children and young people. Prior to the pandemic, one in eight 5-19 year olds in England had a probable mental disorder. In 2020, amongst 5-16 year olds this figure had risen to one in six. Amongst those with a mental health difficulty, almost half of older teenagers and a quarter of 11-16 year olds report having self-harmed or attempted suicide. Extreme psychosocial distress, with or without self-harm, is often referred to as a ‘crisis’. Services for young people in crisis are a UK priority, and provision is expanding in the NHS, social care and educational settings. However, despite this and the appearance of national standards very little research into crisis services for young people has been undertaken. We therefore do not know what crisis responses currently exist, who uses services, or what works best for children and young people and their families.

Against this background this project will answer the question, ‘How are mental health crisis responses for children and young people up to the age of 25 sustained, experienced and integrated within their local systems of services’? We will work with a group of young people who advise on research, some of whom have used crisis services, to address the following three objectives:

  1. To describe and map NHS, local authority, education and third sector approaches to the implementation and organisation of crisis care for children and young people across England and Wales.
  2. To identify eight contrasting case studies in which to evaluate how crisis services have developed and are currently organised, sustained, experienced and integrated within the context of their local systems of services.
  3. To compare and contrast these services in the context of the available international evidence, drawing out and disseminating clear implications for the design and delivery of future crisis responses for children and young people and their families.

To help us answer our research question and to meet our objectives we will make use of normalisation process theory. This supports studies into what helps, and what hinders, the implementation and sustainability of new approaches to care.

We will meet our first objective using a survey, creating a detailed record of crisis responses across England and Wales and how they are organised, implemented and used. To meet our second objective, from this detailed record we will identify eight contrasting services selected for variety in terms of: geographic and socioeconomic setting (England/Wales, urban/rural, and relative affluence/poverty); populations served (including ethnic diversity); and service configuration (including third sector and/or social care involvement). Treating each as a case study, we will conduct interviews with children and young people and family members who have used the service. We will also interview commissioners, managers and practitioners, including those providing a crisis response and those working in other parts of the local system. We will gather operational policies and related documents, and data on how each service is used and by whom. In our analysis we will focus on understanding how each crisis service is provided, experienced, implemented and sustained. To meet our final objective we will compare and contrast each case study, and use our synthesised findings to advance the available international evidence for best practice in service provision. We will close by drawing clear, actionable, lessons for the future commissioning and provision of high-quality crisis responses which are sensitive to the support and access needs of a diverse range of children and young people receiving care from a range of services.

CAMH crisis animations

Over the last few years I’ve been a part of a team led by my Cardiff colleague, Dr Nicola Evans, synthesising the evidence in the area of mental health crisis responses for children and young people. Here is a link to the project, which has been funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery (HSDR) Research Programme.

Now, with the project having concluded, an animation with English and Welsh language versions has been produced. Here they are:

Conferences

This month brought, for me, the welcome return of face-to-face conferences. First, I was pleased to have received an invitation earlier in the year to deliver a keynote lecture at the RCN International Nursing Research Conference 2022, which took place at the Royal Welsh College of Music and Drama on September 5th and 6th. Rather than speak about any one, particular, study I used this as an opportunity to travel over a larger programme of research in the mental health field, pulling out underpinning ideas and key messages along the way.

Boiled down, my talk revolved around four ideas: health care can be thought of as a complex system; complex health systems can be understood through the study of cases, existing at different ‘levels’ of organisation (macro, meso and micro); to appreciate cases of health care system complexity it makes sense to use a plurality of analytic and methodological approaches; and research of this type demands a collaborative, stakeholder-informed, approach. These will be familiar themes to readers of this blog site. My talk at the RCN event, however, represented the most sustained effort I’ve made to date to articulate the principles and practices underpinning the research programme I have been involved in, to synthesise the main lessons learned, and to pull out some overarching observations. At some point it would make sense to write all of this up in an article.

Hot on the heels of the RCN International Nursing Research Conference came the 28th International Mental Health Nursing Research Conference, which took place at St Catherine’s College, Oxford, on September 8th and 9th. St Catherine’s was the home for the Network for Psychiatric Nursing Research Conference, as this event was originally known, for many years: returning there earlier this month seemed fitting after the two online editions of the event which happened in 2020 and 2021. I was pleased to be part of a symposium presenting findings from three NIHR-funded studies into mental health crisis services. Led By Dr Nichola Clibbens, this included a talk by Nicola and Michael Ashman drawing from their (and their colleagues’) realist synthesis of how, for whom and in what circumstances different community mental health crisis services work. Also featuring was a presentation from Professor Steve Gillard and Dr Katie Anderson on mental health decision units in acute care pathways. Third in the linked series of presentations was my talk summarising findings from an evidence synthesis, led by Dr Nicola Evans, into crisis responses for children and young people aged 5 to 25.

More generally, I very much appreciated the opportunity at both these events to renew my connections with friends and colleagues, and to meet and hear new people with interesting things to say. In the case of MHNR2022, particular thanks are due to the organising committee, which brought this conference together under the umbrella of Mental Health Nurse Academics UK without a dedicated events team in support.

Studentships

In the School of Healthcare Sciences at Cardiff University we’re preparing to advertise two full-time, funded, doctoral studentships open to nurses, midwives or allied health professionals registered in the UK. This reflects an ambition to grow capacity in our field, through supporting people at the start of their research careers. We’ll be advising interested people to pay close attention to our research themes, and will expect that project ideas are congruent with these. Information on these two opportunities will appear on the School website in the near future. Growing research interest and expertise in the healthcare professions is an important task, which I’ve referred to in a variety of earlier posts on this site (see here and here for examples). Services and practice need evidence to underpin them, and in Wales we have the Research Capacity Building Collaboration (RCBC Wales) leading the way. Information on the RCBC Wales website tells me that this scheme has thus far made 115 fellowship awards since commencing its work in 2005, leading to the production of no fewer than 377 publications. An impressive return. And yet, as the REF 2021 Main Panel A and Sub-panels 1 to 6 overview report indicates, with regards to the allied health professions, dentistry, nursing and pharmacy:
There remains considerable scope for development […], particularly in capacity and capability building and the support of early career researchers. The sub-panel identified that fostering a collaborative cadre of research active individuals with such expertise, equipped, and resourced to deliver international multicentre studies, was important for the future vitality and sustainability of these disciplines.
In this context, the two School of Healthcare Sciences studentships which are on their way promise to make an important contribution to promoting both ‘vitality and sustainability’, and here’s to them attracting lots of interest.

New theses

Here is news of two completed doctoral theses which I have helped support as a supervisor, both being within the mental health field. First is Fortune Mhlanga’s Implementing recovery-oriented practice in mental health services: a qualitative case study, which is all about how recovery ideas are used in everyday practice. The summary for Fortune’s study is this:

Although the recovery philosophy has been adopted in mental health services in various Western countries including England, its implementation in practice has been described as “slow and patchy”. Furthermore, there are suggestions in the literature that there is a lack of clarity around the implementation of recovery-oriented practice (ROP) and a dearth of research exploring the phenomenon. This study aimed to discover how recovery-oriented practice is implemented in an NHS Trust providing care for people experiencing mental health problems, in order to add to what is already known about the implementation of ROP to inform future practice.

A qualitative case study approach was employed to investigate the implementation of ROP from strategic to grassroots level in two practice settings (Community Mental Health Team and Rehabilitation ward) within one NHS Trust providing mental health services in the South of England. Semi-structured interviews were conducted with 16 participants (senior managers, practitioners, service users) investigating their perceptions and experiences of ROP. Data were analysed using thematic analysis and further interpreted by situating it in the literature.

Main findings

• Whilst there was a shared common understanding of the meaning of recovery and ROP in the organisation, there was a fundamental difference between practitioners and service users’ conceptualisations with service users leaning more towards clinical recovery.

• At strategic level, strategies to facilitate implementation of ROP focused on changing the culture within the organisation through Implementing Recovery through Organisational Change (ImROC) recommended interventions such as: Recovery College, peer workers and use of the Recovery Star. At grassroots level, implementation was via the development of therapeutic relationships between service users and practitioners.

• Salient barriers to the implementation of ROP included: time taken completing paperwork resulting from performance measures used by commissioners in the community team, the shortage of resources and the tension between risk management and ROP in both settings.

Study contribution

This study addresses the gap in research on the implementation of ROP through an exploration of how ROP was being implemented in two practice settings in an NHS organisation providing mental health care. Methodologically, the qualitative case study approach adopted in the study allowed triangulation of data from participants ranging from grassroots level to strategic level. Furthermore, the approach taken with the sample consisting of service users, senior managers and practitioners from inpatient and community practice settings within the same organisation is not comparable with any other studies on ROP that have been conducted in England. This study therefore informs implementation efforts of similar organisations and makes recommendations for practice, commissioners and research.

Second up is Bethan Mair Edwards’ A window of opportunity: Describing and developing an evidence, theory, and practice-informed occupational therapy intervention for people living with early-stage dementia, which addresses the development of OT practice in the support of people with memory difficulties. The summary from Bethan’s thesis is this:

Aim

There is a scarcity of evidence generated in a UK context to inform the practice of occupational therapists working with people living with early-stage dementia. This Thesis’ overarching aim was to describe and develop an evidence, theory, and practice-informed occupational therapy intervention for people living with early-stage dementia.

Methods

In accordance with the MRC Framework for the Development and Evaluation of Complex Interventions, an Intervention Mapping approach was utilised to guide the development process. Thesis Objectives were developed based on Intervention Mapping Steps 1 – 3, and to meet these objectives, this Thesis consists of three studies. Study 1 (a two-stage mixed methods evidence synthesis) and Study 2 (semi-structured interviews with people affected by dementia and occupational therapy practitioners) sought to understand the intervention population and context, as well as identify existing research and practice-based interventions. Study 3 involved describing and developing an intervention programme theory and programme design.

Findings

Studies 1 and 2:

Multiple personal and environmental (social, physical, and occupational) determinants associated with the occupational performance problems that people living with earlystage dementia may experience were identified. Existing research and practice-based interventions were heterogenous in nature and no programme theories were reported; however, strategies that problem-solve occupational performance problems were identified as a primary intervention component. In practice contextual barriers were associated with resources, other professionals’ awareness and understanding of occupational therapy, and a lack of control and influence over service development and policy.

Study 3:

A logic model of the problem and population, matrices of change, and a simple intervention logic model were developed to articulate a proposed programme theory. A broad overview of the proposed interventions’ design, including components and context, were specified and key uncertainties outlined.

Conclusion

This research has developed a robust foundation for further development work at Intervention Mapping Steps 4 – 6, including developing theoretically informed implementation strategies and producing materials in preparation for a feasibility evaluation.

Two super pieces of work, with real relevance for interprofessional mental health services and practice: congratulations to both.

Postgraduate research symposium

Most of today I spent in the School of Healthcare Sciences’ Bringing us back together postgraduate research symposium, and very much enjoyed hearing about the projects which doctoral students in the School are engaged in. The event was opened by Eluned Morgan, Minister for Health and Social Services in the Welsh Government, who spoke in support of the health care workforce and of the importance of research which makes a difference to the care and treatment which people receive.

The talks which followed demonstrated, faultlessly, how applied the School’s postgraduate research projects are. Amongst our 90 or so research students are people investigating the improvement of clinical interventions. Many are also examining the experiences of people with long-term conditions and the support they receive, whilst others are exploring aspects of the workforce and the organisation and delivery of services.

This symposium, set up by Dr Tina Gambling who served with great distinction as the School’s Director of Postgraduate Research prior to her untimely passing in November 2020, is (or has been) an annual event, the organisation of which is always led by students with support from staff. The organising committee for today did a very fine job, as did the session chairs and speakers. The Bringing us back together theme, too, felt right.