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.

Research Excellence Framework

I teach a session on the politics of research funding, offered now as part of our workshop and seminar series for postgraduate research students in the School of Healthcare Sciences at Cardiff University. One of the things I talk about is the Research Excellence Framework (REF), and how the outcomes from the REF are used to inform the annual distribution of quality-related (QR) funding to universities as part of the ‘dual support’ approach, along with providing evidence of a return on public investment and generating information for the purposes of benchmarking and comparison.

The REF moves in long cycles. The first took place in 2014, replacing the Research Assessment Exercise which had previously run every five or so years from the middle of the 1980s to 2008. For the 2021 Research Excellence Framework (REF2021) universities made submissions to up to 34 units of assessment, each covering a subject area and each operating underneath one of four main panels. Most research conducted by nursing academics in the REF2021 census period will have been submitted to the Allied Health Professions, Dentistry, Nursing and Pharmacy unit of assessment (UOA). In each UOA, expert panels reviewed the quality of three separate components within each submitting university’s return: outputs, impact and environment. An output might be a single journal article, or perhaps a book or monograph, assessed by members of the relevant expert panel for its ‘originality, significance and rigour’. The assessment of impact involved the expert review of university-submitted case studies exemplifying the ‘reach and significance’ of research beyond academia. Environment involved review of how far each university was enabling the ‘vitality and sustainability’ of excellent research in the subject area.

Suffice to say, the REF is a big deal for universities, subject areas and researchers, with very considerable resources being devoted by institutions to secure as favourable a set of outcomes as possible. As a process it has both its supporters and its detractors, with a summary of controversies surrounding the REF appearing on this Wikpedia page. Debates aside, results from REF2021 have now been published, with the data searchable both by university and by unit of assessment. Main panel reports have also appeared, with more data (including the detail of each submission to each UOA) expected in due course. Both the Times Higher and the Wonkhe teams have produced independent analyses of what the results mean, with the Council of Deans of Health publishing a response highlighting how ‘research undertaken by our members [as submitted to the Allied Health Professions, Dentistry, Nursing and Pharmacy UOA] tackles real life health challenges facing patients, health services and local communities as well as addressing wider societal challenges and global health inequalities.’

Extracted directly from the Overview report by Main Panel A and Sub-panels 1 to 6, here is a summary of the average assessed quality profile of research submitted to the Allied Health Professions, Dentistry, Nursing and Pharmacy UOA:

Reproduced from the Overview report by Main Panel A and Sub-panels 1 to 6

Here, 4* refers to ‘world-leading’, 3* to ‘internationally excellent’, 2* to ‘internationally recognised’ and 1* to ‘nationally recognised’. Overall, then, this table gives lots to celebrate, pointing to allied health, nursing and related research being done to a very high quality, and making a significant difference beyond academia. This much is acknowledged explicitly in the UOA-specific overview report, but so too is a note on the importance of continued investment in research capacity-building and in supporting early careers. I find it hard to disagree with that sentiment. Whilst REF outcomes come round only once every six or seven years, the work of enabling and growing research capability is a constant.

Accessible summary

In what will, I imagine, be a final post about the MENLOC evidence synthesis here is our accessible summary. This has been produced with a wide readership in mind, and for completeness includes links to the full Health and Social Care Delivery Research monograph reporting the project in full, and to our two derived papers. The first, in Palliative Medicine, reports on our research, policy and guidance synthesis and the second, in BMJ Open, reports on findings from our synthesis of case studies.

For a copy, click below:

MENLOC monograph

With funding from the National Institute for Health Research comes the opportunity (and indeed, the requirement) to produce a detailed monograph reporting on all aspects of the project which has been supported. The Health and Social Care Delivery Research monograph arising from the MENLOC evidence synthesis, about which I have added various posts on this site, has now appeared. As with all NIHR project reports, this is free to download.

Here is the plain English summary:

In this study we brought together evidence from research, policies, guidance and case studies in the area of end-of-life care for people with severe mental illness. End-of-life care refers to the help given to people with life-threatening conditions in their expected last 12 months of life. Severe mental illness refers to a range of issues for which care is usually provided by specialist mental health services.

An advisory group, which included people who had experience of mental health and end-of-life care, helped us throughout our project. We searched research databases, journals and online sources. We assessed research articles for their quality and summarised their content. In one review we combined content from research with content from policy and guidance. In another review we combined the content of the case studies. We wrote synthesis statements summarising the research evidence, and assessed how much confidence decision-makers should have in these statements.

We included 104 documents overall. We synthesised research, policy and guidance under themes reflecting their content: the structure of mental health and end-of-life care services; professional practice; providing and receiving care; and living with severe mental illness. We synthesised case studies under themes relating to delays in diagnosis, making decisions, treatment futility, supporting people and the experience of care.

Our project has implications for care. The evidence suggests that partnerships should be built between mental health and end-of-life care staff, and that people should be supported to die where they choose. Care staff need education, support and supervision. A team approach is needed, including support for advocacy. Physical health care for people with severe mental illness needs to be improved so that life-threatening conditions can be recognised sooner.

Future research should involve people with severe mental illness at the end of life and their carers. Research is also needed to evaluate new ways of providing and organising care.

Three hundredth post

By the looks of it this is my three hundredth post on this site. My blog writing and curating has waxed and waned over the years, and from time to time I’ve needed to engage in furious catch-ups. But that’s ok. Rather than write something about mental health policy, services, nursing, research or education on this occasion I’ve chosen to upload some outdoors photographs with some short explanatory notes, simply because it pleases me to do so. Enjoy.

Sgwd yr Eira

First up is a photograph taken in early 2020, shortly before the first pandemic-related lockdown, of Sgwd yr Eira. Located in the Brecon Beacons National Park, Sgwd yr Eira is a waterfall behind which it is possible to walk. The landscape of Wales is one of the many reasons why it’s good to live, work and study in this part of the world, which is exactly what I’ve been doing for well over half of my life.

The Taf Estuary from Laugharne

Somewhere we’ve visited lots over the years is Laugharne, a town in Carmarthenshire known particularly for its association with Dylan Thomas. Here is a view from Laugharne of the Taf Estuary, taken in April 2021 during a lockdown window when travel within Wales was possible.

Heading to the top of Cat Bells

In September 2021 it was possible to travel within the UK. This picture was taken en route to the top of the (very walkable) Cat Bells, near Keswick in the ever-beautiful Lake District. This modest mountain is a family favourite, and I’ll look forward to a return visit at some point.

A rather sinister-looking corvid

Whilst Covid can’t disappear quickly enough, corvids (a family of birds which include crows, jackdaws and ravens) are a wholly different proposition. Intelligent and good at problem-solving, this particular example was spotted in Cornwall in February 2022.

That’s it for now. In November 2022 I’ll have reached another blog-related milestone, which is to have maintained this site for ten years. I’ll see if I can keep on top between now and then.

Second MENLOC paper

Here is our second published paper from the MENLOC project, which has synthesised what is known about end of life care for people with severe mental health problems. This article, led by Michael Coffey, reports on our theming of the evidence derived from previously-published case studies. The paper is in BMJ Open, is open access, and has this as its abstract:

Objectives: People with severe mental illness (SMI) have significant comorbidities and reduced life expectancy. The objective of the review reported in this paper was to synthesise material from case studies relating to the organisation, provision and receipt of care for people with SMI who have an end-of-life (EoL) diagnosis.
Design: Systematic review and thematic synthesis.
Data sources: MEDLINE, PsycINFO, EMBASE, HMIC, AMED, CINAHL, CENTRAL, ASSIA, DARE and Web of Science from inception to December 2019. Supplementary searching for additional material including grey literature along with 62 organisational websites.
Results: Of the 11 904 citations retrieved, 42 papers reporting 51 case studies were identified and are reported here. Twenty-five of the forty-two case study papers met seven, or more quality criteria, with eight meeting half or less. Attributes of case study subjects included that just over half were men, had a mean age of 55 years, psychotic illnesses dominated and the EoL condition was in most cases a cancer. Analysis generated themes as follows: diagnostic delay and overshadowing, decision capacity and dilemmas, medical futility, individuals and their networks, care provision.
Conclusions: In the absence of high-quality intervention studies, this evidence synthesis indicates that cross-disciplinary care is supported within the context of established therapeutic relationships. Attention to potential delay and diagnostic overshadowing is required in care provision. The values and preferences of individuals with severe mental illness experiencing an end-of-life condition should be recognised.

Synthesising data

A not-uncommon research strategy in health and social care research is to generate different types of data and, through some process of transformation, bring these together into a coherent whole. The idea here is that combining data produces a more complete, detailed, analysis than can be created using one type of data alone. For example, in my doctorate, which focused on the system of mental health care and the division of labour, I conducted lots of qualitative interviews but also used written records as a source of data and observed people going about their day-to-day work. What people say, what people do, and what people write about they’ve done are not the same thing: knitting together a rich, or ‘thick’, description of a social setting is helped when different classes of data are available to be drawn upon. In more recent studies of care planning and coordination (see here and here) the research teams I’ve been a part of have variously combined interviews, documentary review, questionnaires and observations.

In a slow-burn kind of way, over a period of many months I’ve been working with members of the 3MDR project team to bring together data of very different types. The 3MDR study, led by Jon Bisson, is something I’ve written about before and involved examining the efficacy of a novel intervention for people with post-traumatic stress disorder. Across the project overall three, distinct, classes of data were generated: outcomes, derived from clinician-assessed and self-reported standardised measures; psychophysiological, including breathing and heart rate, walking pace, words and phrases used by participants during therapy, plus subjective unit of distress scores; and qualitative, namely post-therapy interviews where people talked about their views and experiences. Working particularly closely, in the first instance, with Robert van Deursen and Kali Barawi our task has been a mixed-methods data synthesis to explore the interrelationships between people, interventions and context and to investigate how factors within these three domains interact in specific outcome typologies.

This has been an interesting and challenging project, and we’re not yet done. Whilst many of the ideas underpinning this analysis are familiar ones (complexity, interconnections, the search for patterns) the combined dataset we’re mixing together is an unusual one. This work is also proving to be a reminder of how much can be found out through the detailed study of relatively small numbers of participants. Our data relate to ten people only, but our total dataset is both comprehensive and varied. At some point (but not quite yet) we’ll have a paper ready for journal submission, and I’ll be able to share more on this site.