Author: benhannigan

End of life care for people with severe mental illness

Here is a first publication from the MENLOC study, reporting on a synthesis of research, policy and guidance in the area of end of life care for people with severe mental illness. This is in the journal Palliative Medicine, and the abstract is here:

Background: Parity of esteem means that end-of-life care for people with severe mental illness should be of equal quality to that experienced by all.
Aim: To synthesise international, English language, research and UK policy and guidance relating to the organisation, provision, and receipt of end-of-life care for people with severe mental illness.
Design: A mixed methods systematic review was conducted following the Evidence for Policy and Practice Information and Coordinating Centre approach and informed by a stakeholder group. We employed thematic synthesis to bring together data from both qualitative and quantitative studies, and from non-research material. We assessed the strength of synthesised findings using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approaches.
Data sources: Ten electronic databases were searched from inception to December 2019, along with 62 organisational websites. Quality appraisal was conducted using Critical Appraisal Skills Programme checklists or other study design-specific alternatives as necessary.
Results: Of the 11,904 citations retrieved, 34 research publications were included plus 28 non-research items. The majority of research was of high or acceptable quality. An overarching synthesis including 52 summary statements, with assessments of confidence in the underpinning evidence, was produced using four themes: Structure of the system; Professional issues; Contexts of care; and Living with severe mental illness.
Conclusions: Implications for services and practice reflect evidence in which there is a high degree of confidence. Partnership should be developed across the mental health and end-of-life systems, and ways found to support people to die where they choose. Staff caring for people with severe mental illness at the end-of-life need education, support and supervision. End-of-life care for people with severe mental illness requires a team approach, including advocacy. Proactive physical health care for people with severe mental illness is needed to tackle problems of delayed diagnosis.

We have a second paper from this study currently under review in another journal, and the complete, unabridged, report is soon to be appearing in the NIHR’s Health Services and Delivry Research journal.

Perinatal mental health care

Continuing from this recent post celebrating the publishing of papers from doctorates I’ve had a hand in supervising, here now are links to Nicola Savory’s PhD and to a first article from this in the journal Midwifery. Nicola is a midwife, and in her thesis (funded by RCBC Wales) used quantitative and qualitative methods to investigate women’s mental health needs in the antenatal period.

Nicola’s whole-thesis summary is this:

Background: Existing research on poor perinatal mental health largely focuses on recognition and treatment of postnatal depression. Consequently, there is a need to explore antenatal mental health.
Aim: To assess poor mental health prevalence in pregnancy, its relationship to sociodemographic characteristics, self-efficacy and perceived support networks. To understand experiences and barriers preventing women with mental health problems from receiving help and explore midwives’ understanding of their role.
Method: Questionnaires were completed by women in early pregnancy. A subset identified to have mental health problems, were interviewed in late pregnancy to explore their experiences and barriers to receiving care. Midwives completed questionnaires exploring their experiences of supporting women with mental health problems and focus groups further discussed the issues raised.
Results: Amongst participants (n=302), the Edinburgh Postnatal Depression Scale (EPDS) identified 8.6%, and the Generalised Anxiety Disorder Assessment (GAD-7) 8.3%, with symptoms of depression or anxiety respectively. Low self-efficacy (p=0.01) and history of previous mental health problems (p<0.01) were most strongly associated with anxiety or depression. Thematic analysis of interviews with women (n=20) identified three themes: ‘past present and future’; ‘expectations and control’; and ‘knowledge and conversations’.
Questionnaires were completed by 145 midwives. The three themes identified from the focus groups with midwives were: ‘conversations’; ‘it’s immensely complex’; and ‘there’s another gap in their care’.
Conclusion: Prevalence rates of anxiety and depression amongst women in early pregnancy were found to be similar to those reported in the literature. Low self-efficacy and previous poor mental health were significant predictors of anxiety and depression. Continuity and more time at appointments were suggested by midwives and women to improve discussions regarding mental health. Midwives were keen to support women but lacked knowledge and confidence. Consistent reference was made to the need for training regarding the practical aspects of supporting women’s mental health.

Nicola has a series of journal papers lined up from her doctorate, with the one I’ve linked to above (‘Prevalence and predictors of poor mental health among pregnant women in Wales using a cross-sectional survey’) being just the first.

Cardiff University Press

Here’s a shout-out for Cardiff University Press, established in 2014 and a publisher of diamond (‘free in, free out’) open access books and journals. I’ve been involved with the Press since 2015, and in July 2021 joined colleagues online for a monograph commissioning panel meeting followed by a meeting of the full editorial board.

CardiffUP is remarkably interdisciplinary, and through the Press I get to work with colleagues from all three Colleges of the University. Though small in number, the monographs thus far published by the Press are nothing if not diverse: martial arts studies, living with cancer, human-computer interaction, media narratives of poverty and health care professional education. Further monographs are under review, and my impressions are that interest in the Press is on the up (check out this link to the most recent CardiffUP annual report). This reflects, I think, the extent to which funding bodies are increasingly concerned to make sure that the publications arising from the research they support appear in open access form.

#MHNR2021 and summer MHNAUK meeting

June 2021 brought both the International Mental Health Nursing Research Conference and the summer 2021 meeting of Mental Health Nurse Academics UK (MHNAUK). Unsurprisingly given the ongoing pandemic, both happened online, with #MHNR2021 again run as a collaboration between MHNAUK and the Royal College of Nursing.

In the event I was able to make less of the conference than I had intended, but I did have the opportunity to co-present a paper with Michael Coffey titled Involving stakeholders and widening the net: reflections on going beyond database searching arising from an evidence synthesis in the area of end of life care for people with severe mental illness. Our presentation arose from the MENLOC study, and specifically addressed the incorporation of non-research materials in evidence syntheses and the value of directly working with people with experience of the field. Here’s a link to the recording we made, on behalf of the whole project team:

At June’s MHNAUK meeting the group heard from Dr Crystal Oldman, of the Queen’s Nursing Institute, who spoke about specialist practice qualifications. Updates from colleagues across the four countries of the UK were followed by meetings of each of MHNAUK’s standing groups, where in the Research group we talked (amongst other things) about the importance of growing capacity in mental health nursing research. Elsewhere in the whole-group meeting we heard of plans to seek charitible status for MHNAUK: an exciting move, in my view.

Understanding continuous education

One of the nicest things about my job is the opportunity to supervise and support doctoral students, and to then publish with them. Belatedly (as this has been available for some time), here is a paper arising from Freda Browne’s doctorate. Freda works at University College Dublin, and in her thesis used a realist approach to understand how knowledge and skill are transferred from the education context to clinical practice.

This paper, appearing in the journal Nurse Education Today, is a fine piece of work and a good example of theory-informed evaluation. Here’s the abstract:

Background: Continuing professional education (CPE) for nurses is deemed an essential component to develop, maintain and update professional skills. However, there is little empirical evidence of its effectiveness or factors which may influence its application into practice.

Objective: This paper explores a continuing professional education programme on the safe administration of medication and how new knowledge and skills are transferred into clinical practice.

Design: Realist evaluation provided the framework for this study. Realist evaluation stresses the need to evaluate programmes within “context,” and to ask what “mechanisms” are acting to produce which “outcomes.” This realist evaluation had four distinct stages. Firstly, theories were built as conjectured CMO configurations (Stage 1 and 2), then these cCMO were tested (Stage 3) and they were then refined (Stage 4).

Methods: Data was collected through document analysis and interviews (9) to build and refine CMOs. The conjectured CMOs were tested by clinical observation, interview (7), analysis of further documents and analysis of data from reported critical incidents and nursing care metric measurements.

Results: This study has shown the significant role of the ward manager in the application of new learning from the education programme to practice. Local leadership was found to enable a patient safety culture and the adoption of a quality improvement approach. The multi-disciplinary team at both organisation and local level was also found to be a significant context for the application of the education programme into practice. Reasoning skills and receptivity to change were identified to be key mechanisms which were enabled within the described contexts.

Conclusion: The findings from this study should inform policy and practice on the factors required to ensure learning from CPE is applied in practice. The realist evaluation framework should be applied when evaluating CPE programmes as the rationale for such programmes is to maintain and improve patient care.

Counting the hours

If ‘ten thousand hours is the magic number of greatness‘, then after how many hours of study and practice should a student of nursing be able to register? According to the EU, in the case of nurses with responsibility for general care the answer is four thousand six hundred. Of these total hours, the theoretical component must amount to a minimum of one-third of the overall length of programmes of preparation and the clinical component at least one-half. Here in the UK, in usual times (i.e., not whilst emergency, and then recovery, standards during the pandemic have been in place) this 4,600 hours is split down the middle with 50% spent in practice and 50% devoted to theory.

Now that the UK has left the EU, the Nursing and Midwifery Council (NMC) is sounding out the views of stakeholders on its current education programme standards. As the NMC puts it, the research they are commissioning as part of this work aims to:

[…] provide us with up-to-date evidence about parts of our pre-registration programme standards, looking at standards in other countries and for other professions within the UK.

It covers the areas of the standards that reflect aspects of EU law, including:

  • the length of programmes and the number/ratio of theory and practice hours
  • the definition of practice learning for adult nursing and the lack of reference to simulation
  • general education required for admission
  • recognition of prior learning
  • entry to shortened midwifery programmes
  • content and clinical experience requirements for nursing and midwifery programmes, with specific mention of minimum numbers in midwifery such as 40 births.

By way of comparison, via Lorna Moxham I learn that, in Australia’s generalist nursing education system, students complete only 800 hours in clinical practice:

Meanwhile, students of physiotherapy in the UK must complete a minimum of 1,000 hours in practice as part of their pre-registration preparation, as must students of occupational therapy. Looking at the diagnostic radiography programme run in Cardiff University, where I work, I see a figure of 1,460 hours in practice for students before registration, and for students of social work I see a minimum number of 200 days. As another point of comparison, I am also aware of how the 4,600 hours of theory and practice expected of pre-registration undergaraduate nurses in Ireland is spread over four years, and not the usual three that we have here in the UK.

I have no idea how these differing figures for the minimum number of hours necessary for health and social care professional registration came to be arrived at, or how decisions have been made on the balance between placement learning and university-based learning. As Steven Pryjmachuk has also pointed out, not all hours are necessarily equal:

The ‘number of hours’ question is not one we’ve particularly considered here in the UK in recent reviews of nursing education, this being tied up at EU level: but what we most definitely have done is to have reviewed (and re-reviewed), pretty much everything else about how we educate nurses. I’m grateful to Jo Stucke for sharing this paper written by Karen Ousey, which sets out some key moments in the history of preparing nurses, included in which is the understatement that ‘nurse education is not static’. In universities and in practice areas up and down the country, students of nursing are now either engaged in programmes of preparation linked to the NMC’s 2018 standards of proficiency, or are completing their studies linked to NMC standards of pre-registration education produced in 2010 and to standards of competence for registered nurses produced in 2014. By my count not one new registered nurse will have graduated, by April 2021, from a programme linked to the 2018 standards. Already, though (signalled by the NMC’s newly launched programme to review those parts of the UK’s standards linked to EU law), moves are afoot to  reflect on, and review again, our approach to the initial preparation of nurses. As it happens, I think there is a discussion to be had on the issue of hours: but, more generally, I believe there is a strong case for introducing more stability into nursing education, and for placing much greater emphasis on the evaluation of what we currently do before making wholesale changes.

Early careers

A discussion unfolding at the Mental Health Nurse Academics UK meeting held on March 12th 2021 was how best to support colleagues making the transition from clinical practice into higher education. Given the very limited success within nursing in growing clinical academic careers, through which people might sustainably combine roles in practice with roles in education and/or research, this transition is a very real one. It is also, as Jan Hunter and Mark Hayter observe, relatively neglected.

The rhythms and demands of clinical practice are very different from those in universities. Most nursing, midwifery and allied health professional academics come to work in higher education without having had prior opportunities to hone their research skills through doctoral-level study. Many need to grow their skills and experiences in teaching, too, but it is on developing early career researchers that I wish to focus in this post. Along the way I draw on experiences of my own to illustrate some wider points.

I was helped to write two doctoral fellowship applications, the second after the first was unsuccessful. In this, I proposed using a set of design and methods crafted in an existing study of recovery from stroke to examine work and roles in the trajectories of people using mental health services in the community. With part-funding from a competitively secured fellowship and then employer support I was on my way. I therefore benefited from a very sensible, strategic, approach to research capacity-building which combined mentorship, help with funding applications, ongoing institutional support, and supervision. Very importantly, I was also encouraged to think programmatically, and to link my research to existing lines of enquiry with the aim of adding to a concentration of substantive, theoretical and methodological expertise.

Sharing my thesis findings through publishing was an absolute given, informed by the view that a study is not completed until it is shared. Beyond this, having concluded my PhD I both wanted, and was encouraged, to develop further the body of research commenced in my thesis. I moved swiftly from doctoral studies to a part-time post-doctoral fellowship, in which I again examined service user trajectories, work and roles but this time in the context of mental health crisis services. I was grateful for the support I received for this project from the Research Capacity Building Collaboration Wales. I also reflect, now, that our collective efforts to grow a doctorally qualified nursing, midwifery and allied health profession academic workforce have not been matched by equal efforts to enable holders of new PhDs to grow their research programmes into the post-doctoral period. It is deeply frustrating to see the holders of new doctorates devoured by teaching and related activities, their research expertise and aspirations risking extinction barely as soon as they have emerged. Mentorship to develop ongoing research plans, space for dissemination and grant-writing, and strategies for networking are so very important in the immediate post-doctoral period.

My view is also that institutional and external support for a PhD brings with it the obligation, in time, to become a PhD supervisor. Debra Jackson, Tamara Power and Kim Usher have recently published findings from a study of doctoral supervision within nursing, accurately pointing to the labour involved in this work and the degree to which it needs to be recognised by employers. Without supervision there can be no doctoral study, and without doctoral study no future research leaders.

Finally, my impressions are that, historically, research careers have tended to begin many years after initial registration and periods in practice. I would like to see more encouragement to newly registered nurses to consider research (and a career in academia) as an option, beginning with early registration for PhD study. Quite possibly this takes me back to where I started in this post, which is to observe that, despite many years of talking and trying, we haven’t yet managed to create coherent career pathways for clinical academics in nursing.

Animating research

A short post arising from the observation of the extent to which researchers are increasingly turning to animations as a way of sharing their findings both succinctly and accessibly.

On this site in the past I’ve written about the 3MDR trial for people with post-traumatic stress disorder, led by Jon Bisson, and this month I’m alerted to this fine animation produced with the help of Studio Magenta in Cardiff:

 

More observations from a small country

This new paper has been a long time in the making. Work on it began with preparations for an address given at the Australian College of Mental Health Nurses conference in 2018. Refinements and updates happened towards the end of 2019, in the context of preparing for a talk delivered at a Royal College of Nursing-sponsored event in Cardiff in 2019, with a further version presented at an online conference organised by Julia Terry, from Swansea University, during the 2020 coronavirus lockdown. Along the way the written article has benefited from a critical reading from both Michael Coffey and  Nicola Evans, and from no fewer than four anonymous peer reviewers. My thanks to all of them.

Observations from a small country: mental health policy, services and nursing in Wales can be downloaded in green open access form from the Cardiff University institutional repository, and has this as its abstract:

Wales is a small country, with an aging population, high levels of population health need and an economy with a significant reliance on public services. Its health system attracts little attention, with analyses tending to underplay the differences between the four countries of the United Kingdom (UK). This paper helps redress this via a case study of Welsh mental health policy, services and nursing practice. Distinctively, successive devolved governments in Wales have emphasised public planning and provision. Wales also has primary legislation addressing sustainability and future generations, safe nurse staffing, and rights of access to mental health services. However, in a context in which gaps always exist between national policy, local services and face-to-face care, evidence points to the existence of tension between Welsh policy aspirations and realities. Mental health nurses in Wales have produced a framework for action, which describes practice exemplars and looks forward to a secure future for the profession. With policy, however enlightened, lacking the singular potency to bring about intended change, nurses as the largest of the professional groups involved in mental health care have opportunities to make a difference in Wales through leadership, influence and collective action.

The argument I’ve developed here is that policy for health care in Wales, and for mental health care specifically, has distinctive features. As a peer reviewer I continue to have to correct manuscripts which conflate ‘England’ with the ‘UK’, and I’ve tried in this article to point out some of the things which make Wales different. I have also highlighted what seem, to me, to be gaps between well-intentioned policy aspirations and actual experiences as revealed through research. Overall, though, I intend the paper to convey a message of optimism, noting (amongst other things) the high value placed on the relational work of mental health nurses and the positive differences nurses make. Enjoy the read!

Out with the old

As this most difficult of years reaches its end here’s a big shout-out for registered and student mental health nurses everywhere, whose work and study has been tipped on its head during the pandemic. It’s not been easy, as this preprint from the Mental Health Policy Research Unit shows. The article reports pre-peer review findings from a survey examining how the coronavirus crisis has exerted an impact on the care provided by mental health nurses in the UK. Here’s the ‘what this paper adds’ section:

This paper provides a unique insight into the experiences and impact that the Covid-19 pandemic has had on mental health nurses across a range of community and inpatient settings to understand what has changed in their work and the care they can and do provide during this crisis. This includes exploring how services have changed, the move to remote working, the impact of the protective equipment crisis on nurses, and the difficult working conditions facing those in inpatient settings where there is minimal guidance provided.

The detailed findings in this paper paint a picture of members of a profession working at great pace to adjust to new ways of practising, to manage risk to self and others and to continue to provide quality care. It’s worth remembering that mental health nurses were in short supply prior to the pandemic, and possess skills, knowledge and qualities that will continue to place them in great demand in the months and years ahead.

In a second (and very specific) shout-out, here again are my thanks to the #mhTV crew comprising Dave Munday, Nicky Lambert and Vanessa Gilmartin Garrity for the very fine work they’ve been doing with #mhTV throughout the year. #mhTV has helped the mental health nursing (and wider) community to stay connected, despite the challenges of social distancing and repeated lockdowns. Dave, Nicky and Vanessa also stepped in to support the International Mental Health Nursing Research Conference 2020, and to host this year’s Skellern Lecture and Journal of Psychiatric and Mental Health Nursing Lifetime Achievement Award evening

Wishing a safe and a peaceful new year to all, and here’s to a 2021 which improves considerably on the year now departing.