Category: Mental health

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.

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.

Crisis responses

In recent months I’ve been part of a team, led by Nicola Evans, bringing together the evidence in the area of responses for children and young people in mental health crisis. Our working definition of a ‘crisis response’ has been the provision of a service in response to extreme psychosocial distress, which for children and young people may be provided in any location such as an emergency department, primary care, a specialist or non-specialist community service, a school, a college, a university, a youth group, or via a crisis support line. Our objectives have been:

  • To critically appraise, synthesise and present the best available evidence on the organisation of crisis services for children and young people aged 5 to 25 years, across education, health, social care and the third sector.
  • To determine the effectiveness of current models of mental health crisis support for children and young people.
  • To explore the experiences and perceptions of young people, families and staff with regards to mental health crisis support for children and young people aged 5 to 25 years.
  • To determine the goals of crisis intervention

As a project team we’ve been informed by a stakeholder advisory group, and have cast a wide net by searching not only for research but also other relevant evidence including guidance, case studies and more. Methodologically, therefore, this review bears comparison with others I’ve previously written about on this site including the RiSC study and MENLOC. More on this crisis care evidence synthesis to follow in due course.

Getting started in research

Currently I’m serving a term as Director of Postgraduate Research in the School of Healthcare Sciences, which means I have responsibilities for our PhD and our Doctorate in Advanced Healthcare Practice (DAHP) programmes. For aspirant researchers a doctoral degree is a necessary qualification, with the PhD culminating in the production of a thesis of some 80,000 words whilst the DAHP in Cardiff combines taught modules and a shorter thesis of no more than 50,000 words. In the School we have numbers of students in the thesis stage of their DAHP degrees, but this particular programme no longer recruits new entrants. The PhD, though, continues to attract people from the UK and around the world and information on it can be found here.

October is the first opportunity in each academic year for postgraduate student enrolment, and compared to the numbers of people commencing their undergraduate and taught postgraduate studies our newly starting students are small in number. This is to be expected, but this also takes me to the general observation that the health professions need many more people to get involved in research and knowledge creation.

Information on developing research careers in the mental health field can be found at the NIHR Incubator for Mental Health Research website. There is lots of value here, including advice on first steps, on sources of funding, and on finding support and mentorship. There are case studies, too, of people from a range of backgrounds and at different stages of their research careers (including people studying for doctorates), and a whole section aimed at nurses.

Meanwhile, the Royal College of Nursing has launched the Annie Altschul Collection, an online repository of doctoral degrees completed by mental health nurses. The repository is searchable, and is also themed, with hyperlinks to the full text of each included thesis where these are available.

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.

#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.

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.