Category: Mental health

Ordinary risks and accepted fictions

Ordinary risksThis new paper you need to read. You also can, because it is published in gold open access form and is therefore free to download to anyone with an internet connection. Lead authored by Michael Coffey, and arising from the larger COCAPP study (see also here, here and here), it draws on qualitative data to examine in detail what staff, service users and carers say about risk assessment and management. Here’s the abstract:

Background

Communication and information sharing are considered crucial to recovery-focused mental health services. Effective mental health care planning and coordination includes assessment and management of risk and safety.

Objective

Using data from our cross-national mixed-method study of care planning and coordination, we examined what patients, family members and workers say about risk assessment and management and explored the contents of care plans.

Design

Thematic analysis of qualitative research interviews (n = 117) with patients, family members and workers, across four English and two Welsh National Health Service sites. Care plans were reviewed (n = 33) using a structured template.

Findings

Participants have contrasting priorities in relation to risk. Patients see benefit in discussions about risk, but cast the process as a worker priority that may lead to loss of liberty. Relationships with workers are key to family members and patients; however, worker claims of involving people in the care planning process do not extend to risk assessment and management procedures for fear of causing upset. Workers locate risk as coming from the person rather than social or environmental factors, are risk averse and appear to prioritize the procedural aspects of assessment.

Conclusions

Despite limitations, risk assessment is treated as legitimate work by professionals. Risk assessment practice operates as a type of fiction in which poor predictive ability and fear of consequences are accepted in the interests of normative certainty by all parties. As a consequence, risk adverse options are encouraged by workers and patients steered away from opportunities for ordinary risks thereby hindering the mobilization of their strengths and abilities.

Reported here is one of the most important sets of findings arising from the COCAPP study. Diana Rose has written a post on the article, which is scheduled to appear on the inestimable Mental Elf site next week. I’m very much looking forward to reading that.

Resilience of community mental health nurses in Palestine

Earlier this week a new article lead authored by Mohammad Marie, and co-authored by Aled Jones and me, was published in the International Journal of Mental Health Nursing. The title of the article is Resilience of nurses who work in community mental
health workplaces in Palestine, and is the second paper arising from Mohammad’s completed PhD. As the article appears in gold open access form copies can be directly downloaded from the journal’s website for free: or indeed, by clicking either the hyperlinked title or image above.

The larger part of Mohammad’s qualitative dataset is interviews conducted with CMHNs working in the West Bank. Fifteen practitioners took part, from a total population of 17. For the record, that’s 17 community mental health nurses for a population of some three million people. That’s an astonishingly low number by UK standards; for more on mental health needs and services in Palestine, the place to go is Mohammad’s first paper (Mental health needs and services in the West Bank, Palestine) about which I previously blogged here.

Here is the abstract from this latest paper:

People in Palestine live and work in a significantly challenging environment. As a result of these challenges they have developed resilient responses which are embedded in their cultural context. ‘Sumud’, in particular, is a socio-political concept which refers to ways of surviving in the context of occupation, chronic adversity, lack of resources and limited infrastructure. Nurses’ work in Palestine is an under-researched subject and very little is known about how nurses adjust to such challenging environments. To address this gap in the literature this study aimed to explore the resilience of community mental health nurses (CMHNs) who work in Palestine. An interpretive qualitative design was chosen. Fifteen face-to-face interviews were completed with participants. Thirty-two hours of observations of the day-to-day working environment and workplace routines were conducted in two communities’ mental health centres. Written documents relating to practical job-related policies were also collected from various workplaces. Thematic analysis was used across all data sources resulting in four main themes, which describe the sources of resilience among CMHNs. These sources are ‘Sumud and Islamic cultures’, ‘Supportive relationships’, ‘Making use of the available resources’, and ‘Personal capacity’. The study concludes with a better understanding of resilience in nursing, which draws on wider cultural contexts and social ecological responses. The outcomes from this study will be used to develop the resilience of CMHNs in Palestine.

The idea of ‘Samud’ which is referred to above is an important one in Mohammad’s work, and (as I have learned) for Palestinian people. Drawing on the work of Toine Van Teeffelen, here is what Mohammad says about it in his thesis:

[Samud] is the art of living to survive and thrive on their homeland in spite of hardship and under occupation practices. These skills of how to live are used in different aspects of life such as economic, political and social. They can also be used at many levels: individual, family and within the Palestinian community. Moreover, Sumud has been divided into two types: tangible resources such as the infrastructure supporting basic needs (for example, schools and hospitals) which enable the existence of the Palestinians on their land and help them to be more resilient. In addition intangible sources of Sumud also exist, which include: belief systems, religion and social and family support which help the Palestinians to cope with their chronic daily collective suffering.

For Mohammad, Samud is closely related to the more familiar (to me, at any rate) idea of resilience. Or, more properly put, Samud connects to social ecological variants of resilience which place as much emphasis on the social and cultural as they do on the individual.

I’ll stop here and leave people to download and read this new paper for themselves. For those interested, Mohammad, Aled and I are working on further publications from this doctorate: so more will follow in due course.

Understanding mental health systems and services — Mental Health / Iechyd Meddwl

Here’s a link to my first post for a new Cardiff University Mental Health Blog. The content will be broadly familar to people who have dipped into my personal blog in the past, insofar as I have chosen to say something general about doing mental health services research.

Working in collaboration with colleagues across the UK, including with people who have directly used services, researchers in the School of Healthcare Sciences at Cardiff University study mental health systems.

via Understanding mental health systems and services — Mental Health / Iechyd Meddwl

Clicking the hyperlink above, which appears beneath the brief snippet of text, will take you to the full piece. There are already some interesting other posts on the site, too, including a piece by Mike Owen written as an opener.

COCAPP main findings

In a post last week I drew attention to a recent run of publications, promising to write a single post for each as it appears. Yesterday saw the appearance of Recovery-focused care planning and coordination in England and Wales: a cross-national mixed methods comparative case study. This is the main findings paper from COCAPP, published in BMC Psychiatry. Here’s the abstract, for readers wanting a taster:

Background: In the UK, concerns about safety and fragmented community mental health care led to the development of the care programme approach in England and care and treatment planning in Wales. These systems require service users to have a care coordinator, written care plan and regular reviews of their care. Processes are required to be collaborative, recovery-focused and personalised but have rarely been researched. We aimed to obtain the views and experiences of stakeholders involved in community mental health care and identify factors that facilitate or act as barriers to personalised, collaborative, recovery-focused care.

Methods: We conducted a cross-national comparative study employing a concurrent transformative mixed-methods approach with embedded case studies across six service provider sites in England and Wales. The study included a survey of views on recovery, empowerment and therapeutic relationships in service users (n = 448) and recovery in care coordinators (n = 201); embedded case studies involving interviews with service providers, service users and carers (n = 117) and a review of care plans (n = 33). Quantitative and qualitative data were analysed within and across sites using inferential statistics, correlations and framework method.

Results: Significant differences were found across sites for scores on therapeutic relationships. Variation within sites and participant groups was reported in experiences of care planning and understandings of recovery and personalisation. Care plans were described as administratively burdensome and were rarely consulted. Carers reported varying levels of involvement. Risk assessments were central to clinical concerns but were rarely discussed with service users. Service users valued therapeutic relationships with care coordinators and others, and saw these as central to recovery.

Conclusions: Administrative elements of care coordination reduce opportunities for recovery-focused and personalised work. There were few common understandings of recovery which may limit shared goals. Conversations on risk appeared to be neglected and assessments kept from service users. A reluctance to engage in dialogue about risk management may work against opportunities for positive risk-taking as part of recovery-focused work. Research to investigate innovative approaches to maximise staff contact time with service users and carers, shared decision-making in risk assessments, and training designed to enable personalised, recovery focused care coordination is indicated.

People may be interested to learn that COCAPP will also be the subject of a Mental Elf blog and podcast in a week or so’s time:

And, for those wanting the fine-grained detail, there is always our main report to the National Institute for Health Research (NIHR) Health Services and Delivery Research (HS&DR) Programme.


Bus blogging

Time, just about, to use a bus journey across Cardiff en route to the University Hospital of Wales site (for the purposes of teaching) to post an update on recent activities.

There’s lots to say. Projects I’ve blogged about on this site (COCAPP, COCAPP-A, Plan4Recovery) are now being written up. Our main findings paper from COCAPP appears imminently in BMC Psychiatry. Alan Simpson, as lead author, completed checking the proofs of this in the last few days so we know it’s on its way. Michael Coffey has lead authored a COCAPP paper addressing risk; earlier this week this was accepted for publication in Health Expectations. Further papers will follow, as they will in the future from COCAPP-A. I’ll make a point of posting about each as they appear. Plan4Recovery has been about shared decision-making and social approaches to care, and here, too, work on a first publication is well underway. 

Meanwhile, Therapeutic skills for mental health nurses edited by Nicola Evans and me has just been published by Open University Press. This is a fine text indeed (though I say so myself), which we hope proves particular useful to students.

A big highlight of the last few weeks has been the award of a doctorate to my colleague and (now former) student Pauline Tang. Pauline used qualitative methods to investigate the use of electronic patient records in a medical assessment unit, and you can read her thesis here. And talking of doctorates: Mohammad Marie, writing with Aled Jones and me, has a second paper from his study of resilience in Palestinian community mental health nurses about to appear: this one in the International Journal of Mental Health Nursing. 

Right! I’m off the bus and walking to a classroom. Time to fly, and to remind myself that it is perhaps better to post more frequently than to cram so much into a single, short, piece like this. 

Sticking up for qualitative research

Technological failure meant I was unable to participate in this week’s Mental Elf campfire discussion, What has qualitative research ever done for us? The context for the event was the recent decision by the BMJ to reject a paper submitted for publication by members of the McGill Qualitative Research Group on the grounds that qualitative research reports are of low priority. This, the BMJ editors added, is because they are downloaded and cited less often than are reports of quantitative research. The BMJ communication conveying this news to the McGill team was posted on social media, triggering significant protest and then a letter to the BMJ making the case for qualitative methods and urging an editorial rethink.

These kinds of debates over the relative value of different research approaches flare up from time-to-time. Sixteen years ago Philip Burnard and I wrote a paper on the emergence of two camps within mental health nursing. We characterised these with reference to a quantitative/qualitative divide, and made a case for rapprochement and synthesis.

In the event, this week’s campfire which I missed was a sensible and informed one, with excellent speakers. The recording can be viewed here:

For the record, the exemplar piece of qualitative mental health research which I had prepared to talk about is Strauss and colleagues’ Psychiatric ideologies and institutions. I wrote a short piece about this book in 2014, on the occasion of its fiftieth birthday. My view remains that many of the observations made within it are as relevant now as they were in 1964. Ideas and practices, for example, remain contested.

Suffice to say that there has been no shortage of very high-quality qualitative mental health research produced in the years since, including by nurses. Check out these papers by two other invited campfire participants: Alan Simpson on the squeezing of community mental health nurses’ time, and Michael Coffey on the use of time in the accounts of conditionally discharged patients living in the community. Both show how the considered analysis of detailed qualitative data can reveal vital new knowledge of mental health systems, and of the views and experiences of people working within, or using, them. For readers wanting more, over on the Mental Elf website there are currently more than 200 blog posts on recent qualitative research: a rich repository indeed.

This week’s Mental Elf campfire discussion also included some commentary on the use of mixed methods. COCAPP and COCAPP-A demonstrate the value of combining quantitative and qualitative approaches, and reveal how data from surveys, interviews, observations and documentary review can be fruitfully brought together. This type of study is becoming increasingly popular, informed by the idea that different research questions (of a type which might be brought together in a single project) simply require different methods to answer them. This is a position I remain comfortable with.

And so we press on. I’ve been involved in lots of writing lately, as projects yield papers. As per my usual practice, as these appear in journals I’ll aim to write posts on this blog about them and include links to open access versions as I am able. Thanks for reading, and feel free to comment.

Collaborative care for depression

Happy April. Here’s a new venture for me: blogging for the Mental Elf, part of the National Elf Service. This is a fine site indeed, which André Tomlin set up in 2011 with the aim of helping people find ‘just what you need to keep up-to-date with all of the important and reliable mental health research and guidance’.

Here’s a summary of my first post, which can be read in full by following the link at the bottom.

Ben Hannigan writes his debut blog on the CADET cluster RCT, which investigates the clinical effectiveness and cost-effectiveness of collaborative care for depression in UK primary care.

via Collaborative care for depression: acceptable, effective and affordable — Elf Service – National Elf Service

Mental health needs and services in Palestine

Mohammad Marie, Aled Jones and I have co-authored a paper arising from Mohammad’s PhD. This appears in the gold open access International Journal of Mental Health Systems, and a copy can be downloaded by following this link.

The article is titled Mental health needs and services in the West Bank, Palestine and has this for an abstract:

Background: Palestine is a low income country with scarce resources, which is seeking independence. This paper discusses the high levels of mental health need found amongst Palestinian people, and examines services, education and research in this area with particular attention paid to the West Bank.
Methods: CINAHL, PubMed, and Science Direct were used to search for materials.
Results and conclusion: Evidence from this review is that there is a necessity to increase the availability and quality of mental health care. Mental health policy and services in Palestine need development in order to better meet the needs of service users and professionals. It is essential to raise awareness of mental health and increase the integration of mental health services with other areas of health care. Civilians need their basic human needs met, including having freedom of movement and seeing an end to the occupation. There is a need to enhance the resilience and
capacity of community mental health teams. There is a need to increase resources and offer more support, up-to-date training and supervision to mental health teams.

Further papers from Mohammad’s study will follow, and I’ll aim to post updates as work progresses.

End of an Era

Last Friday afternoon I took the opportunity to visit the End of an Era exhibition at Whitchurch Hospital. The hospital opened in 1908, for more than a century providing inpatient mental health care for the people of Cardiff and its surroundings. Now, all clinical staff and current inpatients are about to move to a newly built facility in the grounds of Llandough Hospital in the Vale of Glamorgan.

The exhibition was the work of the Whitchurch Hospital Historical Society, and was excellent. Extracts from the written archives, images and objects were on display, painting a fascinating picture of life inside the hospital over the decades. I hope a permanent home is found for at least some of this in the future. Here, for now, are some of the photographs I took.

2016-03-11 14.58.092016-03-11 14.59.21

2016-03-11 15.10.05

Meanwhile, here is what people have been saying about the new Hafan y Coed unit which is about to open at the start of April 2016:

#MHNAUK meets in Leeds, and talks work and roles

MHNAUK members in Leeds
MHNAUK meets in Leeds

Mental Health Nurse Academics UK met yesterday in Leeds, hosted by John Baker and chaired by Joy Duxbury. Our discussions were wide-ranging: proposed changes to the composition of the English NHS workforce signalled by the introduction of associate nurses; the arrival, in England, of student fees for nursing degrees from 2017; safe staffing (see also this editorial in the Journal of Psychiatric and Mental Health Nursing); plans for #NPNR2016; arrangements for a second student mental health nursing conference; the Shape of Caring; England’s Five Year Forward View for Mental Health; guidance for adult field nurses caring for people with mental health problems; this year’s Skellern Lecture and JPMHN Lifetime Achievement Award; the current call for papers for a themed care planning and coordination issue of the Journal of Psychiatric and Mental Health Nursing (which Michael Coffey, Alan Simpson and I are co-editing); and the hot-off-the-press announcement of a Foundation of Nursing Studies-sponsored review into the role of mental health nurses.

In this post I’ll largely confine myself to some thoughts on the mental health workforce and on the place of nurses within this. Yesterday’s discussions in this area exercised MHNAUK members greatly. Proposed changes to the occupational mix to be found within mental health services, debates over nursing numbers and safe staffing, and new arrangments for the funding of education have the potential to trigger significant turbulence in an already-complex system of care. MHNAUK members rightly identified how the appearance of a new associate nurse role, sitting in between health care support workers and registered nurses, will trigger unrest. This is always the case when professional jurisdictions come under pressure (see here and here for papers I have co-written which expand on this point). In this current case, some registered nurses will see new associates as a threat to their hard-won jurisdiction. At a time when nurses are pressing for safe staffing, some are likely to argue that the introduction of associates will also open the door to role substitution and eventual reductions in numbers of registered nurses, thereby threatening both quality and safety.

Should associate nurses appear, we can be certain that plenty of inter-occupational jostling will take place as support workers, associates and registered nurses (amongst others) negotiate their relative positions and assert control over areas of work. In this regard, abstract descriptions of the tasks which new associates will (and will not) be permitted to carry out will provide only the most limited of guides. Differentiations between who does what will inevitably be hammered out in the workplace.

And what of the cross-UK implications for all of this, given that the Department of Health’s associate nurse announcement is for England only? To me it is unclear how new associates will be regulated, or how transferable their future qualifications might be should any wish to move to, say, Wales. Across the four countries of the UK important differences are appearing in the ways people are prepared for health care practice, and in the funding of this. Student nurses will pay fees in England from next year, but student nurses in Scotland will not and will continue to receive a bursary. Here in Wales (unless I’ve been asleep and have missed a piece of essential news), we will need to wait until after our forthcoming Assembly elections and the formation of a new Welsh Government for an announcement on future financial arrangments for nursing education. Perhaps we’ll hear more about the shape of the future Welsh NHS workforce then, too.