Category: Mental health

Getting back to it

IMG_1414A quick post following a half-term break. Cornwall proved to be a fine place to spend last week. It is, truly, a most beautiful part of the country. Here’s a photo of the beach at St Ives to prove it.

Now it’s back to it. This week I’m working on two projects, and in the case of one will hope, by Friday, to be clearer on local arrangements for making payments to service user researchers. There’s some work to be done on preparing NHS R&D applications, too. Over the next week or so I also need to put some time aside to respond to Cardiff University’s consultation on the reorganisation of schools within the College of Biomedical and Life Sciences. The idea has been formally proposed that the School of Nursing and Midwifery Studies (where I work) and the School of Healthcare Studies (home to the academic occupational therapists, physiotherapists, radiographers and operating department practitioners) might merge. A move of this type has been on the cards for some time, so no surprises there.

Giving a fig about roles

Hannigan and Allen 2011In a paper published in the Journal of Psychiatric and Mental Health Nursing at the start of 2011, Davina Allen and I drew on detailed, qualitative, research data to examine the relationships between policy, local organisational context and the work of community mental health practitioners. A version of the article, which carries the short title Giving a fig about roles, can be downloaded from the ORCA repository here.

Our paper drew on many of the social scientific ideas previously introduced on this blog in my Sphygmomanometers, remedial gymnasts and mental health work post, and which are rehearsed more fully in this earlier Complexity and change paper. Davina and I observed how recent mental health policy had triggered disruption in the system of work, with occupational groups advancing new, public, jurisdictional claims in response to perceived threats to their positions in a dynamic division of labour. One of the examples we gave was the response by sections within the profession of psychiatry to the policy of new ways of working, and its emphasis on ‘distributed interprofessional responsibility’ in particular.

The larger part of our paper reported new research findings. In the project from which it was drawn I had the opportunity to compare and contrast the organisation of community mental health services in two parts of Wales. With a view to understanding each site’s contextual features I read local policy documents, interviewed senior managers and practitioners and observed people at work. I was also interested in gaining a detailed, micro-level, view of the actual delivery and receipt of care. To this end I had permission from three service users in each site to follow their journeys through the mental health system, each over a period of four to five months. I interviewed all six about their experiences, and using snowball sampling mapped out the range of people providing them with care, whether paid or unpaid. The nurses, social workers, psychiatrists, psychologists, occupational therapists, general medical practitioners, pharmacists, health and social care assistants, family members and neighbours identified in this way were invited to take part in interviews focusing on work and roles. I also observed interprofessional care planning meetings and home visits, and read the written notes about each of the six service user participants made by practitioners.

As the full text of the paper reveals, in the analysis developed here we were particularly interested to explore the relationships between workplace characteristics and what practitioners actually did. Not unexpectedly, nurses carried out medication tasks, social workers (as the sole group able to do this at the time data were generated) fulfilled the ‘approved’ role during the operation of the Mental Health Act, doctors diagnosed and prescribed, and the sole participating psychologist provided structured therapy.

Word cloud 02.02.13Beyond this we also found that the work of professionals was ‘patterned’ (to use the phrase coined in this context by Anselm Strauss) by immediate organisational forces. In one of the two sites nurses and social workers had enlarged ‘bundles of tasks’ (this being Everett Hughes’ term). This shaping of what people did could be understood with reference to a variety of contextual features. Key informants in this site described a particularly long and positive history of health and social care staff working together. This manifested during fieldwork in an approach to care provision which emphasised shared tasks and downplayed rigid demarcations. Single community mental health workers, rather than multiple representatives of different groups, tended to be attached to the care of individual service users. Health and social care organisations in this site were also small, lacking pools of staff from which people might be drawn to cover gaps left by departed colleagues. In this constellation of circumstances nurses and other members of staff fulfilled roles which were more ‘generalist’ than was the case in the other of the two sites.

Davina and I were interested to set our findings in the new and emerging context for mental health care. We pointed to larger policy trends favouring unpredictability in working practices, and to the idea that competency (rather than professional background) should determine practitioners’ eligibility to fulfil roles. We observed that ‘flexible, boundary-blurring, professionals competent to carry out multiple tasks may find favour with managers concerned with meeting local needs in local ways’. We reflected on the implications of this for continuity of care, capability and the preparation of new professionals. The paper ended with our thoughts on the challenges all this poses to professions and their jurisdictional claims.

In a later post I’ll return to this study, and in particular to what I learned about the experiences of the people whose unfolding care I followed as each moved through the different parts of his or her local, interconnected, system of mental health care. But that’s for another day.

Resilience and community mental health nursing in Palestine

With his permission, let me introduce you to Mohammad Marie. I know Mohammad as a PhD student in the Cardiff School of Nursing and Midwifery Studies. He is also a mental health nurse and teacher, who (when he isn’t attending to his thesis in south Wales) works at An-Najah National University in Nablus, in the Palestinian West Bank.

Mohammad is interested in resilience, both generally and in community mental health nurses in particular. Through his writing I have gained a glimpse of mental health needs and services in the occupied Palestinian territories, and of the day-to-day realities of living and providing health care in this part of the world. Quite rightly, nurses in the UK complain about lacking resources, of coping with high caseloads and of the dangers of burnout. Here, however, we can barely comprehend the enormity of the challenge facing those who do nursing in Palestine. Human rights are violated, and free movement restricted. Access to medicines is limited, and rates of trauma and mental ill-health high. Few practitioners have had opportunities to develop knowledge and skills specific to the provision of mental health care. For readers wanting to know more, the World Health Organization has made available information on health and health services in Palestine here.

A simple question drives Mohammad’s study: given their circumstances, what are the sources of resilience which help community mental health nurses continue in their caring work? As part of laying out the background to his project Mohammad has introduced me to the uniquely Palestinian concept of ‘samud’. ‘Samud’ and ‘resilience’ look, to me, to be close cousins, with the former referring to steadfastness in the face of adversity. It manifests in individual and social action, as well as in specific policy (for example, to support the development of an infrastructure for public services). From what Mohammad tells me, samud has become an important part of Palestinian culture and identity.

To get answers to his research question, Mohammad returned home last year to generate data. In ethnographic style he observed nurses and other staff going about their day-to-day tasks, basing himself in a series of government and non-governmental community mental health centres. He read local documents relating to the organisation of services. In order to explore nurses’ experiences and views in depth, Mohammad conducted detailed interviews with a sample of practitioners. The absolute number of participants in this phase was modest, but still a majority of the total population of community mental health nurses working in the West Bank.

Right now Mohammad is surrounded by transcripts and notes, doing his best to make sense of everything he has seen, read and heard. It’s for him to tell the story of his findings, but I know these will be both interesting and important. I’m looking forward.

More on health and social care

A second brief post, now that Andy Burnham (Labour’s Shadow Health Secretary) has delivered the speech I heard mention of earlier today. I’ve found this version on the Labour Party’s website, and also this response from Chris Ham at the King’s Fund.

It’s interesting, and bold in places, and there’ll be more on the way as this is the start of a major Labour Party policy review. I see that Andy Burnham describes the mental health system as being quite separate from the system of social care, and from the system providing care for people with physical conditions. I also see that, in England, a future Labour government would seek ways of improving integration and coordination without imposing a further round of top-down structural change. I guess there might be different ideas about what counts as ‘structural change’, as some of what is proposed here is pretty radical: single points of access for all care, single budgets for all services provided, just one body (the NHS) providing ‘whole person care’. And whilst I like what I’m reading, I’m also aware that there are no ‘final fixes’ for the challenges facing public services. Change, even that which is driven by laudable ideas like promoting integration, can trigger unintended as well as desired consequences, and solve problems in one place only to create new problems elsewhere. Which takes me back to wicked problems and complex systems…

Here’s to hearing the next, more detailed instalments: and indeed, any initial response from within Wales where responsibility for health and social care is a matter for the devolved Government.

What I do at work, described using only the commonest 1,000 words in the English language

Via a link in a tweet from @bengoldacre I came across the Bad Science (and now Bad Pharma) author’s secondary (!) blog, and this page in particular. Here, Ben describes how randomised controlled trials work, using the English language’s commonest 1,000 words.

The idea of making complex things simple in this way comes from Randall Munroe at http://xkcd.com, who produced the wonderful graphic I’ve reproduced here (with his permission) of how the Saturn V rocket works. Called Up Goer Five, the supporting text (as you can see for yourselves) explains things ‘using only the ten hundred words people use the most often’.

So that anyone can have a go at making difficult stuff understandable in this way, a text editor has now sprung up at http://splasho.com/upgoer5/. In goes your explanation, and if you happen to use a word from outside of the list of 1,000 commonest you’ll get a message telling you that it is not permitted. Such fun. You can also tell others of your efforts through Twitter using the #upgoerfive hashtag.

Yesterday and today I’ve been using this online tool to chip away at a description of what I do at work. It turns out that an awful lot of the words I’m fondest of fall outside of the list of those permitted. Examples include ‘process’, ‘system’, ‘nurse’, ‘health’, ‘complex’ and ‘organise’.

Anyway, here’s my effort:

For over 60 years people in this part of the world have believed that those who are sick should be looked after, without having to pay for their care at the time they need it. So to make sure there are always people around to do the job of caring, and to make sure there are places to go when we’re sick, everyone who works gives some of their money to pay for doctors, hospitals and so on. The important thing is that if you’re sick you should get the help you need, no matter how much money you have (or don’t have). I think this is a great way of doing things, and so do lots of other people.

But what do we mean by being sick, and what type of care is best? Some people have problems like their hearts not working in the way they should, or other bits of their bodies going wrong. But there are also people who have problems with how they think, feel or act when they are with others. They can get very sad, scared and worried. They can get confused, and/or hear things which aren’t really there. Families and friends get concerned when these things happen, but don’t always know what best to do. As it happens, we don’t completely know what causes these kinds of problem. It may be because something is wrong in the body, and/or it might be because bad stuff happens to people which makes them sad.

Maybe one day we’ll know much more about what causes people to be sick in these ways, and be able to help them more or even stop their problems happening in the first place. But for now, and I guess always, we need people who spend their time looking after those who get very sad, or worried, or confused, or who hear things which aren’t there. This is serious and important work, and there are lots of different types of people who do it. Those who do it as a job can be found in teams both in, and out of, hospitals. In truth, how these people and the teams they work in fit together can be really confusing. Nothing ever stands still, as new ways of getting stuff done appear.

So here’s what I do. I trained to look after people who have problems with thinking, feeling and acting and now I help to train others in this field. I also study people who do this kind of caring work, the teams they work in and what it’s like to be someone getting help. I do this because it’s important to find out how the different parts (the people, the teams) fit together, and to learn how caring work can be done in different, and maybe better, ways. Working with friends with the same interests I have used a number of approaches to study these things. I have sat with people and asked them questions about the work they do. I have read what people write about the care work they have done, and have watched people doing their day-to-day jobs. I have asked about the care work that people (like family and friends) do, and for which no-one is paid. I have asked people to tell me what it is like to get help from people in different jobs, and what it is like to have care across different teams over time. I have given people pieces of paper with questions about what they think and feel, and asked them to return their answers for us to read and study.

What have I found? The work that people do is changed by where and when they do it, and by who else is around. So you and I might think we know about the work that people in caring jobs do, but it turns out that there are lots of different ways of getting stuff done. Jobs change over time, and sometimes people do not agree who should do what. In teams, people sometimes do work which has to be done because there is no-one else to do it. I happen to think this is interesting and important, for lots of reasons. One reason is that if we don’t know what types of work people will end up doing, how do we know how best to train students? I have also found that a lot of caring work is hidden, because it is done by people who are not paid and/or who are on the edges. This is especially so in the case of people living in their own homes, and who get help from care teams which are placed outside of hospitals. Everyone thinks of doctors, but who remembers the work done by the person living next door? The way the different bits (the people, the teams) fit together means that those who are in need sometimes have problems getting the right help at the right time. And, when new teams appear, I have found that these can do great work but at the same time cause new problems to pop up somewhere else. This is because everything is joined to everything else. From studies completed with friends some years ago, I have also found that doing caring work is not easy. People who do it can get to feel very worn out.

Here is some new stuff I’m doing now. With friends I’m going to look at how people plan care, and what this means for the person who needs help. I’m also about to start a new study where we will read about young people in hospital, and how those who care for them keep them safe.

New year…

Cardiff University Colleges and SchoolsHappy new year. 2013 promises plenty. I’m committed to two externally funded research projects, collaborating with outstanding folk located both in, and out, of Cardiff University. In the fullness of time I’ll perhaps blog about these studies when there’s more to say. I’ll be supervising people working on their doctorates, and as always will be teaching and assessing across the range of academic levels. I’ll be working up grant applications (there’s one in the pot at the moment), writing papers (including the one I’ve mentioned before), and contributing to various types of ethics and scientific review processes. I also have a number of external examining roles to fulfil, at doctoral and pre-registration undergraduate level.

In the year ahead I suspect there will be some interesting organisational changes to adjust to as Cardiff University refashions itself, and as the new College and School structure (which I’ve reproduced to the left of this post, with an added oval to highlight where I work) takes shape. As it happens, the University is making headlines at the moment. Just before the Christmas and New Year break Cardiff’s collaboration with the Open University (and others) to develop ‘MOOCS’ (Massive Open Online Courses) was widely reported. As I understand it, MOOCS are free-to-access courses made available via the web to pretty much anyone with use of a computer and an internet connection. I’m not sure how, if at all, people are able to work towards achieving formal academic awards in this way but I very much like the idea of freely available knowledge. Meanwhile, in this week’s Times Higher Education there’s a report on the new Vice Chancellor’s plans to develop the University’s international presence.

REF 2014In 2013 there’s also the small matter of the Research Excellence Framework (REF). I think the REF (like its predecessor the Research Assessment Exercise, or the RAE) is a flawed process, but it remains a (very) big deal for the UK’s universities. In this cycle, formal submissions will be made at the end of the year. Panel members will then have their work cut out in 2014, reading and assessing the quality of outputs (typically, journal papers), judging the impact of completed research beyond the realms of academia (for example, on policy and practice), and reviewing the institutional environment for research activity. Universities will be ranked on the results, and money will flow (or not). For an ambitious, research-led, Russell Group university like Cardiff this is an exercise of great import. It’s also significant for the professions of nursing and midwifery, which have spent the last decades upping their evidence base. In the last RAE, the outcomes of which were made known at the end of 2008, nursing and midwifery research fared pretty well. Let’s hope this can be sustained.

Outside of work I’ll keep running, hoping to stay injury free. As a meticulous record keeper I track my miles. So far for 2013 it’s 22-and-a-bit, and the aim is to manage 1,000 in total. This I achieved in 2012, and more besides. There’s also an increasingly good chance that this year will see Cardiff City climb out of the Football League Championship. I’m liking this, and it’s something I follow (with season tickets) with one of my boys. And, for those interested in the health and well-being angle of all this, check out the work of Alan Pringle and his colleagues on using football as a means to promote mental health, particularly amongst young men. Alan gave a fantastic talk on this at last year’s Network for Psychiatric Nursing Research conference.

That’ll do for now, I think: enough of the rambling.

The Mayan apocalypse and The King’s Fund

According to some interpretations of the Mayan long count calendar, tomorrow – December 21st 2012 – will see the end of the world. If the apocalypse does happen then none of us, I’m afraid, will get to know how accurate the predictions contained in Future Trends might otherwise have been.

I came across this report earlier today via a link tweeted by @TheKingsFund. It’s part of the organisation’s new Time to Think Differently programme, and sets out ‘the significant trends and drivers that we [The King’s Fund] believe will affect health and social care services over the next 20 years’. Properly speaking this is all about the outlook for England, though I think Future Trends offers plenty of food for thought for those of us in other parts of the UK, too.

The document addresses issues across a number of areas: demographic change, health-related behaviours, disease and disability, the workforce, attitudes and expectations, determinants of health, medical advances, information technology, sustainability and economic pressures. Future Trends also has some important, specific, things to say about mental health and illness and about services in this area. One is to restate the connections between mental and physical health. As The King’s Fund says, poor physical health is associated with poor mental health and vice versa. Future Trends also points to the existence of significant unmet mental health need, and to the fact that demand for services can be expected to rise at times (like now) of economic downturn. Elsewhere there are sections dealing with the workforce, and the risk of a growing ‘care gap’ as sources of informal care diminish. Changing patterns of disease are likely to increase demand for home (rather than hospital) care, and for new types of worker able to cross traditional professional boundaries.

To my mind the broad picture Future Trends paints is an entirely plausible, and simultaneously challenging, one. More plausible, certainly, than predictions of an imminent end to the world. I think we might want to start thinking, sooner rather than later, about how we improve the physical well-being of people using mental health services. We should consider what the rise of chronic conditions means for education and training, and how to better meet need.

Mental Health Nurse Academics UK: hot off the press

For the last couple of weeks I’ve been acting as a returning officer of sorts, as members of Mental Health Nurse Academics UK (MHNAUK) have been voting for a new Vice Chair. This is a position held for two years, after which the incumbent becomes Chair for a further two years.

This morning I’ve emailed members of MHNAUK with news of the outcome. Well done to Professor Joy Duxbury, from UCLan, who is duly elected. Joy knows lots about risk, safety, aggression and coercion in mental health services (see, for example, this paper and this paper). She takes up her position in the new year, picking up from Dr Michael Coffey (Swansea University) who now becomes Chair. That’s a great combination of people, let it be said: MHNAUK remains in very capable hands. By the way, I’m not sure if Joy tweets, but for the Twitter-users out there Michael does as @D10Coff.

Taking a well-earned breather having done an excellent job chairing MHNAUK for the last two years is Professor Alan Simpson from City University, or @cityalan as he’s known in Twitter-land. Good work, Alan. Now go and prepare that talk you have to give as Skellern Lecturer for 2013!

On writing a paper about mental health systems, and running in mud

A fortnight ago I blogged about a paper I gave at this year’s Network for Psychiatric Nursing Research conference. My aim in this presentation was to move lightly through a series of completed studies I’ve previously been involved in, with a view to saying something cumulative about the mental health system. I mentioned my ambition of working this talk up into something a little more substantial and enduring, and sending this to a journal for peer review and (hopefully) eventual publication.

Progress has been slow, largely because of competing priorities. But I have at least made  a start, of sorts. One of the points I’m going to make is that, taking the long view, the story of how mental health care in the UK has evolved remains a quite remarkable one. A quarter of a century ago, which is when I first began working in mental health care, untold numbers of people remained resident in outdated institutions. Community services certainly existed, but were relatively under-developed. Many teams were uni-professional, and lacked a clear focus. Ideas of recovery, personalised care and collaborative working with service users were in their infancy.

It’s all very different now. I suspect it’s possible to qualify as a mental health nurse without having many hospital placements at all, and to spend the greater portion of practice time in varieties of community setting. There are locality community mental health teams (still the bedrock of specialist services for working age adults), and similar teams serving older people, and children and adolescents. There are crisis resolution and home treatment teams, assertive outreach teams, primary mental health teams, and more besides. I also think that the values which underpin care have changed. So, whilst it may not be a perfect system, it is much improved.

How much the investment in mental health systems which took place over the late 1990s and throughout the first decade of the new century can be sustained, in the face of crushing public services cuts, I do not know. In Wales, which is far more public services oriented than England, a strong case was made a few years ago for the importance of investing in mental health. Mental ill-health affects individuals, families, communities and the economy. I hope that the Welsh Government’s emphasis on public mental health in its new cross-cutting strategy ‘works’, without pulling vital resources away from dedicated services for people with long-term and disabling mental illnesses.

On the non-work front, this morning’s run entirely lacked the clear, hard, frostiness of recent Saturdays. It was wet, and muddy. Clinging, in fact, and thoroughly energy-sapping. It will take a few days for my (tired-looking) shoes to dry out, so I’m glad to have my second pair to hand (to foot?) should the need arise. Now it’s Christmas tree purchase time.

Mental health R&D

Following an afternoon interviewing potential new mental health nursing students, today it’s all about research and development. I’m off to Cardiff and Vale University Health Board’s annual mental health R&D meet-up, which on this occasion is titled ‘Updates, Opportunities and Overcoming Challenges’. The agenda is pretty packed, and includes (in the morning) an overview of, and progress report on, the National Centre for Mental Health. There’s also a session scheduled on research funding schemes managed by the National Institute for Social Care and Health Research (NISCHR). NISCHR is supported by the Welsh Government, and develops policy and priorities for health and social care research. It also directly supports research activity through its registered research groups and via its various competitive funding schemes.