Category: Mental health

New nurses

This afternoon I’ll be joining colleagues to interview potential students of mental health nursing. I imagine I’ll meet a variety of candidates: young people who are still at (or have just left) school, others who are looking for a second (or third) career, and others again who have considerable experience in caring work gained through employment as health care assistants or similar. The range of educational backgrounds people have is likely to be varied. Some may have A levels, or undergraduate degrees (often in the humanities or social sciences). Others may have (or be studying for) Access qualifications via their enrolment at colleges of further education.

From my accumulated experiences of interviewing in this context I expect that most, if not all, of the candidates I meet today will have thought very carefully about their applications. I expect them to be enthused about the prospect of learning and practising, and informed about what this involves. I expect people to demonstrate an interest in others, to be inquisitive and engaged, and to be motivated by a desire to help.

I also imagine that candidates will be aware of today’s proceedings taking place in a context of heightened scrutiny: of nurses, their roles, and their preparation. Cynon Valley MP Ann Clwyd, for example, has had strong things to say about nurses and nursing following the death of her husband at the University Hospital of Wales in Cardiff. To repeat what I’ve said before on this blog: the fact that nurses now qualify with undergraduate degrees does not make them any less compassionate than those without. To me, the idea that there might be some kind of automatic, inverse, relationship between education and capacity to care makes no sense whatsoever. For those interested, here’s a very thoughtful piece touching on some of this on the notsobigsociety blog.

Learning together, and more on peer review

Along with spending time with students rehearsing research ethics, this week I have also had the chance to be part of a small interprofessional education initiative. This involved pre-registration mental health nurses and pre-registration occupational therapists. Two linked sessions, the last of which was a few days ago, were facilitated by a teaching team led by my excellent colleague Gerwyn Jones, and Ruth Squire (who I hadn’t met before, but was pleased to meet in this context). Also taking part was the fine Teena Clouston, an occupational therapy academic who I have enjoyed working with, on and off, over a period of many years. As an aside, meeting up again with Teena gave me the opportunity to congratulate her on her freshly minted doctorate. That was nice.

Interprofessional education in health and social care is hardly a new idea. It’s also good to do. In the workplace nurses, occupational therapists, doctors, social workers, physiotherapists and all the rest have to rub along together. So why not create opportunities for students from across these fields to learn together first, in the classroom as well as in practice placements?

It’s worth reflecting on the extent to which we still recruit and teach students in uniprofessional isolation. There’s work involved in making connections across different university departments, in creating materials and in planning what will take place. Timetables need to be aligned, and facilities booked. Only then does cross-disciplinary, university-based, learning occur. Having brokered interprofessional education initiatives of this type in the past I appreciate the time and organisation required. But I think we have to collectively put this effort in, and more.

On this occasion, this mental health-focused two days of joint learning culminated in students participating in a role played care planning meeting. I have to say that I was impressed – very impressed – by the way students managed the process. Interactions between professionals, the service user, his carer and an advocate were respectful and productive. I’ve seen a whole lot worse in real life. I left feeling optimistic.

Unrelatedly: yesterday a journal I haven’t reviewed for before got in touch and asked if I would comment on a paper submitted for publication. Last weekend I blogged about peer review, and wrote about having graciously declined an invitation. Yesterday afternoon’s request was different: I know the area being written about, and was happy to give a view.

Changing the subject again, South Wales once more is spectacularly beautiful this morning. Frosty, and dry: perfect for my run.

On not lying-in

I’m not very good at lying-in. Once I’m awake (which, on most mornings, is earlier rather than later) I’m up. It’s then a matter of creeping downstairs to do some soundless chores, before making my mandatory mug of strong coffee and grabbing breakfast. Whilst in the kitchen I’ll have the radio on, tuned (at low volume) to BBC R4, for company. Invariably I’ll then make my way to the computer: the very one I’m sitting in front of now.

This blog is about a week old, and a number of my posts have started life in this pre-dawn window of opportunity. Papers I’ve written for publication have often been chipped away at at a similar time. So far the relationship between my writing-for-this-blog and my writing-for-journal-submission has been one-way, in that I’ve used this space to share ideas rehearsed at greater length in already-published academic articles. Indeed, this was one of my purposes in setting this site up: I wanted to experiment with blogging as a way of promoting work, and as a means of engaging beyond the production of lengthy outputs for paid-for journals.

It now occurs to me that this blog might also become a working space for the development of new ideas, and that the relationship between writing-for-journals and writing-for-the-blog might sometimes run in the opposite direction. This forum will never be a substitute for my academic journal-writing, and I’m not proposing to dump heaps of unmanaged data here (even if I had it!) for some kind of public write-in. But I might bring fledging ideas which I’m in the process of working through in my head.

Which brings me to…

At this year’s Network for Psychiatric Nursing Research conference I gave a talk titled, ‘Past, present and possible future in the system of community mental health care’. I intended this to be a kind of reflective run-through, taking in a decade-and-a-half of research and writing in the field. I wanted to touch lightly over a string of studies and papers I’ve had the good fortune to be involved in, and to knit together something cumulative around the themes of system interrelatedness, complexity and change. I’m not sure I pulled this ambition off in that forum, and in the longer term I’d like to work this all up into a full-blown paper. This space might become a repository of some sort for this type of work-in-progress. We’ll have to see, though, and I’ll need to think through how this might happen.

Unrelatedly: I’ll be opening the Mental Health Nurse Academics UK Vice Chair elections on Monday. My congratulations, too, to Louise Poley (Consultant Nurse in Substance Misuse, Cardiff and Vale UHB) for becoming RCN Wales Nurse of the Year. Lou has done outstanding work improving the health of people who are homeless, collaborating with partners across the statutory and non-statutory sectors.

Now I’m off out for run. Thanks, again, for reading.

Sphygmomanometers, remedial gymnasts and mental health work

For an example of how health care tasks can become attached to different groups of people over time, then look no further than the measurement of blood pressure. One of the stories my grandmother told me when she was alive was how, whilst working as a nurse in the 1920s, whenever a new-fangled sphygmomanometer was to be used a doctor would come to the ward to operate it. The recording of blood pressure then became a task that nurses and midwives routinely did, and indeed support workers. Now it is something that anyone can do, using electronic gadgets purchased from the high street.

Tasks move around in mental health systems, too. Think, for instance, of the provision of formal therapies. Cognitive-behavioural family work used to be something which only a sprinkling of nurses did. Not any more. In this part of the UK, some of the tasks which only social workers used to fulfil as ASWs (approved social workers) during the operation of the Mental Health Act are now equally fulfilled by others working as AMHPs (approved mental health professionals).

Just as tasks appear and move between groups, so too do whole groups emerge, change and sometimes merge or even disappear. Remedial gymnasts appeared in the years after the second world war, before being subsumed within the profession of physiotherapy. Peter Nolan has told the story of mental health nursing growing from the keepers and attendants found within the asylum system. Community mental health nursing, as a particular sub-division, did not exist until the early 1950s. Now within the mental health system there are peer support workers, carrying out tasks which professionals and health care assistants might once have done.

Complexity and changeDavina Allen and I wrote about processes of this type in a paper called Complexity and change in the United Kingdom’s system of mental health care. This appeared in the journal Social Theory & Health in 2006, though a post-peer-review version of the article can also be downloaded from here. Davina is a nurse and sociologist (and was one of my PhD supervisors; the other was Philip Burnard), and in this article we drew on sociological theories to explore the changing division of mental health work in the post-war years. We used the ‘ecological’ ideas of Everett Hughes and Andrew Abbott to frame our analysis, about which you can read more here. These emphasise the division of labour as a complex and dynamic social system, which is responsive to all sorts of internal and external forces. Technology is one driver for change (for example, no-one could measure blood pressure until a device to do so had been invented. Mass production brought this work to the masses). Hughes had lots of interesting things to say about ‘mandate’ (the kinds of things groups say they ought to be doing) and ‘licence’ (what they actually do), and the ‘bundles of tasks’ which become attached to occupations at particular times and places. Abbott writes about the things that professions do to secure and advance what he calls their ‘jurisdiction’, in the face of claims made by competitors. ‘Jurisdiction’ refers to a group’s control over work.

In our Complexity and change paper Davina and I wrote about the historic success of the profession of psychiatry in drawing on biomedical knowledge to underpin and maintain a position of power in the mental health system. But as I’ve already suggested, interrelated systems of work are in motion, and in our paper we were also interested to explore sources of change. So we wrote, for example, about the challenges to biomedicine raised by dissident anti-psychiatrists in the 1960s and 1970s. We also wrote about the claims of mental health nursing to the possession of profession-specific knowledge underpinning the maintenance of helpful therapeutic relationships, and the appeals of social workers to having profession-specific ‘social model’ insights.

We also made quite a thing about the significance of community care for work and roles, and reflected on the expansion of state intervention in the mental health system (via a proliferation of policies) in the early years of this century. Now I think about it, there’s a link here between the wicked problems paper I wrote with Michael Coffey, and blogged about in both this and this earlier post. Policymakers’ recent formulation of ‘the problem’ as being one of unhelpful professional demarcations and restrictive practices has been a source of considerable disturbance in the mental health system of work. I’m thinking here, again, about the opening up of the Mental Health Act ‘approved’ role to nurses, psychologists and occupational therapists as well as to social workers, and what the longer-term implications of this might be. I’m also thinking about the division of labour consequences of peer support workers, and mental health nurses who prescribe medications, and graduates without ‘professional’ qualifications providing psychological therapies in primary care. Whatever the merits or otherwise of developments of this type, I think we should look carefully at their wider impact. Sometimes change can manifest in unpredictable ways.

And that brings me to another matter altogether: the intended and unintended consequences of action in interconnected systems. But that’s for another day, and for another post, entirely. Thanks for reading.

Blogging on the bus: floods, mental health and more wicked problems

A brief post as I make my way, by bus, to a meeting at the University Hospital of Wales.

What’s the connection between the prevention of floods (noting the terrible weather we’ve been having, again) and the promotion of mental health? Both are problems of the wicked variety. Here I’m using ‘wicked’ in the way I used it in my previous posts, with due acknowledgment of Rittel and Webber and their 1973 paper. Flood management and improving mental health and well-being are complex problems. Responsibilities are dispersed across different people, groups and organisations. There are no ‘stopping rules’, in that there is potentially no end to what could be done.

That’s it: bus journey over.

Mental Health Nurse Academics UK (MHNAUK)

Over a period of almost a decade Mental Health Nurse Academics UK (MHNAUK) has grown in size and stature. The group has been chaired by a series of fine people: Patrick Callaghan, John Playle, Linda Cooper (who I work with in Cardiff) and Alan Simpson. Incoming chair to serve for two years from the start of 2013 is Michael Coffey.

I’m managing the process through which the group’s next vice chair will be identified, and pretty soon we’ll be moving to an election. Whoever takes up the position will spend two years working with Michael, before spending the two years following as chair. More news on all this at a later point.

The Mental Health (Wales) Measure 2010

This is important, if you happen to use (and/or work in) mental health services in Wales. The Mental Health (Wales) Measure 2010 sets out to drive up standards across a number of areas: mental health in primary care; care coordination and care and treatment planning; the assessment of people who have previously used mental health services; and independent advocacy.

For ‘Measure’ read ‘law’, because that’s exactly what it is. I applaud the Welsh Government’s commitment to improving services, though I’d love to know more about the politics behind the decision to attempt this through the use of statute. What we now need is high-quality, independent, research to find out what impact (intended and unintended, helpful and unhelpful) the Measure is having.

Some opening thoughts (2)

Yesterday I opened this blog with a reference to a paper Michael Coffey and I published in 2011. I briefly talked about ‘wicked problems’, linking back to Rittel and Webber’s original article introducing this term.

In our paper Michael and I commented on the pace of change in mental health policy and services across the UK. We were particularly interested in the years from 1997, beginning with the election of New Labour. At the start of this period there were some bold statements from members of the then-new government, including the claim that community care had ‘failed’. At the time I thought this to be far too bald and simplistic a formulation of ‘the problem’. I still do, as it happens. As a solution, more (and different types of) community mental health care became the policy prescription. It was in this context that assertive outreach teams and crisis resolution and home treatment services appeared.

What struck Michael and me was how quickly this problem/solution formulation yielded to a replacement, this time emphasising shortcomings in professional practice. Policy pronouncements in the early/mid 2000s referenced occupational boundaries as a problem. Now, eroding demarcation became a key goal of policy: and it is in this context that new ways of working emerged. This was all about redrawing divisions of labour, and I’m sure this is something I’ll return to in the future because it interests me very much.