mental health, nursing, policy, services, people, research, education
Category: Nursing
The School of Healthcare Sciences in Cardiff University is hosting the 2023 Skellern Lecture and Lifetime Achievement Award evening, which takes place in the Glamorgan Building on June 15th. An Eventbrite link to book tickets to be there, in person, can be found here. Here, too, is the evening’s order of events:
A packed evening, for sure, with an invitation now to secure a place and to spread the word!
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This month brought, for me, the welcome return of face-to-face conferences. First, I was pleased to have received an invitation earlier in the year to deliver a keynote lecture at the RCN International Nursing Research Conference 2022, which took place at the Royal Welsh College of Music and Drama on September 5th and 6th. Rather than speak about any one, particular, study I used this as an opportunity to travel over a larger programme of research in the mental health field, pulling out underpinning ideas and key messages along the way.
Boiled down, my talk revolved around four ideas: health care can be thought of as a complex system; complex health systems can be understood through the study of cases, existing at different ‘levels’ of organisation (macro, meso and micro); to appreciate cases of health care system complexity it makes sense to use a plurality of analytic and methodological approaches; and research of this type demands a collaborative, stakeholder-informed, approach. These will be familiar themes to readers of this blog site. My talk at the RCN event, however, represented the most sustained effort I’ve made to date to articulate the principles and practices underpinning the research programme I have been involved in, to synthesise the main lessons learned, and to pull out some overarching observations. At some point it would make sense to write all of this up in an article.
Hot on the heels of the RCN International Nursing Research Conference came the 28th International Mental Health Nursing Research Conference, which took place at St Catherine’s College, Oxford, on September 8th and 9th. St Catherine’s was the home for the Network for Psychiatric Nursing Research Conference, as this event was originally known, for many years: returning there earlier this month seemed fitting after the two online editions of the event which happened in 2020 and 2021. I was pleased to be part of a symposium presenting findings from three NIHR-funded studies into mental health crisis services. Led By Dr Nichola Clibbens, this included a talk by Nicola and Michael Ashman drawing from their (and their colleagues’) realist synthesis of how, for whom and in what circumstances different community mental health crisis services work. Also featuring was a presentation from Professor Steve Gillard and Dr Katie Anderson on mental health decision units in acute care pathways. Third in the linked series of presentations was my talk summarising findings from an evidence synthesis, led by Dr Nicola Evans, into crisis responses for children and young people aged 5 to 25.
More generally, I very much appreciated the opportunity at both these events to renew my connections with friends and colleagues, and to meet and hear new people with interesting things to say. In the case of MHNR2022, particular thanks are due to the organising committee, which brought this conference together under the umbrella of Mental Health Nurse Academics UK without a dedicated events team in support.
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I teach a session on the politics of research funding, offered now as part of our workshop and seminar series for postgraduate research students in the School of Healthcare Sciences at Cardiff University. One of the things I talk about is the Research Excellence Framework (REF), and how the outcomes from the REF are used to inform the annual distribution of quality-related (QR) funding to universities as part of the ‘dual support’ approach, along with providing evidence of a return on public investment and generating information for the purposes of benchmarking and comparison.
The REF moves in long cycles. The first took place in 2014, replacing the Research Assessment Exercise which had previously run every five or so years from the middle of the 1980s to 2008. For the 2021 Research Excellence Framework (REF2021) universities made submissions to up to 34 units of assessment, each covering a subject area and each operating underneath one of four main panels. Most research conducted by nursing academics in the REF2021 census period will have been submitted to the Allied Health Professions, Dentistry, Nursing and Pharmacy unit of assessment (UOA). In each UOA, expert panels reviewed the quality of three separate components within each submitting university’s return: outputs, impact and environment. An output might be a single journal article, or perhaps a book or monograph, assessed by members of the relevant expert panel for its ‘originality, significance and rigour’. The assessment of impact involved the expert review of university-submitted case studies exemplifying the ‘reach and significance’ of research beyond academia. Environment involved review of how far each university was enabling the ‘vitality and sustainability’ of excellent research in the subject area.
Suffice to say, the REF is a big deal for universities, subject areas and researchers, with very considerable resources being devoted by institutions to secure as favourable a set of outcomes as possible. As a process it has both its supporters and its detractors, with a summary of controversies surrounding the REF appearing on this Wikpedia page. Debates aside, results from REF2021 have now been published, with the data searchable both by university and by unit of assessment. Main panel reports have also appeared, with more data (including the detail of each submission to each UOA) expected in due course. Both the Times Higher and the Wonkhe teams have produced independent analyses of what the results mean, with the Council of Deans of Health publishing a response highlighting how ‘research undertaken by our members [as submitted to the Allied Health Professions, Dentistry, Nursing and Pharmacy UOA] tackles real life health challenges facing patients, health services and local communities as well as addressing wider societal challenges and global health inequalities.’
Extracted directly from the Overview report by Main Panel A and Sub-panels 1 to 6, here is a summary of the average assessed quality profile of research submitted to the Allied Health Professions, Dentistry, Nursing and Pharmacy UOA:
Here, 4* refers to ‘world-leading’, 3* to ‘internationally excellent’, 2* to ‘internationally recognised’ and 1* to ‘nationally recognised’. Overall, then, this table gives lots to celebrate, pointing to allied health, nursing and related research being done to a very high quality, and making a significant difference beyond academia. This much is acknowledged explicitly in the UOA-specific overview report, but so too is a note on the importance of continued investment in research capacity-building and in supporting early careers. I find it hard to disagree with that sentiment. Whilst REF outcomes come round only once every six or seven years, the work of enabling and growing research capability is a constant.
Follow @benhanniganCurrently 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.
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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.
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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:
Follow @benhanniganBackground: 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.
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.
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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.
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!
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.
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