Category: Nursing

Making psychiatric wards safer and more peaceful

Safewards, led by Professor Len Bowers, has been funded through a National Institute for Health Research (NIHR) Programme Grant for Applied Research and aims to make psychiatric hospitals more peaceful, safer and therapeutic.Twice in the last year I have had the opportunity to hear Len present the thinking behind the Safewards model, outline the design and methods of the Safewards randomised controlled trial and talk through its main findings.

Following the link from the Safewards logo above takes you to the project’s website. This is packed full of useful information, including the detail of the simple nursing practices which Len and his team found reduced rates of conflict and containment in the hospital wards participating in their study. For an accessible introduction to what Safewards is all about, there is also this video in which Len presents his work to an audience in Melbourne in October 2013:

As I suggested in a meeting yesterday with esteemed Cardiff and Vale University Health Board colleagues, this really is exceptionally important new knowledge for mental health nurses. Now that the main trial is complete Len and his collaborators look to be devoting much of their energies to helping inpatient mental health staff and managers make use of the Safewards interventions in their everyday practice. I wish them every success, and am encouraging people to find out more and to spread the word.

Reviewing health and social care research in Wales (reprise)

Time this morning, before I head off for a second day of MMI-ing, to draw attention to revised restructuring proposals from (and for) the National Institute for Social Care and Health Research here in Wales. I’ve written about the NISCHR review in this earlier post, and this latest document is the version which has gone out for external peer review.

I’m pleased to see that NISCHR proposes a continuation of its support for research capacity building in nursing and the allied health professions. Here’s a snip from the new document:

Research Capacity Building Collaboration (RCBC) – RCBC was established in 2006 as a collaboration between six universities in Wales to increase research capacity in nursing/midwifery and the allied health professions in Wales. It does this through a number of funding schemes including PhD Studentships and Post-doctoral Fellowships.
v. It is proposed that a new specification is developed for an application for renewal of RCBC/ a new initiative to increase research capacity in nursing/midwifery and the allied health professions in Wales.

For those not familiar with the RCBC scheme I recommend a visit to this website.

Elsewhere, I see that NISCHR proposes pressing ahead with its plans to close the gap between its funded Registered Research Groups, Biomedical Research Centres and Biomedical Research Units. It says:

There is a need to further integrate the functions of the BRC, BRUs and RRGs into the NISCHR infrastructure and to provide clear objectives and indicators to ensure NISCHR funding makes a real difference and contributes to future outcomes. There is also a need to avoid duplication and address the perception of NISCHR’s infrastructure being unnecessarily complicated.
b. It is proposed to create new entities known as NISCHR Centres and Units. These will replace BRCs, BRUs and RRGs and become central pillars of the NISCHR infrastructure to create a more streamlined and integrated structure, improve cost-effectiveness and foster collaboration across sectors to facilitate translation.
c. It is proposed that NISCHR Centres will have responsibility for portfolio development and delivery in their areas across the translational spectrum, in collaboration with other elements of the infrastructure. In some instances they may also provide elements of infrastructure support themselves.
d. It is proposed that NISCHR Units will be smaller entities than NISCHR Centres and focus on specific points of the translational spectrum, specific activities, or represent emerging areas of research strength with aspirations to become NISCHR Centres in the future.
e. It is proposed that a competition is held for NISCHR Centres and Units; the existing BRC, BRUs and RRGs will be able to apply and be encouraged to consider how best to augment existing functions and strengths to become more integrated entities in the future. They may also incorporate the functions of other elements of the existing infrastructure. The NISCHR Centres and Units will have a Director, Operational Manager and Leads for specific specialties/areas. They will be multi-professional and multidisciplinary, including Public and Patient, NHS, HEI, Industry and Social Care representation as appropriate.

This is a significant, if not unexpected, proposal. As future arrangements begin to become clearer I’ll be looking for ways to make sure that research into mental health systems and services continues to be supported. Plenty to think about, then, as I head for the train.

Multiple Mini Interviews

Over the weekend I was sorry to learn that Inspector Michael Brown’s much-respected, and award winning, MentalHealthCop blog and twitter account have been suspended. I hope he is able to get back to both in the very near future.

Meanwhile, back at base I spent pretty much all of today helping select future students of nursing using multiple mini interviews (MMIs). Not sure about MMIs? Neither was I until recently. Here’s what we’re saying about them in the School of Healthcare Sciences at Cardiff University:

The interviews at Cardiff University School of Health Care Sciences for Nursing involve the use of a Multi Mini Interview procedure which is based on the Objective Structured Clinical Examination format that is commonly used by Health Sciences programmes to evaluate clinical competence.

The interview process is an opportunity to assess interviewees in person and assess information, such as personal qualities, that is not readily forthcoming in traditional application processes. The majority of these interviews will take place the week commencing 17 February 2014. 

The MMIs are made up of a series of short, carefully timed interview stations which provide information about applicants’ ability to think on their feet, critically appraise information, communicate ideas and demonstrate that they have thought about some of the issues that are important to the nursing profession. There are six stations in total. Each mini interview lasts a maximum of 5 minutes.

The School assesses the ability to apply general knowledge to issues relevant to the culture and society in which students will be practising, should they be successful in gaining admission to (and ultimately graduating from) the School. Equally important will be an assessment of the ability to communicate and defend personal opinions.

That’s pretty much it in a nutshell. Sticking to time is clearly important, and there’s plenty of moving around for applicants as they shuttle from station to station. As a process I rather liked it. I’ll be back for another slice of the same tomorrow, but will spare a thought for my esteemed Mental Health Nurse Academics UK colleagues who will be meeting at Lincoln University.

Restrictive practices

Today is the closing date for responses to the RCN’s consultation on the use of restrictive practices in health and adult social care and special schools. Michael Coffey has solicited views from members of Mental Health Nurse Academics UK, and has used these to inform the group’s formal submission. You can see what MHNAUK has contributed by following this link.

End of week catch-up

This week I learnt a whole lot more about framework analysis, having made the trip to City University London to join others in the COCAPP team for a NatCen training event. This was also my first introduction to the use of NVivo (a computer-assisted qualitative data analysis software package), my experience having previously been with Atlas.ti.

Elsewhere the RiSC project team convened, via teleconference, for an important decision-making meeting. We’re entering the closing stages of this study, and it’s interesting stuff: about which I’ll be able to say more in time.

And, as planned, this was also the week I made the short hop to Cardiff Met (at the invitation of Lynette Summers in the University’s Library and Information Services) to meet with folk there to talk about my experiences in using this blog, and other things, to bring my research and writing to a wider audience. That was fun, and I hope useful, too.

Along with some classroom teaching, marking, a committee meeting and reading a nearly-there doctoral thesis that just about sums up my recent workplace activities. Varied, as always. Looking ahead, I realise that (unusually) I’ll be missing the next meeting of Mental Health Nurse Academics UK due to take place at Lincoln University on February 18th. Other commitments have won out on this occasion.

20th International NPNR Conference: call for abstracts

Early news of this year’s International Network for Psychiatric Nursing Research conference, and a call for abstracts, have just appeared. The event takes place at Warwick University on September 18th and 19th, and more information can be found by following this link. With support once again from both the Royal College of Nursing and Mental Health Nurse Academics UK this promises to be a special occasion, this being the 20th running of this esteemed event.

Activity based funding and student research in the NHS

Yesterday I spent time with a group of MSc students, talking about research review processes. I’ve written on this blog in the past about my experiences of seeking approvals for my PhD, and in Monday’s session I urged people to be exceptionally cautious about planning NHS-related research in pursuit of their Master’s degrees.

Preparing for and securing NHS research ethics committee and R&D office approvals takes time. In this part of the world at least, some healthcare organisations are also likely to ask researchers to cover the costs to the NHS of supporting studies which are not portfolio adopted. Here I’m thinking of, for example, the costs arising when staff leave the workplace to participate in interviews or join focus groups, or suchlike.

The relatively new practice of directly seeking payment from research teams for the costs of studies which are not eligible for portfolio registration has appeared with the shift to activity-based funding. Here in Wales, the National Institute for Social Care and Health Research (NISCHR) has published criteria for entry to its portfolio, which are summarised here and are elaborated on here. It is from this second document that I have snipped the following:

A research study is a structured activity which is intended to provide new knowledge which is generalisable (ie of value to others in a similar situation) and intended for wider dissemination.

Studies eligible for the NISCHR portfolio should involve face to face contact with NHS patients, social care service users or people involved with their care. Studies must be led from and/or recruiting participants from Wales. All studies must already have research funding before they can be included in the Portfolio.  Research Costs cannot be provided by NISCHR CRC.

The following types of study are not eligible for inclusion in the NISCHR Portfolio:

  • audit,
  • needs assessments,
  • quality improvement projects,
  • directly commissioned studies,
  • secondary research such as systematic reviews,
  • purely laboratory based studies,
  • routine biobanking of samples would not be eligible but a hypothesis based sample collection would be if appropriately peer reviewed and funded,
  • own account funded studies,
  • studies closed to recruitment.

MSc projects invariably do not meet these criteria, meaning that numbers of taught postgraduate students get to cut their dissertation teeth on non-NHS research studies or (where academic regulations allow) on other types of project altogether. Examples are service or quality improvements, service evaluations and systematic reviews. And, in my view, these are sufficiently testing options for students working at MSc level, with some (like local quality improvements) having the added advantage of immediately and obviously benefiting the NHS and those who use its services.

However, a problem arises in the case of postgraduate research degrees. In some disciplines, including nursing, these are often undertaken part-time and are carried out with limited or no external grant income. Opportunities for studentships are relatively rare, and where they are available may be financially unattractive to practitioners who have already built careers in the health service. As with MSc projects, ‘own account’ doctorates will struggle to get onto the portfolio. They therefore run the risk (in some circumstances) of not being supported by organisations within the NHS unless their associated costs are explicitly met. One way of achieving this may be for local NHS managers to agree to carry the costs of non-portfolio studies which it is planned will take place within their services. But securing this kind of support is not straightforward, and for would-be research students the added challenge of finding a means of paying costs is hardly an encouragement. And, where MSc students can usually opt for non-research projects this is not so for those aiming for PhDs or Professional Doctorates. These are awards made only to those who generate new knowledge using sound and defensible research methods.

So what does all this mean? It’s early days, but one likely outcome may be a reduction in small-scale research projects within the NHS, along with an increase in the preparations and negotiations which precede data generation. Another may be the proliferation of non-portfolio projects which are explicitly designed to meet ‘research’ criteria for academic award purposes, but which are constructed to be something else (typically ‘service evaluation’) within the context of NHS research governance. A reasonable, longer-term, concern is that research capacity-building in fields like nursing may falter as potential students rethink their plans. And that, in my view, would be a big step backwards.

‘Psychiatric Ideologies and Institutions’: 50 years and counting

Happy new year. In the midst of a series of holiday period email exchanges Michael Coffey happened to mention that 2014 marks the 50th anniversary of the publication of Anselm Strauss and colleagues’ Psychiatric Ideologies and Institutions.

This is a fine book indeed, which during my time as a PhD student concerned with work and roles in mental health care was an absolute essential. In it, Strauss and his collaborators reported findings from prolonged and intensive fieldwork conducted in two North American psychiatric hospitals. Whilst today’s qualitative research reports will typically include lashings of direct data extracts, Psychiatric Ideologies and Institutions has little in the way of what Strauss et al referred to as ‘illustration and quotation’. Yet I never once recall, as a reader, doubting that Strauss and his team were truly there, participating in and recording everyday hospital life and its organisation.

It is at this descriptive level that the book initially works: as a meticulous account of the interplay between ideas, professions and practices in an area of health care which (both then, and to this day) happens to be particularly contested. One part of the dataset drawn on in the book comes from a questionnaire, designed to capture information about affiliations to particular treatment ideologies. From this nurses emerge as being ‘ideologically uncommitted’. In a later, detailed, section Strauss et al wrote of the problems faced by nurses in reconciling their managerial, administrative and therapeutic tasks and in answering the still-pertinent question:

…at the heart of her professional identity: What does therapeutic action toward patients actually involve for a psychiatric nurse?

My copy of Psychiatric Ideologies and Institutions is the edition published in 1981, for which a new introduction was added. In this, Strauss and his collaborators wrote of their original ambition to produce a book which was not only descriptive, no matter how detailed or accurate, but which was also theorised. It was the fieldwork and the findings reported most completely in this monograph that gave rise to the idea of the negotiated order. This is a sociological theory of importance which, in the decades following its introduction, went on to develop a life of its own. As Strauss et al wrote in their 1981 introduction, their original observation that theory might emerge from data represented a considerable methodological departure, more fully articulated at a later point with the introduction of grounded theory. Here, then, is a second way in which Psychiatric Ideologies and Institutions works, and remains of interest to people unconcerned with research into the world of mental health care: as an exemplar of how data and theory can dance together.

Today I’ve turned up this review of the book, which appeared in 1965 in the journal now called Psychiatric Services. In it the reviewer sums up with the recommendation that:

All in all, most professionals will find this book profitable to read, study and think about.

I concur, and commend this classic text to professionals and others alike. And as an aside, perhaps this short celebratory post can help persuade students (usually undergraduates, in my experience) that books and articles which happen to be more than five years old can still be worth reading.

Education for community mental health work

This week brought a COCAPP meet-up in Bristol, where we had the chance to plan our work for the immediate period ahead. The RiSC team also met, albeit in teleconference rather than face-to-face fashion. I’ve had pre-registration student nurses’ assignment work to begin marking, and this afternoon will be taking part in a joint Cardiff University/Local Health Board discussion on the future provision of post-qualification modules for community mental health practitioners.

This afternoon’s meeting has given me pause for thought, and a chance to reflect a little on my long involvement in post-registration mental health education. It was explicitly to lead a full-time, one-year, programme for actual or intending community mental health nurses (CMHNs) that I was recruited into what was then the University of Wales College of Medicine in 1997. Education, and my role, have changed considerably in the period following. In Wales there is no longer a fully funded, full-time, course of this type. Like pretty much everywhere else, here education for health care workers beyond registration has increasingly become part-time, and modularised.

I once wrote about the CMHN course we ran in Cardiff in the journal Nurse Education Today. The article was titled ‘Specialist practice in community mental health nursing‘, and had an abstract which went like this:

Community mental health nurses (CMHNs) work in an increasingly complex health and social care environment. Over recent years, the evolving direction of general health service and specific mental health policy has directed CMHNs towards: the provision of clinically-effective interventions; a closer attention to meeting the needs of people experiencing severe and long-term mental health problems; the simultaneous provision of services to meet the needs of people experiencing a wide range of mental health problems presenting in primary care settings; greater collaboration with workers representing other disciplines and agencies; and the development of active partnerships with mental health service users. This paper explores the context within which CMHNs practise, and within which education programmes preparing specialist practitioners in community mental health nursing have been developed. One recently-validated specialist practice course for CMHNs is described in detail, with the intention of stimulating discussion and debate surrounding the practice of, and the educational preparation for, community mental health nursing.

I can’t claim that this paper did actually trigger any particular debate, but at least I tried.

I also had the chance, during the time that I ran Cardiff’s full-time CMHN course, to survey the leaders of other programmes of this type offered elsewhere in the UK. A paper called, ‘Specialist practice for UK community mental health nurses: the 1998-99 survey of course leaders‘ appeared in the International Journal of Nursing Studies. This was co-written with Philip Burnard, Debs Edwards (who, I am delighted to say, is now project manager for the RiSC study already mentioned in this post) and Jackie Turnbull. In the paper’s abstract we said:

Surveys of the leaders of the UK’s post-qualifying education courses for community mental health nurses have taken place, on an annual basis, for over 10 years. In this paper, findings from the survey undertaken in the 1998–99 academic year are reported. These findings include: that most course leaders do not personally engage in clinical practice; that interprofessional education takes place at a minority of course centres, and that course philosophies and aims are characterised by an emphasis on both outcomes (in terms of, for example, skills acquisition, knowledge development and the ability to engage in reflective practice), and process (adult learning).

And then there was a paper called, ‘Education for community mental health nurses: a summary of the key debates‘ which Steve Trenchard, Philip Burnard, Michael Coffey and I wrote for Nurse Education Today. Here we said:

A wide range of post-qualifying education courses exist for community mental health nurses (CMHNs) working in the UK. ‘Specialist practitioner’ courses emphasize shared learning between CMHNs and members of other community nursing branches. These programmes typically include course content drawing on the social and behavioural sciences, as well as on material more tailored to the clinical needs of practitioners. Such courses and their predecessors have been subject to criticism, however. Courses have been described as anachronistic, and failing to take account of recent advances in treatment modalities. In addition concerns about the generic focus of some programmes have also been raised. Educational alternatives, such as programmes preparing nurses and other mental health workers to provide ‘psycho-social interventions’ have, correspondingly, become increasingly popular. In this paper we explore some of the debates surrounding the education of CMHNs, and explore the context in which CMHNs work and in which educational programmes are devised. We consider the multidisciplinary environment in which CMHNs practise, the differing client groups with which CMHNs work, the developing policy framework in which mental health care is provided, demands for more user-responsive education, and the relationship between higher educational institutions and health care providers. We conclude the paper with a series of questions for CMHN educators and education commissioners.

And there are other papers and book chapters, too, which I won’t refer to now. But I am reminded that I once spent large parts of my working life running programmes for community mental health workers, and managed to research and write a fair bit about the same. Perhaps today’s meeting will lead to a modest rekindling.

More on mental health services at a time of austerity

For the second time in two months the BBC and Community Care have collaborated to establish the extent of funding cuts to mental health services in England. Freedom of Information requests were sent to 51 NHS trusts, of whom 43 responded. Summaries of this investigation, and headline findings, can be found on the BBC website here and on the Community Care website here. Community Care says:

Data returned by over two-thirds of the mental health trusts, obtained in two separate Freedom of Information requests, showed that:

  • Overall trust budgets for 2013/14 had shrunk by 2.3% in real terms from 2011/12. Ten out of 13 trusts that provided forecast budgets for 2014/15 are projecting further cuts next year.
  • Budgets for ‘crisis resolution teams’ fell 1.7% in real terms compared to 2011/12 while the average monthly referrals to these teams rose 16%. The teams provide intensive home treatment in a bid to prevent acutely unwell people being hospitalised.
  • Budgets for community mental health teams flatlined in real terms but referrals rose 13.3%. These services provide ongoing support in a bid to prevent people’s mental health deteriorating to crisis point.

Community Care also lists 10 ways this underfunding is damaging care.

This is also the month that a special, free-to-download, ‘impact of austerity’ edition of Mental Health Nursing journal has appeared. In an email forwarded to all members of Mental Health Nurse Academics UK by Steve Hemingway (who is both an MHNA member and a member of the MHN editorial board), Dave Munday at Unite the Union (which publishes the journal) says:

This month the Mental Health Nursing journal is focused on austerity and mental health. I hope you’ll agree with me that this is a vitally important topic that not only every mental health nurse should know about, but every citizen. We hope that the journal will help to trigger some thoughts and debates that you can have locally in your workplaces but also outside of work. To this end we’re making the journal free to access even if you’re not a MHNA member or MHN subscriber.