Category: Nursing

All change in East London

How pleasing it was to discover, during a return trip this week to East London, that the site of the now-disused St Clement’s Hospital (this being where I trained as a mental health nurse) is becoming the UK’s first community land trust. This means that the space will be developed for permanently affordable housing for local people.

Having cast an eye through the windows of London estate agents during this trip away I can see why there’s a need. The capital has become a prohibitively expensive place to live and work, it seems.

As it happened, our visit on August 8th coincided with the opening of the Shuffle festival. Curated by Danny Boyle (who made an appearance) this is bringing film, music and other good stuff to the St Clement’s site ahead of its redevelopment.

Further west, in Whitechapel, we discovered that the Royal London Hospital has been built anew under a private finance initiative scheme. The front parts of the old hospital remain, but are unused and propped up from behind for purely ornamental purposes.

At the back, the original nurses’ homes and other notable venues (including the Oxford Arms pub) have been entirely demolished to make way for a tall, exceptionally shiny, new main building. For the time being the Princess Alexandra Building, this being the old School of Nursing site in Philpot Street, remains.

All in all It is – we had to conclude – looking very different.

Thoughts on the occasion of having written 100 posts

My first post was written and uploaded to this site on November 24th last year. I wrote about my interest in exploring the mental health system’s ‘wicked problems’, and drew attention to an article Michael Coffey and I had recently published in this area. In this, my 100th post, I want to think a little about what I have learned using a blog as a medium of communication.

As a mental health nurse academic my job involves researching and writing. I have wanted this site to be a vehicle for bringing some of this work to a wider audience. The main way I have gone about doing this has been to write posts to surround published articles, and where copyright makes this possible to add links to full-text green open access versions of papers stored on Cardiff University’s ORCA digital repository. The link above to Michael’s and my paper on wicked problems is an example. I’d like to think that this strategy has had some effect. As I wrote in this post last month, copies of papers I have deposited and then blogged about have been downloaded. By whom I cannot know. Nor can I be sure what use, if any, people have made of what they’ve read. If anyone wants to let me know, then that would be all to the good.

Over the last eight to nine months I have also learned that a blog needs looking after. So in addition to writing about research I have taken the opportunity to write generally about other things I do at work or am interested in, or about stuff which has simply caught my eye. My approach has been to write little, but to write often. I reflect that adding small pieces here and there has helped me in my teaching, as I noted earlier here. I also realise that in blogging beyond research I have blurred my boundaries somewhat, having added notes along the way about (for example) the simple pleasures of running. As an aside, I’ve been plagued by minor, but annoying, running-related injuries over the last few months and am missing my forest jaunts very much.

Just as a peer reviewed, published, article can be given a leg-up by a post on a blog, so too can a new blog be supported by a tweet. I have taken to using Twitter to draw attention to newly published posts, and indeed have started using this (sporadically, it has to be said) as another, independent, way of exchanging ideas.

That’ll do, for now. But I conclude that I’ll maintain this site in its small niche for a while longer yet.

Care work and health system complexity

Two interesting collections of papers have caught my eye in the last week or so. Davina Allen has edited an online volume of articles, all previously published in the journal Sociology of Health & Illness, addressing the sociology of care work. In her editorial Davina sets the scene with reference to the Francis Inquiries and concludes with this:

[…] in the wake of Francis the predominant response to raising the quality of care and compassion has been to focus on the attributes of individuals and wider regulatory arrangements. As we have seen, however, the kind of care that can be provided depends fundamentally on the social organisation of care work, which in turn hinges on what we (society) are prepared to pay for. Francis has called for national fundamental care standards, but this requires more careful attention to the models of care-giving practice that will sustain them, including care-giver roles, the inter-relationship of care work components and features of the organisational context. The papers in this collection reveal there are no easy answers to these questions, but the insights they yield make an important contribution to these debates. In bringing the papers together in this virtual special issue the aim is to both raise the profile of the individual contributions, but also their collective value to this critical issue of public and policy concern.

Meanwhile, Tim Tenbensel, Stephen Birch and Sarah Curtis have edited a special issue of Social Science & Medicine devoted to the study of complexity in health and health care systems. I have a personal interest here, as it is in this collection of new papers that my article Connections and consequences in complex systems: insights from a case study of the emergence and local impact of crisis resolution and home treatment services appears. Describing himself as ‘a sympathetic outsider to complexity theory’, Tim Tenbensel in his editorial closes with this:

[…] perhaps the most important conceptual issue for complexity theory seems to be the place of ‘top-down’ interventions in complex systems. Are they part of the landscape of complexity, or are they things that ‘impede’ the unfolding of self-organising, emergent phenomena? More sophisticated applications of complexity suggest the former answer, yet the will to control through linear, rational, prescriptive mechanisms remains an ever-present shadow – something that should be minimised – because it this a defining trope of complexity theory applied to the social sciences. This theoretical challenge is perhaps most pressing in contexts in which health services are directly funded from public sources.

My apologies to the doctoral students whose ‘complex systems’ module I taught a few weeks ago, who may erroneously have thought that I knew what I was talking about, but like Tim Tenbensel I regard myself as being a relative newcomer to this whole complexity approach. So I for one am looking forward to reading the other papers in this new collection, and to learning plenty that is new.

Ten good reasons to come to this year’s NPNR conference

This year’s International Network for Psychiatric Nursing Research Conference takes place on the 5th and 6th of September at Warwick University. Here are ten reasons to come along and participate:

  1. to learn from Professor Kate Pickett (co-author of The Spirit Level) talking about global inequalities in mental health;
  2. to hear Professor Len Bowers presenting new findings from his Safewards trial;
  3. to listen to Charles Walker MP, who has talked publicly about his personal experience of mental health difficulties, speaking on the topic of making the personal political;
  4. to hear Dr Simon Duffy from the Centre for Welfare Reform talking about personal responsibility and social justice;
  5. to listen to Dr Fiona Nolan from UCL/Camden and Islington NHS Foundation Trust discussing protected engagement time in acute mental health inpatient wards;
  6. in a packed programme of concurrent sessions, to learn from delegates (from the UK and beyond) talking about their research studies large and small;
  7. to renew existing friendships within the mental health nursing research field, and to make new ones;
  8. because I defy you to tell me you have anything more interesting to be doing over the two days the conference is taking place;
  9. because if (like me) you’re a regular at this conference, being there is the only way to find out how the NPNR at Warwick compares with the NPNR at Oxford;
  10. because you will, undoubtedly, enjoy yourself.

Writing an undergraduate dissertation

Here’s a link to a full-text green open access version of a paper called Preparing and writing an undergraduate dissertation. Philip Burnard and I published this in Nurse Education in Practice in 2001. Our aim was to produce something of practical use to students working on what is, typically, their single biggest piece of written work.

I appreciate that my timing here is very poor. Right now most students will be on, or planning for, their summer holidays. So I’ll draw attention to this paper again once the new academic year has started.

Research and mental health nursing

Over on the Mental Health Nurse Academics UK blog, the group’s chair Dr Michael Coffey writes:

The Research Excellence Framework (REF) looms large for many of us. This is part of the regular round of judging of peer-reviewed research publications on which the UK government bases its decisions on distribution of institutional research funding. Decisions within Higher Education Institutions are being made around now on who is considered returnable and then whether it is strategically advantageous to submit these researchers in the exercise. For individual research careers these decisions weigh heavy. For the profession of mental health nursing there may be wider implications. Previous research assessment exercises have seen more and more evidence of mental health nurses being returned. This has undoubtedly led to an improved profile within individual universities and recognition of the contribution of research to improving the experience of people using mental health services.  There remain significant opportunities for mental health nurse researchers to contribute and bring to bear a professional view on what needs researching and how this should be conducted. We will have to wait until 2014 for an idea of what the landscape will look like in relation to mental health nursing. One thing for sure is that we need a highly engaged mental health nurse academic workforce to continue to provide high quality education and research. By doing this we can make a meaningful contribution to the development of mental health care both here in the UK and beyond.

Nursing certainly did do well in the UK’s last Research Assessment Exercise, the precursor to the REF to which Michael refers in his post. Results for all higher education institutions submitting to Unit of Assessment (UoA) 11 (Nursing and Midwifery) in RAE 2008 can be found here. In his subject overview report for UoA11, Professor Hugh McKenna of Ulster University ended with this:

In conclusion, the sub-panel members were very impressed with most of the submissions they reviewed and with the pervasive pattern of world-leading and internationally excellent research. There are many models of good practice from which developing research groupings can learn in terms of research activities, outputs, environment and esteem. It is clear that investment by Governments, funding bodies and universities has increased research capacity and developed research leaders capable of undertaking nursing and midwifery research that is internationally excellent and world leading. These funding streams need to be sustained and enhanced if the upward trajectory and momentum are to continue and if the quality differentials between the strongest and weakest departments are to be addressed.

And, when the results from the last RAE were published in December 2008, The Guardian ran an article titled Nursing research takes its place on world stage. Here it said:

Nursing, for many years medicine’s poor relation, has come of age in the 2008 research assessment exercise (RAE). Academics in the field can justifiably claim to be world-leading in terms of research. Nursing and midwifery was among the subjects with the most highly rated research in the results published today.

Heady stuff indeed, and testimony to years of hard work, strategy, and capacity-building investment. All this does, though, seem an awful long time ago. As Michael reminds us in his MHNAUK post, attention has long since turned to preparations and prospects for REF 2014.

I have written about nursing and the Research Excellence Framework 2014 on this site before, drawing attention to the workload facing members of UoA A3 (Allied Health Professions, Dentistry, Nursing and Pharmacy) and to the challenges of demonstrating and assessing ‘impact’. So, as we hurtle towards the deadline for REF submission, in what shape does UK mental health nursing research find itself?

Readers of this blog will know that this is a question that MHNAUK is also asking, and is seeking an answer to in organised fashion. Professor Len Bowers led a discussion on this at the MHNAUK meeting held in Cardiff last March. When the group reconvened in Liverpool in June, Dr Fiona Nolan asked members for items to include in her planned survey of research activity and capacity.

Whilst we await findings from Fiona’s project in the first instance, my personal view is that there is much to celebrate in mental health nursing research but also room for development. A small number of universities are home to strong and established research groups. Leaders of these have built national and international collaborations across disciplinary and institutional boundaries. They have laboured to secure funding in open competition and to complete and publish studies with real implications for policy, services, education and practice. This is excellent progress, and I think we now need more of this type of activity across more universities. This means people (and I include myself here) extending their ambition, and perhaps being a little bolder. As an example, early next year the European Union’s Horizon 2020 research and innovation programme invites a first round of applications for funding. How excellent it would be for mental health nurses in the UK to be leading, and collaborating on, high-quality bids submitted there.

My more general reading of the field is that, in many universities, mental health nurse researchers are thinly spread. I’ll bet that in most of the sixty-plus universities represented at MHNAUK the number of people predominantly involved in teaching far outstrips the number predominantly engaged in research. Teaching is important – really important – but the lone researcher in a team of teachers is in a tough place indeed. As I cast an eye around the departments I am most familiar with I also wonder where the younger mental health nurse researchers are. How many mental health nurses in their 20s are studying for PhDs? If the answer is ‘not many’, then what should we collectively be doing to make research a viable, and attractive, career proposition for nurses at the start of their careers? How might we nurture a future generation of mental health nursing clinical academics?

Anyway: all is speculation until we have some evidence. The MHNAUK survey, I anticipate, will paint a more rounded and complete picture of the true state of research activity and capacity than will the Research Excellence Framework. The REF, being what it is, is subject to all sorts of inter- and intra-institutional politicking and will produce only a partial view of what’s really going on.

Learning about complexity and systems

Today has reminded me of the pleasures of university teaching. A day in a classroom with lively doctoral students is to be savoured. Most (but not all) of the group were nurses, and most (but again, not all) were completing the taught elements of their professional doctorate programme ahead of beginning their research.

The module is concerned with understanding health system complexity, and is liberally sprinkled with local research (my own included). Today we began with an overview of the territory, and then discussed policy and services at the large scale using the idea of wicked problems. Pauline Tang gave a fabulous talk based on her study of electronic health records, before we closed with a whistlestop tour of systems of work and divisions of labour.

We meet again tomorrow for sessions led by students, to think about trajectories and critical junctures, and to hear Nicola Evans being interviewed about change in organisations. I’m looking forward.

Vivas, research projects and the Welsh Government on the Francis Report

There’s plenty going on in the continuing baking sun this week. I was pleased to spend yesterday at Sheffield University (where I was once a student) examining, and recommending awarding, a doctorate addressing the use of problem based learning in mental health nursing education.

Meanwhile COCAPP is now generating data, and the RiSC project has reached a critical point as a search strategy is devised for its second phase. And tomorrow and on Friday I’ll be in the classroom with a group of professional doctorate students, talking and learning about systems and complexity.

Elsewhere, via the twitter account of the Minister for Health and Social Services, Mark Drakeford I’ve spotted the Welsh Government’s response to the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. I see there will be an annual Quality Statement for the NHS in Wales from next year, and a future NHS Wales Quality Bill.

Better late than never: thoughts on the mental health system and the DSM5

I drafted a post in May to coincide with the publication of the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM5). Having pitched it to a multi-author news and analysis site which didn’t bite, I then promptly forgot about it. Doing some blog housekeeping this morning I spotted the post squirrelled away in my draft folder, and decided to resurrect and refashion it for uploading here. Apologies in advance for repeating some messages and for linking to green open access papers addressed in other, previous, posts:

As was reported in the spring, the process of revising the DSM prompted fresh debate over the recognition, naming and causation of mental health conditions. For some biological psychiatrists the new DSM has been premature, arriving ahead of advances in understanding promised by genetic, brain imaging and other basic science research. Elsewhere, in a statement released in May members of the British Psychological Society’s Division of Clinical Psychology argued for an entire shift away from psychiatric classifications on the grounds that these lack validity.

So far as I am aware the DSM is not widely used in the UK. Here the day-to-day experiences of people using, and providing, mental health services may not be much affected by its revision. What the furore has been a reminder of, however, is the extent to which knowledge and practice in the mental health field remain open to contest. I have written before about the development of a system of mental health care in the UK, and how knowledge has been important in supporting professional claims to fulfil roles and to do certain types of work. This includes the work of deciding what should be done in response to people who are distressed, and whose thoughts, feelings and behaviour are perplexing and a cause for concern to others. In the case of the profession of psychiatry, its authority has been built on a biomedical knowledge base and on the development and application of associated treatments. Throughout its history, however, psychiatry has also been divided. Some of its sternest critics have come from within.

Historically, as the UK’s mental health system transformed into one in which more and more services were provided in the community new opportunities opened up for other professions, each claiming specific underpinning knowledge to inform their work. Modern mental health teams are staffed by psychiatrists, nurses, psychologists, social workers, occupational therapists and others. For each of these groups public statements and standards appeal to the distinct contributions their members make. In reality the boundaries between staff are often blurred, and the relationships between professions and their tasks are fluid.

All of this makes the UK’s mental health system an interprofessionally complex one. It is also only in the last 10 to 15 years that the challenge of improving mental health has been taken seriously by policymakers. But the problems to which policy action might be directed are not self-evident. They have to be named, and remedies proposed, implemented and defended. Recent policy for mental health has moved through phases. In the late 1990s ‘the problem’ was presented as one of community care failure. New types of team (for example, providing crisis resolution and home treatment, and assertive outreach) were set up as part of the solution. A controversial amendment to England and Wales’ Mental Health Act made provision for compulsory treatment in the community.

Later policy emphasised ‘new ways of working’. This explicitly encouraged professionals to do work previously done by others. Examples include nurses and other health workers taking on the role of approved mental health professional and therefore carrying out tasks previously done exclusively by social workers.

Now, in a context of austerity policy has strands concerned with the promotion of public mental health and wellbeing, and with enabling ‘recovery’ and personalised care for people using specialist services. As Simon Wesseley has argued, for most people using or working in the UK’s mental health system a more immediate and pressing concern than the publication of the DSM5 is protecting existing provision at a time of service retraction.

Summer sun

Just as predicted by those nice people at the Met Office, South Wales is warming up. The sun is high, and I hear the voices of schoolchildren playing football. I’ve been stuck inside all day, which in the circumstances has been something of a drag, but in the last hour or so I’ve gravitated outside to soak up some of this long-awaited summer.

This has been a working week as varied as any. I had a couple of School committees to chair (research ethics, and scientific review), some teaching (MSc), and a meeting with colleagues to plan some pre-registration interprofessional education in the autumn. This is a continuing mental health nursing/occupational therapy initiative (which I’ve posted about before), and on this occasion we’re planning some technological innovation involving the use of video recording and playback. On the research front I’ve been working on RiSC and keeping in touch with COCAPP, and found myself contributing to a rapidly convened meet-up to talk through a brand new project idea. I received page proofs for our new Critical junctures paper, peer reviewed a manuscript submitted for publication, and received a citation alert from Scopus. This was particularly pleasing as it took my ‘h’ index to 15, for what that’s worth. I also completed preparations for a doctoral examination taking place next Tuesday, and managed to squeeze in a pleasant catch-up with an esteemed colleague working in NHS mental health services. Mostly we exchanged news of developments in practice, services and research locally.

And with that, I’m off. Beer in the back garden calls.