Category: Nursing

Cardiff hosting, and NPNR news

This is the week that both Mental Health Nurse Academics and the COCAPP team come to Cardiff. MHNAUK’s meeting on Friday will take place in the Council Chamber in the Main Building, which is really rather grand. Visiting COCAPPers can look forward to a more everyday venue for our Thursday meet-up. This will be in Eastgate House (which is where I’m based).

Other news of note in the world of mental health nursing education and research is the impending move of this autumn’s Network for Psychiatric Nursing Research conference from Oxford to Warwick. The annual NPNR bash has taken place in Oxford pretty much since it was launched in the 1990s. I gather from my Twitter-using pals who sit on the scientific and organising committees that we can expect a relocation for an event scheduled, this year, for September 5th and 6th. It occurs to me that Warwick University is well-placed for delegates travelling from all parts of the UK, and indeed from around the world.

Nursing and the approved mental health professional role

AMHPFurther to my mentioning of a new paper on the development of the approved mental health professional (AMHP) role, and what this might mean for nurses, here now is a link to a full text open access version downloadable from ORCA.

In this article, my friend Michael Coffey and I discuss the implications of the changes made in 2007 to England and Wales’ Mental Health Act for the role of the mental health nurse. We were helped on our way by Jackie Neale, Michael’s colleague and Co-Director of the AMHP programme at Swansea University and by Dr Martin Webber, Reader in Social Work at the University of York, both of whom read and commented on an initial draft of our paper. Writing for this blog, Michael says:

Nurses for the first time can make applications for detention in hospital based upon their independent judgement and with regard to the opinions of their medical colleagues, based upon a social perspective and the principle of least restriction. This is as far as we know unprecedented in UK mental health law. In many ways this changes the provision of mental health nursing in ways that have as yet to be measured. These changes reflect similar moves internationally in mental health law.  There are huge challenges here though. Nurses are creeping into the territory of other professions who are not exactly welcoming them with open arms. Specific occupational knowledge and values are claimed by social workers who have traditionally fulfilled the approved role. These may be seen as jurisdictional claims and nurses have to show that they too can ‘pass’ as workers with a social perspective who are able to be independent of doctors. This is easier said than done and nurses have a chequered history in relation to occupational biomedical dominance. Added to this nursing is chiefly a biomedical task nowadays despite all the claims to being ‘holistic’ and being as focused on the social aspects of people as on anything else. Claims by nurses to be ‘psycho-social’ oriented or even ‘bio-psycho-social’ should be treated with some scepticism as many of these nurses subscribe to ideas of genetic determinism and are overly chemotherapy-focused. So can nurses actually juggle both a primarily biomedical focus and a social one to come to independent decisions in cases where the person might lose their liberty?

The backstory to this publication includes the fact that, with Jackie Neale, Michael runs Wales’ only AMHP programme. You can find out more about this post-qualification, postgraduate, course here. Our new article also comes out of Michael’s and my shared interest in mental health work and roles, and in thinking about (and researching) what nurses and others do. Another piece of behind-the-scenes detail is that Michael and I were once part of a team which came pretty close to getting a large grant to investigate AMHPs, and the experiences of people on the receiving end of their services.

Abstract-sifting, a new publication, and music to work by

Not much time for blogging lately, what with one thing and another. I’ve turned into a kind of abstract-sifting machine, poring over the details of papers for possible inclusion in two unrelated evidence syntheses/literature reviews. Amongst other things I’ve also been making some final preparations for a day away (as an examiner) later this week, catching up with colleagues over various bits and pieces, and arranging to meet up with undergraduate students.

Some good news over the weekend was confirmation of a new paper being accepted for publication, in the International Journal of Nursing Studies. My friend Michael Coffey is lead author, and we’ve written about the emergence of the role of approved mental health professional and what this means for nursing. A quick look at the SHERPA/RoMEO website suggests we’ll be able to add post-peer review versions to our respective institutional repositories. I’ll then add a link, and perhaps a bit of a commentary, on this blog.

As an aside, I am reminded of the majesty of Miles Davis’ Kind of Blue. It’s more than a decade since I was first introduced to this, and it now occupies a special place in my (eclectic) music collection. I mention this as Kind of Blue is an album I often turn to when I’m fretting over tasks requiring concentration: like writing, or indeed sifting abstracts. I listened to it today, in its entirety. Then I listened to it again.

Cash for compassion?

After Francis, what is to be done? Should we employ new hospital staff, and improve the ratio of nurses to health care assistants? Invest in the development of a cadre of strong clinical leaders, equipped with the skills and vision to drive up quality? Abolish gagging clauses? Overhaul professional regulation? Or perhaps instigate a regime of tough external inspections, including unannounced spot-checks? Take nursing education out of universities, and return it in its entirety to the NHS via a new apprenticeship model? Or expand the role of universities by giving them some responsibility for the preparation of health care assistants? Should we draft people in from private companies to show frontline public sector staff how it should be done? How about increasing local accountability by requiring senior hospital managers to report directly to elected councillors or similar? Or might we look to science, by commissioning a research team to design and validate a robust measure of caring of a type which might be administered to all potential entrants to nursing, to newly qualified members of the profession, and to experienced staff at intervals thereafter? We could even link periodic re-registration to the securing of a minimum score.

Who is to say which of these (or any other) solutions, alone or in combination, is what the NHS needs? And how might we know if any selected course of action has ‘worked’? Truly the problems facing the health service are complex and intertwined, and proposed responses to them value-laden and open to challenge. In the event, February 7th’s Guardian led with the headline David Cameron’s prescription for NHS failings: target pay of nurses. The paper went on to say that the Prime Minister:

[…] wants nurses’ pay to be tied to how well they look after patients as part of changes to banish poor care in the NHS in response to the devastating findings of a report published on Wednesday into the Mid Staffordshire hospital scandal.

Well, that’s another ‘solution’, for sure. And how might we determine how well a nurse performs, and quantify this for the purposes of financial reward or sanction? In this version of what ought to be done we might need that researcher-designed measure of caring after all. But let’s think about this further: at what scale would performance and pay be linked? Should the salaries of all staff in a single hospital or organisation be bound together? Or might workers in a ward or team be grouped, each paid a sum reflecting some aggregated measure of performance or collective compassion? How about differentiating at the level of the individual practitioner? And what might the unintended consequences of each and all of these options be (because I can think of a few)?

So, as you will have gathered, I contest the idea of cash for compassionate care. I also thought that Chris Ham from The King’s Fund spoke sense when he wrote, in February 6th’s Independent, that Edicts from Whitehall are not enough. Dignity, quality and a culture of care cannot be driven solely by a deluge of initiatives from the top. If they could, we would by now have created the perfect health system.

Giving a fig about roles

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

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

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

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

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

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

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

Resilience and community mental health nursing in Palestine

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

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

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

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

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

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

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

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

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

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

Anyway, here’s my effort:

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

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

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

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

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

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

Student nurses and degrees (once again)

Writing in today’s Guardian Peter Wilby asks ‘if our long love affair with education is coming to an end’. He refers back to this earlier article reporting a UK government announcement that future accountants, lawyers, engineers and others will be able to qualify without having a degree. Noting that the children of affluent parents do best in education, Wilby argues that the raising over time of the academic bar for entry to many professions has effectively blocked poorer children from getting a foothold.

I agree that we should be concerned over post-compulsory education becoming the preserve of the privileged few, which is why I believe charging tuition fees for university study is a bad policy likely to deter many from applying. I’m also reminded of the efforts that colleagues in my workplace go to in order that people with non-traditional educational backgrounds put themselves forward for university entry, and the work that goes on to help students succeed once they have enrolled. Like Peter Wilby, I too think that education should be something which people engage in over the course of a lifetime, and not in their first two or three decades only.

What I object to is that part of Wilby’s argument where he turns to nursing specifically and says, ‘As Ilora Findlay, professor of palliative medicine at Cardiff University, has put it, “a nurse can graduate without being able…to apply the scientific basis of illness to real patients or respecting the importance of hands-on care”. This is not a scenario I recognise. Student nurses spend half of their time on placement, and whilst there have to demonstrate to the satisfaction of their mentors their ability to perform in practice. This includes providing real care, to real patients.

For more on this, here’s a link back to an earlier post on this site referencing the Willis Commission on Nursing Education.

New year…

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

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

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

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

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