mental health, nursing, policy, services, people, research, education
Category: People
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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Over a period of years, with Dr Nicola Evans and Dr Becky Playle I’ve been supervising Gavin John, whose doctoral studies have focused on (as Gavin himself puts it in his thesis), the ‘interventions and processes that promote or hinder children and young
people’s connections to their education, friends and families during periods of admission to
hospital for mental health care’.
Gavin’s research has built directly on the RiSC study (see here for an accessible summary). Following a viva at the end of 2022, in February 2023 Gavin officially because ‘Dr’: very many congratulations to him! For a direct link to Gavin’s thesis, the place to go is here. And, for flavour of what Gavin did in his research and what he found, here is his summary:
Background: Existing research has identified risks to children and young people’s (CYP)
connections to their friends, family and education during periods of inpatient mental health
care. However, to date there is a dearth of research on what interventions and processes
support CYP to maintain these connections.
Aim: To explore the interventions and processes that promote or hinder children and young
people’s connections to their education, friends and families during periods of admission to
hospital for mental health care.
Method: Case study methodology was used involving the generation of qualitative and
quantitative data in a single CAMHS inpatient unit. Three outcome measures relating to
mental health, friends, family and education were completed by adolescents admitted to
hospital for care and treatment of their mental ill-health (n=26). A subset of children and
young people (n=9), their caregivers (n=6) and health, social and education practitioners
(n=11) were interviewed, multidisciplinary team (MDT) meetings were observed, and policy
and procedure documents were examined.
Results: Demographic data were collected and results from three questionnaires indicate
participants were in the abnormal banding for the total difficulties score on the Strengths and
Difficulties Questionnaire (SDQ). Participants scored highest on the global scale and trust
and communication subscales in relation to mothers in the Inventory of Parent and Peer
Attachment-Revised (IPPA-R). Highest scores were recorded on the behavioural and
emotional engagement subscales of parts A and B of the Student School Engagement
Survey (SSES). Thematic analysis of interviews (n=26), observations and documentary
analysis of policy and procedure documents identified five themes: ‘Remote connections to
friends and family’, ‘Physical connections to friends and family’, ‘Peers in hospital’, ‘Impact
on families’ and ‘Connections to education’.
Conclusion: The study highlights significant barriers to children and young people
maintaining connections to their friends, family and education during periods of inpatient
mental health care. It identifies candidate interventions to help children and young people
maintain these connections.
Crisis care for children and young people with mental health problems: national mapping, models of delivery, sustainability and experience is a new project funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research (HSDR) Programme, which my colleague Clare Bennett and I are jointly leading. The wider team includes Martin Elliott, Leanne Sawle, Aled Jones, Steven Pryjmachuk, Claire Fraser, Euan Hails, Iain McMillan, Nicola Evans, Mair Elliott, Rachael Vaughan and Aneta Taylor.
Our study builds on the now-completed Crisis responses for children and young people: an evidence synthesis of service organisation, effectiveness and experiences, led by Nicola Evans, about which I most recently wrote a post here. It also has a clear connection to the Developing a model for high quality service design for children and young people with common mental health problems project led by Steven Pryjmachuk, with which it shares aspects of study design.
Our new CAMH-Crisis2 study began in November 2022, and a summary of what we’re doing is here:
There has been a sharp and worrying increase in mental health problems experienced by children and young people. Prior to the pandemic, one in eight 5-19 year olds in England had a probable mental disorder. In 2020, amongst 5-16 year olds this figure had risen to one in six. Amongst those with a mental health difficulty, almost half of older teenagers and a quarter of 11-16 year olds report having self-harmed or attempted suicide. Extreme psychosocial distress, with or without self-harm, is often referred to as a ‘crisis’. Services for young people in crisis are a UK priority, and provision is expanding in the NHS, social care and educational settings. However, despite this and the appearance of national standards very little research into crisis services for young people has been undertaken. We therefore do not know what crisis responses currently exist, who uses services, or what works best for children and young people and their families.
Against this background this project will answer the question, ‘How are mental health crisis responses for children and young people up to the age of 25 sustained, experienced and integrated within their local systems of services’? We will work with a group of young people who advise on research, some of whom have used crisis services, to address the following three objectives:
To help us answer our research question and to meet our objectives we will make use of normalisation process theory. This supports studies into what helps, and what hinders, the implementation and sustainability of new approaches to care.
We will meet our first objective using a survey, creating a detailed record of crisis responses across England and Wales and how they are organised, implemented and used. To meet our second objective, from this detailed record we will identify eight contrasting services selected for variety in terms of: geographic and socioeconomic setting (England/Wales, urban/rural, and relative affluence/poverty); populations served (including ethnic diversity); and service configuration (including third sector and/or social care involvement). Treating each as a case study, we will conduct interviews with children and young people and family members who have used the service. We will also interview commissioners, managers and practitioners, including those providing a crisis response and those working in other parts of the local system. We will gather operational policies and related documents, and data on how each service is used and by whom. In our analysis we will focus on understanding how each crisis service is provided, experienced, implemented and sustained. To meet our final objective we will compare and contrast each case study, and use our synthesised findings to advance the available international evidence for best practice in service provision. We will close by drawing clear, actionable, lessons for the future commissioning and provision of high-quality crisis responses which are sensitive to the support and access needs of a diverse range of children and young people receiving care from a range of services.
Follow @benhanniganOver the last few years I’ve been a part of a team led by my Cardiff colleague, Dr Nicola Evans, synthesising the evidence in the area of mental health crisis responses for children and young people. Here is a link to the project, which has been funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery (HSDR) Research Programme.
Now, with the project having concluded, an animation with English and Welsh language versions has been produced. Here they are:
Here is news of two completed doctoral theses which I have helped support as a supervisor, both being within the mental health field. First is Fortune Mhlanga’s Implementing recovery-oriented practice in mental health services: a qualitative case study, which is all about how recovery ideas are used in everyday practice. The summary for Fortune’s study is this:
Although the recovery philosophy has been adopted in mental health services in various Western countries including England, its implementation in practice has been described as “slow and patchy”. Furthermore, there are suggestions in the literature that there is a lack of clarity around the implementation of recovery-oriented practice (ROP) and a dearth of research exploring the phenomenon. This study aimed to discover how recovery-oriented practice is implemented in an NHS Trust providing care for people experiencing mental health problems, in order to add to what is already known about the implementation of ROP to inform future practice.
A qualitative case study approach was employed to investigate the implementation of ROP from strategic to grassroots level in two practice settings (Community Mental Health Team and Rehabilitation ward) within one NHS Trust providing mental health services in the South of England. Semi-structured interviews were conducted with 16 participants (senior managers, practitioners, service users) investigating their perceptions and experiences of ROP. Data were analysed using thematic analysis and further interpreted by situating it in the literature.
Main findings
• Whilst there was a shared common understanding of the meaning of recovery and ROP in the organisation, there was a fundamental difference between practitioners and service users’ conceptualisations with service users leaning more towards clinical recovery.
• At strategic level, strategies to facilitate implementation of ROP focused on changing the culture within the organisation through Implementing Recovery through Organisational Change (ImROC) recommended interventions such as: Recovery College, peer workers and use of the Recovery Star. At grassroots level, implementation was via the development of therapeutic relationships between service users and practitioners.
• Salient barriers to the implementation of ROP included: time taken completing paperwork resulting from performance measures used by commissioners in the community team, the shortage of resources and the tension between risk management and ROP in both settings.
Study contribution
This study addresses the gap in research on the implementation of ROP through an exploration of how ROP was being implemented in two practice settings in an NHS organisation providing mental health care. Methodologically, the qualitative case study approach adopted in the study allowed triangulation of data from participants ranging from grassroots level to strategic level. Furthermore, the approach taken with the sample consisting of service users, senior managers and practitioners from inpatient and community practice settings within the same organisation is not comparable with any other studies on ROP that have been conducted in England. This study therefore informs implementation efforts of similar organisations and makes recommendations for practice, commissioners and research.
Second up is Bethan Mair Edwards’ A window of opportunity: Describing and developing an evidence, theory, and practice-informed occupational therapy intervention for people living with early-stage dementia, which addresses the development of OT practice in the support of people with memory difficulties. The summary from Bethan’s thesis is this:
Aim
There is a scarcity of evidence generated in a UK context to inform the practice of occupational therapists working with people living with early-stage dementia. This Thesis’ overarching aim was to describe and develop an evidence, theory, and practice-informed occupational therapy intervention for people living with early-stage dementia.
Methods
In accordance with the MRC Framework for the Development and Evaluation of Complex Interventions, an Intervention Mapping approach was utilised to guide the development process. Thesis Objectives were developed based on Intervention Mapping Steps 1 – 3, and to meet these objectives, this Thesis consists of three studies. Study 1 (a two-stage mixed methods evidence synthesis) and Study 2 (semi-structured interviews with people affected by dementia and occupational therapy practitioners) sought to understand the intervention population and context, as well as identify existing research and practice-based interventions. Study 3 involved describing and developing an intervention programme theory and programme design.
Findings
Studies 1 and 2:
Multiple personal and environmental (social, physical, and occupational) determinants associated with the occupational performance problems that people living with earlystage dementia may experience were identified. Existing research and practice-based interventions were heterogenous in nature and no programme theories were reported; however, strategies that problem-solve occupational performance problems were identified as a primary intervention component. In practice contextual barriers were associated with resources, other professionals’ awareness and understanding of occupational therapy, and a lack of control and influence over service development and policy.
Study 3:
A logic model of the problem and population, matrices of change, and a simple intervention logic model were developed to articulate a proposed programme theory. A broad overview of the proposed interventions’ design, including components and context, were specified and key uncertainties outlined.
Conclusion
This research has developed a robust foundation for further development work at Intervention Mapping Steps 4 – 6, including developing theoretically informed implementation strategies and producing materials in preparation for a feasibility evaluation.
Two super pieces of work, with real relevance for interprofessional mental health services and practice: congratulations to both.
Follow @benhanniganA not-uncommon research strategy in health and social care research is to generate different types of data and, through some process of transformation, bring these together into a coherent whole. The idea here is that combining data produces a more complete, detailed, analysis than can be created using one type of data alone. For example, in my doctorate, which focused on the system of mental health care and the division of labour, I conducted lots of qualitative interviews but also used written records as a source of data and observed people going about their day-to-day work. What people say, what people do, and what people write about they’ve done are not the same thing: knitting together a rich, or ‘thick’, description of a social setting is helped when different classes of data are available to be drawn upon. In more recent studies of care planning and coordination (see here and here) the research teams I’ve been a part of have variously combined interviews, documentary review, questionnaires and observations.
In a slow-burn kind of way, over a period of many months I’ve been working with members of the 3MDR project team to bring together data of very different types. The 3MDR study, led by Jon Bisson, is something I’ve written about before and involved examining the efficacy of a novel intervention for people with post-traumatic stress disorder. Across the project overall three, distinct, classes of data were generated: outcomes, derived from clinician-assessed and self-reported standardised measures; psychophysiological, including breathing and heart rate, walking pace, words and phrases used by participants during therapy, plus subjective unit of distress scores; and qualitative, namely post-therapy interviews where people talked about their views and experiences. Working particularly closely, in the first instance, with Robert van Deursen and Kali Barawi our task has been a mixed-methods data synthesis to explore the interrelationships between people, interventions and context and to investigate how factors within these three domains interact in specific outcome typologies.
This has been an interesting and challenging project, and we’re not yet done. Whilst many of the ideas underpinning this analysis are familiar ones (complexity, interconnections, the search for patterns) the combined dataset we’re mixing together is an unusual one. This work is also proving to be a reminder of how much can be found out through the detailed study of relatively small numbers of participants. Our data relate to ten people only, but our total dataset is both comprehensive and varied. At some point (but not quite yet) we’ll have a paper ready for journal submission, and I’ll be able to share more on this site.
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Continuing from this recent post celebrating the publishing of papers from doctorates I’ve had a hand in supervising, here now are links to Nicola Savory’s PhD and to a first article from this in the journal Midwifery. Nicola is a midwife, and in her thesis (funded by RCBC Wales) used quantitative and qualitative methods to investigate women’s mental health needs in the antenatal period.
Nicola’s whole-thesis summary is this:
Background: Existing research on poor perinatal mental health largely focuses on recognition and treatment of postnatal depression. Consequently, there is a need to explore antenatal mental health.
Aim: To assess poor mental health prevalence in pregnancy, its relationship to sociodemographic characteristics, self-efficacy and perceived support networks. To understand experiences and barriers preventing women with mental health problems from receiving help and explore midwives’ understanding of their role.
Method: Questionnaires were completed by women in early pregnancy. A subset identified to have mental health problems, were interviewed in late pregnancy to explore their experiences and barriers to receiving care. Midwives completed questionnaires exploring their experiences of supporting women with mental health problems and focus groups further discussed the issues raised.
Results: Amongst participants (n=302), the Edinburgh Postnatal Depression Scale (EPDS) identified 8.6%, and the Generalised Anxiety Disorder Assessment (GAD-7) 8.3%, with symptoms of depression or anxiety respectively. Low self-efficacy (p=0.01) and history of previous mental health problems (p<0.01) were most strongly associated with anxiety or depression. Thematic analysis of interviews with women (n=20) identified three themes: ‘past present and future’; ‘expectations and control’; and ‘knowledge and conversations’.
Questionnaires were completed by 145 midwives. The three themes identified from the focus groups with midwives were: ‘conversations’; ‘it’s immensely complex’; and ‘there’s another gap in their care’.
Conclusion: Prevalence rates of anxiety and depression amongst women in early pregnancy were found to be similar to those reported in the literature. Low self-efficacy and previous poor mental health were significant predictors of anxiety and depression. Continuity and more time at appointments were suggested by midwives and women to improve discussions regarding mental health. Midwives were keen to support women but lacked knowledge and confidence. Consistent reference was made to the need for training regarding the practical aspects of supporting women’s mental health.
Nicola has a series of journal papers lined up from her doctorate, with the one I’ve linked to above (‘Prevalence and predictors of poor mental health among pregnant women in Wales using a cross-sectional survey’) being just the first.
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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.
A
short post arising from the observation of the extent to which researchers are increasingly turning to animations as a way of sharing their findings both succinctly and accessibly.
On this site in the past I’ve written about the 3MDR trial for people with post-traumatic stress disorder, led by Jon Bisson, and this month I’m alerted to this fine animation produced with the help of Studio Magenta in Cardiff:
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