Yesterday Mental Health Nurse Academics UK met at Liverpool John Moores University, for its third and final meeting of this academic year. Hosts were Lisa Woods and Grahame Smith, and the chair was Michael Coffey. In the first part of the day Grahame and Lisa gave an excellent presentation on their cross-European Innovate Dementia project. Business items included updates on plans made at the previous MHNAUK meeting held in March in Cardiff. Andy Mercer presented findings from his and Karen Wright‘s survey of the methods used by universities to select new students of mental health nursing. Fiona Nolan asked members of the group for their suggested items to be included in her forthcoming research expertise, interests and capacity mapping exercise. This will be useful indeed, and at some point soon we will have a better idea of the full range of mental health nursing research being conducted within the UK’s universities.
Category: People
Mental health nursing’s dirty work
Yesterday the national mental health charity Mind released information on the use of face-down restraint in mental health services. It says:
Mind is today calling for the government and NHS England to put an end to life-threatening face down restraint of people with mental health problems in healthcare settings. Data secured by Mind under the Freedom of Information Act reveals that at least 3,439 patients in England were restrained in a face down position in 2011-12, despite the increased risk of death from this kind of restraint.
Restraining people is part of mental health nursing’s ‘dirty work’. This is a phrase which originally comes from the American sociologist Everett Hughes. Robert Emerson and Melvin Pollner picked it up in a paper titled, Dirty work designations: their features and consequences in a psychiatric setting, and more recently Paul Godin wrote about A dirty business: caring for people who are a nuisance or a danger. There are plenty of other ‘dirty work’ articles out there, too, for those interested in finding them.
‘Dirty work’ involves doings things which are in some way tainted or shameful, but which might still have to be done. A professional group’s dirty work is not the first thing its members typically like to talk about when asked to describe what they do. When mental health nurses present themselves to others it is the helping relationships they build, the listening they do and the recovery they promote that are more likely to feature. My guess is that experiences of holding, secluding and forcibly medicating people are not things that nurses immediately volunteer.
Because dirty work can sometimes feel degrading and morally suspect it can feel easier not to talk about it at all. The good news in mental health nursing is that there are plenty of people interested in describing, researching and questioning the more coercive and controlling aspects of what we collectively do. Len Bowers and Joy Duxbury are examples. In addition to calling for a ban on face-down restraint, in its news release yesterday Mind pressed for the implementation of national standards and accredited training in this area. Nurses have a big part to play in the debates which are to follow and in developing new practices, and I’ll be watching with interest.
Theses, vivas and research students
I’ll be examining another doctoral thesis soon, which today I’ve started reading. I won’t say anything about it specifically, but the occasion does give me a starting point for this post.
My own PhD thesis ran to about 450 pages, references and appendices included. It was years in the making, not least as I was a part-time student with plenty of other things to keep me busy. My supervisors, who I’ve mentioned on this blog before, were Davina Allen and Philip Burnard. As an internal candidate it was necessary for me to have two external examiners, and these were Ian Norman from King’s College London and Lesley Griffiths from Swansea University. Here’s the summary from my study:
My viva went well, proceeding in a spirit of collegial inquiry. This is how it ideally should be, and even where a thesis is judged to have major weaknesses I firmly believe that the examination should be conducted fairly and with courtesy. Cardiff University vivas are independently chaired, which I think helps the process, though I know this is not standard practice everywhere.
As it happens the Cardiff School of Nursing and Midwifery Studies has significantly grown its postgraduate research in recent years, and we now have a healthy number of UK and international PhD and Professional Doctorate students. Together they run a lively multi-author blog under the title PhDays. Check it out.
First reflections on two days away
A series of train journeys home gives me space to mull over two days spent in London. Yesterday opened with a meeting of the COCAPP Lived Experience Advisory Group (LEAG), expertly chaired by the wonderful Alison Faulkner. Significantly, key parts of COCAPP are changing in response to LEAG recommendations. Our semi-structured interview schedules, for example, directly reflect the LEAG’s input. This is all good, and I am personally learning huge amounts from the opportunity to be involved.
Yesterday evening saw Alan Simpson give his Skellern Lecture followed by Malcolm Rae receiving his Journal of Psychiatric and Mental Health Nursing Lifetime Achievement Award.
As entirely anticipated Alan gave an informed, engaging and challenging talk, which took in his personal journey into mental health nursing and conveyed key messages from his research. Alan gave us plenty to think about. Might peer support workers be attractive to managers with squeezed budgets? Might they begin to replace members of more established groups, nurses included? Or, as Alan hoped, can peer support workers, nurses and others work side-by-side in harmonious fashion for the benefit of people using services?
Malcolm Rea I do not personally know, though based on the talk on leadership in mental health nursing he gave yesterday this has been my loss. I shall remember his contrasting of ‘drains’ and ‘radiators’ (and try personally to be more of the latter than the former).
Yesterday ended with a convivial social in a London pub, and today was more COCAPP: this time a team meeting followed by a Project Advisory Group (PAG) skillfully chaired by John Larsen from Rethink. Some of our discussion centred on the finer aspects of COCAPP’s design and methods, and for that the study will benefit.
So there we are then: only the shortest summary of some pretty involved discussions, but it will do for now. Home calls.
Skellern lecture, JPMHN lifetime achievement award and MHNAUK
Just enough time for me to draw attention to some important happenings about to take place in the world of mental health nursing. Tomorrow evening (June 12th) Alan Simpson delivers this year’s Skellern Lecture and Malcolm Rae receives his Journal of Psychiatric and Mental Health Nursing Lifetime Achievement Award. Here are the flyers for these linked events, both taking place at City University London:
Next week brings this term’s meeting of Mental Health Nurse Academics UK, taking place at Liverpool John Moores University. Hosts are Lisa Woods and Grahame Smith, and the agenda is looking interesting.
Nursing beleaguered?
Catching my eye earlier this week was an interview in The Guardian with Jane Cummings, Chief Nursing Officer (CNO) with a place on NHS England‘s National Commissioning Board. Under the header, ‘Nobody can say care is brilliant all the time’ the article opened with this understated quote:
‘It was very clear that nursing was getting a bit of a bad name and it felt like the profession was being quite beleaguered and criticised.’
Nursing certainly has been under siege. Responses to descriptions of poor care have included the three year Compassion in Practice strategy introduced by the CNO and her Director of Nursing counterpart at the Department of Health, Viv Bennett. It is in this document that the 6Cs are described:
It is also in this general context, but specifically following the publication of the Francis Report into Mid Staffordshire NHS Foundation Trust, that the proposal was made that student nurses should spend a year doing health care assistant (HCA) work before beginning their training. This government plan has proven mightily controversial, and when announced provoked immediate broadsides from (amongst others) June Girvin (a nurse, and Pro Vice Chancellor at Oxford Brookes University) and Jackie Kirkham (a health visitor and researcher at Edinburgh University). Now it has drawn a closely referenced rebuttal from the Council of Deans of Health. Here is what the Council says in its conclusion:
The proposals for HCA experience prior to joining a pre-registration nursing programme are underpinned by a set of assumptions about nursing education and selection of prospective students that is deeply flawed. It paints a picture of students who have never had experience of caring and little interest in patient care, picked out for their grades by a group of academics in total isolation from staff working in clinical services. The message from current practices and the NMC Standards that govern them is that this mental picture needs to change. In particular, the assumption that students are not recruited for their values and that students do not have prior care experience are incorrect.
What about the nub of the proposal: that exposure to the clinical frontline as a HCA will create better nurses? The evidence here is equivocal at best. What care experience does seem to do is give prospective students exposure to the reality of working in healthcare and so it may reduce attrition from programmes. But there is also evidence that working as a HCA can socialise prospective students into poor practice and inhibit their development as nurses. Unless the evidence is looked at carefully, these proposals could therefore embed rather than challenge poor patient care. As the pilots of the proposals are developed, care must be taken both to recognise existing practice and carefully test assumptions against the evidence.
So, nursing practice and nursing education are in the spotlight, and the profession has responded. Senior members have asserted a set of fundamental values (the 6Cs), and in resisting the year-as-an-HCA idea have reminded people of the differences between what nurses and other health care workers do.
Nurses discomforted by this heightened scrutiny might consider their position alongside that of other public services workers. Social workers draw attention to the problem they face of being ‘damned if they do and damned if they don’t’. Then there are teachers, who fear the erosion of their professional standing as former servicemen and women prepare to enter the classroom without having to study for degrees. Back in the health service, some doctors (psychiatrists, in this instance) express concern over threats to their role and identity, whilst the profession as a whole is accused of greed.
We are therefore in good company. Other workers know what it is like to be told they have collectively fallen short, and understand how it feels to have their status undermined. Status-knocking sometimes happens because professional groups engage in ongoing division of labour skirmishes, as I have drawn attention to on this site before. But nursing’s current predicament, in which we are charged with having a ‘compassion deficit’ and sacrificing a commitment to care in the pursuit of academic credentials, is different.
Perhaps nurses have finally lost enough of the untouchable, ‘angel’, image (no bad thing, in my view) to now be viewed as ‘just’ another professional group in whom trust is conditional. We control entry to our profession, expect degrees from new entrants, have university departments and lead interprofessional teams and whole services within the NHS. In turn, we must expect to face questions when things go wrong, and to justify why we do practice and education in the ways that we do. For the record, I strongly favour system explanations for what happens in the health service (including its failures), see no evidence that student nurses no longer care and much prefer practitioners to be educated than not. But I also think we must expect, and should prepare for, more ‘bashing’ in the future.
Researching with service users and carers
Not much time for adding to the blog at the mo’, but enough to note that it was good to have spent this morning with the MHRNC Service User and Carer Partnership Research Development Group. This is an important initiative, and today’s meeting brought together user representatives, charity sector staff, colleagues from Involving People and academics. I’m something of a late arrival to the group, and lots of interesting work has already been done: including a research priority-setting exercise. More to follow in due course, I’m sure.
The Next Big Things
Here’s what will probably be a final Hay Festival-related post. Last Thursday the Nobel Laureate Professor Sir John Sulston chaired a discussion titled The Next Big Thing. This began with four researchers talking about what they do: Alison Rust, a volcanologist; Zita Martins, an astrobiologist; Nicole Grobert, a nanotechnologist; and Jenny Nelson, a physicist working on materials for solar cells.
All gave fascinating talks, and exemplified the art of conveying complex ideas to the interested but non-specialist listener. And who doesn’t want to hear about supervolcanoes (for the record, they’re bad news, and are definitely best avoided)? Or amino acids from space, the practical applications of graphene or comparing different ways of capturing energy from the sun?
This discussion has since got me thinking about the Next Big Things in nursing and midwifery research (and mental health nursing research in particular). Generally nurses do not do fundamental or basic science, and are not in the business of discovering how bits of the natural world work. So, no volcanoes or extraterrestrial chemicals for us. But practical applications of health-related technologies, and exploring and comparing different ways of doing health work? That’s more up our street, I think, even if graphene and solar power are unlikely to immediately feature.
To the applications-of-technology and exploring-and-comparing questions which might be asked within mental health nursing I would personally add some others related to the examination of health and health care experiences. We know that mental health nurses do ‘people work’ in a big way, spend much of their time coordinating (or ‘articulating’) complex trajectories of care and are often present during service users’ critical junctures. There are applications of skill and technology in this, and how nurses do their work and the effects this has are wide-open areas for study. COCAPP, as I’ve mentioned on this site before, is aiming to distil the components of care planning and care coordination associated with recovery-oriented and personalised mental health services, and is a great example of applied research in this broad field. I’d like to think that its findings will, in some way, be directly useful to practitioners and others in the fullness of time.
But these are just my thoughts, reflecting the things that happen to interest me personally. I wonder what mental health nursing’s current, collective, priorities for research would be if people were asked? What might members of the profession see as The Next Big Things for the period immediately ahead? There are plenty of past examples of this kind of exercise being undertaken within nursing. Over a decade ago the National Coordinating Centre for NHS Service Delivery and Organisation R&D commissioned a study to ‘identify priorities for research funding in the fields of nursing and midwifery’. More recently, the Academy of Nursing, Midwifery and Health Visiting Research (UK) conducted a Delphi study to establish areas for research commonly agreed by nurse leaders in health services and in academia. Within mental health nursing exclusively, I recall (because I’ve cited it in past publications) Ted White’s 1994 paper in the journal Mental Health Nursing titled, ‘Research priorities for community psychiatric nursing’. In its second position paper, appearing in 2004, Mental Health Nurse Academics UK set out its view of the principles to underpin future research studies and the areas it believed were in need of development.
Thinking of Graham Thornicroft’s recent editorial on the poor physical health of people using mental health services, referred to on this blog here, if asked to give their research priorities now perhaps some would make a case for researchers and practitioners to combine their efforts to seriously improve this situation. I know there are people working in this area already, but given the magnitude of the problem it seems to deserve some serious new investment. And how about extending research into the mental health nursing contribution to the vital care of older and vulnerable people, including those with dementia? Again, there are people, such as John Keady, doing this already, but possibly not in sufficient numbers. Or research in the area of quality improvement and safety? And what about workforce research, including studies into factors sustaining nurses’ resilience to provide care in conditions of adversity?
However they might be identified and emerge I suspect that any Next Big Thing candidates for nursing research will be the products of sustained collaborations. To return to last Thursday’s four discussants at Hay: all were explicit about interdisciplinarity, and the importance of crossing boundaries to do high quality research aimed at answering ‘big questions’. There are established academic mental health nurses doing this already (I’m thinking of people like Len Bowers, Karina Lovell, Patrick Callaghan and Alan Simpson), but more of us need to make friends with colleagues possessing specific substantive and methodological expertise relevant to our intended studies. Depending on the questions at hand this might mean finding collaborators with disciplinary backgrounds in various of the social and physical sciences and in the humanities, and if necessary with experience in the practical conduct of clinical trials, qualitative investigation and so on. Crucially, and arguably most importantly, it also means forging meaningful collaborations with people with experience of using services, whose priorities are the ones which really matter.
What future the NHS (2)?
Further to my last post referring to Raymond Tallis’ staunch defence of the NHS, a second excellent health service-related talk at Hay was Andrew Edgar’s. Andrew is a philosopher at Cardiff University, and on Tuesday he gave a customarily considered account of (amongst other things) the principles underpinning the NHS and how these contrast with those associated with health care systems elsewhere in the world. I particularly appreciated Andrew’s view of the NHS as being more than a way of simply (simply?) funding and delivering health care. It is a unifying force, embodying the majority view that some things are best paid for and organised collectively. Insurance based systems, as Andrew observed, are abhorrent to many in the UK because they treat health care as a commodity and pay insufficient regard to need.
Beyond the principles, as Andrew also pointed out, lie some difficult day-to-day health service realities. These include the existence of rationing (which clearly exists, but is rarely talked about in an open way), and the fact that the system retains a capacity to grind down, and sometimes even brutalise, those who work within it. But opening the service up to market forces, along the lines happening in England with the passing of the Health and Social Care Act 2012, is no remedy. Note my reference to ‘England’ here. Quite correctly, in my view, Andrew was careful to talk of not one but four ‘NHSs’ reflecting the divergence in systems across the different countries.
What future the NHS?
Yesterday at the Hay Festival I heard Raymond Tallis deliver a strong attack on the coalition government’s ‘redisorganisation’ of the NHS in England. The Health and Social Care Act 2012 has opened the NHS to the market in unprecedented fashion. Tallis talked of the dominance of private providers on clinical commissioning groups, and gave examples of patients being cherrypicked by organisations more concerned with profit than with meeting need. He also contrasted the upheaval with pre-2010 general election promises by both the Conservatives and the LibDems not to unleash major top-down change on the health service.
Tallis was critical of his own profession (medicine) for having failed to coordinate opposition to the legislation as it worked its way through parliament. He did, though, pick out and praise Clare Gerada of the RCGP for leading the resistance. I’m aware that the RCN was against the proposed Act, but I’m not sure that nurses as a group were particularly visible during the debates.
The first question from the audience asked what needs to be done to prevent the Act infecting Wales. The balance of politics here is different than in England, but it was a good question nonetheless.
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