Category: Research

Risk in inpatient child and adolescent mental health services

This week our full report from the RiSC study, An evidence synthesis of risk identification, assessment and management for young people using tier 4 inpatient child and adolescent mental health services, has been published in Health Services and Delivery Research. This is in gold open access form, and is free to download and read.

Here’s our plain English summary:

In our two-part study we brought together evidence in the area of risk for young people admitted to mental health hospital. First, we searched two electronic databases, finding 124 articles. Most were concerned with clinical risks, such as the risks of suicide. Using diagrams we grouped these articles together under a number of themes.

Young people who had been inpatients in mental health hospital, carers, managers and professionals helped us prioritise the types of risk we should concentrate on in the second part of our study. Our top two priorities were the risks of dislocation and contagion. We used the word ‘dislocation’ to refer to the risks of being removed from normal life, of experiencing challenges to identity and of being stigmatised. We used it to refer to the risks to friendships and families, and to education. We used ‘contagion’ to refer to the risks of learning unhelpful behaviour and making unhelpful friendships.

We searched 17 databases and a large number of websites for evidence in these areas. We asked hospital staff to send us information on how they managed these risks and we searched journals and reference lists. We identified 40 items to include in our review and 20 policy and guidance documents. The quality of the studies varied. We grouped the evidence together under seven categories.

We found little evidence to guide practice. The risks of dislocation and contagion are important, but research is needed to inform how staff might identify, assess and manage them.

This has been an excellent project to work on: a great team, and some good engagement with young people and others with a shared interest in what we’ve been up to. Next up is an accessible summary, and some writing of articles. More to follow!

Health and Care Research Wales

Last week I had the opportunity to join colleagues at the Millennium Stadium for the launch of Health and Care Research Wales. This is the new name for what was, until very recently, the National Institute for Social Care and Health Research (NISCHR).

I’ve written before about the reorganisation of the research infrastructure here in Wales (see here and here), and Thursday’s event was an important unveiling of the outcome of recent deliberations. For a shortcut, here’s the public information video:

And, for a single-page diagram of how everything is fitting together, follow this link. As this shows, one of the things Health and Care Research Wales has done is to (re)commission a number of Centres and Units, an example of the former being the National Centre for Mental Health (NCMH).

By the looks of things, funding streams are to remain much as they were under NISCHR, with opportunities for PhD, post-doctoral and project awards to follow. Researchers in Wales can continue applying for support to many (but not all) of the National Institute for Health Research (NIHR) programmes. This is vital, because it is through this mechanism that funding is available for studies into health services and delivery (amongst other things). This is an area of research in which Wales has no dedicated funding stream of its own, and in which the new Centres and Units may be interested to varying degrees. 

Finally, a word on a Welsh Government centrepiece, HealthWise Wales. This is aiming to prospectively, and electronically, recruit many thousands of people into future health and social care research. 

Research capacity building in Wales

The Nursing and Midwifery Council (NMC) here in the UK tells us that, at the end of March 2014, there were 680,858 nurses and midwives on the register. The Health and Care Professions Council (HCPC), which regulates 16 different professions, tells us that on the same date approximately 322,000 individuals were registered. Adding these numbers together gives a total in excess of one million. That’s an awful lot of registrants. Only a small number of these, however, are directly engaged in research to inform current and future practice and fewer still have had opportunities to become fully independent investigators. As the Shape of Caring review puts it with regard to nursing:

It is currently estimated that 0.1 per cent of the nursing workforce in England are professors of nursing: an indication that there are simply inadequate numbers for the task of leading research and evidence-based practice. Many of these academics will retire in the next 10 to 15 years.

Given this mismatch, efforts to grow research are immensely important. Leading the way in this part of the UK is the RCBC Wales scheme, which:

[…] was established in order to increase the research capacity of nursing, midwifery and allied health professions in Wales and to contribute toward the development of clinical academic roles.

I was fortunate enough to be awarded an RCBC Wales post-doctoral research fellowship in 2006. In the last few weeks three Cardiff-based colleagues have been successful in securing the same in the most recent round of applications: Dr Jessica Baillie, Dr Lucie Warren and Dr Liba Sheeran. Jess is a nurse who will be researching the experiences of people who develop peritonitis as a result of peritoneal dialysis, Lucie is a midwife who will be investigating an intervention to improve the diet and physical activity of pregnant women, and Liba is a physiotherapist who is exploring how smartphone technology can help people recovering from back pain. Congratulations to all three.

Spring election, and the politics of mental health

It hasn’t always been like this, but mental health is something which politicians now talk about. In the run-up to next week’s general election mental health has even featured in public appeals to voters. The Liberal Democrats have particularly campaigned in this area, and in their manifesto promise £500 million per year for better mental health, and specifically make a case for investing in research. Labour talk about giving mental health the same priority as physical health, and the Conservatives say pretty much the same. Reviewing all the main parties’ manifesto promises for evidence of concrete plans for post-election improvements to mental health care, over on his blogsite the Psychodiagnosticator observes ‘that many of them were so vague as to amount to no promise at all‘. I think he has a point.

Possibly the broad manifestos produced in the run-up to a general election are not the places to look for fully worked-up blueprints of what future mental health policy across the UK might look like. Perhaps, more accurately, we should not think about ‘UK policy’ in this context at all. Members of Parliament elected to Westminster next week, from amongst whom a new government will be formed, will have authority to directly shape services in England only. Health and social care remain areas over which devolved authorities have jurisdiction, and for a ballot delivering a government with the power to pronounce on mental health care here in Wales we must look to the National Assembly elections to be held in 2016. I’ve indicated before that mental health policy here is different from that in England, and indeed from other countries in the UK. Consider again the case of the Mental Health (Wales) Measure. This is a piece of legislation for Wales alone, mandating for care and treatment plans, care coordinators, access to advocates in hospital and the right of reassessment within secondary mental health services following discharge. It was introduced in the face of some strong, pre-legislative, criticism from at least one senior law academic (Phil Fennell) who in 2010 began his submission to the National Assembly by saying,

The gist of my submission to the Committee is that this measure, although well-intentioned, is cumbersome, unduly complex, and will lead to a delay in providing services which ought to have been available already to service users and their families in Wales under the National Service Framework for Adult Mental Health and the Care Programme Approach.

Five years on the Measure has not only passed into law, but been subjected to a round of post-legislative scrutiny by the National Assembly’s Health and Social Care Committee (see my post here), to which the Welsh Government has now responded. With data from across both England and Wales, COCAPP (and in the future, COCAPP-A) will have something to say about how care planning and care coordination are actually being done, and readers will be able to draw their own conclusions on the extent to which changes in the law trigger changes to everyday practice. And, whilst we’re in policy comparison mode, for a view from Scotland try Paul Cairney. He argues that divergence in mental health policy across the UK, exemplified by contrasting English and Scottish experiences of reforming the law, reflect differences in both the substance of policy and in policymaking style.

In all of this I am, again, reminded of the wicked problems facing all policymakers who seek to intervene in the mental health field. Whatever direction it takes, future policy will be open to contest and will surely trigger waves of consequences.

Research in the School of Healthcare Sciences

In February 2015, in the School of Healthcare Sciences at Cardiff University we launched our new research strategy. The School’s main research webpage can be found here, and for the nuts-and-bolts of our four research themes the links to follow are these:

Meanwhile, in the very near future the School (including its researchers) will be occupying additional floors at our base in Eastgate House. This, for those who know Cardiff, is a building situated at the junction of Newport and City Roads. My office, I think, will move: giving me fine views over the city and beyond.

Here are some photos of the 12th floor, as previously shared via a Tweet:

It is very welcome that we will soon have these new facilities available to us, with the rooms in the photos being used mainly by PhD and Professional Doctorate students.

Which brings me neatly to…

Other interesting developments in the School on the postgraduate research student front are plans to recruit very pro-actively. Research theme members have been busy generating topics for doctoral study, which reflect existing areas of substantive and methodological expertise and where capacity to supervise is known to exist. We’ll be advertising these soon, and inviting potential students to tell us how their plans align. The aim, obviously, is that we grow research in programmatic style by building on established and emerging lines of enquiry. For anyone interested, I’m looking to supervise people who want to use in-depth qualitative methods to examine mental health systems (no surprises there, then!). Specifically, this means projects investigating aspects of: policy; service organisation and delivery; work, roles and values; and user and carer experiences.

Other postdoctoral news includes Mohammad Marie‘s (that’s Dr Mohammad Marie’s) successful defence of his thesis at viva last month. Well done! Mohammad has been supervised by Aled Jones and me, and the title of his thesis is Resilience of nurses who work in community mental health workplaces in West Bank, Palestine. Next up for him are papers for publication: and jolly interesting they’ll be, too.

Fieldwork

FieldworkToday brought some interesting discussions on qualitative fieldwork, including on researcher roles and relations during data generation. First up was a COCAPP-A project meeting which included a conversation about observational methods in inpatient mental health settings. Second was a seminar led by Michael Coffey‘s PhD student Brian Mfula, drawing on his ongoing PhD experiences of ethnographic fieldwork centring on care planning and care coordination in forensic mental health care.

Brian shared his experiences of negotiating access, and of his reading and thinking about insider and outsider roles. This led to a wide-ranging talk amongst those present on fieldnotes and approaches to qualitative research (Grounded theory, anyone? Phenomenology? Or perhaps thematic analysis is more your thing?). We talked, too, about reflexivity, and knowing when (and how) to leave the field. Along the way this took us to the National Centre for Research Methods’ excellent Review Paper, How many qualitative interviews is enough?

Around ten years ago I contributed a chapter covering some of this territory to Davina Allen and Patricia Lyne’s edited book, The Reality of Nursing Research: Politics, Practices and Processes. Titled Data generation, this contrasted survey principles and practices in The All Wales Community Mental Health Nursing Stress Study with the ideas and methods in my (then-ongoing) ethnographic PhD, Health and Social Care for People with Severe Mental Health Problems. I wrote about decision-making, and the extent to which data are interactionally produced by researchers and participants together:

Whilst different strategies place different expectations and demands on nurse researchers, this chapter has also shown that – whatever approach is followed – data generation is always a purposeful activity demanding a reflexive stance. The principle of reflexivity underpins the idea that research always takes place in contexts, shaped to significant degree through an interaction between researcher and researched. The character of data produced in a study is moderated by aspects of the researcher’s personal biography and their interaction with research participants. This is a well-established principle in the social sciences. In nursing research, however, reflexive investigators have to give consideration not only to general biographical aspects such as age and gender, but also to their specific occupational backgrounds and practitioner experiences. A self-conscious, reflexive approach includes acknowledgement of the utility and the limitations of practitioner knowledge, and the implications of this for data production.

I’m now thinking that today’s seminar and discussions show how live these issues remain, and will ever remain so.

#NPNR2015 news

I’m pleased to have had the chance to join the scientific and organising committee for the NPNR Conference, and to have taken part in a series of face-to-face and electronic discussions to plan this autumn’s event.

Nowadays the NPNR Conference is a collaboration between Mental Health Nurse Academics UK and the RCN. Early information about the 21st running of the event can be found here. For ease, here is an extract with an outline of this year’s themes and more:

21st International Network for Psychiatric Nursing Research conference
“Building new relationships in mental health nursing: opportunities and challenges”
17 September 2015 – 18 September 2015 – Manchester Conference Centre, Sackville Street, Manchester M1 3BB

As the NPNR conference convenes for the 21st time developments in research, education and delivery of mental health nursing care continue apace. New knowledge opens the way for new forms of relationships with people who use services, their families and with colleagues within and outside our discipline. The way mental health nurses are educated and how they develop and research their practice is also changing, bringing with it new opportunities and many challenges.

This year’s conference will engage with the emerging evidence and changes in the landscape of care as we seek to craft new understandings of what it means to be a mental health nurse. As we become attuned to the vagaries of policy and the volume of new knowledge for our profession we must also rise to the challenge of ‘seeing’ in new ways. Our intention is to provide a space where colleagues can debate and critically engage with flux in the profession.

The NPNR is the place for mental health nurses and those we work with to present and learn new knowledge. We encourage you to submit your research and practice development initiatives and participate in discussion so that you leave the conference informed, enlightened and with new energy to engage with the challenges ahead. Alongside our expert speakers, great practice development and research papers the conference promotes a friendly and welcoming atmosphere that has been the hallmark of NPNR for 20 years. This year in addition to our exciting themes we include new developments for 2015.

Conference Highlights for 2015

• Two day conference for academics and practitioners working across mental health nursing
• Renowned keynote speakers
• Call for abstracts including options to present posters, concurrent, symposia and workshops
• Networking, collaborating and discussing the latest in mental health nursing research
• Conference reception and networking dinner
• Announcing the recipients of both the Eileen Skellern Lecture and the Journal of Psychiatric and Mental Health Nursing Lifetime Achievement Award 2016
• Special discounts for conference presenters; RCN members; students; carers and service users
• Enhance your continuing professional development
• Poster Trail
• Fringe events
• RCN exhibition

Call for Papers will be open from the beginning of March 2015

Concurrent themes:

• New Conversations, New Platforms, New Evidence
• Collaborations and Partnership in Research
• New Voices, New Researchers
• Innovation and Development in Practice and Education
• Changing Systems, Changing Relationships

Abstracts addressing the conference themes are invited for the following types of presentations:

1. concurrent sessions
2. poster presentations
3. symposia
4. workshops
5. fringe events

Key timings:

Thursday 17 September 2015
8.30am – 10am: Registration and Fringe Events
10.00am – 6pm: Conference

Friday 18 September 2015
9.00am – 9.45am: Registration
9.45am – 4.15pm: Conference

The hashtag for the conference will be #NPNR2015:

And, for those who also use LinkedIn, there is this group.

I’ll aim to post further updates on all this over the coming weeks and months.

Taking Measure

Here in Wales we have the Mental Health Measure. This is a piece of legislation passed in 2010 and implemented in phases in 2012, and which is intended to improve the quality and timeliness of mental health services. Specifically, it provides for:

  • primary mental health care;
  • care and treatment planning and care coordination;
  • the right for an automatic reassessment of needs in secondary mental health services for people discharged within the previous three years;
  • advocacy in hospital.

This month the National Assembly for Wales Health and Social Care Committee has reported on its post-legislative scrutiny of the Measure. The Welsh Government has already committed to conduct a formal evaluation of the legislation through a duty to review, built in as the Measure passed into law. In pursuit of this an inception and an interim report have already appeared, with a final document due in 2016. With the Health and Social Care Committee’s report appearing this month it is clear that the Mental Health Measure is becoming seriously scrutinised.

When the Committee published its call for evidence last year the COCAPP research team submitted a response alerting Assembly Members to our ongoing study. It would have been ideal had we been able to report key findings, given that COCAPP is an examination of care planning and care coordination and is, therefore, of interest to anyone wanting to know how part 2 of the Measure (dealing with care and treatment planning) is being experienced. But the Health and Social Care Committee’s timescales and those of COCAPP were not aligned, meaning the best we could do was to draw attention to our project.

This month the Committee praises many aspects of the Measure but also makes ten recommendations. They address:

  1. meeting demands for primary mental health care, particularly in the case of children and young people;
  2. improving the collection of data to better support the evaluation of primary mental health services;
  3. taking action to improve the form, content and quality of care and treatment plans, with a view to increasing service user involvement and spreading best practice through training;
  4. making sure that rights to self-refer for reassessment are properly understood and communicated to all;
  5. improving staff awareness of service users’ eligibility for independent mental health advocacy in hospital;
  6. setting timescales for new task and finish groups reviewing the Measure, and setting out plans to respond to their recommendations;
  7. during evaluations of the legislation, consulting with as wide a range of people as possible using traditional and novel approaches;
  8. ensuring that information is available in a variety of formats, so that all groups of people are able to access this and to understand;
  9. following the publishing of new plans for the improvement of child and adolescent mental health services, making clear how these will be realised;
  10. carrying out a cost benefit analysis of the Measure.

Clearly, Assembly Members have detected evidence of an uneven pace in the development of primary mental health care across Wales, and are particularly concerned to make sure that the mental health needs of children and young people are properly identified and met in timely fashion. As a COCAPP-er, I am interested to read that the Committee thinks care and treatment planning for everyone can be improved, informed by examples of best practice and through investment in staff training. I also pick out the recommendations on improving service user collaboration, and estimating the costs and benefits of the Measure. These resonate, to me, with current concerns in Wales with prudent health care and co-production.

And as for COCAPP’s findings? Suffice to say our draft final report is now under review with the National Institute for Health Research (NIHR) Health Services and Delivery Research (HS&DR) Programme. More to follow in due course…

Critical junctures goes green

CJIn a series of earlier posts on this site (here and here), and in a piece for the LSE’s Impact Blog here, I wrote about Nicola Evans‘ and my article, ‘Critical junctures in health and social care: service user experiences, work and system connections’. This is published in the journal Social Theory & Health, and the behind-the-paywall link to the full text can be found here. Now that 18 months has passed since the article first appeared online, Palgrave’s copyright rules allow a post-peer-review, pre-copyedit, green open access version of the full text to be made publicly available. So, for a free copy of the paper downloadable from Cardiff University’s ORCA repository the link to follow is this:

Hannigan B. and Evans N. (2013) Critical junctures in health and social care: service user experiences, work and system connections. Social Theory & Health 11 (4) 428-444

The paper draws on data from Nicola’s PhD, ‘Exploring the contribution of safe uncertainty in facilitating change‘, and from my post-doctoral study of crisis resolution and home treatment services, ‘Mental health services in transition‘. For a reminder of what the paper is about, here’s the abstract in full:

This article makes an original contribution through the revitalisation, refinement and exemplification of the idea of the ‘critical juncture’. In the health and illness context, a critical juncture is a temporally bounded sequence of events and interactions which alters, significantly and in a lasting way, both the experience of the person most directly affected and the caring work which is done. It is a punctuating moment initiating or embedded within a longer trajectory and is characterised by uncertainty. As contingencies come to the fore, individual actions have a higher-than-usual chance of affecting future, enduring, arrangements. These ideas we illustrate with detailed qualitative data relating to one individual’s journey through an interconnected system of mental health care. We then draw on observations made in a second study, concerned with the improvement of mental health services, to show how micro-level critical junctures can be purposefully used to introduce instability at the meso-level in the pursuit of larger organisational change. In addition to demonstrating why scholars and practitioners should pay closer attention to understanding and responding to critical junctures we are, therefore, also able to demonstrate how their emergence and impact can be examined vertically, as well as horizontally.

REF results out, COCAPP in

The publication of results from the Research Excellence Framework 2014 (#REF2014) has made this a big week for universities. REF is important for lots of reasons. First, it is assumed that recurring, quality-related (QR), research funding from the UK’s four higher education funding councils will be weighted to the REF results (I say ‘assumed’ here in the light of reports, today, on possible changes to the dual support system: see below for more). Second, universities and the departments within them are ranked based on REF outcomes, making the exercise a crucial one for relative reputations. Third, for governments the REF (like the various research assessment exercises (RAEs) before it) is a way of showcasing the value of research investment and the wider benefits this brings.

Universities will have followed different strategies in managing their REF submissions. In Cardiff a selective return produced a result comfortably better than had been aimed for with the University now ranked in the top five based on research quality. Check out this short video for an overview:

As I hinted above there are, already, questions being asked of how the REF results will (or will not?) be converted into future funding. A report in today’s Observer suggests that changes may be afoot to the dual support (QR and programme/project-related) system. Here’s an early morning tweet from Phil Baty at the Times Higher Education:

So that’s an evolving story which deserves to be closely watched.

Meanwhile…

…moving from research in the round to research projects specifically, this has also been the week that our draft final report from COCAPP has been submitted for peer review to the NIHR Health Services and Delivery Research Programme:

COCAPP has been an investigation into care planning and care coordination in mental health services, and has already been partnered by COCAPP-A. This related study is asking questions in the hospital setting similar to those asked by COCAPP in the community. The coming year sees COCAPP-A getting into full swing, with qualitative and quantitative data being generated across multiple NHS sites in England and Wales.