Critical junctures (reprise)

This morning Nicola Evans’ and my paper on Critical junctures has appeared in advance online publication form on the Social Theory & Health website. This is very pleasing, though as I noted in my original post the terms of Palgrave’s copyright agreement mean that we have to wait for a period of 18 months from now before depositing a green open access version of the full text to accompany the article’s ORCA entry.

In the meantime, here again is the article’s abstract, which I hope at least whets readers’ appetites:

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.

Writing an undergraduate dissertation

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

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

Research and mental health nursing

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

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

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

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

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

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

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

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

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

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

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

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

Academic networking

There are plenty of places where academics can tell the world about their interests and expertise, and generally show off their publication records, ‘h’ indices and all the rest. Blogs, like this one, are an example. Then there are services like ResearcherID, ResearchGate, Academia.edu and so on. These often have a networking function to allow people to get in touch and develop collaborations. Some also have space to store open access papers, in much the same way that university-based digital repositories (like Cardiff University’s ORCA) do.

Yesterday I published my Google Scholar profile. This may be just another way of promoting and networking, but I’ve also spotted a button titled, ‘My updates’. Here it is, pointed to with a big red arrow:

And, here’s a description from the Google Scholar blog of what this new(ish) function does:

We analyze your articles (as identified in your Scholar profile), scan the entire web looking for new articles relevant to your research, and then show you the most relevant articles when you visit Scholar. We determine relevance using a statistical model that incorporates what your work is about, the citation graph between articles, the fact that interests can change over time, and the authors you work with and cite. You don’t need to configure updates or enter any queries. We’ll notify you about new updates by displaying a preview on the homepage and highlighting a bell icon on search results pages.

This service looks very useful, not least because it appears to actually work. When I’m logged into Scholar and click on the ‘My updates’ link today I get interesting references to crisis resolution and home treatment research, continuity of mental health care and interprofessional community mental health work (amongst others). All very much up my street.

The accidental grounded theorists

On Friday I had reason to ponder the relationships between theory and data, and the boundaries between different types of qualitative research. This was day two of my Working and Leading in Complex Systems professional doctorate module. What I discovered is that I may, in fact, have become an accidental grounded theorist. Or possibly not…I’ll let the reader decide.

During a talk about critical junctures I said how, in our recent paper, Nicola Evans and I had elected to lay out our theoretical contribution (i.e., our idea of ‘critical junctures’ as pivotal, punctuating, moments initiating or taking place within longer individual trajectories of care) ahead of displaying our data. We had done this even though our ‘theory’ had in fact been fieldwork-driven, as we then demonstrated in our article with extended, illustrative, extracts. Quite reasonably, in the classroom I was asked if we had therefore used a grounded theory approach.

This question got me thinking. My immediate response was that Nicola and I had developed a concept from empirical data but had absolutely not claimed to be ‘doing grounded theory’. In fact, the thought had never occurred to us (or to me, at any rate).

And there’s the nub of it. What does it actually mean to ‘do grounded theory’? Follow a stepwise recipe from a methodological cookbook? Or range freely over one or more sets of data in the search for new insights? Without wanting to suggest that ‘anything goes’ in terms of methods, I wonder if we can sometimes get too hung up on techniques and ‘rules’ when it’s the principles which really matter? In our critical junctures paper these included a commitment to the inductive ‘drawing out’ of conceptual insights from an analysis of talk and action. They also included the idea of staying close to our data, and of offering fieldwork extracts in support of the theory. I personally have no wish to agonise over what flavour of ‘doing qualitative research’ we have done here, and I’m also not sure that all of the finer distinctions and sub-divisions necessarily matter or even make sense.

But perhaps I’m missing something.

Learning about complexity and systems

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Summer sun

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

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

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

Increasing the visibility of research

Where publishers’ copyright rules permit, since last year I have been uploading green open access versions of peer reviewed research papers I have written or co-written to ORCA, Cardiff University’s digital repository. I have then been adding hyperlinks to these papers to research-related posts on this blog. To round this all off I’ve been using Twitter to draw attention to what I’ve been up to.

Having a WordPress blog means that I get to see which hyperlinks anonymous readers are following, and I know that some onward clicks are taking people to my open access articles. At the end of last week I asked colleagues managing ORCA if any tools existed to help me find out which of my papers have been downloaded, and when.

What I now have is access to an application allowing me to interrogate ORCA in all sorts of ways. So I know, for example, that full-text papers I have authored and saved to the repository have been downloaded 360 times between January 1st 2005 (the earliest date I can select) and today, July 3rd 2013. Two hundred and eighty eight of these downloads have taken place since November 24th 2012, this being the date I created this blog and first posted.

Here is a summary of my ORCA ‘eprints’ and the number of times each has been downloaded up to today:

Eprint Fulltext Downloads
Hannigan, Ben and Allen, Davina Ann 2013. Complex caring trajectories in community mental health: contingencies, divisions of labor and care coordination. Community Mental Health Journal 10.1007/s10597-011-9467-9
file
150
Hannigan, Ben and Coffey, Michael 2011. Where the wicked problems are: the case of mental health. Health Policy 101 (3) , pp. 220-227. 10.1016/j.healthpol.2010.11.002
file
70
Coffey, Michael and Hannigan, Ben 2013. New roles for nurses as approved mental health professionals in England and Wales: A discussion paper. International Journal of Nursing Studies 10.1016/j.ijnurstu.2013.02.014
file
65
Hannigan, Ben and Allen, Davina Ann 2011. Giving a fig about roles: Policy, context and work in community mental health care. Journal of Psychiatric and Mental Health Nursing 18 (1) , pp. 1-8. 10.1111/j.1365-2850.2010.01631.x
file
24
Hannigan, Ben 2013. Connections and consequences in complex systems: insights from a case study of the emergence and local impact of crisis resolution and home treatment services. Social Science & Medicine 10.1016/j.socscimed.2011.12.044
file
20
Hannigan, Ben and Allen, Davina Ann 2006. Complexity and Change in the United Kingdom’s System of Mental Health Care. Social Theory & Health 4 (3) , pp. 244-263. 10.1057/palgrave.sth.8700073
file
18
Hannigan, Ben and Allen, Davina Ann 2003. A tale of two studies: research governance issues arising from two ethnographic investigations into the organisation of health and social care. International Journal of Nursing Studies. 40 (7) , pp. 685-695. 10.1016/S0020-7489(02)00111-6
file
13

All are papers I have specifically blogged about, and have subsequently flagged up on my Enduring posts page. I am therefore going to tentatively conclude that the approach I have taken to increase the visibility of my research is having an effect.

What I do not know is who has been downloading (and hopefully reading!) these articles, and for what purposes. I would like to think it has been a mixture of researchers, practitioners, managers, policymakers and service users. I also hope they have found what they have read to have been both interesting and useful.