On writing a paper about mental health systems, and running in mud

A fortnight ago I blogged about a paper I gave at this year’s Network for Psychiatric Nursing Research conference. My aim in this presentation was to move lightly through a series of completed studies I’ve previously been involved in, with a view to saying something cumulative about the mental health system. I mentioned my ambition of working this talk up into something a little more substantial and enduring, and sending this to a journal for peer review and (hopefully) eventual publication.

Progress has been slow, largely because of competing priorities. But I have at least made  a start, of sorts. One of the points I’m going to make is that, taking the long view, the story of how mental health care in the UK has evolved remains a quite remarkable one. A quarter of a century ago, which is when I first began working in mental health care, untold numbers of people remained resident in outdated institutions. Community services certainly existed, but were relatively under-developed. Many teams were uni-professional, and lacked a clear focus. Ideas of recovery, personalised care and collaborative working with service users were in their infancy.

It’s all very different now. I suspect it’s possible to qualify as a mental health nurse without having many hospital placements at all, and to spend the greater portion of practice time in varieties of community setting. There are locality community mental health teams (still the bedrock of specialist services for working age adults), and similar teams serving older people, and children and adolescents. There are crisis resolution and home treatment teams, assertive outreach teams, primary mental health teams, and more besides. I also think that the values which underpin care have changed. So, whilst it may not be a perfect system, it is much improved.

How much the investment in mental health systems which took place over the late 1990s and throughout the first decade of the new century can be sustained, in the face of crushing public services cuts, I do not know. In Wales, which is far more public services oriented than England, a strong case was made a few years ago for the importance of investing in mental health. Mental ill-health affects individuals, families, communities and the economy. I hope that the Welsh Government’s emphasis on public mental health in its new cross-cutting strategy ‘works’, without pulling vital resources away from dedicated services for people with long-term and disabling mental illnesses.

On the non-work front, this morning’s run entirely lacked the clear, hard, frostiness of recent Saturdays. It was wet, and muddy. Clinging, in fact, and thoroughly energy-sapping. It will take a few days for my (tired-looking) shoes to dry out, so I’m glad to have my second pair to hand (to foot?) should the need arise. Now it’s Christmas tree purchase time.

Mental health R&D

Following an afternoon interviewing potential new mental health nursing students, today it’s all about research and development. I’m off to Cardiff and Vale University Health Board’s annual mental health R&D meet-up, which on this occasion is titled ‘Updates, Opportunities and Overcoming Challenges’. The agenda is pretty packed, and includes (in the morning) an overview of, and progress report on, the National Centre for Mental Health. There’s also a session scheduled on research funding schemes managed by the National Institute for Social Care and Health Research (NISCHR). NISCHR is supported by the Welsh Government, and develops policy and priorities for health and social care research. It also directly supports research activity through its registered research groups and via its various competitive funding schemes.

New nurses

This afternoon I’ll be joining colleagues to interview potential students of mental health nursing. I imagine I’ll meet a variety of candidates: young people who are still at (or have just left) school, others who are looking for a second (or third) career, and others again who have considerable experience in caring work gained through employment as health care assistants or similar. The range of educational backgrounds people have is likely to be varied. Some may have A levels, or undergraduate degrees (often in the humanities or social sciences). Others may have (or be studying for) Access qualifications via their enrolment at colleges of further education.

From my accumulated experiences of interviewing in this context I expect that most, if not all, of the candidates I meet today will have thought very carefully about their applications. I expect them to be enthused about the prospect of learning and practising, and informed about what this involves. I expect people to demonstrate an interest in others, to be inquisitive and engaged, and to be motivated by a desire to help.

I also imagine that candidates will be aware of today’s proceedings taking place in a context of heightened scrutiny: of nurses, their roles, and their preparation. Cynon Valley MP Ann Clwyd, for example, has had strong things to say about nurses and nursing following the death of her husband at the University Hospital of Wales in Cardiff. To repeat what I’ve said before on this blog: the fact that nurses now qualify with undergraduate degrees does not make them any less compassionate than those without. To me, the idea that there might be some kind of automatic, inverse, relationship between education and capacity to care makes no sense whatsoever. For those interested, here’s a very thoughtful piece touching on some of this on the notsobigsociety blog.

Learning together, and more on peer review

Along with spending time with students rehearsing research ethics, this week I have also had the chance to be part of a small interprofessional education initiative. This involved pre-registration mental health nurses and pre-registration occupational therapists. Two linked sessions, the last of which was a few days ago, were facilitated by a teaching team led by my excellent colleague Gerwyn Jones, and Ruth Squire (who I hadn’t met before, but was pleased to meet in this context). Also taking part was the fine Teena Clouston, an occupational therapy academic who I have enjoyed working with, on and off, over a period of many years. As an aside, meeting up again with Teena gave me the opportunity to congratulate her on her freshly minted doctorate. That was nice.

Interprofessional education in health and social care is hardly a new idea. It’s also good to do. In the workplace nurses, occupational therapists, doctors, social workers, physiotherapists and all the rest have to rub along together. So why not create opportunities for students from across these fields to learn together first, in the classroom as well as in practice placements?

It’s worth reflecting on the extent to which we still recruit and teach students in uniprofessional isolation. There’s work involved in making connections across different university departments, in creating materials and in planning what will take place. Timetables need to be aligned, and facilities booked. Only then does cross-disciplinary, university-based, learning occur. Having brokered interprofessional education initiatives of this type in the past I appreciate the time and organisation required. But I think we have to collectively put this effort in, and more.

On this occasion, this mental health-focused two days of joint learning culminated in students participating in a role played care planning meeting. I have to say that I was impressed – very impressed – by the way students managed the process. Interactions between professionals, the service user, his carer and an advocate were respectful and productive. I’ve seen a whole lot worse in real life. I left feeling optimistic.

Unrelatedly: yesterday a journal I haven’t reviewed for before got in touch and asked if I would comment on a paper submitted for publication. Last weekend I blogged about peer review, and wrote about having graciously declined an invitation. Yesterday afternoon’s request was different: I know the area being written about, and was happy to give a view.

Changing the subject again, South Wales once more is spectacularly beautiful this morning. Frosty, and dry: perfect for my run.

Research ethics and governance

Hannigan and Allen 2003

This week I spent an afternoon in the company of a lively and engaged group of pre-registration mental health nursing students, talking about processes for the ethics review of human participant research studies conducted both in, and out, of the NHS. We discussed the purpose of ethics review and the organisation of research ethics committees (RECs) across the UK, before I invited the group to become a REC and to consider an application placed before it.

As it happens, over the last ten or so days I’ve also been helping prepare a new application for NHS REC and R&D approval, and in my capacity as chair of the Cardiff School of Nursing and Midwifery Studies REC I’ve been steering another proposal through our committee. So all in all I’ve been having something of a personal research ethics-fest.

One of the first papers from my PhD was a piece, written with Davina Allen, rehearsing our experiences of seeking REC and research governance approval for two studies sharing the same design. There’s a version of the full paper available here, via the Cardiff University research repository.

In this article we started by writing about the rise of institutionalised ethics and governance review processes in the UK and globally. We then shared our experiences of ethics committee inconsistency, and of the limited understanding RECs sometimes have of qualitative research.

I now realise that some of the things which happened to my proposal are not as unusual as I thought at the time this paper was written. Not uncommonly projects will be described as ‘research’ in one context (for example, for funding purposes or for progression towards academic awards) but not in others (for example, in the context of NHS research governance and ethics review where they might be classified as ‘service evaluation’ or similar). I also realise, then as now, that ‘[e]thical decision-making is a complex process, and one that is not amenable to the application of formulaic guidelines’. This is a direct quote from our 2003 paper, and it reminds me that we should not expect absolute consistency in decision-making across different committees. But there is something to be said for committees paying attention to precedent. It is also important that RECs are clear in setting out their reasons why studies need to be amended (or indeed, refused). My recent experiences of applying for NHS REC approval have been positive, in that committee members have been open to in-the-round discussions of the issues raised. I’d like to think that researchers who have submitted their proposals to the university REC I chair have felt similarly well-treated.

Peer review

This morning, with good grace and a reasoned explanation, I declined an invitation to review a paper submitted for publication. The journal the article has been sent to is a good one, serving an international and interdisciplinary readership. I published in there once, and was pleased to have done so. This particular paper (having read the abstract) looked interesting, and broadly put was in my field insofar as it dealt with matters mental health-related.

Peer review is at the heart of academic practice. I wrote about it once, with Philip Burnard, in this paper published in Nurse Education Today. To write articles for publication in scholarly journals, and/or to write grant applications for research funders, is to submit to the process. In return for having other people read what I write I am happy to play my part in the system, and to take my share of papers to review.

It is certainly true that peer review is far from perfect, as the former editor of the BMJ spells out here, and as Stephen Mumford writes here in a recent edition of Times Higher Education. But it might be the best system we’ve got, even if it could be improved. And for me, today: why the refusal to review? Simply put, the article I was invited to give an opinion on was reporting findings from a study using specialised methods in which I entirely lack expertise. Declining was the only way to go. Maybe a better match next time.

On not lying-in

I’m not very good at lying-in. Once I’m awake (which, on most mornings, is earlier rather than later) I’m up. It’s then a matter of creeping downstairs to do some soundless chores, before making my mandatory mug of strong coffee and grabbing breakfast. Whilst in the kitchen I’ll have the radio on, tuned (at low volume) to BBC R4, for company. Invariably I’ll then make my way to the computer: the very one I’m sitting in front of now.

This blog is about a week old, and a number of my posts have started life in this pre-dawn window of opportunity. Papers I’ve written for publication have often been chipped away at at a similar time. So far the relationship between my writing-for-this-blog and my writing-for-journal-submission has been one-way, in that I’ve used this space to share ideas rehearsed at greater length in already-published academic articles. Indeed, this was one of my purposes in setting this site up: I wanted to experiment with blogging as a way of promoting work, and as a means of engaging beyond the production of lengthy outputs for paid-for journals.

It now occurs to me that this blog might also become a working space for the development of new ideas, and that the relationship between writing-for-journals and writing-for-the-blog might sometimes run in the opposite direction. This forum will never be a substitute for my academic journal-writing, and I’m not proposing to dump heaps of unmanaged data here (even if I had it!) for some kind of public write-in. But I might bring fledging ideas which I’m in the process of working through in my head.

Which brings me to…

At this year’s Network for Psychiatric Nursing Research conference I gave a talk titled, ‘Past, present and possible future in the system of community mental health care’. I intended this to be a kind of reflective run-through, taking in a decade-and-a-half of research and writing in the field. I wanted to touch lightly over a string of studies and papers I’ve had the good fortune to be involved in, and to knit together something cumulative around the themes of system interrelatedness, complexity and change. I’m not sure I pulled this ambition off in that forum, and in the longer term I’d like to work this all up into a full-blown paper. This space might become a repository of some sort for this type of work-in-progress. We’ll have to see, though, and I’ll need to think through how this might happen.

Unrelatedly: I’ll be opening the Mental Health Nurse Academics UK Vice Chair elections on Monday. My congratulations, too, to Louise Poley (Consultant Nurse in Substance Misuse, Cardiff and Vale UHB) for becoming RCN Wales Nurse of the Year. Lou has done outstanding work improving the health of people who are homeless, collaborating with partners across the statutory and non-statutory sectors.

Now I’m off out for run. Thanks, again, for reading.

Sphygmomanometers, remedial gymnasts and mental health work

For an example of how health care tasks can become attached to different groups of people over time, then look no further than the measurement of blood pressure. One of the stories my grandmother told me when she was alive was how, whilst working as a nurse in the 1920s, whenever a new-fangled sphygmomanometer was to be used a doctor would come to the ward to operate it. The recording of blood pressure then became a task that nurses and midwives routinely did, and indeed support workers. Now it is something that anyone can do, using electronic gadgets purchased from the high street.

Tasks move around in mental health systems, too. Think, for instance, of the provision of formal therapies. Cognitive-behavioural family work used to be something which only a sprinkling of nurses did. Not any more. In this part of the UK, some of the tasks which only social workers used to fulfil as ASWs (approved social workers) during the operation of the Mental Health Act are now equally fulfilled by others working as AMHPs (approved mental health professionals).

Just as tasks appear and move between groups, so too do whole groups emerge, change and sometimes merge or even disappear. Remedial gymnasts appeared in the years after the second world war, before being subsumed within the profession of physiotherapy. Peter Nolan has told the story of mental health nursing growing from the keepers and attendants found within the asylum system. Community mental health nursing, as a particular sub-division, did not exist until the early 1950s. Now within the mental health system there are peer support workers, carrying out tasks which professionals and health care assistants might once have done.

Complexity and changeDavina Allen and I wrote about processes of this type in a paper called Complexity and change in the United Kingdom’s system of mental health care. This appeared in the journal Social Theory & Health in 2006, though a post-peer-review version of the article can also be downloaded from here. Davina is a nurse and sociologist (and was one of my PhD supervisors; the other was Philip Burnard), and in this article we drew on sociological theories to explore the changing division of mental health work in the post-war years. We used the ‘ecological’ ideas of Everett Hughes and Andrew Abbott to frame our analysis, about which you can read more here. These emphasise the division of labour as a complex and dynamic social system, which is responsive to all sorts of internal and external forces. Technology is one driver for change (for example, no-one could measure blood pressure until a device to do so had been invented. Mass production brought this work to the masses). Hughes had lots of interesting things to say about ‘mandate’ (the kinds of things groups say they ought to be doing) and ‘licence’ (what they actually do), and the ‘bundles of tasks’ which become attached to occupations at particular times and places. Abbott writes about the things that professions do to secure and advance what he calls their ‘jurisdiction’, in the face of claims made by competitors. ‘Jurisdiction’ refers to a group’s control over work.

In our Complexity and change paper Davina and I wrote about the historic success of the profession of psychiatry in drawing on biomedical knowledge to underpin and maintain a position of power in the mental health system. But as I’ve already suggested, interrelated systems of work are in motion, and in our paper we were also interested to explore sources of change. So we wrote, for example, about the challenges to biomedicine raised by dissident anti-psychiatrists in the 1960s and 1970s. We also wrote about the claims of mental health nursing to the possession of profession-specific knowledge underpinning the maintenance of helpful therapeutic relationships, and the appeals of social workers to having profession-specific ‘social model’ insights.

We also made quite a thing about the significance of community care for work and roles, and reflected on the expansion of state intervention in the mental health system (via a proliferation of policies) in the early years of this century. Now I think about it, there’s a link here between the wicked problems paper I wrote with Michael Coffey, and blogged about in both this and this earlier post. Policymakers’ recent formulation of ‘the problem’ as being one of unhelpful professional demarcations and restrictive practices has been a source of considerable disturbance in the mental health system of work. I’m thinking here, again, about the opening up of the Mental Health Act ‘approved’ role to nurses, psychologists and occupational therapists as well as to social workers, and what the longer-term implications of this might be. I’m also thinking about the division of labour consequences of peer support workers, and mental health nurses who prescribe medications, and graduates without ‘professional’ qualifications providing psychological therapies in primary care. Whatever the merits or otherwise of developments of this type, I think we should look carefully at their wider impact. Sometimes change can manifest in unpredictable ways.

And that brings me to another matter altogether: the intended and unintended consequences of action in interconnected systems. But that’s for another day, and for another post, entirely. Thanks for reading.

Blogging on the bus: floods, mental health and more wicked problems

A brief post as I make my way, by bus, to a meeting at the University Hospital of Wales.

What’s the connection between the prevention of floods (noting the terrible weather we’ve been having, again) and the promotion of mental health? Both are problems of the wicked variety. Here I’m using ‘wicked’ in the way I used it in my previous posts, with due acknowledgment of Rittel and Webber and their 1973 paper. Flood management and improving mental health and well-being are complex problems. Responsibilities are dispersed across different people, groups and organisations. There are no ‘stopping rules’, in that there is potentially no end to what could be done.

That’s it: bus journey over.