Tag: COCAPP

COCAPP main findings

In a post last week I drew attention to a recent run of publications, promising to write a single post for each as it appears. Yesterday saw the appearance of Recovery-focused care planning and coordination in England and Wales: a cross-national mixed methods comparative case study. This is the main findings paper from COCAPP, published in BMC Psychiatry. Here’s the abstract, for readers wanting a taster:

Background: In the UK, concerns about safety and fragmented community mental health care led to the development of the care programme approach in England and care and treatment planning in Wales. These systems require service users to have a care coordinator, written care plan and regular reviews of their care. Processes are required to be collaborative, recovery-focused and personalised but have rarely been researched. We aimed to obtain the views and experiences of stakeholders involved in community mental health care and identify factors that facilitate or act as barriers to personalised, collaborative, recovery-focused care.

Methods: We conducted a cross-national comparative study employing a concurrent transformative mixed-methods approach with embedded case studies across six service provider sites in England and Wales. The study included a survey of views on recovery, empowerment and therapeutic relationships in service users (n = 448) and recovery in care coordinators (n = 201); embedded case studies involving interviews with service providers, service users and carers (n = 117) and a review of care plans (n = 33). Quantitative and qualitative data were analysed within and across sites using inferential statistics, correlations and framework method.

Results: Significant differences were found across sites for scores on therapeutic relationships. Variation within sites and participant groups was reported in experiences of care planning and understandings of recovery and personalisation. Care plans were described as administratively burdensome and were rarely consulted. Carers reported varying levels of involvement. Risk assessments were central to clinical concerns but were rarely discussed with service users. Service users valued therapeutic relationships with care coordinators and others, and saw these as central to recovery.

Conclusions: Administrative elements of care coordination reduce opportunities for recovery-focused and personalised work. There were few common understandings of recovery which may limit shared goals. Conversations on risk appeared to be neglected and assessments kept from service users. A reluctance to engage in dialogue about risk management may work against opportunities for positive risk-taking as part of recovery-focused work. Research to investigate innovative approaches to maximise staff contact time with service users and carers, shared decision-making in risk assessments, and training designed to enable personalised, recovery focused care coordination is indicated.

People may be interested to learn that COCAPP will also be the subject of a Mental Elf blog and podcast in a week or so’s time:

And, for those wanting the fine-grained detail, there is always our main report to the National Institute for Health Research (NIHR) Health Services and Delivery Research (HS&DR) Programme.


Bus blogging

Time, just about, to use a bus journey across Cardiff en route to the University Hospital of Wales site (for the purposes of teaching) to post an update on recent activities.

There’s lots to say. Projects I’ve blogged about on this site (COCAPP, COCAPP-A, Plan4Recovery) are now being written up. Our main findings paper from COCAPP appears imminently in BMC Psychiatry. Alan Simpson, as lead author, completed checking the proofs of this in the last few days so we know it’s on its way. Michael Coffey has lead authored a COCAPP paper addressing risk; earlier this week this was accepted for publication in Health Expectations. Further papers will follow, as they will in the future from COCAPP-A. I’ll make a point of posting about each as they appear. Plan4Recovery has been about shared decision-making and social approaches to care, and here, too, work on a first publication is well underway. 

Meanwhile, Therapeutic skills for mental health nurses edited by Nicola Evans and me has just been published by Open University Press. This is a fine text indeed (though I say so myself), which we hope proves particular useful to students.

A big highlight of the last few weeks has been the award of a doctorate to my colleague and (now former) student Pauline Tang. Pauline used qualitative methods to investigate the use of electronic patient records in a medical assessment unit, and you can read her thesis here. And talking of doctorates: Mohammad Marie, writing with Aled Jones and me, has a second paper from his study of resilience in Palestinian community mental health nurses about to appear: this one in the International Journal of Mental Health Nursing

Right! I’m off the bus and walking to a classroom. Time to fly, and to remind myself that it is perhaps better to post more frequently than to cram so much into a single, short, piece like this. 

Sticking up for qualitative research

Technological failure meant I was unable to participate in this week’s Mental Elf campfire discussion, What has qualitative research ever done for us? The context for the event was the recent decision by the BMJ to reject a paper submitted for publication by members of the McGill Qualitative Research Group on the grounds that qualitative research reports are of low priority. This, the BMJ editors added, is because they are downloaded and cited less often than are reports of quantitative research. The BMJ communication conveying this news to the McGill team was posted on social media, triggering significant protest and then a letter to the BMJ making the case for qualitative methods and urging an editorial rethink.

These kinds of debates over the relative value of different research approaches flare up from time-to-time. Sixteen years ago Philip Burnard and I wrote a paper on the emergence of two camps within mental health nursing. We characterised these with reference to a quantitative/qualitative divide, and made a case for rapprochement and synthesis.

In the event, this week’s campfire which I missed was a sensible and informed one, with excellent speakers. The recording can be viewed here:

For the record, the exemplar piece of qualitative mental health research which I had prepared to talk about is Strauss and colleagues’ Psychiatric ideologies and institutions. I wrote a short piece about this book in 2014, on the occasion of its fiftieth birthday. My view remains that many of the observations made within it are as relevant now as they were in 1964. Ideas and practices, for example, remain contested.

Suffice to say that there has been no shortage of very high-quality qualitative mental health research produced in the years since, including by nurses. Check out these papers by two other invited campfire participants: Alan Simpson on the squeezing of community mental health nurses’ time, and Michael Coffey on the use of time in the accounts of conditionally discharged patients living in the community. Both show how the considered analysis of detailed qualitative data can reveal vital new knowledge of mental health systems, and of the views and experiences of people working within, or using, them. For readers wanting more, over on the Mental Elf website there are currently more than 200 blog posts on recent qualitative research: a rich repository indeed.

This week’s Mental Elf campfire discussion also included some commentary on the use of mixed methods. COCAPP and COCAPP-A demonstrate the value of combining quantitative and qualitative approaches, and reveal how data from surveys, interviews, observations and documentary review can be fruitfully brought together. This type of study is becoming increasingly popular, informed by the idea that different research questions (of a type which might be brought together in a single project) simply require different methods to answer them. This is a position I remain comfortable with.

And so we press on. I’ve been involved in lots of writing lately, as projects yield papers. As per my usual practice, as these appear in journals I’ll aim to write posts on this blog about them and include links to open access versions as I am able. Thanks for reading, and feel free to comment.

COCAPP findings published

This morning saw the publication of the full and final report from COCAPP. COCAPP has been led by Professor Alan Simpson from City University London, and (as readers of this blog will know) has been concerned with care planning and coordination in community mental health, and the relationships between these processes and recovery-oriented and personalised care.

Today’s report appears in a single issue of the NIHR’s Health Services and Delivery Research journal. Following the link above takes you to a page from which the complete, 218-page, document can be downloaded. For a shorter read, follow the links instead to either the scientific or the plain English summaries.

Over on the COCAPP blog site, meanwhile, Alan Simpson and Alison Faulkner have written this accessible summary:

Who carried out the research?

The research was carried out by a team of researchers from three universities: City University London in England, and Cardiff and Swansea Universities in Wales. The team was led by Professor Alan Simpson at City University.

Service user and carer involvement:

Of the 13 researchers working directly on the study, six were involved in part time roles as service user researchers: one as co-applicant and the others to interview service users and carers. In addition, there was an advisory group of people with lived experience.

Who funded the research?

The National Institute for Health Research (NIHR) Health Services and Delivery Research Programme (HS&DR 11/2004/12). This is a Government research funding body.

Why did we do the research?

Although there are two different systems in England and Wales, both mean that people receiving mental health services should have a care coordinator, a written care plan and regular reviews of their care. With the introduction of the recovery approach and personalisation, it is now expected that care planning and coordination should be recovery-focused and that people will be taking more control over their own support and treatment.

What were the aims of the research?

We wanted to find out what helps and what hinders care planning for people with mental health problems to be collaborative, personalised and recovery-focused.

By collaborative we mean that care planning is completed in partnership with the service user: the care coordinator works with the service user to plan their care.

By personalised we mean that care is designed with the full involvement of the service user and designed to meet their individual needs.

By recovery, we mean ‘a personal journey … one that may involve developing hope, a secure base and supportive relationships, being more in control of your life and care, social inclusion, how you develop coping skills, and self-management … often despite still having symptoms of mental illness.’

Where was the research carried out?

The research was carried out in six NHS mental health service provider organisations: four in England and two in Wales. One of the reasons for carrying out the research in both England and Wales is that Wales has a legal framework in place called the Mental Health Measure, introduced in 2010. This is intended to ensure that where mental health services are delivered, they focus more appropriately on people’s individual needs. In England, care planning is informed by guidance and is not legally required.

What did we do?

The focus of our research was on community mental health care. We wanted to find out the views and experiences of all of the different people involved: care coordinators (in community mental health teams), managers, senior practitioners, service users and their carers.

  1. We carried out an extensive literature review.
  2. We sent out questionnaires to large numbers of people, and received replies from service users (449) and care coordinators (205); these included questions on recovery, therapeutic relationships, and empowerment.
  3. We interviewed senior managers (12) and senior practitioners (27), care coordinators (28), service users (33) and carers (17).
  4. We reviewed 33 care plans with the permission of the service users concerned.

What did we find?

Summary of the survey findings:

  • There were no major differences between the six sites on the empowerment or recovery scores on the service user questionnaires;
  • There were some significant differences between the sites on therapeutic relationships: where there was good collaboration and input from clinicians, relationships were rated as more therapeutic;
  • We also found significant differences between sites on some recovery scores for the care coordinators: where they saw a greater range of treatment options, the service was rated as more recovery-focused;
  • We found a strong positive correlation between scores on the recovery scale and the therapeutic relationship scale for service users; this suggests that organisations perceived to be more recovery-focused were also perceived as having more therapeutic relationships.

Cumulative insights

Not for the first time, I’ve attempted to produce some cumulative insights from the past and present mental health research studies I’ve had the opportunity to work on. These include my PhD investigation into work and roles in community mental health care, my post-doctoral study of crisis services, and more recent projects which Alan Simpson, Michael Coffey or I have led on.

The prompt, on this occasion, has been the chance to give a presentation at a School of Healthcare Sciences research seminar taking place this afternoon. For anyone interested, here is the PowerPoint I used. I opened with some general comments on the need for mental health research, and on the funding landscape. I then had some things to say about theory, design and methods. Many of the individual slides have hyperlinks to green open access publications:

Fees, theses and project updates

Last week brought the news that, in England, people beginning nursing degrees from the 2017-18 academic year will need to take out student loans to cover the cost of their tuition fees. The cap on student numbers will also be removed. The Council of Deans of Health broadly supports this move, having previously argued for change. One of the things it points out is that current funding for students (via the agreement of the benchmark price) does not cover the real costs of educating new nurses. The Royal College of Nursing, on the other hand, is concerned that last week’s announcement prepares to break the connection between the NHS and financial support for student nurses, and simultaneously risks making nursing a less attractive career option. This concern particularly relates to mature students and those contemplating a second degree, for some of whom the prospect of additional debt may be exceptionally unappealing. As a nurse academic in Wales I wait with interest to see what policy on fees will emerge from the Welsh Government.

In other news, I find myself engaged in a prolonged period of doctoral student activity. I’ve examined a number of theses in and out of Cardiff in recent months, and have sat with students during their vivas as either supervisor or independent chair. This term has been particularly packed. Plenty of writing has also been taking place: papers and reports are being written from COCAPP, RiSC and Plan4Recovery, and from completed theses I have helped to supervise. Data generation in COCAPP-A has almost concluded, and new research ideas are taking shape. Exciting times, if a little frenetic. 

NPNR 2015 review

About to commence: #NPNR2015
About to commence: #NPNR2015

The 21st Network for Psychiatric Nursing Research (NPNR) conference took place on Thursday and Friday, September 17th and 18th 2015, with the theme of ‘Building new relationships in mental health nursing: opportunities and challenges’. The occasion was a fine one, with just short of 200 people in attendance. For those not able to make it but wanting to know more, the programme can still be found here and the book of abstracts here.

I’ve been on the NPNR scientific and organising committee this year, courtesy of my membership of Mental Health Nurse Academics UK. This afforded me the chance to welcome delegates at the conference opening, and to draw attention to the just-breaking news of Professor Len Bowers’ planned retirement at the start of 2016. Len has been an inspirational mental health nurse researcher: more on this later.

2015-09-17 15.58.04
#NPNRselfie with Karina Lovell

Introduced by Professor Liz Hughes as day one conference chair, this year’s keynotes commenced with Professor Karina Lovell giving an overview of the current state of knowledge in remote psychological therapies. Karina is a world leader in research into interventions for people with commoner mental health problems such as depression and anxiety, as well as being actively involved in services and practice through her work with organisations like Anxiety UK and others. For an example of important new research in this area check out the REEACT trial into computerised CBT for people with depression. This is an important study which Karina both referenced in her talk, and is actively involved in.

Dr Geraldine Strathdee, NHS England’s National Clinical Director for Mental Health, delivered a second keynote on using mental health intelligence. She praised the work of nurses, and made a strong case for mental illness prevention. Geraldine also reminded delegates of the high rates of premature mortality of people living with mental health difficulties, and the continued exclusion of many from employment. As routes to improvement she pointed to leadership, and the value of data to benchmark and drive up standards.

Keeping up with the evidence: an impossibility?

Day one’s final keynote presentation was delivered by André Tomlin, founder of the Mental Elf website and author of this pre-conference blogpost. André is an information scientist, who illustrated the challenge of keeping up-to-date with the evidence using this slide. Podcasts, social media, tweetchats and other new technologies are all part of André’s solution to the challenge of information overload, and as strategies to help plug the leaky evidence pipeline. The National Elf Service, of which the Mental Elf is a part, plays a big part in this area; for an overview of what’s on offer, here’s one of André’s videos:

Therapeutic approach, or therapeutic alliance?

Chair for day two was Professor Doug MacInnes, one of whose duties was to introduce Professor Shôn Lewis from the Institute of Brain, Behaviour and Mental Health at the University of Manchester as the deliverer of the conference’s fourth keynote lecture. Shôn spoke about current approaches to the care and treatment of people with psychosis and schizophrenia, using findings from the non-commercial CATIE and CUtLASS trials to suggest that newer antipsychotics are generally no better than first generation antipsychotics. Shôn also referenced the SoCRATES trial to evidence the idea that outcomes are associated with the quality of the therapeutic alliance, rather than with the specific therapeutic approach used. SoCRATES, I have now discovered, compared the effectiveness of (1) CBT plus routine care, (2) supportive counselling plus routine care and (3) routine care alone for people with schizophrenia. Shôn devoted the last part of his presentation to ClinTouch (a mobile phone app to record and upload symptoms) and CareLoop (which is testing if ClinTouch can be connecteded to NHS IT systems and to everyday practice).

Mark Brown about to begin his talk
Mark Brown about to begin his talk

#NPNR2015’s final keynote was delivered by Mark Brown, and the full text of his talk can be read here. Mark edited One in Four magazine, and is now development director of Social Spider, runs the Day in the Life project and is part of the team behind the WeMHNurses Twitter meeting place. Drawing on personal experience of its usefulness he described digital technology as less of a possible future than an unfolding present. One example of tech in action, which Mark referred to in his talk, is his own Doc Ready website. This was designed to help people prepare for discussions with doctors about their mental health difficulties.

SUGAR does Dragons' Den
SUGAR does Dragons’ Den

That’s summary enough of the keynotes. From the concurrent sessions I participated in, chaired or observed I’ll first start with the SUGAR meets Dragons’ Den workshop. Three volunteers – Jason Hickey, Laoise Renwick and Cher Hallett – pitched their research ideas to SUGAR members. In the event, SUGAR offered their time and support to all three, but also voted Cher’s plans (on intramuscular injections) as the best of the batch. In the second concurrent I’m picking out, Julian Hunt, Alan Meudell and Michael Coffey presented reflections from Plan4Recovery. This project, which I’m also part of, is examining shared decision-making and social networks for people using secondary mental health services. And, finally, a word about our COCAPP symposium. This started with an overview paper from Alan Simpson, was followed by a presentation from Michael Coffey titled, ‘Ordinary risks and accepted fictions: how contrasting and competing priorities work in risk assessment care planning’ and concluded with a paper from Sally Barlow and me on participants’ views and experiences of recovery and personalisation.

The RCN's history of mental health nursing exhibition
The RCN’s history of mental health nursing exhibition

Organised by Laoise Renwick, this year for the first time the NPNR conference featured a poster trail. This worked well. Displayed posters were themed, and during lunchtime on day two guided delegates took opportunities to speak with those associated with them. Along the way I spotted some interesting posters from the RCN, drawing attention to an upcoming history of mental health nursing exhibition (organised with lots of help from Ian Hulatt) about to launch in London.

Elsewhere, the NPNR conference has become the place where the names of the following year’s Eileen Skellern Lecturer and the winner of the Journal of Psychiatric and Mental Health Nursing Lifetime Achievement Award are announced. Check out my tweet below for news for 2016. Many congratulations indeed to both Cheryl and Tony:

Len Bowers at #NPNR2015
Len Bowers at #NPNR2015

Finally, a word on Len Bowers. At Doug MacInnes’ invitation, Len took to the lectern during the afternoon of day two to confirm his upcoming retirement and his plans for the future. These include (we learned) playing the flute, travel, photography and electronic music-making. Very nice. Len is a generous, principled and humble man whose contribution to creating new knowledge for mental health nursing has been immense. Take Safewards as an example. This is Len’s NIHR-funded programme grant, findings from which are changing practice in the UK and around the world. That’s some achievement, in my book. We wish him well.

Final call for #NPNR2015 delegates

Next week the 21st International Network for Psychiatric Nursing Research (NPNR) conference takes place in Manchester. There is still time to book a place, but only for those who act quickly as demand has been high. Here is what we’re saying about this year’s event:

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 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.

NPNR 2015And, for a taster, here’s a snip from the conference website giving some information on this year’s keynote speakers. Very impressive indeed.

As always, the two-day programme also features concurrent sessions, supplemented (this year) with workshops and symposia. I’ll be part of a COCAPP delegation delivering three linked papers: a main findings presentation, a paper with an interesting emerging analysis of risk in care planning and coordination, and a presentation on how people talk about recovery and personalisation.

First COCAPP publication

COCAPP BMC protocol

Here’s a brief post to flag this week’s appearance of a first published paper from COCAPP. This is the study protocol, and can be found in BMC Psychiatry. Clicking the image above will take you directly to the gold open access PDF of the article.

Protocol publishing is a fairly new phenomenon. It encourages transparency, and in the case of health intervention studies is a way of meeting the registration and reporting standards which organisations like AllTrials are campaigning for. COCAPP has not been an intervention study, but publishing the protocol is still valuable for the purposes of openness. When findings are published at a later point, readers can also be given the briefest of summaries of the methods used coupled with a reference to the protocol paper for the full detail.

Mental Health Nurse Academics UK meets in Nottingham

I was unable to make Thursday evening’s Skellern Lecture and Journal of Psychiatric and Mental Health Nursing Lifetime Achievement event hosted by Patrick Callaghan at Nottingham University. My congratulations to Ian Norman and to Marion Janner, this year’s very worthy award winners. As it happens, Ian was one of my PhD examiners. My following of Thursday’s proceedings from afar, via Twitter, tells me I missed a treat.

I was, however, able to make the trip to Nottingham for Friday’s summer term meeting of Mental Health Nurse Academics UK (MHNAUK). This was held in the new, and rather impressive, Institute of Mental Health building:

Here’s a picture I took of the sculpture, titled House for a Gordian Knot, displayed at the entrance to the Institute’s main building:

We had three local presentations. First up was  Paul Crawford, who gave a broad overview of the Creative Practice as Mutual Recovery research programme which he leads, followed by Andrew Grundy giving an account of qualitative findings from the Enhancing the Quality of User Involved Care Planning in Mental Health Services (EQUIP) study. EQUIP is an important, NIHR-funded, programme of work which (along with COCAPP and COCAPP-A) is producing evidence of how care planning is being done and how it might be improved. Here’s a photo, taken and shared by Karen Wright, of one of Andrew’s final slides outlining steps to successful user involvement in this process:

Tim Carter talked us through his freshly-minted mixed methods PhD, in which he investigated the use of a preferred-intensity exercise programme for young people with depression. I thought this to be a very well-designed study, which generated considerable discussion around the active ingredients of the intervention and plans for a future follow-up.

Elsewhere Lawrie Elliott, editor of the Journal of Psychiatric and Mental Health Nursing, was welcomed by the group to give an update on developments at the journal in his first year at the helm. I really liked what I heard, and said as much in our discussion. Quality of papers, and relevance to mental health nursing, are being prioritised. Word limits have been increased to allow for more in-depth analysis in accepted articles. To extend its reach the journal now has a Twitter account, which can be followed by clicking the following link:

Ben Thomas from the Department of Health opened a discussion on the future of the Student Mental Health Nursing Conference, the inaugural event having taken place at the O2 Arena in London in February this year. As I understand it, much of the organising was done by staff and students at Greenwich University: well done, them. A group of MHNAUK members representing different universities has agreed to collaborate to keep this initiative going, and with a view to turning it into a cross-UK, rather than an England-only, opportunity.

Following David Sallah’s meeting with MHNAUK in York in March 2015, Joy Duxbury and Steven Pryjmachuk chaired a discussion on the current status of the Shape of Caring review. Since returning from Nottingham I have found that Health Education England is planning to sound out opinion through a series of events running into the autumn. Details are to follow.

Thanks particularly to John Baker, in the weeks leading up to this latest meeting MHNAUK published a response strongly criticising the announcement that the National Institute for Health and Care Excellence (NICE) was ending its work in the area of safe staffing. This decision, defended two days ago by Jane Cummings (Chief Nursing Officer at NHS England), has also been challenged by others including Sir Robert Francis and now the Council of Deans of Health. The Safe Staffing Alliance campaigns in this area, and MHNAUK will continue to make a contribution via a further response the outline of which was agreed in Nottingham. As a reminder of some of the key evidence supporting the importance of registered, graduate, nurses for quality and safety follow this link to an earlier post on this site and this link to a recording of Linda Aiken delivering the Winifred Raphael Memorial Lecture at the University of South Wales on October 1st 2014. And, for those interested in how #safestaffing is shaping up differently across the countries of the UK, follow this link for a record of the progress of the Safe Nurse Staffing Levels (Wales) Bill through the National Assembly for Wales. Following this link brings you to a report reviewing the evidence, commissioned by the Welsh Government and produced by a team led by Aled Jones in the Cardiff School of Healthcare Sciences.

Fiona Nolan shared progress on her survey of mental health nursing research interests and expertise in UK higher education institutions. And, finally, on behalf of the organising and scientific committee Russell Ashmore, Laoise Renwick and I took the chance to update MHNAUK members on progress for the 21st International Network for Psychiatric Nursing Research conference.

#NPNR2015 takes place at the Manchester Conference Centre on Thursday 17th and Friday 18th September 2015. We think the programme is shaping up perfectly, with keynote speakers including England’s National Clinical Director for Mental Health Dr Geraldine Strathdee, Prof Shôn Lewis from the University of Manchester, Mark Brown who ran One in Four magazine and is now involved with The New Mental Health, and André Tomlin who runs The Mental Elf service. We have symposia, workshops and concurrent sessions with papers accepted from presenters around the world, a walking poster tour and the opportunity for fringe events. Make your booking now!