Back in summer 2019 (which seems, for pandemic-related reasons, to be much longer than a year ago) I wrote a short post introducing the 3MDR study. Here, now, is the main findings paper in early view in the journal Acta Psychiatrica Scandinavica. Working on a clinical trial has been an interesting, learning, experience for me and this feels like an important project to have made a contribution to.
I realise, too, that I’ve neglected to draw attention on this site to two papers co-written with Ray Samuriwo, both drawing on systems perspectives, wounds and mental health: see here and here. Ray is an original thinker, and makes interesting connections across different fields: check out, too, Values in health and social care for which Ray was lead author.
The Nursing and Midwifery Council is consulting on its programme of change for education. Information can be found here, and there’s a lot of it. Mental Health Nurse Academics UK (MHNAUK) will be submitting a response, with Anne Felton from Nottingham University (who leads MHNAUK’s Education Standing Group) coordinating this work.
On July 11th, with mental health nurse academic colleagues in the School of Healthcare Sciences in Cardiff I spent part of our annual summer away day formulating a team response to the NMC’s proposals. Once we’re happy with the content we’ll be forwarding it to Anne, and simultaneously submitting directly to the NMC.
Individually and collectively, other mental health nurses will be formulating responses too. For now, the NMC confirms that the four nursing fields (mental health, adult, child and learning disability) will remain. For an explanation of the importance of preserving mental health nursing as a pre-registration speciality, follow this link for MHNAUK’s relevant position paper. But, as MHNAUK Chair Steven Pryjmachuk pointed out last month in this piece (£) for the Nursing Times, the list of nursing procedures contained in the NMC’s draft standards of proficiency is heavily skewed towards the adult field. This is the Cardiff University mental health team’s concern too, and we’ll be saying so (with specific examples) in our response. Another place for this (and any other) view to be given is at this forthcoming WeMHNurses chat:
Meanwhile, last week ended with two days of professional doctorate teaching. With Nicola Evans I lead a module which addresses working in, and examining, complex systems of health and social care. We’ve run this module before, and as always the student group was a lively and engaged one. Amongst the things we discussed together are the connections running within and between systems of different scale, and the sometimes unforeseen consequences of introducing change. These are matters about which both Nic and I have written (see here, here, here and here).
To link the two parts of this post together: the NMC is a big player, and for better or worse its programme of education reform will trigger significant disruption. A systems thinking perspective encourages us to consider the possible impact of the NMC’s proposals alongside other sources of change. These include the introduction of fees for student nurses in England, the arrival of nursing associates and reductions in the size of the UK’s registered nurse workforce. As cumulative shifts take place I’m hoping mental health nursing as a distinct profession emerges intact, with its current and future practitioners able to fulfil their places in a system which continues to very much need them.
Two interesting collections of papers have caught my eye in the last week or so. Davina Allen has edited an online volume of articles, all previously published in the journal Sociology of Health & Illness, addressing the sociology of care work. In her editorial Davina sets the scene with reference to the Francis Inquiries and concludes with this:
[…] in the wake of Francis the predominant response to raising the quality of care and compassion has been to focus on the attributes of individuals and wider regulatory arrangements. As we have seen, however, the kind of care that can be provided depends fundamentally on the social organisation of care work, which in turn hinges on what we (society) are prepared to pay for. Francis has called for national fundamental care standards, but this requires more careful attention to the models of care-giving practice that will sustain them, including care-giver roles, the inter-relationship of care work components and features of the organisational context. The papers in this collection reveal there are no easy answers to these questions, but the insights they yield make an important contribution to these debates. In bringing the papers together in this virtual special issue the aim is to both raise the profile of the individual contributions, but also their collective value to this critical issue of public and policy concern.
Meanwhile, Tim Tenbensel, Stephen Birch and Sarah Curtis have edited a special issue of Social Science & Medicine devoted to the study of complexity in health and health care systems. I have a personal interest here, as it is in this collection of new papers that my article Connections and consequences in complex systems: insights from a case study of the emergence and local impact of crisis resolution and home treatment services appears. Describing himself as ‘a sympathetic outsider to complexity theory’, Tim Tenbensel in his editorial closes with this:
[…] perhaps the most important conceptual issue for complexity theory seems to be the place of ‘top-down’ interventions in complex systems. Are they part of the landscape of complexity, or are they things that ‘impede’ the unfolding of self-organising, emergent phenomena? More sophisticated applications of complexity suggest the former answer, yet the will to control through linear, rational, prescriptive mechanisms remains an ever-present shadow – something that should be minimised – because it this a defining trope of complexity theory applied to the social sciences. This theoretical challenge is perhaps most pressing in contexts in which health services are directly funded from public sources.
My apologies to the doctoral students whose ‘complex systems’ module I taught a few weeks ago, who may erroneously have thought that I knew what I was talking about, but like Tim Tenbensel I regard myself as being a relative newcomer to this whole complexity approach. So I for one am looking forward to reading the other papers in this new collection, and to learning plenty that is new.
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.
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.