Tag: division of work

Abstract-sifting, a new publication, and music to work by

Not much time for blogging lately, what with one thing and another. I’ve turned into a kind of abstract-sifting machine, poring over the details of papers for possible inclusion in two unrelated evidence syntheses/literature reviews. Amongst other things I’ve also been making some final preparations for a day away (as an examiner) later this week, catching up with colleagues over various bits and pieces, and arranging to meet up with undergraduate students.

Some good news over the weekend was confirmation of a new paper being accepted for publication, in the International Journal of Nursing Studies. My friend Michael Coffey is lead author, and we’ve written about the emergence of the role of approved mental health professional and what this means for nursing. A quick look at the SHERPA/RoMEO website suggests we’ll be able to add post-peer review versions to our respective institutional repositories. I’ll then add a link, and perhaps a bit of a commentary, on this blog.

As an aside, I am reminded of the majesty of Miles Davis’ Kind of Blue. It’s more than a decade since I was first introduced to this, and it now occupies a special place in my (eclectic) music collection. I mention this as Kind of Blue is an album I often turn to when I’m fretting over tasks requiring concentration: like writing, or indeed sifting abstracts. I listened to it today, in its entirety. Then I listened to it again.

Giving a fig about roles

Hannigan and Allen 2011In a paper published in the Journal of Psychiatric and Mental Health Nursing at the start of 2011, Davina Allen and I drew on detailed, qualitative, research data to examine the relationships between policy, local organisational context and the work of community mental health practitioners. A version of the article, which carries the short title Giving a fig about roles, can be downloaded from the ORCA repository here.

Our paper drew on many of the social scientific ideas previously introduced on this blog in my Sphygmomanometers, remedial gymnasts and mental health work post, and which are rehearsed more fully in this earlier Complexity and change paper. Davina and I observed how recent mental health policy had triggered disruption in the system of work, with occupational groups advancing new, public, jurisdictional claims in response to perceived threats to their positions in a dynamic division of labour. One of the examples we gave was the response by sections within the profession of psychiatry to the policy of new ways of working, and its emphasis on ‘distributed interprofessional responsibility’ in particular.

The larger part of our paper reported new research findings. In the project from which it was drawn I had the opportunity to compare and contrast the organisation of community mental health services in two parts of Wales. With a view to understanding each site’s contextual features I read local policy documents, interviewed senior managers and practitioners and observed people at work. I was also interested in gaining a detailed, micro-level, view of the actual delivery and receipt of care. To this end I had permission from three service users in each site to follow their journeys through the mental health system, each over a period of four to five months. I interviewed all six about their experiences, and using snowball sampling mapped out the range of people providing them with care, whether paid or unpaid. The nurses, social workers, psychiatrists, psychologists, occupational therapists, general medical practitioners, pharmacists, health and social care assistants, family members and neighbours identified in this way were invited to take part in interviews focusing on work and roles. I also observed interprofessional care planning meetings and home visits, and read the written notes about each of the six service user participants made by practitioners.

As the full text of the paper reveals, in the analysis developed here we were particularly interested to explore the relationships between workplace characteristics and what practitioners actually did. Not unexpectedly, nurses carried out medication tasks, social workers (as the sole group able to do this at the time data were generated) fulfilled the ‘approved’ role during the operation of the Mental Health Act, doctors diagnosed and prescribed, and the sole participating psychologist provided structured therapy.

Word cloud 02.02.13Beyond this we also found that the work of professionals was ‘patterned’ (to use the phrase coined in this context by Anselm Strauss) by immediate organisational forces. In one of the two sites nurses and social workers had enlarged ‘bundles of tasks’ (this being Everett Hughes’ term). This shaping of what people did could be understood with reference to a variety of contextual features. Key informants in this site described a particularly long and positive history of health and social care staff working together. This manifested during fieldwork in an approach to care provision which emphasised shared tasks and downplayed rigid demarcations. Single community mental health workers, rather than multiple representatives of different groups, tended to be attached to the care of individual service users. Health and social care organisations in this site were also small, lacking pools of staff from which people might be drawn to cover gaps left by departed colleagues. In this constellation of circumstances nurses and other members of staff fulfilled roles which were more ‘generalist’ than was the case in the other of the two sites.

Davina and I were interested to set our findings in the new and emerging context for mental health care. We pointed to larger policy trends favouring unpredictability in working practices, and to the idea that competency (rather than professional background) should determine practitioners’ eligibility to fulfil roles. We observed that ‘flexible, boundary-blurring, professionals competent to carry out multiple tasks may find favour with managers concerned with meeting local needs in local ways’. We reflected on the implications of this for continuity of care, capability and the preparation of new professionals. The paper ended with our thoughts on the challenges all this poses to professions and their jurisdictional claims.

In a later post I’ll return to this study, and in particular to what I learned about the experiences of the people whose unfolding care I followed as each moved through the different parts of his or her local, interconnected, system of mental health care. But that’s for another day.

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.