So what?

"So what"?
Apart from being the title of a superb piece recorded by the Miles Davis Quintet it is the acid test of many a critical reader of research papers. Nowhere is that more true than in the world of mental health nursing research. Now I know many people can discuss research methods in a passionate and frankly frighteningly intensity, but to many readers of a more casual (or practical ) ilk it's the findings they care about.
Many will wonder about how long until this finding will drizzle down to the realities of practice, or indeed find it's way into policy.
There will of course be those who just evoke the "so what" response and move on..
This question of relevance became all the clearer at the Network for Psychiatric Nursing Research conference in Oxford in September. It was a rousing success and well attended . Delegates were present from over 20 countries, and more PhD's present than you could shake a stick at.
The opening adress was in the form of a conversation between Professor Alan Simpson and that venerable sage Professor Peter Nolan. Now Peter is a raconteur that always manages to leave you wanting more, he has a wealth of stories, views and perspectives that have come from a long (sorry Peter) and thoughtful life.He was fascinating to listen to but possibly kept his final and most challenging thought until last.
I am paraphrasing rather badly here, but essentially he asked when will researchers in the field of mental health start utilising thier skills to ask questions that really matter. Projects , he mused, may be fascinating and personally rewarding ; but where was their relevance to the users of the services provided.
An eloquent "So what" , that challenged those present and perhaps the wider community to consider how they could use their knowledge to achieve outcomes that would hold real meaning and relevance to those living lives challenged by poor mental health.
Perhaps a challenge for research agendas that are challenging and  radical.
Perhpas an era of findings that cannot be dismissed with a cynical "so what".

Hospital car parks

Contentious things aren't they? we have all visitted someone and resented the scrabble for change, or even how much we have to pay for visiiting someone frequently and how much it costs. Some people find hospital car parks a very useful metaphor for many issues. Here's one i really like. Hospitals are just like car parks because .......as soon as you build one it fills up.Well I guess that does hold up as an illustration. We are often told there is an over provision of beds in some sectors, yet the beds are all full.I suppose if you restrict parking then people find other means of getting to places, and the belief is that if you close beds and transfer the funds to community services then lo and behold the beds just aren't needed. I suppose as occured in the massive down sizing of psychiatric provision in the 80's.
Hospital car parks are another useful indicator of activity. If you go to your average District General Hospital at the weekend , what do you find? The consultants car park with its designated spaces will of course be largely empty, likewise the admin peoples. Yet the nurses car park (if there was such a thing) will be full as usual. Why so? Probably because patient need doesn't keep office hours and acutiy doesn't drop off at 5pm on a friday. In fact we are now told that mortality rates rise by up to 10% at the weekends due to the non availablity of senior medical staff to advise their junior colleagues (although available on a phone). It has been suggested that this needs to change.
Perhaps we will see all the car parks starting to be as full as the nurses' one?

My "London face"

I was introduced to a fascinating idea the other day from a colleague who was visiting London for the day. He had at one time worked in London and then had moved to the West Country. Whilst we waited for the meeting to commence he told me that he hadn't been in London very long that day and he had found himself re-adopting his "London face". I was intrigued by this and asked what such a face looked like. He told me it was essentially a blank stare and he proceeded to demonstrate it to me.
It was as he said blank. In some ways similar to the blank expressionless stare that some people with Parkinson's disease have. Devoid of expression and at the same time a bit threatening.
We discussed what the purpose of such a stare was. He considered it was to avoid contact, in particular to avoid interactions with people who are trying to sell or beg. I was familiar with the tricky issue of eye contact on the Tube and how that took some managing on a busy trip, but this really interested me. Was it a way of keeping to oneself, or a means of keeping people away.
A look that says "don't bother me".
As I was making my way to the Tube at Oxford Circus I noticed that all three Big Issue sellers I had passed didn't offer me their magazine.
I became worried, was I wearing my very own "London face"?

Orgone accumulator

"I've got an Orgone accumulator
and it makes me feel greater
its a one man isolator
made out of orgone"
So sang Robert Calvert on probably Hawkwind's greatest album "Space ritual" , and if you haven't heard it I thoroughly recommend it (in particular the original  fold out sleeve is an exercise in 70's excess)
But this was a song based on an actual device that you were supposed to sit inside and somehow it would not only isolate you but capture Orgones and do you good (sorry about the lack of precision here). I came to think about this song (which I really must place on my I Pod) when I was on one of my usual long commutes to London to do RCN business. I am always impressed how we as humans choose to not engage with each other. In fact I would argue we seem to live in fear of the "other". Opprtunities to isolate the self in a public and indeed crowded place are now more numerous than ever. I like most commuters/travellers on the long haul to London have in my possession an I Pod and a Kindle (and probably a Guardian as well), and like a lot of others I probably use my IPod to erase or exclude the sound of the "others" around me. There is something really strange about being party to private conversations in public places facilitated by mobile phones.
We travel forced by circumstance to be with strangers and isolate ourselves by means of technology.
I wonder is this isolation healthy?

We've only just begun

Now I am pretty sure that was the first line of a Carpenters song in the 70's, and was probably about the commencement of a new relationship or something equally slushy (as I am sure I thought at the time). It also is true if the Guardian can be believed true of another relationship. According to an article last week by Polly Toynbee (who still gets ribbed by her call for readers to vote Lib Dem in the Election of 2010), we are also at the start of something else, another less welcome relationship. A relationship with Austerity. According to her article only 6% of actual public sector cuts planned have yet occurred. thats right readers, only 6%. Now there was no citing of sources, no references (Geneva or Harvard), so maybe she got it wrong. Say for arguments sake she's out by 300%, so  approximately 20% of projected cuts have occurred.
With a public sector payfreeze and an expensive reorganisation (marketisation) of the NHS occurring then what does this hold out for us? I wager its a bit more serious than the chatterati camping outside their Libraries in North London or indeed twice weekly bin collections.What will it actually look like? How we can envisage a rolling back of services at such a scale? How will it look in the sleepy hamlet where I live. Well mabe the libary is at risk, maybe the local schools will miss out on maintenance, day services for the vulnerable, or possibly a lessening presence  of police. Could be rubbish collection, street cleaning, or public amenities will start charging like parking at the beach . Small stuff maybe, but an eroding feeling, public morale can be vulnerable to such an approach.
To push through this we all need a belief that it can be endured, that we can tolerate the hardships (bit like winter really), and that maybe its in some way tolerable because its inevitable or even fair (just like winter).
So is this approach fair , tolerable or even something that the ordinanry citizen has caused and should pay for? If the answer is no then where will the feeling of injustice go? Here in the UK the usual pattern is to internalise distress , that could mean calls for help to  services that no longer exist. It really has only just begun.

Powerless victims?

Sometimes I catch a persons name, and especially one I haven't heard for a while and I think "I wonder what happened to them". Of course now with Google and other sourcers of information they can be tracked down if you wish. So it was with real pleasure I read an article online in Mental Health Practice by Prof Michael Traynor. It is called "Constrained by impossible ideals" and it offers (wait for it) a psycho-dynamic perspective on nursings apparent inability to resolve some of its more bedevilling contradictions. Indeed an old friends name (not Michaels...but a reference to Freud) is duly mentioned.
One of his four points to illuminate his argument he refers to is nursings apparent pleasure in "a stance of powerlessness and victimhood". This is evidenced by behaviours that are self defeatting and exhibited in that familiar process we often refer to as "wingeing".He supports this by reference to the Death Drive that Freud saw as part of his Pleasure Principle (not to be confused with the Gary Numan album of the same name), and further more this behaviour provides a degree of pleasure and relief from the conflict and tension that the role possesses.
The author really does have a valid point in his argument that nursing faces in many ways an impossible ideal, and as we know today an ideal that is the benchmark against which all nurses are judged, and publically so. Also it sems quite plausible that a powerless workforce that engages in such behaviour is of course more malleable and convenient to direct (guide, bully,influence.....take your pick)
Sigmund Freud certainly a name from the past in many ways but an interesting theoretical insight none the less
Oh just in case you think this is mere psychobabble then remember the work of Isobel Menzies in the 1960's ,quoted by many in reference to task allocation but predicated on the same underpinnings.

Five a day for mental health

Five a day seems a lot when we talk about vegtables and fruit, indeed if you are out and about like me (or indeed a CPN colleague) how can you carry it all. Some say crisps count but I am not to sure. Yet the principle of five a day is possibly equally applicable to our mental health. So what would they be for you? Indeed have you thought of that at all? How do you enhance your sense of well being and increase your resiliance(or even maintain it).
Well for me this is an interesting challenge. I guess my blog gives a clue. so here goes.
1 doing a day in work that feels worthwhile
2 getting outside at some point in the day and stopping and enjoying the fresh air (it can even be done in London)
3 completing a task or role well
4 enjoying time with others (preferably that involves laughing)
5 spending some time on my own (but not to much)
Simples!!!
What about you?

Collective grieving and the NHS reforms

A while ago I read an analysis of the public reaction in Greece to the austerity measures where it was argued that the nation was grieving. It wasn't an outburst of sadness or anger but a progression through the stages proposed by Kubler -Ross all those years ago. you probably remember how it goes (Denial Anger Bargainning Depression Acceptance). The commentator was asking whether the reaction of the Greek public was more than attributable to a mediterranean temprament but in fact the Anger phase of the Kubler -Ross model. Since then publication of the suicide figures for Greece would indicate that collectively they are in a state of malaise.
Could the application of that model be applied here in the UK as we face a momentous change to a nationally cherished system of health care from which we all have probably benefitted? Its hard not to see the events of the last few weeks as not a hardening of self interested stances but a real move to a phase of Anger.As any student of Kubler -Ross's model will tell you , it's not necessary to progress through the stages in a ordered sequence. So just perhaps the preceived failure of Bargainning may take us back to Anger in a way never experienced before in the history of the NHS.

Intentional rounding in mental health settings?

Well you know how it is, you admit to something and it dates you. I guess things like the advent of colour TV, the recollection of steam trains (engines to be more precise) and oh yes Supercar. But nothing has made me feel more old than the notion of rounds. I remeber the tyranny of back rounds, obs rounds, comfort rounds, tidy rounds. Oh yes and then being told they were "task oriented" and then we had to pretend we weren't doing them any more. That was because we had become "patient centred".Now however thanks to the insights of the Prime Minister we are to be engaged in them once again. Now I can see the virtue of regular patient contact, and I can also see how they will be welcomed by patients who really do want to have "nurse time". I just am trying really hard to imagine what they would look like in a mental health setting.
Now we do know that if we take "anytown" acute psychitric admission ward, there will be patients who say that they do not see enough of the nurses.We know that they will be frustrated occasionally by what they see as a lack of interest. We also know that there are wards that have engaged in the process of rigorous 1:1 sessions, all duly documented and scrutinised by clinical supervision. Yet will that meet the "intentional rounding" that the PM has? Or is that limited to where the machines go "beep" and the nurses all wear uniforms?

Diabetes led the way

Interesting day today, discussing and considering how primary care services could and probably will care for people we consider labelled as having "serious mental illness"(SMI). In other words the psychoses such as Schizophrenia and Bi-Polar disorder. Why Diabetes in the header to this entry? Well not so long ago people with diabetes would attend diabetic clinics in hospitals, spend times in waiting areas and have their blood sugars measured and their insulin levels titrated. Something that a GP or Practice nurse was not considered competent to do. Then a change occurred and the staff in Primary care were trained up (or developed competencies if you prefer) and the ongoing care of people with diabetes was transferred to primary care. No more trips to hospitals, and only probably going there at all if matters became outwith the scope of primary care.
Now could the same occur for people with  SMI? Could their routine care be in the primary care setting, could this be achieved with the presence of existing secondary mental health staff located in primary care for support of their colleagues? Consider the gains. no more attending out patient clinics in possibly stigmatising settings, no more six monthly appointments where you see a different person each time, and possibly the chance to address the issue of poor physical health which still blights the lives of these clients.
Could it happen?

Here we go!

Hello and welcome to my blog! This will be my musings or indeed "mental notes", as I go about my business as Mental Health Adviser for the Royal College of Nursing. It's not intended to be a replacement for stuff in the professional press, but rather a useful and more immediate adjunct. I hope here to place ideas, impressions and thoughts that occur to me. As the tiltle suggests its going to very much be about whats going on in the world of mental health , and I hope it will be interesting for you to read.
Ian