I published Recovering from Psychosis: Empirical Evidence and Lived Experience in 2016 and having done that you would think that was enough and I should get on with business as usual. But no. I had already started working on a second book idea which was originally going to be a book on Recovery Oriented Nursing – a sort of how-to guide combined with a critical perspective on it. And then everything went pear-shaped. Well, no not really. I started approaching people and talking about the book looking for contributors because another solo effort seemed to be a bridge too far and one that I’ll revisit later (yes there is a Book III idea wanting to get out). Instead surely editing a book and having others write the chapters was easier? The astonishing naivete.
Now we are some 3 months into the writing process for book two. It’s not a Recovery Oriented Nursing book as you may have gathered as the conversations with contributors and gathering co-editors took shape. That and the fact that another book exactly on that topic turned out to already be in press. Instead we have a completely different animal – Critical Mental Health Nursing. Offered up in conjunction with the Critical Mental Health Nursing Network.
CMHN is a vehicle. For multiple perspectives from nurses being critical of nursing, from people who have had experience of being cared for by mental health nurses, from professionals of other disciplines working alongside nursing to be heard. It will have a strong applied to practice focus, an ethnographic and autoethnographic flavour along with empirical evidence, multiple-theoretical-analytical approaches, and is driven by the authors and not the editors. At least that’s the plan! More to come as I have it. We are looking to see it published in 2018 by PCCS.
I’ve recently participated in two review consultations to present a commentary on the recent proposals by Health Education England to introduce a new support role on the back of the Shape of Caring review. In both of these review meetings the context of the proposals and potential implications of the wider context of recent changes to nursing and nurse education, in particular, was a common focus. I’m going to outline these here and voice the kinds of predictions that have been made by both groups about what the future of nurse education looks like.
So if we review the changes that have been happening across both the current Conservative government and the previous Coalition government we can see a number of interventions happening. Firstly in relation to nursing education, we have the establishment of £9,000 tuition fees amongst many Universities wherein the Liberal Democrats ditched their election pledge to not raise student’s fees. The impact of this has been a decline in undergraduate student numbers as quoted verbatim here from the Universities UK 2014 report in conjunction with the HESA (Higher Education Statistics Agency) on the Patterns and Trends in UK Higher Education.
“In 2012–13 there were 140,000 more students studying at UK higher education institutions than in 2003–04, an increase of 6.4%. However, the rate of change fluctuated across the period: 2009–10 saw the largest year-on-year increase, of 4.1%; between 2009–10 and 2011–12 numbers remained stable at around 2.5 million, and then in 2012–13 numbers decreased by 6.3% (156,000 students). First-year undergraduate student numbers increased by 13.7% from 2003–04 to 2009–10, followed by a 22% decrease between 2009–10 and 2012–13.” (Universities UK, 2014; p6). The devil is in the contextual details when it comes to monitoring student numbers – depending on which year we start measuring from and which subset of students get included in the counting.
This should be considered also in light of the upcoming proposals to move away from a student bursary for nursing students to a student loan arrangement. This led to a considerable outcry, protest, a professional and parliamentary debate about the relative merits and potential harms of such a move. It is worth considering that research indicates that in over 40% of such existing loan schemes in HEI institutions in 44 different countries the recovery of such loan monies is 40% or less (Shem and Ziderman, 2009). It’s also worth mentioning that bursaries for Social Workers are being mooted as next on the government’s agenda.
Nurse revalidation “to strengthen the … registration renewal process and increase professionalism” (NHS Employers, 2016) was introduced as one of the measures following the Francis Report (2013). I would argue that whilst this has been ‘spun’ as a way to strengthen nursing and validate our professionalism what has actually been taken away and implemented from the 290 recommendations is in places far removed from this. Whilst the report indicates a number of individualized failings and also managerial shortcomings amongst others the whole of the nursing profession has been made effectively, tacitly to accept as a professional group the responsibility for these failures.
For example, the Francis Report made recommendations regarding ‘safe-staffing’ that the government promised to implement by commissioning NICE to review this independently. They’ve already back-peddled on this and now it is in internal NHS/DOH hands and is only now at the time of writing starting this work picking up from NICE’s previous analysis.
We also now have the government led work-force development plan to create a ‘nursing associate‘ role that Health Education England (HEE) says is intended to sit between care-assistants and qualified nurses . Several issues spring out of this – if the intention is to improve the quality of care (as is alluded to in the HEE documentation and subsequent discussions) then what is the evidence that such a role would do so? (It’s worth noting that when looking at patient mortality rates from acute myocardial infarction in the States studies have shown lower mortality rates when the nursing staff ratio had higher proportions of RN’s and higher mortality rates when nursing staff ratios had higher proportions of LPN’s (Licensed Practitioner Nurses) – a role very similar to that proposed as the nursing associate Person et al. 2004).
HEE also intends that ‘nursing associates’ would form another career-pathway towards nursing qualification then the existing graduate-pathway. Exactly how this would work, and how we could be certain that this more apprenticeship style route would have equivalency in terms of the education delivered is highly contentious. What we would have in the interim however is a new tier of work-force that registered nurses would have to take responsibility for – more management and less hands-on nursing from qualified staff then – that decreases patient safety. Nursing associates will not for instance be putting together care-plans, so that’s a job left to the RN. Another consequence I see of this workforce change is that we have cheaper care and less of it directly in the hands of RN’s. I would argue further that we also get less consistency in terms of how nursing education is delivered through the introduction of a new career pathway.
There is also the matter of the use of the word nursing in the job-title. Registered Nurse is a protected term, whereas ‘Nurse’ is not. Nursing associate implies the practitioner is of the nursing persuasion, and yet clearly they are a new tier of health-care support worker – not regulated by the NMC. I wonder if the average patient receiving care is going to appreciate what and who this new level of practitioner is and what their expectations will be of what nursing associates can and can’t do?
Once more we have poor work-force planning, not backed by evidence of improved quality of care, that is politically-led and austerity driven. This is coupled with the hanging of responsibility on nursing and education for the complex systemic and individual failings highlighted in the Francis Report. Alongside this we have changes pushed through to student nursing bursaries and graduate fees that will undoubtedly change the landscape of recruitment into the profession.
So, bottom line predictions: the move to a nursing associate will create a new pathway to a nursing qualification. This cheaper for employers option with an ‘earn as you learn’ sales pitch will compete and even become the dominant route into the profession. Regulate nursing associates in the NMC and we have a new two-tier nursing with employers recruiting for more nursing associates into their rotas because, well it’s cheaper. RNs will have an increased clinical-supervisory/managerial role as a result and decreased hands on care. Care quality will be threatened as a result. Nursing isn’t teaching with its attractive golden hello, TV marketing campaign and decent starting salary. Without a bursary a proportion of nurses that would train by the graduate route will go elsewhere or into the NA route instead. We will have less diversity in our workforce as a result. Having axed bursaries the government will turn to social work and claw back funds from there to shore up some other aspect of the incessant goal towards nullifying our countries deficit. To the cost of an already beleaguered health and social care system.
Lately thinking over dialogues I have been observing and participating on twitter, online and in practice has led me to the conclusion that there is a significant socio-political problem at the heart of ‘mental health’ practice. This comes from an assumed idealism of what constitutes ‘mental health’ itself. Mental health is defined as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (World Health Organisation, 2013).
Perhaps on the face of it this positive spin on what constitutes good ‘mental health’ may seem benign and aspiringly inclusive. I find it question-begging. Shouldn’t we all wish to ‘work productively and fruitfully’ and ‘contribute to our community’? Shouldn’t we all wish to realize our potential? And it’s in reflecting upon the superficially desirous goals that I strike upon some potentially stony ground. If mental health is about realizing potential, getting on with life and being a contributing citizen – to paraphrase the definition – then what if my circumstances are such that I am obstructed from attaining any or perhaps all of these? Am I thus devoid of a state of mental well-being as a result? Are these truly necessary conditions for flourishing mental-well-being? If so then what of those who are for whatever reason unable to deal with the stresses and strains of day-to-day living and contribute to their national insurance contributions?
I had a troubled phase of my life (in the mid-latter part of my 20’s) where I was deemed unfit to work and signed off sick. This was because of my ‘mental health’. Already we are in some a kind of tautological trap before we’ve even got started. What sense does it make that I can be deemed ‘unfit for employment’ by virtue of my mental health that is defined as partly as a capacity to contribute to working life? Excluding me from work on these grounds is excluding me from a component of activity that constitutes my mental health! How do I regain this part of my mental health and be seen as ‘fit for employment’ despite my mental health if being in employment is considered to be a necessary feature?
Let’s look at this from a slightly different angle. Looking at research into retirement indicates that we are treading some very swampy ground here. On one hand some research recently published by the Institute of Economic Affairs demonstrates that retirement increases the chances of suffering from clinical depression by 40% and the chances appear to increase the longer you spend in retirement (Sahlgren, 2013). This research isn’t the last word on the matter. A cohort study of people working for Electricite de France (EDF) looked at the annual trend in reported mental fatigue, depression or physical fatigue over the seven years before and the seven years after retirement. It found reductions in depressive symptoms and mental and physical fatigue comparing the year before with the year after retirement. This led to the conclusion that retirement is related to improvements in well-being (Westerlund et al., 2010). So we have conflicting evidence – some suggesting that being out of work contributes to a healthier lifestyle and better mental health and another, equally credible that it leads to a deterioration.
This suggests to me that a serious danger to guard against are adopting ways of working that map goals and outcomes that perhaps generalise well to larger populations (and are the output of research) without care and attention, unthinkingly, to the individuals with whom we are working. Whatever ‘mental health‘ is will differ significantly from person to person and will vary through time – what affords my mental health now is not the same as 20-odd years ago. So for example with a client I worked with in a community service as a CMHN (community mental health nurse) her physical disabilities precluded her from paid employment (as deemed by her and the health and social care organisations). Thus for her mental health defined as necessarily being constituted out of working contributions was pretty toxic and irrelevant. Instead her mental health was living well and having control of her life within the infrastructure of services that provided her with care. She thrived from having support that she could flex around her – being more supportive at certain times, and stepping back with confidence when she was feeling more capable of self-support. For her skills of being able to differentiate between the two and communicating this level of support need accurately – and for that to be heard – scaffolded good ‘mental health’. She felt a sense of mastery and satisfaction from being able to direct her own care as it fluctuated over time.
Looking at governmental interventions that have affected mental health we have had years of NHS staffing cuts, resource cuts, bed losses, ‘back door’ privatisation and rhetoric and tokenism. Take Nick Clegg’s recent pledge (not a good word to associate with Mr Clegg – notorious as he is for reneging on promises) of a £50M ‘boost’ into mental health research. What does this actually do for the much vaunted ‘parity of esteem’? Well firstly from a research perspective it could help maybe fund a few randomised control trials worth of studies. This may improve understanding or enable a new therapy to be trialled. As for what this would do for the experience of the service – next to nothing I would imagine. So this kind of pledge strikes me as nothing more than a misguided and empty political piece of misdirection. Sort of – don’t look at what a terrible dangerous mess this is all in, look at the offer of shiny-shiny money – aren’t we caring and doing something about it after-all?
Let’s also consider this idea of ‘parity of esteem’ – that mental health which has pretty much from its inception within medical and health care practice always played second-fiddle to physical health services in terms of image, funding and priority. Perhaps it seems, at first glance, laudable to call for a parity? When I first heard the phrase it immediately seemed to me that this was going to be another bit of ‘rhetoric’ that would never translate into meaningful action – i.e. raising resources and funding for mental health services. The disproportionate cuts between acute services and mental health services seems to bear this assumption of mine out. (See http://www.bbc.co.uk/news/uk-england-sussex-26530733, http://www.bbc.co.uk/news/health-25777429, and http://www.bbc.co.uk/news/health-27942416 for examples of how cuts demonstrate that ‘parity of esteem’ is a hollow political promise).
Given the potentially devastating impact that mental health difficulties can have on a person’s well-being, life circumstances, relationships, emotional state, livelihood, physical health, citizenship, personal security, status, longevity and employability is it reasonable to suggest that ‘mental health’ should just be ‘on a par’ with physical health? I’m bound to argue that in some respects addressing mental health difficulties should be given priority according to its own needs and impacts, in its own right. This might mean that it needs funding above and beyond acute and physical care and that calling for a ‘parity of esteem’ is doing mental health and healthcare in general a disservice. Is acute and physical care necessarily getting the attention, funding and resourcing it needs and deserves? Somehow I doubt it given the shear depth and breadth of the services encompassed. Equality is not necessarily about “treating everybody equally”, it’s more about making adjustments that enable those persons needs to be met – tailored to obstacles that are present within that person’s life circumstances.
In my upcoming book on Recovering from Psychosis (Williams, In Press) I have a chapter that critically reflects on the potential abuses of the widely discussed ‘recovery’ movement. Within this reflection a point I make is that an organisational requirement to developing clinical practice founded upon partnership in decision-making necessitates a shift in terms of power and authority within professional roles and practices (Slade et al., 2014). This is particularly problematic in the case of treatment under section within the Mental Health Act (1983; 2007) and it is hard to see how services can maintain a recovery approach when this legal enforcement of aspects of treatment are in place. What follows now are my reflections on CTO’s excerpted from my current book draft.
Community Treatment Orders (CTO’s) were introduced as a means of reducing the need for admission and detention in inpatient settings. The data on rates of admission and implementation of CTO’s does not support these ideas, and neither do early randomized trials evaluating the efficacy of CTO’s. According to the Health and Social Care Information Centre (2009; 2013) rates of detention to inpatient facilities in the U.K. increased from 47,600 in 2007/2008 – 2008 being the year in which CTO’s were introduced – to 50,408 in 2012/2013.
Within the limitations of designing and implementing randomized control trials those conducted to investigate the efficacy of CTO’s in reducing the need for admission to hospital each unequivocally indicate that CTO’s do not have an impact statistically on such outcomes (Burns and Molodynski, 2014). There is in counter-balance to this some evidence that the use of CTO’s can reduce the length of hospital stay for certain groups of people (Light, 2014).
As Light (2014) points out in discussing the whys and wherefores of the legitimacy of CTO’s in the face of unfolding contradictory and in places unequivocally negative evidence is that the process of study design, choice of ‘outcomes measures’ and what kinds of evidence inform evidence-based care are philosophical matters. An implication of such studies thus far on CTO’s is that inpatient treatment in some sense is the result of a failure of the CTO. That is there is an assumption that the function of community care is to prevent the need for inpatient treatment. In a clinical context this does not always make particularly good sense – sometimes the purpose of community mental health care is to facilitate access to inpatient care. It has also been argued that CTO’s, like recovery, amounts to a process – wherein what benefit is entailed within the treatment order is in the improved access and availability of clinical resources to the person (Kisely et al., 2013).
These studies also fail to speak as to the qualitative nature of experiencing a CTO – the most recent studies of which in Australia (Light, 2014) paint a consistent picture of distress and ambivalence about the use of CTO’s there. Strangely, whilst studies of lived experience or qualitative data tend to have a reduced regard in terms of health-economic decision-making where randomised trials are seen as the gold-standard for research, a rebuttal of the OCTET trial evidence by Mustafa (2013) argues against the withdrawal of CTO’s based largely on evidence from a fictitious case of anecdotal evidence of its efficacy! It’s a perversely inconsistent world where on one hand we have arguments against the narrow use of existent psychological therapies for psychosis based stoutly and solely on hard-won expensive scientific empirical evidence (via RCT’s) that has limited room for the complexity of user-experience outside of often researcher originated numerical scales of symptom intensity. Yet again we have arguments for the persistence of a typically unpopular form of legally enforceable intervention in the face of the same kind of evidence that draws on a putative case of user-experience to justify this. We are well overdue embracing mixed-methodologies in psychological health ‘science’ and finding ways to draw upon user-experiences so that we can provide interventions that are both empirically valid and experientially attentive.
Given that mental health services is under-pinned by professional mandate to be ‘evidenced-based’ (Goodman and Ley, 2012) and so far CTO’s fail to meet the much prized and costly gold-standard of evidence – how can we be justified in their persistent mandatory usage in the Mental Health Act as is?
This, amongst other arguments, is the basis for the #ChallengeCTOs campaign. We are calling for a review of the relevant legislation that governs the usage of CTO’s. If you agree that a review is warranted you can help get this heard in Parliament by signing up to our e-petition: http://epetitions.direct.gov.uk/petitions/67906.
Burns, T. and Molodynski, A.(2014), Community treatment orders: background and implications of OCTET trial. Psychiatric Bulletin, 38, pp3-5.
Goodman, B. and Ley, T.(2012), Psychology and Sociology in Nursing, London: Sage Publications.
Great Britain. Mental Health Act 2007. London: The Stationary Office. Available at: http://www.legislation.gov.uk/ukpga/2007/12/contents (accessed 30/06/14)
Health and Social Care Information Centre (2009), Inpatients Formally Detained in Hospitals Under the Mental Health Act, 1983 and Patients Subject to Supervised Community Treatment – 1998-1999 to 2008-2009, http://www.hscic.gov.uk/article/2021/Website-Search?productid=13209&q=rates+of+CTO%27s+2007&sort=Relevance&size=10&page=1&area=both#top[Accessed: on 30/06/2014].
Health and Social Care Information Centre (2013), Inpatients Formally Detained in Hospitals Under the Mental Health Act, 1983 and Patients Subject to Supervised Community Treatment, England – 2012-2013, http://www.hscic.gov.uk/article/2021/Website-Search?productid=13209&q=rates+of+CTO%27s+2007&sort=Relevance&size=10&page=1&area=both#top[Accessed: on 30/06/2014].
Kisely S, Preston N, Xiao J, Lawrence D, Louise S, Crowe E, et al. (2014), An eleven-year evaluation of the effect of community treatment orders on changes in mental health service use. J Psychiatr Res,47,pp 650-6.
Light, E. (2014), The epistemic challenges of CTOs: Commentary on Community treatment orders. Psychiatric Bulletin, 38, pp6-8.
Mustafa F., (2013) On the OCTET and supervised community treatment orders. Med Sci Law doi:10.1177/0025802413506898
Slade, M., Amering, M., Farkas, M., Hamilton, B., O’Hagan, M., Panther, G., Perkins, R., Shepherd, G., Tse, S. and Whitley, R. (2014), Uses and abuses of recovery: implementing recovery-oriented practices in mental health systems, World Psychiatry, 13(1), pp12-20.
Williams, S. (In Press), Recovering from Psychosis: Empirical Evidence and Lived Experience, Routledge Press.
Several weeks ago whilst taking part in some discussions on service-user involvement on Twitter that were, in fact, generally positive about this idea I had to profess that lately I have become ‘against involvement’. It’s tricky when you are limited to 140 characters to express nuanced ideas without oversimplifying what it is that you are endeavouring to express. I don’t wish to sound as if I am against ‘inclusion’ or embracing the ideas of service users. As an ex-service user myself that would be somewhat strange – I would have to censor and exclude myself! So I’ve resorted to expressing these ideas at more length here in this blog post. It’s particularly pertinent I think to reflect on this now given the recent thought provoking Guardian article by Peter Beresford in the wake of the DOH’s (Department of Health’s, 2014) project to extend user involvement and live up to the policy pledge (rhetoric?) of “nothing about me without me”.
My problems with ‘involvement’ are that it is an ill-considered idea in the first place. It seems like something initially that is highly laudible and worthwhile. However my difficulties with it stem from what is implicit in setting up programmes with an ‘involvement’ agenda and from having being ‘involved’ in the running of such programmes in organisations in the past. My experience as a professional in educational, healthcare and research organisations is that when ‘involvement’ is raised it’s at the point when most of the work in developing the educational, service or research project has already been done within the organisation itself. “Involvement” can all too typically devolve down to inviting a service-user or outsider of the host organisation to participate in some pre-determined aspect or element of the service or programme that has already been committed to. They might have their expenses provided or receive some form of token payment for their activity. They might participate in the evaluation of a project as participants in a focus-group. My point here is that this is very much a form of “involvement” that stands to maintain the status-quo of the user as an “outsider” to the programme, project and host organisation. To put it in a nutshell “involvement” as has initially been developed is at risk of being “othering”.
If not “involvement” then, because of this “othering” risk, what instead? I would like to see the development of projects that aim instead from the outset to be collaborative and co-productive. Seek out and employ service users on an equal footing as participants in developing, designing, implementing and evaluating programmes across organisational settings as co-producers. Developing from this co-production I would then envisage programmes that head towards service-users leading and developing services/programmes in their own right.
The potential advantages of co-production and service-user leadership are, amongst other things, in the expressed values and diversity of the project. This is reflected in the Writing for Recovery research project of Taylor et al. (2014) who employed a service-user/writer to lead their project group. Group members in this project reflected on the difference this made, and one reflected that:
‘Undertaking a service user led group gave me the courage to speak out, as I knew we had all faced major life challenges at some stage’ (WfR member). (Taylor et al., 2014, p 6).
Taylor, S. , Leigh-Pippard, H. and Grant, A. (2014), Writing for recovery: a practice development project for mental health service users, carers and survivors, International Practice Development Journal, 4(1) , pp. 1-13.
Are NICE Guidelines Enabling Our Caring Professionals to Meet NMC Standards of Evidence-Based Practice?
By Stephen Williams, Sian Jackson and Sarah O’Donnell (2013)
This is a proposed @WeNurses chat co-written by Steve Williams aka @MHNurseLecturer, Sian Jackson aka @firecracker1305 and Sarah O’Donnell aka @sarah_searz. This proposed twitter chat came about as a result of a pre-registration nursing @BradfordUni debate on evidence-based practice in healthcare. This represents a strand of ‘SoMe’ (Social Media) integration and dissemination of student-nursing practice as explored in Williams (2013).
The NMC (Nursing and Midwifery Council) (2008) code states we must: “deliver care based on the best available evidence” (p.6) and keep our “knowledge and skills up to date” (p.6). NICE (National Institute of Health and Care Excellence) guidelines have assisted practice since 2001. With a variety of treatment options/pathways it seeks to enable professionals to provide evidence-based advice and care. However is the evidence assessed by NICE sufficiently contextually relevant for our patients’ clinical needs?
Research evidence can become rapidly out dated and some academics and practitioners might argue it’s not always sufficiently well developed for practice. Nurses establish their practice in a variety of ways and their ability to critically evaluate research varies (Funk et al., 1991; Kirkevold, 2008). NICE guidelines take two years to be developed prior to publication. This suggests that upon publication they are already out of date and indeed may not be updated for a further three to four years.
An example of such issues with NICE guidance can be seen in the development of guidelines for self-harm (Pitman and Tyrer, 2008). Pitman and Tyrer (2008) point out that this was developed on research evidence with only one recommendation based on a RCT (randomised controlled trial) quality of evidence. Most of the research at the time was on the physical impact of self-harm and the guidelines received criticism for amalgamating self-poisoning and self-laceration as a single kind of problem (Barker and Buchanan-Barker, 2004). Is it pertinent to argue then that a culture of ‘following NICE guidelines’ perhaps disables nurses obligation to critically review nursing research and related evidence themselves?
NICE guidelines set out to reduce inequalities in treatment provision. Whilst this is a laudable ideal the reality of treatment provision is considerably murkier. Take the provision of IVF (in vitro fertilization): NICE guidelines in 2004 recommended three full cycles of treatment for those who met agreed clinical criteria. By mid-2005 PCTs (primary care trusts) were being asked to make at least one cycle available by the secretary of state. There was no mandate or mechanism for ensuring the recommendations were implemented (House of Commons Health Committee, 2008). A further critical point is that PCT’s in England were able to set the eligibility criteria for access to NHS funding above and beyond clinical criteria set out in the guideline (House of Commons Health Committee, 2008). This being the case – are they really addressing health inequalities and are we confident the advice they prompt us to give is sufficiently empirically robust?
A twitter chat in conjunction with @WeNurses is scheduled for Tuesday 15th April 2014 at 8pm online.
Barker, P.Buchanan-Barker, P., (2004), NICE and self-harm: Blinkered and exclusive,Mental Health Nursing,24,6,pp.4–6.
Funk, S.G., Thornquist, E.M., Wiese, R.A. and Champagne, M. T. (1991), Barriers to using research findings in practice: The clinicians perspective. Applied Nursing Research. 4, pp 90-95.
House of Commons Health Committee (2008), Health Inequalities: Written Evidence, Session 2007-08, Volume II, Her Majesty’s Stationery Office.
Kirkevold M. (1997), Integrative Nursing Research – An Important Strategy to Further The Development of Nursing Science and Nursing Practice, Journal of Advanced Nursing, 25, pp 977-984.
Nursing and Midwifery Council (2008), The Code: Standards of conduct, performance and ethics for nurses and midwives, NMC.
Pitman, A. and Tyrer, P. (2008), Implementing clinical guidelines for self-harm – highlighting key issues arising from the NICE guidelines for self-harm, Psychology and Psychotherapy: Theory, Research and Practice, 81, 4, pp. 377-397.
Williams, S. (2013), Embracing Digital Education for Nursing (An @WeNurses Web-blog Article), The Inside Skinny Latte Blog, September 9th 2013, Available from: http://mhnurselecturer.co.uk/?p=8, [accessed 19th November 2013].
This is the original article text for my @WeNurses WebBlog Article on Embracing Digital Education for Nursing. Teresa Chinn (@AgencyNurse) invited me to write this blog article for @WeNurses over at WeNurses.co.uk as she became aware of how we are developing the integration of social media use, and twitter chats in particular, in our pre-registration nursing curriculum at Bradford University (@BradfordUni). I chose to take a somewhat personal perspective and incorporate the story of my development as a ‘twittering’ nurse for want of a better phrase and how the project ensued.
Embracing Digital Education for Nursing
Earlier this year I did something quite major in terms of my twitter identity. Having reviewed the NMC’s SoMe (Social Media) guidelines (NMC, 2012) I changed my identity to a professional one on twitter. I’m now @MHNurseLecturer. From this moment on I shifted the emphasis to largely tweeting about the needs of people with mental illness and how we can learn from their struggles. I wanted to get serious about helping liberate us from what I largely see as something of a mess that our society’s fear and lack of understanding has created. Twitter is a way of communicating and connecting with others who share your interests and also challenging the views of others who maybe don’t.
I became aware of other professionals, groups, service users and nurses in particular. I can’t recall how I stumbled upon @WeNurses initially as an organization. I honestly didn’t like the sound of it at first –“How could it include all of us?” I remember thinking. However, I resolved to give it a try and joined in on a few twitter chats. So I eventually found myself rather late at night in the University hunched over my computer as my colleague was giving a seminar on Diversity in the office via Skype. I was helping co-lead a nursing twitter chat! I had connected with some organizational development professionals I met over twitter in a previous @WeNurses chat when it became apparent that we shared the same kind of interest in resiliency and mindfulness. We led a twitter chat together having collaborated to put in our proposal and you can read the write up I put together for that here, and also here at WeNurses.co.uk (Williams, 2013).
At this time I was in the throes as a module leader of putting together the first run of our Year Three, Semester One module for nurses. At this point of their training they are ‘developing proficiency’ and consolidating their skills. I’d also been charged with threading cognitive based talking therapies and their derivatives throughout the curriculum to bring our nursing training up to and beyond scratch in terms of delivering evidence-based interventions for serious mental illnesses. That’s my area of expertise from my own experience and on-going clinical practice since 2002. I’m currently a nurse-therapist part-time, so I just started weaving in what I do into the curriculum and developed the delivery of teaching sessions that focus on skills coaching, recovery and talking therapy interventions by nurses. I’ve also engaged nurse turned psychotherapist professionals in practice to come into education and co-teach sessions with us.
It occurred to me to join some of these things up. Why not, I thought, get the students to run a twitter chat? First let’s get twitter streamed in our school. I quickly got my learning resource team colleagues to stream @WeNurses chats on one of the displays as a trial. I say ‘quickly’ that was several months of e-mails and effort! Students could have their lunch and watch the tweets of professionals, carers, service-users and others on the current topics as they arose. This trial run quickly showed me that we need a dedicated display so that the screen can be rapidly controlled directly by an academic and not have to compete for space with other necessary university information. So my learning resource team colleagues figured out how to have a dedicated display page that we could switch from #hashtag to #hashtag according to what was topical and also control the time-parameters of the twitter stream so that it could be displayed retrospectively.
At present we have a business case for the screen being processed to have this dedicated display create a permanent social media presence in the school. The vision is that Academic Twitter Champions (ATC’s) will form a multi-disciplinary academic team that can seek out interesting SoMe users, dialogues and #hashtag streams. The ATC will then be responsible for ensuring that they are of relevant interest and are suitable for student consumption so we can respond rapidly and safely to emerging debates. Naturally we are wanting as an organization to safeguard the quality of the content and minimise the risk of deleterious twitter activity from being displayed. Another knock on benefit we forsee from this is being able to role model the use of SoMe and NMC SoMe guidelines for nurses in training.
I took things a step further by making a twitter chat a vehicle for student learning. So for example something we examine really closely at this stage of the nurses education is what they understand of ‘evidence’. As a whole collection of nursing fields they come to grips with the nature of research informed evidence, evidence based practice and evidence informed practice. These are perhaps, to some, relatively subtle distinctions and are further complicated when you consider how these kinds of practice and evidence differ from say practice-based evidence! It may sound as if I’m merely shuffling the same words about but these are distinct relationships between kinds of evidence and types of practice.
I’d already planned on a whole field in class structured debate for the module. That is: there will be a student-led debate after a key lecture on the nature of evidence. This trigger lecture refreshes what they’ve already learned and sets out some of the pro’s and con’s of different kinds of evidence, efficacy vs effectiveness, mixed methods vs single methods and so on. They then have a whole field debate that we facilitate on whether NICE (National Institute of Health and Care Evidence) standards of evidence are sufficient for nursing practice.
From this the students will put together a small working party and use their initial debate to put together a @WeNurses twitter chat on what they found interesting about being ‘evidence based practitioners in nursing’. Everybody in the fields will be able to contribute to the discussion on twitter though and therefore the learning that comes from it. The elected group will make a full submission and lead a twitter chat and see what it is like to disseminate and discuss knowledge creation and sharing in this digital medium. This hopefully will help them draw upon a wider range of critical views, improve their own constructive critical thinking and show them the value of knowledge transfer in the digital age. It will hopefully also show them some of the pitfalls too.
The first run of this module is coming up in September. Part of the evaluation of learning will be the twitter chat transcripts and bits of work following on from the dissemination fed back into the module. I hope they put together a good submission for @WeNurses so that we end up with some healthy sharing of student nurse and professional perspectives on the nature of what we call evidence, and how we put it into our practice. If this would be of interest to the @WeNurses blog-o-sphere, I’ll come back with what we learned and ask some of my student nurse colleagues to give you their account of the process of getting involved in this kind of digital literacy in their nurse education and training. You can then be instrumental in the educational development of your upcoming colleagues who are getting ready to join you in improving and maintaining the delivery of high-quality, compassionate nursing care in our unfolding post-Francis world.
Williams, S. (2013), A Twitter Chat for @WeNurses on Resilience (Hosted 7th March 2013), The Inside Skinny Latte Blog, 8th March 2013, Available From: http://mhnurselecturer.co.uk/wp/?p=10, [accessed 21st August 2013].