Critical Mental Health Nursing

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.

The Politics of Nursing and Nurse Education

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.

Troubling Definitions of ‘Mental Health’

Troubling Definitions of ‘Mental Health’

Image result for mental health

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.


Sahlgren, Gabriel, (2013), Working Longer, Live Healthier: The relationship between exonomic activity, health and government policy, [Accessed on 17/03/2014].

Westerlund H, Vahtera J, Ferrie JE et alEffect of retirement on major chronic conditions and fatigue: French GAZEL occupational cohort study. British Medical Journal 2010; 341:c6149

World Health Organisation, 2013, Mental health: a state of well-being, [Accessed on 17/03/2014].

Writing “Recovering from Psychosis: Empirical Evidence and Lived Experience”: Some Reflections

I started writing my soon to be published book (eek!) “Recovering from Psychosis: Empirical Evidence and Lived Experience” way back in the summer of 2012, and today handed my completed manuscript over to my critical readers for their commentary. So I am in the last throes of this piece of work – a little bit over 2 years of work.

I’m excited and nervous to get their feedback. It’s challenging to think that others are going to read and reflect on what I have written and proffer their expert opinions on the material. Writing this book has been a long undertaking – emotional at times, grueling in places when it felt like it was never going to end, and an education in terms of understanding first-hand what’s involved in publishing an academic book. Certainly its not something to be taken lightly – and there all kinds of hoops to jump through in the process that I had no inkling of when I sent my proposal off to Routledge 2 years ago.

I’d completed a survey for the publishers on pre-registration mental health nursing textbooks and noticed in the email that they were open to proposals of new books. I realized I did have something in mind to write and completed their initial form outlining what I had in mind. Then a sample chapter (the introductory chapter that is now Chapter 2 of Recovering from Psychosis) was put together and reviewed anonymously. I was really pleased to get such positive comments back from the anonymous review – my writing is not devoid of merit after all! This then led to the negotiation of the contract and setting a deadline (which moved several times as the enormity of the task set in).

Recovering from Psychosis isn’t just a review of the state of empirical evidence, although it does do that, it also explores my own lived experience of overcoming this devastatingly potent condition that tore my life into bits in my early 20’s. I was aiming to write something that synthesized the more ‘objective’ academic review of our understanding of psychosis with a testimony of my experience as it relates to this. So when I reviewed the range of treatments I included relevant aspects of my own experience of these. When I wrote about recovery and research into it, I reflected upon my own battle and growth from the experience of psychosis. What I hadn’t really anticipated was how powerfully emotional that would be. Indeed I had some sleepless nights and some reliving of those darker days, and this has made me even more grateful for where and who I am now 20 years after the episodes I reflect on in the book.

This is far from the ‘definitive account’ of psychosis because of the individual nature of the personal experience. There are certain commonalities and themes in the experience of psychosis that are present in my account that will undoubtedly resonate with others who have had the challenge or are living through the enormous challenge of psychosis. In terms of the review, already portions of it are losing their contextual edge because research continues into refining our understanding and capabilities to work meaningfully and productively with it. It also presents, I hope, a robust critique of the limitations and disadvantages, if not dangers, of the ‘recovery’ approach as well as summarizing what we can gain from this perspective. I expect that later editions will be able to address advances and changes to our knowledge about psychosis, although I’m hoping I won’t have to write a second edition too soon!

If you are considering writing, or are just embarking on writing a book something I’ve learned about the process is this. You’ll pretty much always think what you’ve written is rubbish, and first drafts tend to be raw in the first instance. Be prepared to revisit stuff, rewrite stuff and detach yourself from the process as much as you can. Getting into a disciplined routine of writing really helps – so if you can join a writing group that meets regularly, and sets up a space where everybody gets their heads down and hammers some words out – this is a ‘must’ do. Looking now at what I’ve written with some distance almost feels like an ‘out of body’ experience – did I really write this? It’s not too shoddy after all. Others will be the best judge of what you have written and you may be surprised what they think of your stuff. Certainly they are never going to know unless you commit some words onto the page and see what happens!

An @WeNurses WebBlog Article on Digital Education in Nursing


Embracing Digital Education for Nursing (An @WeNurses WebBlog Article).

Originally Posted on Sept 9, 2013 by mhnurse

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 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 (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.


Nursing and Midwifery Council (2012), Practical guidance for students, nurses and midwives using social networking sites [online], London:  Nursing and Midwifery Council. Available from: [accessed 21st August 2013].

Williams, S. (2013), A Twitter Chat for @WeNurses on Resilience (Hosted 7th March 2013), The Inside Skinny Latte Blog, 8th March 2013, Available From:, [accessed 21st August 2013].