On the bullshitisation of mental health nursing: A reluctant work rant.

This discussion paper offers a critical provocation to my mental health nursing colleagues. Drawing upon David Graeber's account of bullshit work, work that is increasingly meaningless for workers, I pose the question: Is mental health nursing a bullshit job? Ever-increasing time spent on record keeping as opposed to direct care appears to represent a Graeberian bullshitisation of mental health nurses' work. In addition, core aspects of the role are not immune from bullshit. Professional rhetoric would have us believe that mental health nursing is a therapeutically beneficent occupation organised around ideals of care and compassion and providing fulfilling work for practitioners. Yet, there are some key characteristics of the experience of mental health nursing work that afford alternative judgements on its value and meaningfulness. Not least of these is the fact that many mental health nurses feel quite existentially unsettled in the practise of their work and many service users do not recognise the professional ideal, especially when compelled into increasingly coercive and restrictive services. In this context, Graeber's thesis is explored for its applicability to mental health nursing with a conclusion that many aspects of mental health nursing work are commensurate with bullshit but that mental health care can possibly be redeemed from bullshitisation by authentically democratising reforms. Engaging with posthumanist ideas, this exploration involves a flexing of aspects of Graeber's theory.

A qualitative evaluation of coproduction of research: 'If you do it properly, you will get turbulence'.

BACKGROUND: Patients and public members are increasingly involved across the different stages of the research process. Their involvement is particularly important in the conception and design of applied health research where it enables people with lived experience to influence the aims, content, focus and methods. OBJECTIVE: To evaluate the process of coproducing a mental health-related research proposal suitable for funding through a national health research funding body. METHODS: Reflections from members of the public (n = 3) and academic researchers (n = 3) were collected through semi-structured interviews. Data were thematically analysed. RESULTS: Thematic analysis identified five overarching themes: valuing the lived experience perspective; matching ambitions to the funded research process; 'Us and them': power, relationships and trust; challenges; and benefits of coproduction. CONCLUSIONS: Our findings suggest that for successful coproduction of a research funding application, an open and trusting atmosphere, where equal relationships are established and a shared common goal agreed is essential. Although relationships with research professionals were framed by trust and mutual respect for some public advisors, others felt a sense of 'us and them'. With various tensions played out through interpersonal conflict, difficult conversations and disagreements, coproduction was not a positive experience for all stakeholders involved. Among the learning was that when collaboration of this kind is constrained by time or funding, genuine, impactful coproduction can be more challenging than is generally acknowledged.

The individual, place, and wellbeing - a network analysis.

BACKGROUND: Previous research has examined individual-level and place characteristics as correlates of subjective wellbeing, with many studies concluding that individual factors (e.g. health, finances) are more strongly related to wellbeing. However, this 'dualistic' approach has been challenged, with some arguing that it is impossible to disentangle the effects of the two domains, and that wellbeing should be considered as part of a network of mutually reinforcing relationships between individual, community and place characteristics. We used network analysis to explore these complex associations. METHODS: Data were from a large sample of adults from a socioeconomically disadvantaged region of the United Kingdom (N = 4319). Wellbeing was assessed using the 7-item version of the Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS). Mixed graphical networks were estimated including wellbeing, place and individual-characteristic variables as nodes. RESULTS: We found a densely connected network in which wellbeing was associated, both directly and indirectly, with all of the individual, community and place characteristics assessed. Wellbeing was most strongly connected with individual characteristics, in particular financial difficulty and subjective physical health. However, controlling for all other variables in the network model, wellbeing was positively associated with local greenspace usage, civic agency, and neighbourhood cohesion, and negatively associated with housing disrepair. Greater specificity in these associations was observed when the wellbeing construct was broken down into its constituent parts. CONCLUSIONS: These findings highlight the complex relationships that exist between individual, community and place characteristics in the context of subjective wellbeing, and that all domains need to be considered when developing population-level strategies to improve wellbeing. Further consideration needs to be given to how this might happen in practice, for example through a combination of consistent use of community engagement methodologies alongside Health in All Policy (HiAP) approaches.

Mental health nursing and conscientious objection to forced pharmaceutical intervention.

This paper attempts a critical discussion of the possibilities for mental health nurses to claim a particular right of conscientious objection to their involvement in enforced pharmaceutical interventions. We nest this within a more general critique of perceived shortcomings of psychiatric services, and injustices therein. Our intention is to consider the philosophical and practical complexities of making demands for this conscientious objection before arriving at a speculative appraisal of the potential this may hold for broader aspirations for a transformed or alternative mental health care system, more grounded in consent than coercion. We consider a range of ethical and practical dimensions of how to realize this right to conscientious objection. We also rely upon an abolition democracy lens to move beyond individual ethical frameworks to consider a broader politics for framing these arguments.

Restraint minimisation in mental health care: legitimate or illegitimate force? An ethnographic study.

Coercive practices, such as physical restraint, are used globally to respond to violent, aggressive and other behaviours displayed by mental health service users.1 A number of approaches have been designed to aid staff working within services to minimise the use of restraint and other restrictive practices. One such approach, the 'REsTRAIN Yourself' (RYS) initiative, has been evaluated in the UK. Rapid ethnography was used to explore the aspects of organisational culture and staff behaviour exhibited by teams of staff working within 14 acute admission mental health wards in the North West region of the English NHS. Findings comprise four core themes of space and place; legitimation; meaningful activity; and, therapeutic engagement that represent characteristics of daily life on the wards before and after implementation of the RYS intervention. Tensions between staff commitments to therapeutic relations and constraining factors were revealed in demarcations of ward space and limitations on availability of meaningful activities. The physical, relational and discursive means by which ward spaces are segregated prompts attention to the observed materialities of routine care. Legitimation was identified as a crucial discursive practice in the context of staff reliance upon coercion. Trauma-informed care represents a potentially alternative legitimacy.

It's the talk: a study of involvement initiatives in secure mental health settings.

BACKGROUND: A study of involvement initiatives within secure mental health services across one UK region, where these have been organized to reflect alliances between staff and service users. There is little previous relevant international research, but constraints upon effective involvement have been noted. OBJECTIVE: To explore and evaluate involvement initiatives in secure mental health settings. DESIGN: A case study design with thematic analysis of qualitative interviews and focus groups. SETTING AND PARTICIPANTS: Data collection was carried out between October 2011 and February 2012 with 139 staff and service users drawn from a variety of secure mental health settings. FINDINGS: Our analysis offers four broad themes, titled: safety and security first?; bringing it all back home; it picks you up; it's the talk. The quality of dialogue between staff and services users was deemed of prime importance. Features of secure environments could constrain communication, and the best examples of empowerment took place in non-secure settings. DISCUSSION: Key aspects of communication and setting sustain involvement. These features are discussed with reference to Jurgen Habermas's work on communicative action and deliberative democracy. CONCLUSIONS: Involvement initiatives with service users resident in secure hospitals can be organized to good effect and the active role of commissioners is crucial. Positive outcomes are optimized when care is taken over the social space where involvement takes place and the process of involvement is appreciated by participants. Concerns over risk management are influential in staff support. This is germane to innovative thinking about practice and policy in this field.

Understanding communication pathways to foster community engagement for health improvement in North West Pakistan.

BACKGROUND: This paper describes the community engagement process undertaken to ascertain the focus, development and implementation of an intervention to improve iodised salt consumption in rural communities in North West Pakistan. The Jirga is a traditional informal structure, which gathers men respected within their community and acts in a governing and decision-making capacity in the Pukhtoon culture. The Jirga system had a dual purpose for the study: to access men from the community to discuss the importance of iodised salt, and as an engagement process for the intervention. METHODS: A number of qualitative data collection activities were undertaken, with Jirga members and their wives, male and female outreach workers and two groups of women, under and over 40 years old. The aim of these was to highlight the communication channels and levers of influence on health behaviour, which were multiple and complex and all needed to be taken into consideration in order to ensure successful and locally sensitive community engagement. RESULTS: Communication channels are described within local families and the communities around them. The key influential role of the Jirga is highlighted as linked both to the standing of its members and the community cohesion ethos that it embodies. Engaging Jirga members in discussions about iodised salt was key in designing an intervention that would activate the most influential levers to decision making in the community. Gendered decision-making processes within the household have been highlighted as restricting women's autonomy. Whilst in one respect our data confirm this, a more complex hierarchy of decisional power has been highlighted, whereby the concept of 'wisdom'- an amalgamation of age, experience and education- presents important possibilities. Community members with the least autonomy are the youngest uneducated females, who rely on a web of socially and culturally determined ways to influence decision-making. CONCLUSIONS: The major lines of communication and influence in the local community described are placed within the wider literature on community engagement in health improvement. The process of maximisation of local cultural knowledge as part of a community engagement effort is one that has application well beyond the particular setting of this study.

Mental health advocacy and African and Caribbean men: good practice principles and organizational models for delivery.

BACKGROUND: Advocacy has a critical role to play in addressing concerns about access to appropriate mental health care and treatment for African and Caribbean men. AIM: To investigate good practice principles and organizational models for mental health advocacy provision for African and Caribbean men. STUDY DESIGN: The study consisted of: (i) A systematic literature review. Bibliographic and internet searching was undertaken from 1994 to 2006. The inclusion criteria related to mental health, advocacy provision for African and Caribbean men. (ii) Four focus groups with African and Caribbean men to explore needs for and experiences of mental health advocacy. (iii) An investigation into current advocacy provision through a survey of advocacy provision in England, Wales and Northern Ireland. (iv) Twenty-two qualitative stakeholder interviews to investigate the operation of mental health advocacy for this client group. The study was undertaken in partnership with two service user-led organizations and an African Caribbean mental health service. RESULTS: Primary research in this area is scant. Mainstream mental health advocacy services are often poor at providing appropriate services. Services developed by the Black Community and voluntary sector are grounded in different conceptualizations of advocacy and sharper understanding of the needs of African and Caribbean men. The lack of sustainable funding for these organizations is a major barrier to the development of high-quality advocacy for this group, reflecting a lack of understanding about their distinctive role. CONCLUSIONS: The commissioning and provision of mental health advocacy needs to recognize the distinct experiences of African and Caribbean men and develop capacity in the range of organizations to ensure equitable access.

Football metaphor and mental well-being: an evaluation of the It's a Goal! programme.

BACKGROUND: The It's a Goal! programme utilises football metaphor and football venues as a means to frame and deliver a non-clinical, group-based therapeutic intervention, targeting men with mental health needs. A pilot in the North West of England was hosted by seven professional football clubs in partnership with local Primary Care Trusts. AIMS: To evaluate the impact of the intervention and to identify the benefits and key components of the approach from the perspective of participants. METHOD: Analysis of impact utilised before and after well-being scores measured on a modified version of the Warwick-Edinburgh Mental Well-being Scale. Focus groups provided additional qualitative data that were analysed thematically. RESULTS: Findings suggest that It's a Goal! had a significant impact upon participant's well-being. In addition, participants reported a range of positive benefits especially in relation to confidence, self-esteem and developing better coping mechanisms. Participants related these benefits to a number of key components, not least the therapeutic value of football metaphor, the focus on goal-setting and the mutual support developed within the groups. CONCLUSIONS: Using football metaphor to deliver a group therapeutic programme aimed at men appears to be an effective means of facilitating mental health benefits.

The mental health and wellbeing impact of a Community Wealth Building programme in England: a difference-in-differences study.

BACKGROUND: Wide differences in health exist between places in the UK, underscored by economic inequalities. Preston, an economically disadvantaged city in England, implemented a new approach to economic development, known as the Community Wealth Building programme. Public and non-profit organisations modified their procurement policies to support the development of local supply chains, improve employment conditions, and increase socially productive use of wealth and assets. We aimed to investigate the effect of this programme on population mental health and wellbeing. METHODS: Difference-in-differences techniques compared trends in mental health outcomes in Preston, relative to matched control areas before (2011-15) and after (2016-19) the introduction of the programme. Outcomes were antidepressant prescribing, prevalence of depression, and mental health related hospital attendance rates using data provided by National Health Service Digital, the Quality and Outcomes Framework, and the Office for National Statistics. Additional analysis compared local authority measures of life satisfaction, median wages, and employment with synthetic counterfactuals created using Bayesian Structural Time Series. FINDINGS: The introduction of the Community Wealth Building programme was associated with reductions in the prescribing of antidepressants (1·3 average daily quantities per person [95% CI 0·72-1·78) and prevalence of depression (2·4 per 1000 population [0·42-4·46]), relative to the control areas. The local population also experienced a 9% improvement in life satisfaction (95% credible interval 0-19·6%) and 11% increase in median wages (1·8-18·9%), relative to expected trends. Associations with employment and mental health related hospital attendance outcomes did not reach statistical significance. INTERPRETATION: During the period in which the Community Wealth Building programme was introduced, there were fewer mental health problems than would have been expected compared with other similar areas, as life satisfaction and economic measures improved. This approach potentially provides an effective model for economic regeneration potentially leading to substantial health benefits. FUNDING: National Institute for Health Research.

Relational practice in health, education, criminal justice, and social care: a scoping review.

BACKGROUND: Establishing and maintaining relationships and ways of connecting and being with others is an important component of health and wellbeing. Harnessing the relational within caring, supportive, educational, or carceral settings as a systems response has been referred to as relational practice. Practitioners, people with lived experience, academics and policy makers, do not yet share a well-defined common understanding of relational practice. Consequently, there is potential for interdisciplinary and interagency miscommunication, as well as the risk of policy and practice being increasingly disconnected. Comprehensive reviews are needed to support the development of a coherent shared understanding of relational practice. METHOD: This study uses a scoping review design providing a scope and synthesis of extant literature relating to relational practice focussing on organisational and systemic practice. The review aimed to map how relational practice is used, defined and understood across health, criminal justice, education and social work, noting any impacts and benefits reported. Searches were conducted on 8 bibliographic databases on 27 October 2021. English language articles were included that involve/discuss practice and/or intervention/s that prioritise interpersonal relationships in service provision, in both external (organisational contexts) and internal (how this is received by workers and service users) aspects. RESULTS: A total of 8010 relevant articles were identified, of which 158 met the eligibility criteria and were included in the synthesis. Most were opinion-based or theoretical argument papers (n = 61, 38.60%), with 6 (3.80%) critical or narrative reviews. A further 27 (17.09%) were categorised as case studies, focussing on explaining relational practice being used in an organisation or a specific intervention and its components, rather than conducting an evaluation or examination of the effectiveness of the service, with only 11 including any empirical data. Of the included empirical studies, 45 were qualitative, 6 were quantitative, and 9 mixed methods studies. There were differences in the use of terminology and definitions of relational practice within and across sectors. CONCLUSION: Although there may be implicit knowledge of what relational practice is the research field lacks coherent and comprehensive models. Despite definitional ambiguities, a number of benefits are attributed to relational practices. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021295958.

The design, delivery and evaluation of 'Human Perspectives VR': An immersive educational programme designed to raise awareness of contributory factors for a traumatic childbirth experience and PTSD.

BACKGROUND: A traumatic childbirth experience affects ~30% of women each year, with negative impacts on maternal, infant, and family wellbeing. Women classified as vulnerable or marginalised are those more likely to experience a psychologically traumatising birth. A key contributory factor for a traumatic childbirth experience is women's relationships with maternity care providers. AIMS: To develop, design and evaluate an immersive educational programme for maternity care providers to raise awareness of traumatic childbirth experiences amongst vulnerable groups, and ultimately to improve women's experiences of childbirth. METHODS: A critical pedagogical approach that utilised virtual reality (VR) underpinned the design and development of the educational programme. This involved: a) collecting vulnerable/disadvantaged women's experiences of birth via interviews; b) analysing data collected to identify key hotspots for traumatic experiences within interpersonal patient-provider relationships to develop a script; c) filming the script with professional actors creating a first person perspective via VR technology; d) using existing literature to inform the theoretical and reflective aspects of the programme; e) conducting an evaluation of the education programme using pre-and post-evaluation questionnaires and a follow-up focus group. FINDINGS: Human Perspective VR was very well received. Participants considered the content to have enhanced their reflective practice and increased their knowledge base regarding contributory factors associated with a traumatic childbirth experience. A need for further work to implement learning into practice was highlighted. CONCLUSION: While further research is needed to evaluate the impact of the programme, Human Perspective VR programme offers an innovative approach to reflective education and to enhance participants' care practices.

An integrative review exploring the experiences of service users carrying a diagnosis of personality disorder and student mental health nurses and the time they share together.

OBJECTIVES: This integrative review provides a collective understanding of the experiences of student mental health nurses and service users carrying a diagnosis of personality disorder and the time they share together. DESIGN: Published studies about the time service users and students share together were systematically selected in order to integrate their findings in a thematic analysis. DATA SOURCES: Various databases were searched from 1984 until 2020. Specific search terms were used. REVIEW METHODS: 37 studies were included in the integrative review. The studies were from peer reviewed nursing, student, psychology and health related journals. A quality appraisal was completed using Walsh and Downe (2006) framework. FINDINGS: Four themes emerged from a thematic analysis of the integrative review. These were; With 'Impact of time' as an overarching theme. CONCLUSION: A positive environment which considers time and focuses on seeing the person, as an individual can lead to the development of therapeutic relationships; a core element of the Nursing and Midwifery Council standards for nursing registration in the UK (Nursing and Midwifery Council, 2018). Students attempting to build such relationships need to be mindful of service users' and their own attachment experiences and the impact these can have on experiences of transference and countertransference, particularly for service users carrying a personality disorder diagnosis. It is important for students to be aware of the supportive impact of positive environments and how doing 'everyday stuff' can make a person feel human despite residing in potentially dehumanizing places.

'Care co-ordinator in my pocket': a feasibility study of mobile assessment and therapy for psychosis (TechCare).

OBJECTIVES: The aim of the project was to examine the acceptability and feasibility of a mobile phone application-based intervention 'TechCare', for individuals with psychosis in the North West of England. The main objectives were to determine whether appropriate individuals could be identified and recruited to the study and whether the TechCare App would be an acceptable intervention for individuals with psychosis. METHODS: This was a mixed methods feasibility study, consisting of a test-run and feasibility evaluation of the TechCare App intervention. SETTING: Early Intervention Services (EIS) for psychosis, within an NHS Trust in the North West of England. PARTICIPANTS: Sixteen participants (test-run n=4, feasibility study n=12) aged between 18 and 65 years recruited from the East, Central and North Lancashire EIS. INTERVENTION: A 6-week intervention, with the TechCare App assessing participants' symptoms and responses in real-time and providing a personalised-guided self-help-based psychological intervention based on the principles of Cognitive Behaviorual Therapy (CBT). RESULTS: A total of 83.33% (n=10) of participants completed the 6-week feasibility study, with 70% of completers achieving the set compliance threshold of ≥33% engagement with the TechCare App system. Analysis of the qualitative data suggested that participants held the view that the TechCare was both an acceptable and feasible means of delivering interventions in real-time. CONCLUSION: Innovative digital clinical technologies, such as the TechCare App, have the potential to increase access to psychological interventions, reduce health inequality and promote self-management with a real-time intervention, through enabling access to mental health resources in a stigma-free, evidence-based and time-independent manner. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT02439619.