Crossing disciplinary boundaries and sharing unrelated datasets led to ‘critical junctures’ in practitioner outreach.

Delivering fresh insights on evidence-based practice, Ben Hannigan charts how a combination of action research and qualitative methods helped identify the role of ‘critical junctures’ in improving mental health services and practitioner support. This analysis helped to connect people, processes and systems and was able to overcome the ‘micro’ and ‘meso’ distinctions holding back longer trajectories of care and change

New roles for nurses as approved mental health professionals in England and Wales

This paper critically discusses the challenges mental health nurses face in trying to achieve a balance between fulfilling biomedical and social roles. We suggest that dilemmas exist for nurses in attempting to combine both approaches in their practice. We present a specific example of these as occasioned by the advent of the approved mental health professional role in England and Wales. This statutory role requires the adoption of an independent social perspective as a counterbalance to the biomedical perspective brought by psychiatrists. Using the idea of occupational jurisdictions we discuss how nurses embarking on this new role are effectively crossing into territories previously occupied by the profession of social work. We also reveal the tensions for nurses who fulfil the approved mental health professional role whilst simultaneously carrying out work in other areas which demands a more overtly biomedical approach. We review critical accounts of the validity of bio-psycho-social models and concerns about maintaining positive therapeutic alliances alongside making applications for compulsory detention, assessment and treatment. We argue that the new role may become part of the professional project of mental health nursing, but also present challenges in helping redefine nursing's identity and practice

Social ecology of resilience and Sumud of Palestinians

The aim of this paper is to provide an overview of theoretical perspectives and practical research knowledge in relation to ‘resilience’, the resilience of Palestinians in particular, and the related concept of ‘Sumud’. ‘Sumud’ is a Palestinian idea that is interwoven with ideas of personal and collective resilience and steadfastness. It is also a socio-political concept and refers to ways of surviving in the context of occupation, chronic adversity, lack of resources and limited infrastructure. The concept of ‘resilience’ has deep roots, going back at least to the 10th century when Arabic scholars suggested strategies to cope with life adversity. In Europe, research into resilience extends back to the 1800s. The understanding of resilience has developed over four overlapping waves. These focus on: individual traits; protective factors; ecological assets; and (in the current wave) social ecological factors. The current wave of resilience research focuses on the contribution of cultural contextualisation and is an approach that is discussed in this paper, which draws on Arabic and English language literature located through a search of multiple databases (CINAHL, British Nursing Index, ASSIA, Medline, PsycINFO, and EMBASE). Findings suggest that ‘Sumud’ is linked to the surrounding cultural context and can be thought of as an innovative, social ecological, approach to promoting resilience. We show that resilience is a prerequisite to ‘Sumud’, meaning that the individual has to be resilient in order to stay and not to leave their place,position or community. We close by pressing the case for studies which investigate resilience especially in underdeveloped countries such as Palestine, and which reveal how resilience is embedded in pre-existing cultural contexts

Challenges for nurses who work in community mental health centres in the West Bank, Palestine

Background: Nurses in Palestine (occupied Palestinian territory) work in a significantly challenging environment. The mental health care system is underdeveloped and under-resourced. For example, the total number of nurses who work in community mental health centres in the West Bank is seventeen, clearly insufficient in a total population of approximately three million. This research explored daily challenges that Palestinian community mental health nurses (CMHNs) face within and outside their demanding workplaces. Methods: An interpretive qualitative design was chosen. Face-to-face interviews were completed with fifteen participants. Thirty-two hours of observations of the day-to-day working environment and workplace routines were conducted in two communities’ mental health centres. Written documents relating to practical job-related policies were also collected from various workplaces. Thematic analysis was used across all data sources resulting in four main themes, which describe the challenges faced by CMHNs. Results and conclusion: These themes consist of the context of unrest, stigma, lack of resources, and organisational or mental health system challenges. The study concludes with a better understanding of challenges in nursing which draws on wider cultural contexts and resilience. The outcomes from this study can be used to decrease the challenges for health professionals and enhance the mental health care system in Palestine

Observations from a small country: mental health policy, services and nursing in Wales

Wales is a small country, with an ageing population, high levels of population health need and an economy with a significant reliance on public services. Its health system attracts little attention, with analyses tending to underplay the differences between the four countries of the UK. This paper helps redress this via a case study of Welsh mental health policy, services and nursing practice. Distinctively, successive devolved governments in Wales have emphasised public planning and provision. Wales also has primary legislation addressing sustainability and future generations, safe nurse staffing and rights of access to mental health services. However, in a context in which gaps always exist between national policy, local services and face-to-face care, evidence points to the existence of tension between Welsh policy aspirations and realities. Mental health nurses in Wales have produced a framework for action, which describes practice exemplars and looks forward to a secure future for the profession. With policy, however enlightened, lacking the singular potency to bring about intended change, nurses as the largest of the professional groups involved in mental health care have opportunities to make a difference in Wales through leadership, influence and collective action

"There's a lot of tasks that can be done by any": Findings from an ethnographic study into work and organisation in UK community crisis resolution and home treatment services

Across the United Kingdom (UK) large numbers of crisis resolution and home treatment (CRHT) services have been established with the aim of providing intensive, short-term, care to people who would otherwise be admitted to mental health hospital. Despite their widespread appearance little is known about how CRHT services are organised or how crisis work is done. This paper arises from a larger ethnographic study (in which 34 interviews were conducted with practitioners, managers and service users) designed to generate data in these and related areas. Underpinned by systems thinking and sociological theories of the division of labour the paper examines the workplace contributions of mental health professionals and support staff. In a fast-moving environment the work which was done, how and by whom reflected wider professional jurisdictions and a recognisable patterning by organisational forces. System characteristics including variable shift-by-shift team composition and requirements to undertake assessments of new referrals whilst simultaneously providing home treatment shaped the work of some, but not all, professionals. Implications of these findings for larger systems of work are considered

Connections and consequences in complex systems: Insights from a case study of the emergence and local impact of crisis resolution and home treatment services

In this article the broad contours of a complexity perspective are outlined. Complexity ideas are then drawn on to frame an empirical examination of the connections running between different levels of organisation in health and social care, and to underpin investigation into the intended and unintended local system consequences of service development. Data are used from a study conducted in the UK’s mental health field. Here, macro-level policy has led to the supplementing of longstanding community mental health teams by newer, more specialised, services. An example includes teams providing crisis resolution and home treatment (CRHT) care as an alternative to hospital admission. Using an embedded case study design, where ‘the case’ examined was a new CRHT team set in its surrounding organisational environment, ethnographic data (with interviews predominating) were generated in a single site in Wales over 18 months from the middle of 2007. In a large-scale context favourable to local decision-making, and against a background of a partial and disputed evidence base, the move to establish the new standalone service was contested. Whilst users valued the work of the team, and local practitioners recognised the quality of its contribution, powerful effects were also triggered across the locality’s horizontal interfaces. Participants described parts of the interconnected system being closed to release resources, staff gravitating to new crisis services leaving holes elsewhere, and the most needy service users being cared for by the least experienced workers. Some community mental health team staff described unexpected increases in workload, and disputes over eligibility for crisis care with implications for system-wide working relations. Detailed data extracts are used to illustrate these connections and consequences. Concluding lessons are drawn on the use of evidence to inform policy, on the significance of local contexts and system interfaces, and on anticipating the unexpected at times of change

Health and social care for people with severe mental health problems: an ethnographic study.

In the study reported in this thesis sociological theories were used to underpin an investigation into the organisation and delivery of community mental health care. Set against a background of accelerating change in the wider, macro-level, system of mental health work ethnographic data were first generated relating to the meso-level organisation of interagency services in two contrasting study sites. In each site interviews, observations and documentary analysis were also used to generate data relating to the micro-level care delivered to three exemplar service user case study subjects over a four to five month period. Macro-level public services modernisation was triggering sustained upheaval at the meso-level at which local services were planned, commissioned and provided. Complex structural, historical and people-related factors combined together to both help and hinder efforts to reconstitute local systems of work. Case study data were drawn on to examine the micro-level roles and responsibilities of paid and unpaid workers and the unfolding of complex service user trajectories, as these were played out in the two contrasting meso-level contexts. Findings exemplify the degree to which roles are realised in specific, interactive, workplaces. The work of psychiatrists, social workers, nurses, clinical psychologists, general practitioners, pharmacists, health and social care assistants and unpaid lay carers and service users was found to be highly sensitive to local particularities and to the 'lines of impact' running between macro, meso and micro-levels. Features with consequences for the work of particular groups included: team composition and history relative resource availabilities and arrangements for the funding of particular types of work progress on the agreement of formal policies and procedures spatial and temporal organisational factors the localised exercise of occupational jurisdictional authority differentiations and non-differentiations of roles and responsibilities made by recipients of services and personal factors, including individual practitioners' levels of knowledge and skill

Critical junctures in health and social care: Service user experiences, work and system connections

This paper makes an original contribution through the revitalisation, refinement and exemplification of the idea of the ‘critical juncture’. In the health and illness context a critical juncture is a temporally bounded sequence of events and interactions which alters, significantly and in a lasting way, both the experience of the person most directly affected and the caring work which is done. It is a punctuating moment initiating or embedded within a longer trajectory and is characterised by uncertainty. As contingencies come to the fore individual actions have a higher-than-usual chance of affecting future, enduring, arrangements. These ideas we illustrate with detailed qualitative data relating to one individual’s journey through an interconnected system of mental health care. We then draw on observations made in a second study, concerned with the improvement of mental health services, to show how micro-level critical junctures can be purposefully used to introduce instability at the meso-level in the pursuit of larger organisational change. In addition to demonstrating why scholars and practitioners should pay closer attention to understanding and responding to critical junctures we are, therefore, also able to demonstrate how their emergence and impact can be examined vertically, as well as horizontally

Where the wicked problems are: The case of mental health

Objective To use system ideas and the concept of ‘wicked problems’ to frame examination of a decade-and-a-half of UK mental health policy. Methods Theoretically informed policy analysis. Results Modern health care is complex, and mental health care particularly so. In the UK the mental health system has also become a policymaking priority. Features of this system mean that many of the problems policymakers face are of the ‘wicked’ variety. Wicked problems are resistant. Problem formulations and their solutions are contestable. Solutions which have ‘worked’ in one setting may not ‘work’ in another, and evidence to guide change is open to challenge. Actions trigger waves with widespread system consequences. In the case of the UK's mental health field significant shifts have taken place in formulations of ‘the problem’ to which actions have been directed. These have included assessments of community care failure, formulations emphasising problems with the professions and, most recently, the need for action to promote mental health and wellbeing. Conclusions In their efforts to secure improvement in a neglected field UK policymakers have unleashed a torrent of top-down actions. Attention needs to be paid to constructing strong, system-wide, partnerships and to examining the cumulative impact of policy actions