It’s my life by Euan McLeod

In reading an article regarding co-production of services, it led me to consider co-production in the context of the therapeutic relationship in mental health nursing.

Recent personal experience with a patient who challenged the boundaries of that co-production and the meaning of that therapeutic relationship created opportunities in the team for reflection on how we participated in that relationship. It wasn’t a particularly easy journey I think for us or the patient. Personally I found it taxing and frustrating with moments of joy and sadness as we jostled and jogged our way along this road. “It’s my life” the patient would scream at us, obviously frustrated by our attempts to be therapeutic.

The text which follows is a brief summary of my research into that therapeutic relationship and how legislation both affects and enables it. 

The relationship between nurse and patient seeks to co-produce a plan of care and treatment that leads them back to “their life”. The context of this co-production is a continually shifting balance between autonomy that permits the patient to “travel their own path and make decisions and, paternalistic control that removes decision making from the patient until such times as they are able to retake control and have the capacity to make decisions.

Nurses working in mental health are often faced with working out the right thing to do, and when and in what context it is acceptable for us to limit someone’s freedom, or make choices for them. Sometimes these decisions are made easily because people are either a risk to themselves or others. But there are times when matters are less clear cut

Scotland has been seen as a beacon of good practice in the field of mental health care and has been proud of its legislative approaches in providing humane person centred care, however in the last few years there have been changes in international law that now finds Scottish legislation wanting.

Human rights legislation,  in particular aspects of legislation covering  care, treatment, capacity and consent within the Mental Health (Care and Treatment)(Scotland)Act 2003 and Adults with Incapacity (Scotland) Act 2000 and Adult Support and Protection (Scotland) Act 2007 now appear at variance with aspects of human rights legislation.  In particular the UN Committee on the Rights of Persons with Disabilities that oversees the United Nations Convention on the Rights of People with Disabilities (UNCRPD) has adopted a radical critique of mental health and capacity law. It argues that the justification for any form of non-consensual intervention based, even in part, on a diagnostic label such as ‘mental disorder’ and the use of capacity assessments is inherently discriminatory. 

Discrimination against those who are diagnosed as mentally ill has been a significant issue and has led to a focus on reducing that stigma through education and awareness programmes such as the “See Me “campaign but impact has been poorer than expected. Therefore a revised approach is now in place and is recognition of the substantial impact that stigma attached to mental illness has for people in society. Potentially this stigma has affected perceptions of how competent people with mental illness are to be involved in decisions around care and treatment.

A patient’s ability to contribute to the decision making around their care and treatment has been enhanced through the use of advocacy support and advanced statements.

The Scottish government is currently reviewing both mental health and capacity legislation to ensure it meets with the criteria stated above. There is some evidence from public responses that indicate the review does not go far enough (see SG)

“While the Mental Health Bill has provided an opportunity to revisit the Mental Health Act ten years on, it was felt that it did not appear to have fully explored the issue of how human rights can be further supported within law and practice.

‘I think there’s really interesting challenges ahead in terms of the noises the UN are making about the Convention on the Rights of Persons with Disabilities and what that means for compulsory treatment in mental health and suggesting that it’s discriminatory and that’s raised a lot of useful discussions which I think we should have been having a long time ago about the acceptability and prevalence of forced treatment.’

– Expert Interview (A Review of Mental Health Services in Scotland: Perspectives and Experiences of Service Users,

Carers and Professionals-Report for Commitment One of the Mental Health Strategy for Scotland: 2012 – 2015)

However the UNCRPD believes that current legislation around detention and non consensual treatment needs to change in favour of a supported decision making model. It therefore seems likely that this will impact significantly on Mental Health professionals and will be a paradigm shift in how we relate to those entrusted to our care. Mental Health Nurses will need to consider how this impacts on their practice and how their fairly unique position as potential advocates might develop. Patillo (2011) notes that “Nurses seem better placed as advocates because they are constantly interacting with patients”. How then might this position develop in terms of a supported decision model? 

In considering this we can think about how relationships between mental health professional and patients have been described

Pelto-Piri, V. et al, talk about 3 styles of working with people who have a mental illness:

1. Paternalism 
2. Autonomy
3. Reciprocity 

Sandhu. S et al (2015) suggest that “reciprocity may be conceptualized and incorporated as a component of mental health care, with recurrent and observable processes which may be harnessed to promote positive outcomes for service users.”

Positive outcomes thus may result from Mental Health nurses reflecting on their role as advocates and treatment partners in which reciprocity is the mode of interaction, enhancing the therapeutic relationship whilst discharging our professional responsibilities both as nurses and as members of the Multi-Disciplinary Team, and enabling consideration of changes to practice and education that would make this a reality of mental health care and treatment rather than a desired state.

Euan McLeod is a Mental Health Staff Nurse at Mid Park Hospital, NHS Dumfries and Galloway

 

Being Wrong by Jeff Ace

Being wrong is interesting isn’t it? When you get a call right, your view of the world is unchanged and things are happening much as you expect them to; all very unexciting. But when you’re wrong, there’s something off with your perspective, or lacking in your knowledge; very interesting indeed.

Luckily, I’m wrong particularly often and accumulate large numbers of these excellent opportunities for learning. I’ve been wrong on some big life stuff and on too many professional and work related decisions to keep track of. I was even wrong in recent attempts to help my daughter with her physics homework, leading to her claim that many of the elements hadn’t been discovered when I was in school.

There’s something in this unfunny and (mostly) untrue teenage sarcasm that I think explains one of the common causes of ‘wrongness’ in that people look to the past to explain the present and predict the future. This might be fine but most of us, including my daughter, have an absolutely lousy sense of historical perspective. Smart Alec history teachers will use any number of examples to highlight how poor this perspective can be. A couple of my favourites in this list of things that just don’t seem right are that Cleopatra lived closer in time to ‘Carry on Cleo’ than to the building of the Great Pyramid at Giza, or that Tyrannosaurus Rex was more a contemporary of Marc Bolan than it was to the Stegosaurus. Similarly, England’s 1966 world cup win is as close to the outbreak of WW1 as it is to the present day, despite it being mentioned every four flipping minutes over the summer.

Broad contemporaries: T-Rex and T-Rex

These examples show that people tend to distort historical perspective by magnifying the recent past and diminishing periods further back. So, to me, my schooldays of the 70s and 80s are useful reference points in understanding how the world works and will continue to work, whilst to my daughter it was when we learned to alloy copper and tin to make our swords. This phenomenon has big implications for how we get things wrong (or how we can avoid making mistakes).

Take climate change, for example. The scientific consensus is that we’re now heading for more than a 2 degree temperature rise on pre-industrial levels and likely implications include 3 metre plus increases in sea level rises. By all rational measures, this information should be dominating the political and economic agendas, with urgent risk management and mitigation measures everywhere we look. But 3 metres… that can’t happen, can it? That would swamp St Helen’s cricket ground in Swansea where Sir Garfield Sobers became the first human to hit six sixes in an over, where all great Welsh cricketers have strutted their stuff over the years (well yes I have played there, actually. Don’t like to go on about it. It’s not like there’s a framed picture in my house of me on the pitch or anything like that *). The scale of this change, that would flood Miami and make the Mumbles Road end at St Helen’s appear only at low tide, is way outside our historical reference points, our ability to visualise the world; so we sort of file it somewhere in our brains and get on with more everyday routine problems.  

St Helen’s Swansea – spiritual home of Welsh cricket

So I worry about how our tendency to rely too much on a poor and distorted understanding of the past can make us wrong and complacent over big changes. And I worry about it a lot in the context of health and social care provision. 

Our historical perspective here is dominated by the post war model of service provision. This model is an historic anomaly, of course, radically different from that which existed through the rest of human history, but is nonetheless now seen as an unchanging piece of how our bit of the world works. The difficulty is that if you start projecting the next 20 years of demographic change, workforce availability, technology driven cost increase and the amount of funding that an economy can generate for health and care… it’s really, really hard to see how it all holds together to provide the sort of health and care service that people of my age will by then be expecting. I think there’s a tendency to dismiss these forecasts because, well the Health Service has always been short of money hasn’t it, and winters are always a bit tight, but we always get through it in the end…. and basically because our perspective doesn’t help us to imagine a radically different future. 

This I think would be terribly complacent and would open up our largely wonderful but already creaking system to existential risk. But whilst I’m a bit of a worrier, I’m also a mostly optimistic type of bloke. There is now a lot of work ongoing on the sorts of disruptive changes that could help to address the apparent perfect storm of pressures building on health and care. Organisations like The Kings Fund have been busy in this field lately (https://www.kingsfund.org.uk/publications/eight-technologies-will-change-health-and-care and https://www.kingsfund.org.uk/publications/digital-change-priceless are good examples) and show how we can move perspective from a future of tweaking our models of care to one where they are genuinely transformed. 

I’m wrong about loads of things but I’m pretty confident in predicting that, in order for us to continue to deliver the service our population deserves, we’re going to have to increase the pace of change to models radically different from those established. In D&G we have an outstanding track record of managing major change and this is one aspect of the past that I think is going to be extremely useful in preparing us for the future…

 (* ok there is)

Jeff Ace is Chief Executive Officer at NHS Dumfries and Galloway

Always look on the bright side of life by Ken Donaldson

I published this post on my own blogsite two years ago and, even though it is a little silly and dated, I thought I would share it with you again. Sadly things haven’t changed that much in the past two years.

“I don’t need to remind everyone that 2016 has been a particularly bad year. Who would have thought, 12 months ago, that we’d be leaving Europe, a complete Muppet (and that is an insult to Muppets to be honest) would’ve  been elected to the White House and far right, fascist, borderline Nazi rhetoric would suddenly become acceptable. Not me, that’s for sure, but here we are.

On top of all that we have daily news clips showing unimaginable suffering in Syria and other parts of the world whilst we sit watching helpless. And then there is all the celebrity deaths. It is as if the likes of Bowie, Rickman and Wogan knew it was all coming and thought “Stuff this, I’m out of here”.

So it is for that reason that I thought I would tell a wee story that may lift your spirits. Not much perhaps but hopefully, like me, you may have a smile on your face by the end of it.

A few weeks ago I had a bit of a crazy day trip down to London. Up at 4.30 to catch a train from Lockerbie to Euston, full day finishing at 9.30 (well, when I say ‘finishing’ that was the work bit, I then caught up with friends over some red wine until 1am…I never learn). I had to get up again at 4.30 to catch a return train to Glasgow. Forgive me a slight digression but the contrast between my two ‘walks to the station’ was quite stark. In Lockerbie it was a glorious, still, freezing morning with thousands of stars filling the jet black sky. In London it was slightly warmer walking down Tottenham Court road but there were no stars, just a plethora of homeless people shivering under blankets and, at one horrific moment, being investigated by the biggest rat I have ever seen. In fact the only rat I have ever seen outside of captivity. There was a somewhat Dickensian feel to it.

But back to my story. So I got on the 5.30 from Euston and promptly fell asleep. The next few hours were a bit of a blur but as we approached Preston the guard made his usual announcement – take care leaving the train and remember all your bags etc – but then he added “Ladies and Gentlemen I would like to take this opportunity to remind you that it is 36 days 15 hours and 43 minutes till Christmas. And with that happy thought here is a song” I must confess I was expecting a Christmas hit or carol but instead he played ‘Always look on the bright side of life’ by the Monty Python boys. I started to smile, I really had no choice, and as I looked up and down the carriage at my fellow passengers, folks who had spent the past 2 hours quietly reading the paper or tapping on their laptops and ignoring each other, I noticed that they were all smiling too. And some were staring to chat, probably about the song but who knows. The guard interjected a few times with “I want to hear you singing now” and before the chorus “Altogether now” which just added to the fun. And as the train slowed down and approached the platform the music stopped and he said “Ladies and Gentlemen, Preston” and that was that.

It made me realise the power of a small gesture, a simple thing which raised the spirits of a few hundred tired travellers. It also made me think that, sometimes, ‘Life is a piece of sh*t, when you look at it’ but Eric Idle was right, it helps to look on the bright side.”

“Cheer up, Brian. You know what they say.
Some things in life are bad,
They can really make you mad.
Other things just make you swear and curse.
When you’re chewing on life’s gristle,
Don’t grumble, give a whistle!
And this’ll help things turn out for the best
And
Always look on the bright side of life!
Always look on the bright side of life
If life seems jolly rotten,
There’s something you’ve forgotten!
And that’s to laugh and smile and dance and sing,
When you’re feeling in the dumps,
Don’t be silly chumps,
Just purse your lips and whistle — that’s the thing!
And always look on the bright side of life
Come on!
Always look on the bright side of life
For life is quite absurd,
And death’s the final word.
You must always face the curtain with a bow!
Forget about your sin — give the audience a grin,
Enjoy it, it’s the last chance anyhow!
So always look on the bright side of death!
Just before you draw your terminal breath.
Life’s a piece of sh*t,
When you look at it.
Life’s a laugh and death’s a joke, it’s true,
You’ll see it’s all a show,
Keep ’em laughing as you go.
Just remember that the last laugh is on you!
And always look on the bright side of life

Always look on the bright side of life

Come on guys, cheer up

Always look on the bright side of life

Always look on the bright side of life

Worse things happen at sea you know

Always look on the bright side of life

I mean, what have you got to lose?
you know, you come from nothing
you’re going back to nothing
what have you lost? Nothing!

Always look on the bright side of life”

Lyrics copied from this site