The NMC guidelines suggest that all nursing students should be given experiences in each of the other branches of nursing, ‘to inform branch choice’. There is a certain logic to this, in that it essentially allows you to ‘try before you buy’. Anyone coming from a care background is unlikely to have experienced all types of nursing, and anyone coming from college is basically just taking a guess as to which area they think they might like. So, before plunging into a seriously life changing decision, they very kindly let you have a quick go on the other branches.

As a mental student, I am therefore required to spend time in adult, child and learning disabilities nursing environments, essentially to make sure I know what I’m missing out on. My university, in a move I am infinitely grateful for, only requires that we complete 34.5 hours in each other branch. Not exactly giving us a thorough insight, but a good little taster with the knowledge that, if it’s horrendous, it’s only for a week. I am informed that in other (probably much better) universities, students are farmed out for between 2 and 8 weeks each.

I’m just about finished these tasters, and, whilst none of them have been horrendous, I am very glad I’m doing mental health. Readers of my blog will know that I spent my week with the health visitor biting my tongue as chav parents acted like their kids were just an annoyance, who got in the way of their being drunk at 11am.

My learning disabilities placement (council run respite care) was ok, but rather quiet, as most of the clients had a better social life than me and so were never about. I was slightly bemused (read: pissed off) to learn that a care officer with an NVQ 3 was paid more than a newly qualified nurse in the NHS. Ho hum. Most exciting bit of the week? Trip to Tesco’s with clients. I got a free coffee.

The one I was dreading most was adult, particularly the references about not being a ‘proper’ nurse; I dislike having to justify my career choices to people I’ve just met and don’t like. As it happens I needn’t have worried, as most of the nurses there apparently wished they had done mental health instead of adult. One of the 1^st year students there was changing to MH, a third year student just hated nursing and was going to have babies immediately after qualifying, and both the cadets on the ward couldn’t wait to go somewhere else. It was a very grim ward; half the patients were alcoholics in organ failure and my enduring recollection is going to be that of an elderly lady with C.diff repeatedly asking me to kill her as we changed her incontinence pad. At one point I thought they had mistakenly sent me to a psychiatric ward, as the majority of the patients had some sort of mental health problem; dementia/delirium, depression anxiety (both probably induced by the ward, frankly) and outright psychosis.

The ward itself was complete chaos; supposedly supernumerary students were counted in the numbers and there still wasn’t enough staff to give patients the time they needed and deserved. Some of the staff were fantastic; others were shit, to be blunt, as even I did more work than them…and that’s saying something, considering how completely and utterly clueless I was.

Anyway, I’m glad to be back. Or rather, I’m glad to have finished my last placement of my first year as I now have six weeks off before returning to uni…

• You should go to lectures/classes. Just relying on handouts and powerpoint sheets won’t do much. You’re not really likely to read it, and if you do, are you likely to follow it? The best time to get a proper understanding is in the classroom. There is bound to be at least 1 tit who consistently asks stupid questions and/or has a story to share about the current topic (often totally unrelated), but if you can get a word in, you should to clarify anything you are unsure about. You can also speak to the lecturer at the end or via email if you need to.

• There is usually a suggested reading list. You won’t be expected to read everything, but these articles/texts will help with your understanding, and are usually a good start for references for essays.

• Although everyone is now an adult learner, it’s amazing the number of people have no idea what’s going on, yet still don’t ask.  This course shouldn’t be about just passing assessments, it should be about gaining the most knowledge to enhance your skills and give good care to patients.

• I wanted to add that nursing has a minimum time for attendance. It is watched closely. At the moment, I can’t remember if this is a funding thing or an NMC one. It’s not like other Uni courses that you can skive for most of it. You really need to attend.

• Reading the notes and regurgitating them is something you could do without making the commitment to become a full-time student. Going into them in depth, talking to experts (eg lecturer) about them and reading around the area is what the course of study is for.

• At the very least, start research on your assignments early. This is something I consistently struggled with. It is too hard to do it all last minute. Your essays are likely to reflect your surface learning. Reading and research before hand will help with your deeper learning and will show in your work.

• This may sound obvious, but I believe it is quite a common issue - save regularly and back up your work. Email your essay to yourself, keep it on a memory stick as well as on your own PC. You never know when your PC will decide to die on you. It is probably more likely to happen when you haven’t kept a copy of your almost-finished-essay.

• If you must ask for an assignment extension, you will need a decent reason, such as a medical certificate or a death notice (or other such proof). The uni do not give extensions on a whim, and are not obliged to. The odd lecturer here and there may be a soft touch for extensions, but they could choose your term to change their policy and you could get a nasty surprise.

• If you are struggling for any reason, speak to your personal teacher/tutor or similar as soon as you can to make them aware. They should be able to give advice on what else you can do or how to get an extension if applicable, or if you fail a piece of work, they will be aware of any issues beforehand and will be able to support you in any appeal needed.

• If there is something you aren’t happy with, don’t forget your class rep. They are usually pretty good at knowing the right person to ask about a query about the course/placement. When new procedures and policies are introduced, your class rep is the person to see if you aren’t sure about it or just plain don’t like it!
• Added to the above, if you would like to know what is going on in your school of nursing/uni and have a voice you aren’t scared of using to help your peers, volunteer to be a class rep. It isn’t too much work, it can actually be an eye opener and give satisfaction that you were able to help your fellow students (it doesn’t hurt the CV either!)

From our resident lecturer, beakie on what pisses him off:

People who turn up at my office without an appointment and then get shitty with me because I wasn’t there. People, when I am not teaching you, they don’t just stick me in a cupboard. I have marking, moderating, clinical visits, lesson prep, other classes to teach, meetings, interviews, personal study and a whole host of other things to do.

Or students who think that rules and regulations just don’t apply to them, as long as they can schmooze me enough. It won’t work, chaps. I spent several years in acute psychiatry. I’ve been manipulated by the best and learnt my lessons well. You will not get round me to break the rules for you.

hopefully he isn’t like this…..

or, um, worse, like this…..

The Art and Science of mental health Nursing is an equally challenging issue for ivory tower theorists as it is for grubby little coal face monkeys - and it’s one we share the same general desire: How do we make mental health care better?

Indeed, there is a debate within nursing itself as to whether nursing is an art, a science, or both an art and a science.[ref]

So does it exist? If so, how? And, if not, why all the talk about it?

Google throws these search results up:

Results 1 - 10 of about 14,700 for “the art and science of nursing”

And only

Results 1 - 10 of about 2,090 for “the art and science of mental health nursing”

Yet more despairingly (tho I prefer the term mental health nursing)

Results 1 - 9 of 9 for “the art and science of psychiatric nursing”

So it’s definitely a talked about issue, if only on comparatively smaller scales to other more important issues.

Results 1 - 10 of about 27,800 for “elvis sightings”

Stephen Tilly, in The Mental Health Nurse (1997), discusses;

nursing as craft; an activity which is not specifically an art or science but might have some of the elements of each.

Bloody fence-sitter.

But I agree (and no-one is surprised).

I will however, and in the context of being Olympically topical and wanting to be first to annoy everyone on MN site for mentioning it in a corny fashion, draw an analogy to the art and science of sports.

There are those that have a natural talent; and those that make better spectators tho like to have a dabble here and there.

Those with the talent - have trainers - mentors - and science labs - to try and help shave off that extra millisecond or gain that extra reach or push themselves harder.

Nursing is no less a science and art than boxing; swimming; football; synchronised swimming; fishing; etc; etc. Nursing also has trainers, mentors and science labs. It is a technical skill in art form.

Even with the original talent tho, the science and art of nursing are both pointless to those who can’t grasp the science and never learn how to improve their skill by understanding its workings and those who can’t grasp the art can’t develop the skill if they’re not able to carry out the processes effectively.

Good mental health nursing is a healthy mix of art and science - but unless you have someone with the raw talent to build on - you’re never going to get Gold Standards.

What with Azulinebloo soon to be qualified and unleashed upon the world, the powers that be have very kindly asked me to join and be the resident mental student. How could I refuse?

So, a bit about me for anyone who doesn’t already know…

I’m a mental health nursing student coming to the end of my first year, and at some point in the distant past I somehow achieved a degree in psychology. I also work on a forensic unit as and when they phone and make me. I do have another blog, which I am going to use this site to shamelessly promote (it’s here).

I will try and post some interesting studenty stuff, but no promises…Theoretically I have lots of uni work to do, so I may be quiet on occasion. I don’t particularly enjoy arguing as I get far too much of it at work. Also, I am cursed with the ability to see everyone’s point of view (except Ted’s…sorry Ted) and so poking me with a stick will usually just end up with me either (a) agreeing with you or (b) ignoring you. Of course, reasoned debate is always welcome J

What else? Oh, I’m female (very important to clear that up now) and comparatively young.

Right, am off to hammer my student discount at the shops…

I apologise now if it’s not as good as it should be! (which it won’t!) These things always sound good in my head until I start to type them out.

Being at the end of my time as a student, I would like to impart my wisdom to other students and future students as well as share my observations. I first happened upon this site when I was in first year and I am aware there are other students who read this, although don’t always post comments, hoping for some more information and wisdom (haha, good luck with that one!).

Students have 50% of their time on placement, which tend to be only for a few weeks (between 6 and 12) at a time. Or they are at my Uni anyway. This gives the student a lot of new environments to get used to and quickly. You learn what staff to follow around, ask and speak to and who to avoid. In saying that, you can learn more from how not to do something than how to. One of the most memorable nurses I worked with is one that I got inspiration from in how not to be!

With the short length of placement, I often found that I was just finding my way and it was time to move on. Although in some placements, I was counting the days and glad of the short time there!

At first, it may seem daunting. I remember visiting my first ward before starting on placement there and thinking

“what the feck am I doing?”

Fortunately, the first shift reminded me why I chose this as a career/vocation/job. The patients weren’t actually as scary as they first looked.

Being left to hang about and being told just to talk to the patients was a daunting idea as well.

Talking? That’s hardly work!

What if someone says something and I have no idea how to respond?

Just be quiet and listen to what they have to say, or ask them more about it. It’s perfectly okay to admit you haven’t a scooby. Just don’t be scared.

I have found patients are generally used to students and can be quite accommodating. They are people after all. They don’t expect students to have indepth knowledge in 1st year (or 2nd year even).

Often, the patient would like to know about you and will ask you more questions than you would feel comfortable if it were you doing the asking.

Getting away from the task orientated work can be tough as talking to someone hardly seems like work, however, you’ll be beginning your therapeutic relationship and as Phil Barker said; talking, conversation and discussion are tools for recovery. There is a LOT of literature on the nurse-patient relationship if you fancy enough reading material for a month.

Make friends with the nursing assistant. Most of them are great, but rub them up the wrong way and your placement will not be fun. The student nurse is the bottom rung, not the NA, regardless of how clever you are or think you are.

When you are lost for things to do, the NA will find you something. It may not be fun or glamorous, but you can still learn. (Even down to how to tie the laundry bag - I have met staff nurses who don’t know and get stressed when there is no NA available).

It is not normal to regularly experience violence on an over 65 ward, because the patients have dementia. If you are, you need to pay close attention to the approaches taken. I heard this comment from a fellow student recently and was concerned.

The students biggest challenge is not likely to be the patients. It is the staff and surrounding ward politics.

It can be hard going walking into a ward for report when you are full of enthusiasm (even at 7am) to be met with tired and miserable faces stating the latest patient that presents as a challenge is another personality disorder. This has been covered before, and I’m sure it will be again, so I won’t go into that here. Basically, the nurse is doing exactly what they aren’t meant to…. being judgemental and negative about the people they are there to help. Don’t learn their attitudes, you have plenty of time for that after qualifying (:-p)

There is a fine balance in being a student as you can be classed in (at least) 2 negative ways;

Too quiet and not assertive enough - unable to find things to do, can be interpreted as lacks enthusiasm and/or initiative.

or

Being able to keep busy and/or questioning current practice, can be interpreted as over-confident and a know- it- all.

There are some nurses who are threatened by students but there are others who enjoy the opportunity to learn from, as well as teach students. Mentoring student nurses is part of the NMC code of conduct, therefore it’s written in their contract. Nurses who have no time for students are not doing their job right.

I remember this from school, but it’s still true as a grown up; you’re better to ask a question and learn than act like you know and remain unsure.

I thought that I preferred being at Uni to placement as there are less hours, everyone already knows you and it’s a comfort zone.

However, my nearest and dearest informed me that I hated Uni and much preferred placement. This was noted due to less ranting from me at the end of the work day on placement, than after class. I found this interesting and realised the poor soul who lives with me is much more perceptive than I thought!

The DoH has a current consultation:

The Nursing and Midwifery (Amendment) Order 2008 was made on 11 June. It makes a number of changes to the constitutional arrangements for the Nursing and Midwifery Council. Instead of the constitutional details of the NMC being set out the in the Nursing and Midwifery Order 2001, these details must now be set out in a separate Constitution Order made by the Privy Council.

You see, there’s been some shenanigans down at the Old Bailey for Nurses & Midwives and now parliament is taking the NMC’s ball away until they learn to play nicely.

It’s not new news - the NMC has been under this review by the CHRE since March 2008 so I doubt much of this is a surprise. The review was released last month and has been widely accepted as, well, pretty damning.

CHRE Chief Executive Harry Cayton said: “We have serious concerns about the inadequate operation of the NMC’s fitness to practice processes, governance framework and lack of strategic leadership, the inconsistent availability and provision of information to council to ensure effective planning and decision making and its ability as an organisation to retain the confidence of key stakeholders.”

A CHRE press release identifies the origins of the review as:

a response to a request from the Minister of State for Health Services, Ben Bradshaw MP on 14 March 2008 to address the central question of whether the NMC was fulfilling its statutory functions.

Which shouldn’t have been too difficult, since the CHRE put out a report in May 2007 already that:

..praises the NMC for its approach to partnership working and provision of advice including:

– focus groups involving patients and members of the public to inform the development of policy and provision of help and advice to stakeholders
– seminars to enable employers to understand their responsibilities to nurses and midwives and
– the creation of an on-line ‘A-Z of Advice’ allowing nurses and midwives easy access to advice on best practice and guidance.

I did try to find the CHRE original May 2007 report - but couldn’t. However, the commendation in that 2007 report didn’t stop them making widespread recommendation in the June 2008 report; which suggests a troubled 12 months at the NMC.

There’s been a lot of in-house tantrums and dramas; accusations of over-spending on legal budgets (particularly in relation to Council disagreeing with Executive it seems) and there’s further Tribunal matters afoot on claims of “bullying and harassment”. The report includes significant references to the ’sectional’ disparities - something better explained by, at best, “the left hand not knowing what the right hand was doing” and, at worst, “territorial terrorism”.

The NMC has managed, amidst such apparent disarray, to re-develop the Nursing & Midwifery Code of Conduct, the Code that directs nurses how to act responsibly and accountably and a Code that is used as a point of reference for Fitness to Practice before striking nurses from the Register.

It is therefore ironic to note that the CHRE report specifically recommends:

• The NMC should commit itself to work towards more effective governance. This should include reviewing its committee and accountability structure and agreeing on the level of detail of reporting to meetings. It should also include introducing and enforcing an effective statement of organisational values and code of conduct for Council members and staff, and appraisals for all Council members. Collectively and individually office holders and other Council members accepting responsibility for the current difficulties and for future resolution.

All rather a bit embarrassing for an organisation that is appointed or elected specifically to uphold standards of conduct.

All Crying, Self-Harming Emo Children To Be Banned In Mother Russia

..it makes one stop, notice and ask questions.

But what’s the real story behind the sensational headline of Heckler Spray - whoever they are?

More gripping headlines (and my attempt to contend with E and spice up my posts with pics totally and plagiaristically ripped from the NME author-site a la Persuad) reveal:

Emo to be made illegal in Russia?

My Chemical Romance fans protest at the Daily Mail’s London office

New laws planned to stop ‘dangerous teen trends’

A new Russian law could make being an emo kid illegal in the eastern European country.
Legislation is currenting being formulated in Russia to heavily regulate emo websites and ban emo and goth dress style in schools and government buildings.
The new laws are apparently being driven by fears that these “dangerous teen trends” encourage depression and suicide.

So what’s going on?

At last I find a less sensational headline that gives a slightly more open awareness:

Russia may ban Halloween, emo punk

Russia’s State Duma is currently considering a package of laws aimed at protecting the morality of its children and preventing youth suicide and alcoholism. Some of the ideas kind of seem like overkill:

Together with proposals to combat child alcoholism and pornography, the policy project outlines a raft of draconian measures such as a 10 p.m. curfew for all school-age children and a ban on tattoos and body-piercings.

Ok, so it’s still a little scary to wonder what’s afoot. But what is it the Russian legislative powers of the State Duma, or Государственная дума (for the intellectually superior medically trained readers), are really getting at?

[A] package of bills and amendments, introduced in Russia’s State Duma in June, aimed at “protecting children’s morality.”

Is that so bad?

If some Duma deputies have their way, young Russians could soon find themselves in trouble for activities as seemingly innocent as carving pumpkins or listening to music

Perhaps it is.

But then, how long have we heard the moans and groans against our seemingly irresponsible and parasitic younger generation? And how did it develop into this?

Really - How?

Perhaps Russia has seen the detrimental effects the whole “touchy~feely” brigade has had on our culture and the permissive society has sneaked it’s way insipidly through our very core. I mean, why does juvenile detention seems to be nothing more than a training ground on “How to play the game and win”? Or when young Johnny gets into trouble with the teacher for having a scrap in the schoolyard over a football - it’s the teacher having to explain why *s/he* did not treat young Jimmy like an individual person with rights?

The Moscow Times reports:

Igor Ponkin, one of the bill’s authors and a member of the Interior Ministry’s public oversight council, described emo culture as a “social danger” that demands measures such as dress codes in schools, Internet regulation and state-sponsored after-school activities.

Ponkin said emo kids exchange photographs showing off their slashed wrists. “This type of behavior is a crucial part of emo ideology,” he said.

“Of course there are emo teens who just listen to their music. But our actions are not directed at them but rather at those who also hurt themselves, commit suicide and promote those acts,” Ponkin added.

Not all psychologists agree with Ponkin’s analysis, however.

“Suicide is not a symptom of emo culture. I work with other teens too, and every group has emotionally troubled kids,” said psychologist Inna Cherkova, who has worked with local teenagers, including emo kids, for 15 years.

Many subcultures can, in fact, help children mature into adults, psychologist Alyona Filippova said.

Of course, maturation into adult hood by understanding the best ways of, and engaging in, cutting yourself to express how bad you feel has not yet been proven in controlled clinical trials to be a bad thing, so lets not get all a posteriori about it until we’ve been there. The emo generation may well become the most well bled bred children of our time.

I’d suggest it’s rights vs responsibilities debate - and Russia is perhaps seeing how the Westernised child seems to lack much of it’s sense of responsibility yet appears to enjoy the rights of ‘free expression’ - or is it simply that the responsibility is changing now - and a what was ethical and responsible back then is a thing of the past now?

Together with proposals to combat child alcoholism and pornography, the policy project outlines a raft of draconian measures such as a 10 p.m. curfew for all school-age children and a ban on tattoos and body-piercings.

Under the new measures, schools would be prohibited from celebrating Western holidays like Halloween and St. Valentine’s Day, which are deemed inappropriate to “Russian culture.” Toys in the shape of monsters or skeletons would be banned as “provoking aggression.” [source]

Well, ya gotta start somewhere I guess. Personally, I think they’re all just missing being caned.

That Neil Bacon fellow (essentially an inadequate doctor who pretends he was a renal specialist but decided to go for the dot.com fortune instead with doctors.net.uk) has started something most annoying to the medical fraternity. I won’t link to any of it (except Shrink’s post on the subject and 360 degree feedback - but only cos he’s an honorary nurse*). You know where the rest of it is.

So what’s up? Well in a nutshell he’s started a ‘rating’ site for doctors (Bacon - not Shrink) - with anonymous submissions from.. well, anyone. It’s a bit crass - actually it’s extremely crass - and I sympathise with the medics - (in the same way they might sympathise over nurses pay).

But wait! Cue the cavalry bounding over the hill - Sir Liam Donaldson, Chief Medical Officer has another idea.

The Independent reports it here:

Doctors will face annual assessments so licences can be removed from poor performers, under proposals to be outlined by the Chief Medical Officer today.

He’s changing the way doctors maintain their licenses:

A new revalidation system is being established in response to concerns raised by the Shipman inquiry, and the inquiries into the conduct of a number of other doctors. In future, doctors will be required to demonstrate to the General Medical Council that they are up-to-date, and fit to practise medicine. Doctors who take part in revalidation will be granted a license to practise, and will be reassessed every five years.

Instead of sitting and waiting for someone to get caught after killing 215 patients over 23 years - they’ve decided they should go do some self-checking and peer review. Doctors will be required to regularly provide evidence that they’re actually good at their job.

Now there’s a good idea.

* - Dr “Senior Nurse” Shrink - is currently still without biscuit privileges

As some of you may have guessed by now I am currently reading a book on “Social construction” or social constructivism or constructionism by Ian Hacking called the “Social Construction of What?”. At the risk of boring certain members of the audience even further (audience what audience?). I want to give a resume of Chapter 5 (pp 100 – 125) entitled “Madness: Biological or Constructed” and maybe draw a few conclusions of my own.

There are many controversial diagnosis in psychiatry (Intermittent explosive disorder, ADHD and conduct disorder in children, Sexual addiction and personality disorder in adults) where it is suspected the medical profession is medicalizing certain aspects of behaviour that until recently were considered deviant, naughty, normal or criminal but which are now seen as an illness in need of treatment. There are also cases of diagnoses that have gone the other way (homosexuality and moral imbecility) have all dropped out of current usage and are no longer considered illnesses.

Some mental illnesses are described as transient, they show up at a specific moments in time and place and then mysteriously disappear. Examples include hysteria in 19th century France, Multiple personality disorder in 20th century America and Anorexia which can according to Hacking can be quite local in its history and at the time of writing was particularly virulent in Argentina of all places.

But is there a sense in which mental illness is “constructed” or is it “real” and if mental illness is real what do we mean by real? Hilary Putnam had this to say about reality:

“ (there is a ) Common philosophical error of supposing that reality must refer to a single super thing, instead of looking at the ways we endlessly renegotiate - and are forced to renegotiate – our notions of reality as our language and our life develops”

So is there a sense in which reality is constructed and the dichotomy between what is considered real and constructed a false one in this case? “Socially constructed” and “real” do appear to be at odds with each other. Psychiatry is a part of medicine which views itself as a branch of the natural sciences dealing in “real” things not stuff which has been socially constructed or made up by social workers. Psychiatry sees schizophrenia at its heart as a biochemical/ neurological/ genetic disorder but a minority of critics think that the disorder itself has been socially constructed. Is there a way of reconciling these apparently incompatible views? Hacking thinks there is.

Hacking describes interactive, indifferent and natural classifications or kinds of things. He believes the idea of an indifferent kind of thing can be adapted to resolve the differences between the biological and constructionist camps. Hacking defines an indifferent kind as one that does not interact directly with its environment but is not entirely passive either. Electrons are indifferent to the idea of electrons and do not interact with the concept of what it is to be an electron and so remain unchanged by the concept. Electrons are there fore a natural kind of thing because they have no agency and act as a philosopher would say under description. Likewise the diagnosis of schizophrenia is indifferent to what it means to be a schizophrenic but a schizophrenic on the other hand is conscious of what it is to be schizophrenic and is changed by that diagnosis. Schizophrenics when allied with others who have the same diagnosis (Schizophrenia fellowships and interest groups) are able to influence the diagnosis which in turn changes how the diagnosis is viewed by those so diagnosed. There is in effect an active dialogue between the diagnosis and the diagnosed which evolves over time. A similar dialogue may be occurring between notions of what an electron is thought to be by scientists and how it is thought to behave in the laboratory but this has nothing to do with any independent thought or action carried out by electrons.

The word “kind” was first used in this context by JS Mill and William Whewell and was used to describe the way in which the thing or group being classified interacts with the classification and vice versa. The interaction between kinds and their classifications can be strong or weak in nature and occurs through a looping effect described above in relation to how a diagnosis of schizophrenia changes the individual and is turn changed by the individual. The social sciences (sociology, anthropology, psychology?, Psychiatry?) have for a long time tried to emulate the natural sciences (physics, chemistry, biology, medicine) to identify “true or natural kinds” that is kinds which are fixed and have an objective reality and nowhere is this more clearly demonstrated in Psychiatry than in the research to discover a neuro-chemical basis for schizophrenia.

Indifference does not necessarily imply a fixed and passive response. Schizophrenia may not interact with the idea of schizophrenia but schizophrenics interact with the business of psychiatry and with the psychiatrists who are attempting to treat the condition (or are they treating the individual?). When philosophers talk about natural kinds the indifferent nature of the kind in question is in a technical sense taken for granted, but natural also implies a fixed and passive quality that is not necessarily implied by indifferent. Things classified as natural are not aware of being so classified and do not interact with their classification but schizophrenics do react with their classification or diagnosis so schizophrenia, as it affects the individual, should according to Hacking, be seen as an indifferent rather than as a natural kind.

The targets for the natural sciences are relatively stationary; the targets for psychiatry (literally and figuratively) are, owing to the looping effect, not. The term Schizophrenia was first coined in 1908 by Eugen Bleuler but descriptions of schizophrenia like symptoms are to be found in the Egyprian Ebers Papyrus (BC 2000) and in ancient Greeks and Roman texts which describe symptoms of psychosis but not in a way that would satisfy a modern diagnosis of schizophrenia. However there is a widespread conviction in the psychiatric profession that like America, the condition was always there and waiting to be discovered and will continue to be with us as long as there are people around unluckily enough to be so afflicted. In the constructionist camp disorders like schizophrenia are interactive and essentially man made, in the biological camp they are fixed and timeless. Hacking thinks there is a middle ground by describing mental illnesses like schizophrenia as indifferent.

N.B. Hacking is describing the condition schizophrenia as it affects the individual as an indifferent kind he is not describing those diagnosed with schizophrenia as indifferent to their condition.

An epitaph for the eighties? “There is no such thing as society”

“I think we’ve been through a period where too many people have been given to understand that if they have a problem, it’s the government’s job to cope with it.’I have a problem, I’ll get a grant.’ ‘I’m homeless, the government must house me.’ They’re casting their problem on society. And, you know, there is no such thing as society. There are individual men and women, and there are families. And no government can do anything except through people, and people must look to themselves first. It’s our duty to look after ourselves and then, also to look after our neighbour. People have got the entitlements too much in mind, without the obligations. There’s no such thing as entitlement, unless someone has first met an obligation.”

Prime minister Margaret Thatcher, talking to Women’s Own magazine, October 31 1987

What did Prime Minister Thatcher mean when she famously declared in 1987 that there was no such thing as society? What I think she meant was that society, as it was in the 70’s and early 80’s, was (and remains) a social construct and that she, Maggie Thatcher, was in the process of deconstructing it. But to replace it with what and what exactly was it that was being deconstructed?

Before answering that question we need to ask what we mean by “construction”. Clearly construction has two meanings. We can talk about the process of constructing or building a thing, place or entity or we can talk about the finished product that has been constructed. Hence I can say that the construction of Chatsworth house began in 1687 and ended in 1970 which is to say the process of building Chatsworth took a little over 280 years. Or I can say that the construction that is Chatsworth is a large country house situated in Derbyshire 3 ½ miles north east of Bakewell has been owned by the Dukes of Devonshire since 1694, which is to describe what it is, where it is located and who owns it.

In a similar way we can talk about gender and ethnicity being constructed either as a process or as an end product but what is the difference between the construction that is Chatworth and the construction that is an ethnic minority. Well clearly an ethnic minority while not an individual has a collective consciousness in a way that the bricks and mortar that go to make up Chatsworth house does not. An ethnic minority may not even be aware that it is an ethnic minority until this fact is made known to them but once identified as such the knowledge that “they” are an ethnic minority will change how that group views itself and in turn behaves and is its self described.

So does it make sense to talk about the construction of Chatsworth house in the same way as we talk of the construction that is an ethnic minority or does Chatsworth simply exist? Well on one level yes Chatsworth was built, it exists and one day it will cease to be, it is a thing and no amount of philosophy will change that, wind and rain will eventually wear it away but how we view Chatsworth will not affect its appearance. But is Chatsworth more that just a country house built in Derbyshire 3 ½ miles away from Bakewell owned by the Duke of Devonshire? To the 12th Duke of Devonshire and the many people who live and work there I suspect it is. It is home to the Duke, it is where he was raised where he has lived as an adult and where his children were born. To the people who work there it is where they and possibly generations of their family have worked and where they belong. It is this sense of construction that can be deconstructed and then reconstructed anew without altering the fabric of the house.

And it is this sense of society that I suspect that Maggie Thatcher imagined she could (and arguably did) deconstruct in the early 1980’s. Clearly if all we meant by society was a group of humans coming together to live in close proximity and mutual dependency then “society” has always and probably always will be with us. But society is about more than a group of people living together it is about social morays, ethics, customs, attitudes and prejudices and it was this aspect of society that Thatcher wanted to change.

But why say society does not exist, why not say society must be changed or altered in some way? Here I think we need to look at the agenda that social constructionists often have. By describing society as a social construct that did not in fact exist, Maggie was taking a revolutionary approach towards deconstructing society in much the same way that Feminists have sought to deconstruct gender and Carl Marks attempted to deconstruct capitalism. In this she made the following assumptions about society

1. Society in its present form is taken for granted and would appear to be inevitable but in fact is not. (Historically people have short memories and forget that the welfare state, which arguably was what Thatcher really wanted to deconstruct, had only been around since 1948)
2. Society does not need to be as it is at present
3. Society as it is currently constructed is a bad thing
4. We would be better off if society were to be changed (or in the case of a revolutionary like Thatcher or Lenin completely done away with and replaced with something new).

But society did not cease to be because Margaret Thatcher said it did not exist and the welfare state which I beleive was the true target of her reforms is still very much with us, but society in this country has very definitely changed since the 1980’s. We have gone from an industrial and manufacturing economy to a service economy, from an economy based on physical labour to what is called the “knowledge economy”. There have been winners (the SE and London) and losers (mining, manufacturing and ship building communities) The growth in recent years of the social problems that we see today (unemployment drug use, teenage pregnancy, crime) summed up as “social exclusion” are mainly a result of the wholesale destruction of this countries manufacturing base in the 1980’s and it’s replacement with little more than call centres and flipping burgers . Ironically the social disadvantage that the loss of this countries manufacturing base has produced in the Midlands, the north east of England and Scotland has meant that the welfare state, which Thatcher so detested, is probably more entrenched now than it ever was.

As you may or may not be aware, I am in my final year as a student and will be a qualified Mental Nurse by the end of September.  I’m quite surprised at how the time seems to have gone quickly, although there have been plenty of times I wished it could have gone even faster. Particularly the due dates for course work, which always seemed to be such a long time away, with plenty of time to put off doing any work, and then it’s the last night and I’m up all night typing away, trying not to panic. (I don’t recommend this approach to current and future students)

I digress…..

At university (or if you prefer, the school of nursing) we have been taught, and are regularly reminded, about the importance of reflection, taking the time to think about your actions and thoughts, trying to understand them and learning from it for the future. I have to say, writing essays on reflection is really, really crap, but I do understand the importance of this and regularly practice it.

On reflecting on reflection, I think I have always been a bit reflective and self aware. I think I am the kind of person that at the end of the day, goes over what I’ve said and done. I used to really worry about it and the effect it had on other people.  Particularly the day after a few too many bacardis (that’s another story). Therefore it didn’t take much work for me to be a competent reflector when I started my nursing course.

As for self awareness…….

On a recent placement, I found myself having to perform a basic/essential/core clinical skill. One that isn’t often called upon in my area. I was unable to do it. My reflection in action (are you enjoying the terms here?!) told me I was an idiot and I instantly felt like a failure. Believe it or not, I don’t often feel like this. I regularly question my own competence and try to improve on my practice, but there is a difference to feeling like I can’t do the job at all.  These skills are easily measured, although many other aspects of being a mental nurse aren’t quite so straight forward

How can a mental nurse measure their performance? Ask the patient to fill in a questionnaire:

Q1. Do you think the nurse managed to build a therapeutic relationship with you?

Q2. Did the nurse listen to what you had to say and help you come to the best decision for yourself?

Q3. Did the nurse complete the relevant paperwork in relation to your care in a timely fashion?

Q4. Did the nurse avoid you at all costs, ensure you took your medication and discharged you as soon as the consultant would allow it?

Do you count the number of success stories? The people who aren’t re-admitted within the next 5 years as you cured them (not likely).

It’s not a very quantifiable job.

In the same day I was a failure as a final year student, I managed to perform other actions and tasks with no problem, perhaps even successfully. I was left wondering if I really was any good and and if this was just a hiccup.

Is it because I am near the end of my training that I suddenly feel I am being constantly assessed by every nurse in the ward? Is it because I am under relentless and constant scrutiny and always have been but haven’t been as aware? Or am I just being sensitive since I failed at one task?

I have had good feedback from the nurses on the wards I have been on placement with (mostly) and occasionally a patient or two, but I have constantly wondered if I am managing to fool them because I really am a bit rubbish. Is that then unfair on the trained and experienced nurse to question their own judgement of me? Or am I actually going to be competent upon qualifying? I know that I won’t be good, that’ll take experience, practice and time, but I can at least be competent and safe in practice.

Self awareness and reflection are good things, yes, but not too much. A person could end up constantly criticising themself and thinking of other things they should have/could have done/said. There is a healthy balance here.

As a side note, my clinical skill was later relearned and used correctly with a bit of practice.

I’m away to lose my head as I wonder if I should have published this post…..

Stories such as this one infuriate me. Once again we have a lawyer who is paid far too much money to try to find a way of reducing the punishment of a man who has undeniably committed a heinous crime, and the best he can come up with is “he couldn’t help it; he’s mentally ill”.

Previously on mentalnurse there has been debate on the pathologising of behaviour and it’s not a simple argument to resolve. We are, on one hand, a product of everything we are and experience; but, on the other, as humans we have ability to rationalise and, ergo, we can exercise choice.

This juxtaposition has been something of a burden for mental health law for many years - at what point does someone cease to be culpable?

MMW again;

Are we going to get to the stage where no crime is punishable? Will every crime be attributed to mental illness? Will all murderers, rapists, and paedophiles be regarded as victims of illness rather than bad people? Where does it end?

In my opinion, it doesn’t really matter: If they do something against society - they lose their right to be a part of it. What needs to change is how we deal with those who offend our social laws and values.

As a mental nurse working in forensic mental health, I’ve seen very few (by comparison) of people who break the law in the context of a mental illness. That is, if you exclude all those who have intellectual impairment, substance misuse, personality disorder and psychopathic traits.

It is my opinion that this latter cluster of ‘presentations’ no longer (nor ever did) belong in the mental health system. They are not mental illnesses - they are pathological conditions or behaviours which are not characterised by a transitional illness - but simply who the person is.

At present, this latter cluster often present within the forensic mental health system simply because it is felt prison is not the right place for them (by nature of a natural infirmity) or because their behaviours indicate “something is not quite right” (eg borderline personality).

Unfortunately, for those who break the law and require secure provisions away from society, mental health services have been the default service for anything that doesn’t fit prison. There is no other alternative.

It is widely accepted (without a single reference on that blanket statement - despite extensive research) that those who present differently - require different ‘treatment’. Mental illness requires traditional psychiatric treatment; psychopathic behaviour requires strict, structured systems; personality disorder requires behavioural therapies; intellectual impairment requires the service to provide an ‘external brain‘ to make life and survival more achievable. So why do these different presentations all get lumped together into one generalised service?

I do believe tho that much behaviour can be pathologised. But I agree with not ‘excusing’ all behaviours simply because we can pathologise them. These non-mentally ill - but ‘clearly not right in the head’ people are not appropriately placed in mental health care.

Is this as stupid as it sounds? But perhaps the perfect disposals for these individuals;

Psychopaths can go star in Exile Island.

Personality Disorders in Big Brother.

So it is somewhat shocking and revealing to find this article that provides a new and significant departure from what might be considered traditional medicine.

In this article it is clearly stated:

People who have more birthdays live longer

What implications is this astonishing fact going to have on healthcare for now and the future?

New government targets are aiming to achieve a target of 70 birthdays for each person.

Special task forces have met and have identified the formidable outcome improvements for people who have in excess of 80 birthdays in a life time! How is this longevity occuring? Argument has erupted around whether it is the type of birthday party or the number of presents people receive at birthdays.

Either way, the government have wasted no time at all in making an immediate mandate to increase the number of birthdays each person has from 1 a year to 3. But the implications for this are going to be costly.

Already the NHS has priced the replacement of the pharmacy with a bakery and has approached HJ Wedding Cakes suppliers to purchase as many birthday cakes as they can knock out for an immediate improvement in the nation’s Capital health outcomes. Australia has similarly purchased several Cheesecake Shop franchises in attempt to get ahead of the game.

Senior NHS staff are undertaking research into the maximum amount of birthdays that can be held in a hospital admission. Some departments have given most surprising results, such as one A&E setting with patients who have been able to hold 2 or even 3 birthdays on each attendance. They have subsequently been awarded a Centre Of Excellence Gold Standard Award for this innovative achievement.

One NMC spokesperson has revealed that planned changes to the Nurse Training will include learning to sing “Happy Birthday” in 26 different languages.

Nurse Practitioners have begun setting up some protocols on how to hold a birthday party and special training courses have been set up at the amazing price of 4-99 uk sterling each.

Some centres of excellence are developing ways to encourage patients to hold more than the new government minimums to having 5 birthdays a year and thus improve health outcomes. Others have suggested a complex case-mix scenario where every young patient admission should be matched by the admission of an older in-patient partner in order to avoid distorting average ages. However, this has been considered by some as cheating.

Other Parliamentary questions that have been asked:

Should we un-ban smoking? Tho they are out of breath from smoking and can’t blow out the candles, at least someone will have a light.

We should include the 9 months gestation period to improve outcomes.

Of course, this also means that those born on a leap-day will be likely to die at a much younger age and this issue is currently before the European Ethical Council for Abortions Help to Meet Targets.

Next week: Birthday Party Polyclinics.

Dr Crippen reckons he’s got the answer, in the form of an email from a “soon to be ex-student”, allegedly, complaining about the nature of her course. Apparently, there’s too much “theory” (don’t know what of), not enough information on sticking tubes and needles into people and - oh the horror - far too much emphasis on communicating with patients. Something like that. I glazed over, I have to admit, as we’ve all heard this sort of stuff time and time and time again.

Attrition is a multi-factorial issue, one that doesn’t lend itself to glib explanations and easy answers. Nor should it always be problematised. For some students, dropping out will be exactly the right thing to do. Either they find out they don’t really want to be nurses, or they discover that they’re actually more interested in something else, or they decide that it’s just not the right time in their lives to be studying. Would that more students came to the same conclusions before they found themselves staggering and struggling, already burnt-out and miserable, through the second and third years.

For other students, yes, it may well be the case that the course doesn’t meet their expectations. There’s not really a great deal that can be done about this. No matter how carefully you might explain what the course consists of, it’s never going to reflect adequately the actual lived experience of being on it. You can’t please all the punters all of the time.

But there is a significant number of students for whom attrition is brought about by crap like this. A few highlights of the kind of comments faithwalker has had to endure from a “nurse” for having the temerity to agree with a patient’s comments about a porter: -

“I hope the relative makes a complaint, because when they do we’ll be sending it to your university to deal with and you have caused it. And when it ends up in court- it will be you that gets sued by the porter for what you said about him when you had no right. NO RIGHT.”

“You are an immature and unprofessional bitch to sit there and say all these lies about a porter with a relative. You’ll never get a job on this ward when you qualify. I don’t know what you might say about my nurses.”

“I shall be making sure you don’t get a job in this trust when you qualify. People will look to me for references from your placement and I will tell them what you have done.”

This is bullying, plain and simple. Unfortunately, it’s not all that uncommon in the NHS and I would suspect students are particularly vulnerable to it being very junior, transient members of the team and probably of the opinion that they’re pretty much powerless to do anything about it. Some very wise person way back in the mists of time once said that nursing ‘eats its young’ and faithwalker’s experience illustrates all too vividly the continuing truth of that statement.

The NMC are currently running a review of pre-registration nursing education.

Questions include:

should nurses be prepared to diploma or degree level?

what proportion of a pre-registration programme should be spent learning in practice?

should shared learning be a requirement?

should there be generalist and/or branch programmes, and if so, what should the branches be?

The recruitment numbers in my area for mental health nursing students has been cut by almost 50% for the next year. Those working at the coal face have a feeling of bewilderment at this, but some number crunchers somewhere have decided this is a good idea.

If the decrease were to continue annually, it could be a slippery slope to phasing out the branch entirely.

Look at learning disability nursing. There isn’t much of that training going on these days, with mental health nurses filling many of the posts. Some argue that they are very different specialities and rmns are ill-equipped for such nursing care.

If our branch is phased out, over the coming years we could be working with ordinary general nurses in our highly specialist areas. (gasp!)

I certainly found my first year of generic training quite uninteresting and an effort to remain motivated, but I knew it would be branch specific and interest me more in second and third year. I am not sure I would have done the training at all if I had to do generic training (read = adult nursing).

If we aren’t careful, our nurse training could resemble the training received in the USA and Australia. I certainly don’t think this is a good thing, perhaps others see things differently?

This survey is only open until 8 February (2008) so I would urge you to fill it in as soon as you can and to tell anyone with even a vague link or knowledge of mental health nursing - be they user, carer or worker - to do the same.