Advanced Independent Work
Dynamic complexity, invisible nursing:
the construction of age-related complexity by registered nurses working in mental health services.
Sarah Jane McGeorge
Submitted in partial fulfilment of the requirements for the award of
Doctorate in Professional Studies: Advancing Practice awarded by TeessideUniversity
November 2010
Abstract
Patients who would benefit from specialist mental health services for older people are often described locally as exhibiting ‘age-related complexity’. Despite the local origin of this term, the broader issue of complexity in old age is widely referred to in health policy and literature, but the absence of clear definitions for complexity or complex needs is compounded by the tendency for these terms to be used interchangeably with ‘frailty’ and / or ‘long term conditions’. This research explores how nurses construct the concept of age-related complexity and how that construction is manifested in practice.
The study, carried out in an NHS mental health trust in NE England, was shaped by social constructionist and critical gerontology theoretical perspectives, using a constructivist grounded theory approach. Data were collected through ‘loosely guided interviews’ with thirteen registered nurses working with older people. Purposive and theoretical sampling were used. Data were analysed using the constant comparative method.
The study found that nurses construct complexity as the interaction of needs across a number of internal or external domains. Nurses identify important differences between complexity and frailty. Different nursing approaches may be required accordingly. Significantly, complexity is constructed as a dynamic state from which older people can ‘recover’.
Nursing complex older people is characterised by feelings of stress, frustration, worry and sometimes satisfaction. Nurses can develop ‘deep relationships’ with complex older people which share the characteristics previously described as ‘connected relationships’ (Morse 1991). Nursing work with complex older people involves emotional labour, is invisible to others and remains under-valued.
This research contributes an understanding of complexity and frailty in old age from a nursing perspective, and adds a mental health dimension to the model of nurse-patient relationships previously developed by Morse (1991), identifying implications for practice. Areas for further research on complexity in old age are suggested.
Contents
page
LIST OF FIGURES AND TABLES……………………………………………………5
LIST OF APPENDICES ………………………………………………………………...6
GLOSSARY ………………………………………………………………………………7
ACKNOWLEDGEMENTS ………………………………………………………………9
DEDICATION …………………………………………………………………………….10
AUTHOR’S NOTE ………………………………………………………………………11
CHAPTER ONE: INTRODUCTION
1.1Introduction ……………………………………………………………...13
1.2Origin of the term ‘age-related complexity’………………………...…13
1.3Background ……………………………………………………………..14
1.3.1Demographic trends …………………………………………...14
1.3.2Mental illness in older people …………………………………15
1.3.3A brief history of specialist services for older people ……...16
1.3.4A brief history of older people’s nursing ……………………..18
1.4The setting ………………………………………………………………18
1.5Origins of the study …………………………………………………….19
1.6The researcher …………………………………………………………20
1.6.1The researcher’s background and role ……………………..20
1.6.2The researcher’s personal beliefs ……………………………20
1.7Rationale for the study …………………………………………………20
1.8Potential benefits of the study ……………………………………….. 21
CHAPTER TWO: METHOD
2.1Introduction ……………………………………………………………..23
2.2Rationale
2.2.1Philosophical underpinnings ………………………………….23
2.2.2Theoretical framework ……………………………………..….24
2.2.3Selecting an appropriate research design …………………..26
2.3Study design
2.3.1Grounded theory ……………………………………………….27
2.3.2Constructivist grounded theory ………………………………28
2.4Sample and sampling method ………………………………………...29
2.5 Ethical Considerations
2.5.1Permission to conduct the research …………………………31
2.5.2Confidentiality ………………………………………………….31
2.5.3Participant distress …………………………………………….32
2.5.4Disclosure of poor practice ……………………………………32
2.5.5Participants seeking clinical advice ………………………….32
2.6Data collection and method
2.6.1‘Loosely-guided’ interviews …………………………………..33
2.6.2Interview quality ……………………………………………….34
2.6.3Capturing data …………………………………………………35
2.6.4 Memos ………………………………………………………….36
2.7Data analysis
2.7.1Constant comparative analysis ……………………………...36
2.7.2Computer-assisted analysis ………………………………….38
2.8Rigour ……………………………………………………………………39
2.9Limitations
2.9.1 Generalisability ………………………………………………….39
2.9.2 Triangulation …………………………………………………..…40
CHAPTER THREE: LITERATURE REVIEW
3.1Introduction ……………………………………………………………...42
3.2Defining complexity …………………………………………………….43
3.2.1Patient complexity ……………………………………………..44
3.2.2Complex needs ………………………………………………...46
3.2.3Complexity and old age ……………………………………….46
3.2.4Complexity and mental health ………………………………..47
3.2.5Complexity and nursing ………………………………………47
3.3UK health policy and guidance ………………………………………..48
3.3.1How does policy define and present complexity
in old age? ……………………………………………….…….48
3.3.2How does mental health policy refer to
complexity? ………………………………………………….…50
3.3.3Policy guidance relating to services for people
with complex needs ………………………………………..….52
3.3.4Nursing policy and guidance ………………………………….55
3.4Conclusion ………………………………………………………………56
INTRODUCTION TO CHAPTERS 4 AND 5...... 58
CHAPTER FOUR: FINDINGS AND DISCUSSION – PART 1
Findings relating to the first research question
“How do registered nurses working in secondary mental health
services construct ‘age-related complexity’?”
4.1Introduction …………………………………………………….……..…60
4.2The components of age-related complexity ………………..………..61
4.3The relationship between frailty and complexity …………………….68
4.3.1 Physical frailty versus multi-domain complexity ……….……70
4.3.2 Unidirectional frailty versus dynamic complexity ……………72
4.3.3 Decline versus recovery …………………………………….…74
4.3.4 Frailty associated with long term conditions
versus complexity and acute problems ……………………..75
4.3.5 Visibility versus invisibility ……………………………………..76
4.4Abstract complexity ………………………………………………….…77
4.4.1 Unpredictability and instability …………………………...……78
4.4.2 Subjectivity ………………………………………………………79
4.4.3 Intangibility, immeasurability …………………………………..79
4.5Conclusion …………..…………………………………………………..80
4.6Reflexive considerations ……………………………………………….81
CHAPTER FIVE: FINDINGS AND DISCUSSION – PART 2
Findings relating to the second research question
“How is nurses’ construction of ‘age-related complexity’ played
out in practice?”
5.1Introduction ………………………………………………………..…….83
5.2Working with complexity …………………………………………..…..84
5.2.1Deep relationships ………………………………………….….85
5.2.2Emotional labour …………………………………………….....97
5.2.3The skills and attributes ……………………………………….105
5.3Depending on the team ………………………………………………..110
5.3.1Detecting complexity …………………………………………..110
5.3.2Getting support ………………………………………………...116
5.4Conclusion …………..…………………………………………………..119
5.5Reflexive considerations ……………………………………………….122
CHAPTER SIX: CONCLUSIONS
6.1Introduction …………………………………………………………..….124
6.2Conclusions ………………………………………………………….….124
6.3Implications for practice …………………………………………….….129
6.3.1Implications for registered nurses ……………………………129
6.3.2 Implications for managers of nurses ………………………..129
6.3.3 Implications for the multi-disciplinary team ……………….…131
6.3.4Implications for older people and carers ………………….…132
6.3.5Implications for nurse education ……………………………..133
6.3.5Implications for mental health services for older
people …………………………………………………………..133
6.4 Reflections on the research questions, method,
methodology and theoretical framework …………………………….134
6.4.1 Reflections on the research questions …………………….…134
6.4.2 Reflections on the research method ………………………….135
6.4.3 Reflections on the theoretical framework …………………....137
6.4.4 Reflections on methodology ………………………………..…137
6.5Contribution to knowledge …………………………………………..…139
6.6Future research ………………………………………………………....140
6.7Final reflexive considerations ………………………………………….140
REFERENCES…………………………………………………………………………142
APPENDICES ………………………………………………………………………….167
List of figures and tables
page
Figure 1Selected demographic statistics relating to older people …………. 14
Figure 2Prevalence rates for men and women with dementia ………………15
Figure 3Prevalence rates for people diagnosed with severe depression ….15
Figure 4The relationship between within-case and cross-case
analysis in this study……………………………………..……………38
Figure 5Visual representation of chapters 4 and 5……………………….58
Figure 6CompRel: a model to illustrate nurses’ experience of working with complex older people …………………………………..… 120
Figure 7Excerpt from Interview 12 demonstrating an example of
‘guided discussion’ between participant and researcher …………..136
Table 1The components of complexity identified in each interview ………..64
Table 2Differences between frailty and complexity………………………..70
Table 3Comparison of assertive outreach and age-related
complexity characteristics ………………………………………….…96
Table 4Distribution of references to challenges and rewards
in interviews ……………………………………………………………..102
List of appendices
page
Appendix 1. Participants’ characteristics …………………………….……167
Appendix 2. Invitation to participate – poster ……………………….…….168
Appendix 2b. Participant invitation letter ………………………………..…..169
Appendix 3. Participant information leaflet …………………………………170
Appendix 4. Interview guide – phase one ………………………………….173
Appendix 5. Phase two pre-interview prompts …………………………….174
Appendix 6. Study timeline …………………………………………………..175
Appendix 7. Excerpt from a memo prompted by my own
clinical practice …………………………………………………176
Appendix 8a. First tree structure for codes and emerging
themes, May 2009 ………………………………………….….178
Appendix 8b. Second tree hierarchy, March 2010 ……………………….…179
Appendix 8c. Final tree structure …………………………………………….180
Appendix 9. Application of Chiovitti & Piran’s eight methods for
enhancing rigour in grounded theory research……………...181
Appendix 10. Summary of policy and guidance documents
considered in the literature review……………………………182
Appendix 11.The process of building an illustrative model of nurses’
experience of working with complex older people …….……185
Appendix 12.The illustrative model applied to two cases from
the data ………………………………………………………..188
Appendix 13. Suggested further research questions and
hypotheses ………………………………………………….….189
Appendix 14.Associated conference presentations and
publications …………………………………………………….191
Glossary
Agenda for Change – the framework that determines pay and conditions for most NHS staff in England
Assertive outreach – an approach to providing mental health services to people who have severe mental illness and are hard to engage with. People who are offered assertive outreach are usually working age (18-65 years old) and usually have a diagnosis of schizophrenia. Mental health workers work in teams who share responsibility for patients, have very small caseloads and seek to engage on the patient’s terms, often ‘flexibly and creatively’ (Addis & Gamble, 2004). For example, this might mean meeting the patient in a café rather than a clinic or making multiple attempts to meet the patient rather than issuing set appointment times.
Case management – a pro-active approach to managing the health of people (usually with long-term conditions) in the community. One of the aims is to intervene early to prevent the need for hospital admissions or admission to a care home.
CGT – Constructivist grounded theory
Community matron - a senior community nurse who works with people (all ages) who have long-term or complex health conditions to prevent emergencies (usually community matrons do not include people with long term mental health problems).
CPA – Care Programme Approach. CPA was first introduced in the UK in 1990 and requires health and social care providers to deliver care for mentally ill people in the community in a specific way. The four principles of assessment, care plan, a care co-ordinator and review together with involvement of the person using the service, and where appropriate, their carer are the essential elements of the approach.
CPN – Community Psychiatric Nurse – a registered mental health nurse who works with people in their own homes and communities.
Functional illness – a broad category describing mental illnesses (usually in older people) that have primarily a psychiatric or psychological cause. These include schizophrenia, depression, bi-polar disorder, anxiety disorders and less commonly phobias and obsessive-compulsive disorders.
Intermediate care – a range of services provided in residential or community settings that aim to promote faster recovery from illness, early discharge from hospital or prevent the need for hospitalisation. Intermediate care services are usually provided for a time-limited period (about 6 to 8 weeks).
NHS – National Health Service
MHSOP – Mental Health Services for Older People; a clinical directorate within the mental provider organisation (trust) providing services to people predominantly over the age of 65 years.
Organic illness – a broad category describing mental illnesses that have a biological or physiological cause. The dementias are the main group of illnesses in this category, which also includes delirium and less common conditions such as organic depression and organic hallucinosis.
Personalisation –an approach to care delivery initiated in adult social services which seeks to tailor care to the needs of individuals rather than fitting them into existing services. It is predicated on giving individuals choice about the care they receive (Carr, 2010)
Person centred care –first described in relation to the care of people with dementia by Tom Kitwood, person centred care describes a philosophy and approach that values people with dementia, and their carers; treats them as individuals, attempts to look from the perspective of the person with dementia and seeks to provide a positive social environment that contributes to wellbeing (Brooker, 2004)
Recovery model – a philosophy that underpins mental health care in the UK, the recovery model focuses on a person’s strengths, engenders hope and attempts to promote social inclusion, this reducing the stigma associated with mental illness
Support worker – a health worker who has not professionally trained or registered with a governing professional body.
Acknowledgements
Many people encouraged me to start and complete this study. In particular I would like to thank the following:
Tees, Esk and WearValleys NHS Foundation Trust:
The nurses who participated in the study by sharing their stories and experiences freely with me and the Clinical Service Managers who helped with recruitment.
Harry Cronin and Chris Stanbury (former and current Directors of Nursing), both of whom encouraged me to undertake doctoral study.
My clinical directorate for supporting this study, recognising that I would need time to complete it and creating the space for me to take study leave and Dr Ruth Briel, my practice supervisor.
University:
My academic supervisors, Professor Janet Shucksmith and Dr Sharon Hamilton, who have taught, supported and encouraged me throughout the study.
The DProf student cohort, Atle, Julie, Katie, Mike, Nicola, Philip and Sally, with whom I have shared ups and downs over the past 5+ years.
Professor Rob McSherry, programme leader, for 5 years of continuous encouragement.
Personal:
My parents, for teaching me that learning is a lifelong activity.
My children, Chris and Chloe, for their patience, for offering insights and for their unpaid help with computers.
Dedication
This thesis is dedicated to my father, John Board, 1931-2009.
Author’s note
I have deliberately chosen to write this thesis in the first person where appropriate. Whilst recognising that most academic theses are not presented in this way, I am conscious that the first person is a powerful literary device that I hope, will assist in the process of making my role as researcher explicit. This choice is consistent with a constructivist approach in which the researcher is positioned as partner to the participants rather than a detached and objective outsider (Mills, Bonner & Francis, 2006a). In addition, I have deliberately attempted to avoid reference to ‘patient’ throughout this thesis, using ‘older person’ instead where possible. I made this choice for a number of reasons. Firstly, since I was only interested in talking to nurses about older people they had worked with, all the older people they talked about would be patients or carers. Secondly, I believe that the use of ‘older person’ will serve continually to remind the reader that the study is about older people. The exceptions to this convention are in transcription excerpts where nurse participants used the term ‘patient’ during their interviews my subsequent discussion of these excerpts and when discussing the work of other authors who use the term ‘patient’.
I have included a ‘key messages’ box at the end of each major section in the text. This technique is borrowed from professional health journals and is intended to remind the reader of the most salient issues raised in the section.
Chapter 1
Introduction
Chapter 1:Introduction and background
1.1Introduction
This thesis sets out to report a study whose aims were to explore how registered nurses working in secondary mental health services construct ‘age-related complexity’ and how their constructionsare played out in practice. The main objective was to co-construct nurses’ experiences and understandings and use these to develop a substantive theory of ‘age-related complexity’.
Whilst health policy recognises that some older people have ‘complex needs’ there are only superficial descriptions of how such complexity is defined, how it is recognised, how it affects nursing practice and the experiences of nursing older people with complex needs.This research is driven by a local need to interpret and implement national policy relating to older people with mental health needs. The contribution of knowledge to this area has the potential to inform service decisions made at strategic and clinical levels; for example, at a strategic level it may add to the debate about how mental health services for older people should be structured and delivered. At the same time the research has potential clinical utility; for example in helping to clarify clinical decision making and explain the experiences of nurses working with older people who have complex needs. Thusit may point to ways to improve nursing practice.
This chapter will set the scene for the study within the context of national policy and the local service delivery. It begins by explaining the demographic context, then gives both an outline of mental illnesses common in older people and a brief history of health services for older people, followed by a review of health care policy relating to older people, mental health and nursing. It then moves on to outline the setting in which the research took place, the origins of the research and the researcher’s own professional background. The chapter concludes with a summary highlighting the rationale for, and the importance of, the study.
1.2Origin of the term ‘age-related complexity’
The term ‘age-related complexity’ emerged locally (circa 2006) following debate between senior clinical leaders from older people’s mental health services and those from working age adult services. It was intended to help describe the distinct role that older people’s mental health services played in a health care context that was moving towards needs-led rather than age-led care. In essence then, it seems that the clinical leaders were setting out their position and declaring what they saw as the unique role for their services (R. Briel, personal communication, 21st March 2010). There was, however, a fundamental flaw in this position. The term ‘age-related complexity’ was not defined, nor was there any assurance that there was a common understanding of it, other than amongst the senior clinical leaders (who were doctors). In addition, there was no way of assessing for, or measuring ‘age-related complexity’. This study was encouraged by the (then) Clinical Director for older people’s mental health services as a step towards clarifying how ‘age-related complexity’ should be defined and used as a concept in practice. Despite having had a local origin, I believe that the study of age-related complexity is important and has relevance beyond the local service for reasons that I will now consider.
1.3 Background
1.3.1Demographic trends
There is no doubt that the population of the UK, like that of other developed nations, is ageing (see for example, Smith et al, 2005). There are many illustrative statistics quoted widely in policy and literature, some of which are shown in Figure 1.
Figure 1: Selected demographic statistics relating to older people.
In some circles these statistics have led to predictions characterised by the use of alarmist terms such as ‘the demographic time-bomb’ (Ellson, 2009) or ‘the greying population’ (Smith et al, 2005). The predicted impact of these changes on the UK economy has led to a number of responses, for example the raising of retirement age and a campaign to encourage employers to consider the value of older employees (Department of Work and Pensions, 2009).