Nurses are …

A couple of weeks ago on twitter someone I follow (a historian) tweeted that if you type “historians are” into a google search box you get a brilliant poem:

Historians are
Historians are dangerous people
Historians are past caring
Historians are writers
Historians are prophets in reverse.

I rather liked that, so I thought I’d type in “nurses are” and see what came up.

Nurses are
Nurses are stupid
Nurses are mean
Nurses are great
Nurses are us
Nurses are patient advocates
Nurses are heroes
Nurses are
Nurses are special
Nurses are better than doctors
Nurses are mean to each other.

I have to say, that left me with quite a bittersweet feeling. Along with the stereotypes (heroes/special – though I was amazed “angels” didn’t make an appearance!) there’s plenty to be sad about here, if these reflect the most often-searched phrases.

It’s got me musing on what “nurses are” to me. As someone who is a bit ‘in-between’ nursing-wise at the moment (still registered, not practising although working in health research) Lynne Stobbart‘s recent blog post certainly resonated with me. I can’t quite put my finger one one word or phrase which sums up for me what nursing is and what it means to me and who I am – yet – but without wanting to get too metaphysical about it I do think there’s something ontological there, it’s more than just what I did. It’s something I’ll be musing about for a while I think.

What do you (especially the nurses, although I’m really interested in other views too) think of when confronted with the phrase “nurses are…”?

Book review

Last year I wrote a review essay for Europe-Asia Studies, which is the journal produced by the department where I did my PhD. That review is now (finally) online first (not sure when it’s going to be in a print version). I thoroughly enjoyed both reading the two books and writing the essay – I’d highly recommend both books (“Democracy Building and Civil Society in Post-Soviet Armenia” by Armine Ishkanian, and “Women’s Social Activism in the New Ukraine: Development and the Politics of Differentiation” by Sarah D. Phillips) if you are interested in development issues particularly as they pertain to civil society – although both set in former Soviet countries, a lot of the issues raised are extremely relevant to development studies more widely.

Although my PhD was not a development studies PhD, and I was not looking specifically (or rather exclusively) at civil society issues, it was something the PhD touched upon as several of my respondents were from civil society organisations and reliant on donor funding in order to provide their services and to carry on functioning. I certainly found myself nodding in recognition at several points in both books. In some senses they were a bit depressing – the findings from both studies seem to be that little has changed or been learnt in how many years of development funding and civil society promotion – but as thorough and thoughtful studies which go into enormous detail of both macro-level (Ishkanian) and micro-level (Phillips) experiences of activists and organisations, they are both welcome additions to the literature. As an extra plus, neither of them are remotely stuffy reads (which let’s face it makes a pleasant change from a lot of academic tomes!).

Reflections on a new article

Last week I was delighted to have an article published in the latest volume of Anthropology of East Europe Review. The material in this article was originally intended as a case study for my recent talk at this year’s BASEES conference, but it ended up being such a big issue that it really merited a more detailed treatment. Recently I replied to a tweet I spotted on twitter where a PhD student was lamenting that she had to relegate some data to a footnote in her thesis – the case on which this article is based was a ‘mere’ footnote in my thesis, and here it is published. So there is hope – the thesis is not the end product, but I’m certainly finding that 2 years on from graduating my thinking has developed and the things I am wanting to write now are very different from what is in the thesis itself.

The article is called “Constructions of childhood, victimhood and abortion in Romania: the ‘little-girl mother'”, and is based on articles I gathered during a 2 month period as part of my (much bigger) media review on sexual and reproductive health issues. This is the article abstract:

In June 2008 in Romania an 11-year-old girl found herself thrust into the media spotlight when it was discovered that she was 17 weeks pregnant after being raped by her uncle. Romanian abortion laws permit abortion only up to 14 weeks gestation. In the weeks that followed, the case was rarely out of the popular media, with debates about both the minutiae of this particular case and more general discussion about the appropriateness of the current legal provision taking place within the context of widespread concern about the phenomenon of fetiţe-mame (‘little girl-mothers’). This article considers the way the extensive media coverage of this case contributed to debates in Romania around abortion, childhood and child protection, but also exposed insecurities around national identity and Romania’s place within a wider Europe. It argues that this case serves as a “critical discourse moment” (Brown and Ferree 2005:10) which highlights concerns about legislative shortcomings around abortion, media and professional roles in child protection, and the construction of childhood more generally in Romania.

The full article is available here (open access). In one sense the choice of journal was a bit of a risk – Anthropology of East Europe Review is a journal produced by Indiana University, and submissions are generally editor-reviewed rather than peer-reviewed so from a career perspective it may not be the best thing in that it is not an article that could be submitted for the REF. However I like to think I was very strategic in my choice – due to my current contract I am not being submitted for the 2014 REF in any case, so the first REF (or whatever it will be that replaces it in 2020) that I need to worry about will be considering my publications from 2014 onwards. Obviously I also have to think about my publication record when applying for new jobs, so do need to also be targetting peer-reviewed outlets, but I did feel I could afford for this one article to think about where I would gain most exposure/impact for this particular piece, which as a case study may not have been considered by higher-impact journals. I also really like AEER’s philosophy of aiming for a fast turnaround of research, and of a commitment to disseminating research from regional and early-career scholars. I also very much admired the editor (although this is her final edition before handing over to a new editor) and many CEES scholars (both early career and senior) whose work I respect immensely have also published in AEER, so I am proud to be part of their number. I’m pleased my work can join their conversation. I’m also hopeful that as well as the area studies conversation, this article can contribute to the ongoing debates worldwide about abortion policy and legislation.

Professional use of social media

Recently there was a very interesting debate on GP and clinical lecturer Anne Marie Cunningham’s blog on the General Medical Council updated guidance on use of social media for doctors. There was quite a lot of concern expressed in the (very many) comments about the seeming requirement to avoid pseudonyms and use real names if identifying as a doctor on social media. The GMC clarified the guidance later, see here.

Following the debate made me return to the Nursing and Midwifery Council social media guidance to see what they had to say. As you will see from the link there isn’t anything in black and white (or even grey, particularly) about the use of pseudonyms, and the guidance is based on using facebook but says it is applicable to other sites too, including blogs and personal websites. This guidance seems relatively straightforward with a healthy dose of stating the obvious at first glance – don’t discuss work-related issues, don’t take and post pictures of patients online, don’t use social networks to pursue friendships with patients. The key it seems to me is to use common sense – don’t do anything in real life that would jeopardise your registration, and don’t do anything online either.

The pseudonym issue, which the NMC guidance doesn’t cover but the GMC guidance has elevated to veritable can-of-worms status, is interesting I think. I choose to use my own name on my blog and twitter (the two main places, along with a vaguely neglected academia.edu profile, that I use for largely professional purposes), and am open about the fact that I am a registered health visitor (although I’m currently working in research rather than clinical practice). Nothing I write here or on twitter should come as any great surprise to anyone who’s worked with me – I like to think that what you see here is pretty much what you get. I have chosen not to talk about things that I’m not happy to have my name associated with; and that’s pretty much it. I can see though that using a pseudonym might be helpful to some people – I’ve known people start off on twitter with a pseudonym because they were just nervous about identifying themselves in this unfamiliar environment and then that name becomes established. Some people feel they can be more open and honest in expressing their opinions using a pseudonym, and are concerned that if patients know that they are expressing opinions in social media that this may affect their relationship. I personally have no beef either way – I have made my choice, and obviously I think that other people should make theirs. This is why I must admit I did raise my eyebrows when I read the GMC guidance that doctors who identify as such online “should” use their real names – the clarification that “should” does not mean “must” still seems quite woolly to me in all honesty. I appreciate the reasoning, that if people are making claims in the name of medicine then identifying who they are will help in discerning whether those claims are credible or not. But it does still seem a bit heavy-handed to me.

I would encourage nurses and other professionals to think about professional tweeting and blogging. As a result of this – hardly prolific – blog, I have been able to be part of conversations recently about evidence-based practice and the future of nursing leadership amongst others, opportunities I’d never have had if I wasn’t involved in these sites. The usual provisos apply (see guidance above) – use your common sense, don’t be defamatory, don’t breach patient confidentiality, etc – but see this as an opportunity to be part of wider significant conversations. You never know who will pick it up – I found out after I started in my current post that my boss and colleagues had read my blog (presumably they had googled me when I was shortlisted) so knew that I could write a bit already. I’m not making any claims to literary or academic magnificence, but it’s certainly not done me any harm. I know that some people are nervous about the professional monitoring of social media use – in my last clinical job we were advised by a senior nursing manager that they receive around weekly requests from the NMC related to people’s social media use – but really, if you use your common sense and don’t do anything silly, I think that social media represents much more of an opportunity than a threat both to personal/professional development and to the chance to contribute to the debates that are shaping practice and services.

Nurse-bashing post-Francis

Just over a year ago I wrote a post called Nurse Bashing, in response to a news item which had wound me up, pointing out that nurses were something of an easy target to be singled out for criticism when something goes horrifically wrong in the health system as a whole. Ever since then I have been somewhat depressed (although not surprised) that “nurse bashing” is probably the most frequent search term which gets people finding my blog. And now, in the light of this week’s governmental response to the Francis Report into the failings at Mid-Staffordshire NHS Foundation Trust, the search term “nurse bashing” has been turning up ever more frequently. There has been a veritable storm at the inadequacy of the response, and perhaps unsurprisingly one of the main headlines attracting considerable debate is the recommendation that before training to be nurses, students should spend up to a year working as a health care assistant in order to better learn how to care. Lots of people have written very eloquently about this already (see for example this blog post by June Girvin from Oxford Brookes University, with which I wholeheartedly agree).

I’d like to offer some of my thoughts and questions about this (apologies this will probably be quite long!). In particular, I want to ask 1) why nursing is being targetted when Mid Staffs represents a systemic failure; 2) is a one year health care assistant post prior to nurse training a good thing for nursing; and 3) where next for nursing and nurse education?

1. Why is nursing such an easy target?
I can’t help thinking that the perception of nursing as an easy target is something of a reflection of nursing’s past status and image as ‘handmaids’ to the more powerful medical profession. This is perpetuated by (in my opinion) poor nursing leadership, with the Royal College of Nursing (RCN) and Nursing and Midwifery Council (NMC) seemingly completely separate from the Chief Nurses for the four nations of the UK. Could you name any prominent nursing leader? I’m not sure I could. What this means is that those of us further down the pecking order are easy targets. In addition, given that nursing is such a large workforce within the NHS, any action which impacts on nursing will not only have a big impact, but be seen to have a big impact – so it is relatively easy for the government to be seen to be “doing something”. However, this approach will not reflect the root, systemic causes of health service failure, particularly not when implemented in isolation.

2. The 1 year HCA proposal – is this good for nursing and caring?
Over the last couple of days there have been many arguments and debates for and against the proposal. In order to be transparent I should say that when I trained as a nurse (as a mature student) I had not had previous HCA experience (although I had done a bit of voluntary work with an AIDS charity), so I suppose I would say that a year as an HCA isn’t necessary for nurse training. I don’t have a particular problem with the idea per se – I can see that having had some HCA experience would probably have helped me a bit with confidence in my first couple of placements, and it may well be a good thing for some people to start to familiarise themselves with the ward environment and the realities of the job. I do though have a big problem with the idea as one of the primary policy responses to the failures of Mid Staffs, for all the reasons highlighted in June Girvin’s blog post.

I do have some other concerns about the proposal. Firstly, the proposal as espoused by Health Secretary Jeremy Hunt appears to be equating basic caring tasks (as carried out by HCAs) with caring as a quality, and I worry that this equation if not challenged will move nursing back towards being a primarily task-based occupation which will, in my opinion, have the opposite effect to the effect intended. Secondly, I think there are a number of logistical problems which I suspect may well not have been thought through fully, such as where does this leave existing health care assistants, and what will be the demarcation between permanent HCAs and pre-nurse training HCAs? What will be the impact on wards who invest time in training someone to be an HCA only for them to leave after a year? Will those people working as HCAs in the pre-training period be subject to the NMC Code of Conduct? (or, at least in Scotland and Wales, will they be subject to the HCA code of conduct?). In England, why has the Department of Health ruled out the registration of HCAs? (this is an issue which I think is much more urgent to address than what pre-training nursing students do).

In addition to these logistical issues, I will return to my usual bugbear when I am ranting about nursing and politicians: how will working on a ward as an HCA prepare students to work as nurses in the community? It’s not the first time I’ve complained about this, but it does just annoy me so much that politicians (of all stripes) seem to equate ‘nursing’ with ‘ward work’, when there are plenty of us who haven’t worked on a ward for years. I also have big concerns about the implications for university-based nurse education. Ever since Project 2000 first saw responsibility for nurse education shift from individual hospitals to universities, there have been vocal nay-sayers objecting that university-educated nurses have poorer practical skills, that essays and books are pointless and don’t prepare nurses for the practical realities of the job, and there seemed to be an implication that university-educated nurses were less caring as universities supposedly can’t teach caring as well as learning the job in situ. As a university-educated nurse I’m obviously going to disagree with this – I think a focus on being on the ward all the time (which is something I am starting to hear more and more from our esteemed political leaders) risks both dumbing-down of the nursing profession and maintaining nursing’s ‘handmaid’ status as students are less well-equipped to challenge poor practice and management (actually I suspect this is something that this current crop of political leaders would prefer). I’ve written before here about the attempted depoliticisation of the nursing profession as an aim and implication of a move away from university-based nurse education, and I think that this is something that should be vigorously resisted.

3. Where next for nursing?
I am not saying that there is no need for reform of nursing as a profession. I am though concerned that the target for policy change in response to major systemic problems in both the nursing profession and in NHS leadership and systems more widely are (as usual) the less powerful, lower-level frontline staff. This is why I think that nursing leadership is something that really needs to be looked at. The Francis Report did highlight shortcomings with the RCN, and I do think that as an organisation the RCN is ripe for a radical rethink as to its role and purpose. Unlike the medical Royal Colleges, the RCN is not solely an organisation for the promotion of and advocating for the profession of nursing. This is part of what it is tasked to do, but it also acts as a trade union for its members and provides considerable education resources. I think that a model more akin to the medical Royal Colleges would be preferable, and would strengthen the RCN’s leadership role in nursing and ability to influence the political debates. So I would like to see the RCN as solely a professional body, along the lines of the RCGP, freeing up RCN leaders to advocate for nursing and give it real ‘teeth’ to address weaknesses in the organisation of the profession. The union function should, I think, be either hived off into a separate organisation (for those who would prefer to be represented by a specialist nursing union), or incorporated into another of the existing trade unions active in representation in the NHS, such as Unite or Unison. In addition to the RCN, I think it is clear that the NMC has never really been fit for purpose (and I must admit whenever I send off my annual fee I always wonder what on earth it is being used for), with backlogs and internal staffing issues meaning that its vital regulatory function is being stifled and undermined. The fact that senior nurses leave the leadership of the NMC speaks volumes about the sorry state of UK nurse leadership, and I am not sure that with the current leadership of the nursing profession there will be any significant improvement in its shortcomings. I think leaders of the calibre of the RCGP’s Clare Gerada, who is regularly asked for opinions in the media and by politicians and who campaigned tirelessly to highlight the significant flaws in Andrew Lansley’s Health and Social Care Bill in England, are what is required as a first step in sorting out nursing. It is not leadership alone, of course, all of us nurses have the responsibility to challenge poor practice and management and promote higher quality patient care, but I do think that intelligent and inspirational leaders would be a good start. Certainly a focus on student nurses working as HCAs will do little to address the considerable shortcomings in nursing management and leadership, and it absolutely won’t address the systemic failures of the health service which resulted in Mid Staffs.

I do anticipate that there will be further attacks on university-based nurse education. Pat Thomson highlighted her concerns about Education Secretary Michael Gove’s bonkers, swivel-eyed response to academic critique of education policy here, and I wouldn’t be surprised in the least if there is an equally mad attack on nurse education before too long. Certainly the government has said more than once that nurse education should be moved back to the wards from the classroom (whilst not going so far – yet – as to advocate its complete removal from university). I am really concerned about this. I think that this represents a much more insidious attack on nursing and the profession’s ability to advocate for disadvantaged and vulnerable patients and challenge poor management and leadership than the frankly bizarre policy of insisting on a year of HCA work for students. I really hope I’m wrong.

Experiences of NVivo

When I did my PhD I had the chance to have training in NVivo, which is a qualitative data analysis software package provided by QSR International. Initially I had the training (I think in NVivo version 2) quite early on in the PhD – prior to data collection – and the theory was that if we got used to it before collecting data then adding data as we went along would be a piece of cake and we would be thoroughly versed in the software so be able to use it to its full potential. I could certainly see the logic of that, and with retrospect it may well have been that if I had started off with my literature review and research diary I could have perhaps ordered them within NVivo and then used it a bit more consistently throughout the PhD.

Of course real research life is not like that, and hindsight is a wonderful thing! My diary keeping prior to fieldwork was sporadic at best and didn’t really amount to anything much, and the literature review I undertook prior to fieldwork ended up being at least partly irrelevant once I had collected a bit of data and realised that entirely new themes were emerging which I hadn’t even considered; hence I had to completely redo it once I got back. Although this was a bit soul-destroying at the time, it was nonetheless quite a useful exercise because I was reading literature in light of my data, and reviewing the literature at the same time as analysing my data meant that I made so many more connections between them than if they had been done as entirely the linear, separate processes that PhD timetables (and by extension the advice of the NVivo trainers) often seem to assume. I ended up not using NVivo for either diary or literature purposes, but started the process once back from the field of importing my interview transcripts into NVivo (which by now had morphed into NVivo 7, I think) and coding them. I had also collected, over the course of my PhD, more media articles than I knew what to do with, so putting them into NVivo in order to create some sort of order was very useful.

Despite the training I fell into the classic ‘coding trap’ of micro-coding every last little detail, and I found that (for my interview transcripts in particular) this was spectacularly unhelpful as I was left with fragments of texts and no sense at all of any overarching narrative (this was though at least in part mitigated by the ability of the software to grab text a specified number of lines above and below the coded segment). I avoided this trap with the media articles by coding entire articles to just one code (rather than microcoding within that); that was more successful at getting an overall view of what was ‘out there’, but was not without its own problems in that because there were such large chunks of text within a single code, I often found when I tried to do a search that my PC would just crash. However, by using NVivo to identify the documents where I could find articles on particular topics and going to the hard copy just prior to the big search, I managed to avoid the constant crashing, generally found what I was looking for, and overall found that using NVivo was more helpful (from the coding and retrieving point of view) than having paper fragments of texts cut up, differently coloured and stuck together. I can’t say that I ever used NVivo to its full potential – a lot of the whizzy features were pretty much surplus to requirements – but as a tool for coding and retrieval it was fine for what I needed. I could pretty easily specify the location of my respondents and the type of source (blog, newspaper article etc) with a couple of clicks, and that was really helpful in my searching and querying of my data.

Now I am undertaking a new research project for this postdoc position, and still using NVivo. My university is using NVivo 9 now (the most recent version is NVivo 10 apparently), and it appears that a couple of versions down the line, there are more bells and whistles than ever. I have learnt my lessons from the micro-coding debacle of my PhD interviews, and this time am doing a lot of broad-brush coding which is preserving the narrative and enabling me to access the rich data that is emerging. One of the features that seems to have disappeared is that ability to widen out the search to lines above and below the coded segment, so this more broad-brush approach seems to be doing the same thing. For my baseline data I have been able to run reports on codes and access them fairly straightforwardly.

However, now that I have started the next phase of data collection, I now want to add a bit more information to my sources, so that I can differentiate them more easily. Up till now keeping it simple has been fine, as all I’ve really wanted up till now is “everything that every respondent says about X”. Now though I am undertaking a second round of interviews with the same people, and also interviewing a second category of respondents (professionals as well as the patients I have already interviewed), so I want to be able to differentiate between baseline and follow-up interviews, between treatment types, between patient and professional, and also specify gender and location of respondents (amongst other things). Having previously found that reasonably simple (as mentioned above, it was pretty easy to specify that my sources were from one country or the other, or that they were blog posts rather than newspaper articles, by in effect ‘tagging’ the source) I wasn’t expecting this to be a big issue. So I have to say that I am not happy with the amount of time I have spent trying to work out how to do this in NVivo 9. I first tried a few weeks ago, but got so confused by the help topics that I gave up. I have tried again today, and spent pretty much the whole afternoon trying to work it out, writing down everything I’m doing as I go along as I won’t remember it otherwise, and I still haven’t got there. It seems that in adding all the bells and whistles, the manufacturers have created something which is so counter-intuitive I am tearing my hair out. Being able to specify gender and location for respondents should not be difficult – previous versions seemed to be able to do it with a few clicks – but in this version it is so spectacularly complicated that I am still struggling. I am not being helped at all by the help topics – they tell me what to do up to a point, and describe what I should be seeing on the screen, but aren’t telling me why things are as they are. I am also struggling because something which should be so simple is now totally illogical. I appreciate that I am no techie, but I am not stupid and have managed with other software packages, so I know I’m not completely thick! If I want to specify that someone is a woman and is based in Edinburgh, it seems to me that the most logical thing to do would be to ‘tag’ the interview transcript with those attributes. However, in this version I need to create a new node (code) unique to that person (which then sits alongside all my thematic codes), then classify that new node with the classification ‘gender’, and from there I should be able to then specify male or female. However, following the attributes help page I can only get as far as classifying the node – adding separate attributes (male, female) within this is not obvious or intuitive at all. Once I get that far I learn that attribute values are either ‘unassigned’ or ‘not applicable’, but nowhere does it tell me a) the difference between these things, b) what they signify, or c) how to add the specific values ‘male’ and ‘female’. I’m amazed I have any hair left, because I am pulling it out at the moment.

I am persevering with this a. because NVivo is the software the university uses and supports, and b. because once I manage this simple thing I know my coding and retrieval is going to be relatively smooth and not complicated. But I really do want to register my frustration that in making their software all-singing and all-dancing QSR seem to me to have thrown out the simple basic functionality that is always going to be the foundation for any of the more complex searching and analysis. Whilst not being the world’s biggest technophile, I am comfortable with and relatively adept at using technology to assist my work, and I shouldn’t have to spend entire afternoons trying to figure out how to tag a respondent with basic demographic data. Although I mainly want to use NVivo for coding and retrieval, once it’s set up I like that I can, if I want, be more creative with it and do quite complex queries. However, in order to be able to do that I need to get the basics right, and so it seems obvious to me that the basics need to be simple, intuitive and quick.

To give credit where it is due, when I tweeted the NVivo support people they did respond quickly (within the boundaries of different timezones) – but ultimately directed me to the NVivo help pages which as outlined above make an awful lot of assumptions about knowledge and give no illustrative examples. It is still not clear to me why I have to assign demographic classifications to nodes (codes) rather than sources (transcripts), it is still not clear to me the difference between unassigned or N/A attribute values, and most of all it is still not clear to me why something so simple has to be so frustratingly complicated. I really hope NVivo do something about this for the next version, because I have wasted so much time on this today that I am really grumpy and not at all inclined to recommend their software as a research tool. If anybody has any suggestions as to alternatives (especially if they are open source) I’d be all ears.

Some thoughts on Triple P and evidence based practice

Over the last few weeks, thanks to the power of twitter (and particularly tweeter @LMarryat) I became aware of some journal articles and blog posts about the Triple P parenting support programme. I must confess to a possibly not entirely unbiased interest in this, as before my current academic position I worked as a health visitor in an authority which invested heavily in the Triple P programme and over a period of a few years we were all trained up and expected to deliver the programme at every possible opportunity.

Triple P is marketed as an evidence-based programme which provides support for parents of 0-18s who have issues with various aspects of behaviour. It is provided at several levels and the support can be provided to individual families or done as group work. As a practitioner, I was trained at level 3, which is the basic parenting support package for individual families. It meant that I was trained to give advice and support around all sorts of parenting issues – food refusal, tantrums, toilet training, home safety, whining, hitting, etc etc – through the structured programme, supported by tipsheets and a DVD (although I must confess to never using the DVD myself). For some families it seemed to be really helpful, for others less so – to be honest the materials seemed as good as anything else I’d seen, but not especially better, and there were some aspects of it that really jarred. Triple P is based in Australia so all the materials are developed there, and part of the deal is that the purchasing authority does not deviate from them, photocopy them or adapt them in any way. In particular I got a right bee in my bonnet about the Home Safety tipsheet – in an inner-city area of multiple deprivation, high rise flats etc it really got on my wick that I had to hand families a sheet which told them how they must make sure that their children don’t go near the swimming pool in the garden unattended. That’s the most extreme example, but I just think it typifies the issues that many of us had with the actual materials. The other thing that made me cross was how we weren’t allowed to get the sheets translated for our families who spoke minimal or no English – there were some sheets in a few languages, but not enough for everyone who needed to use them across the city, and not in all the languages we came across in our practice, in a city which was one of the major reception cities for dispersed asylum seekers. This meant that it was really hard to offer the same level of support to families who were just as much in need of help as the English-speaking population. We also did have other issues which in a way were not Triple P’s fault and were more to do with the way management basically forced us to deliver the programme whether we wanted to or not – it became an exercise in numbers, in filling in forms and ticking boxes, and is one of the main reasons why I finally decided it was time to leave. It was getting to the point where I felt that I had no choice but to offer families a Triple P intervention, regardless of whether I thought it was what they needed, because of the pressure (and there really was pressure) to meet targets and figures. What also irritated was that Triple P was rolled out across the city at the same time as all the staff had to endure a 2 year pay freeze, and when we complained about the pressure to deliver Triple P we were basically told that as they had spent so much money bringing it in, tough we had to do it anyway. So when I say that I’m not entirely unbiased, perhaps it would be more accurate to say that I’m really quite bitter about it! (grrrr!)

One of the things that we were often told, again and again, was that Triple P was so great because it was “evidence-based”. I didn’t have access to university libraries at the time so it wasn’t easy to access articles, only abstracts, but I did a Google Scholar search and noticed that pretty much every article about Triple P featured the name of Dr Matt Sanders, who is the person from the University of Queensland who developed Triple P and is very involved in the materials, promotion and training development for the programme. I wasn’t able to get hold of the full articles due to paywalls, but this discovery did leave me with some questions about the evidence and the risk of conflicts of interest.

More recently, studies have started to emerge which call the evidence base for Triple P into question. Mostly they seem to be highlighting that the claims of the evidence to date can be questioned due to small sample sizes of the various research. There is also a recent trial with larger numbers that did not involve the Triple P team which compared Triple P level 4 with two other parenting programmes in Birmingham (Little et al 2012) where there were no discernible effects from Triple P. Following this, a systematic review and meta-analysis article by Scottish researchers in BMC Medicine (Wilson et al 2012) raised questions about the current evidence base (as outlined above – small sample sizes, potential conflicts of interest), which was also blogged about at PLOSOne by Dr James Coyne here. There then followed a response from Dr Matt Sanders et al here, and Dr James Coyne & Dr Linda Kwakkenbos also responded to both article and response here. [And as an aside, hooray for open access!] There is also a blog post which summarises the discussion and issues by Dr Pedro De Bruyckere here, which also provides a link (unfortunately in Dutch, not one of my languages sadly) to a recently defended PhD which found no significant effect of Triple P interventions. I must say from my experience as a practitioner I absolutely agree with his concern about a lot of money being involved which I do think affected how we as professionals were expected to push the programme.

What is worrying about that final blog post is the discussion about the difficulty in publishing null or negative results of research. This seems like the ideal point to publicise the Alltrials campaign, which is highlighting how much publicly-funded clinical research is not reported at all, meaning that trial results are lost to future researchers. Please do sign the petition if you have not already done so! There are all sorts of reasons why research might be buried, but regardless I agree that it is vital that all clinical trial results are published so that their findings are available not only to inform future research but also to inform current clinical practice. There can be no excuse, particularly in these straitened times, for publically funded research to be buried. What has shocked me though – I guess I must be naive, it hadn’t actually occurred to me before that this could happen – was the issue of publishers declining null/negative research results. That is a really worrying development that must be resisted.

[Edited to add]

One thing which saddened me as a practitioner was that, in discussing with my health visiting colleagues it seemed that there was another parenting programme (whose name escapes me at the moment) that they had been trained in and using before the drive to use Triple P. All of them were unanimous about how much they liked it, how much they thought it was making a difference, but that when the decision was made to plump for a programme which would be rolled out across the city it lost out as it did not have the requisite “evidence-base”. I just think that is such a lost opportunity – I appreciate that in a city where parenting and anti-social behaviour is often an issue at a large level that a community approach needs to be taken, but why could they have not done some good quality research, perhaps even comparing this programme with Triple P, to start to build an evidence base? I wish they had been brave enough to do that – they might well have kept the goodwill of their staff (which was sorely lacking with the way Triple P was introduced) and seen some great results. I can think of one researcher (not a million miles away) who would have loved to have been involved with the qualitative aspect of that sort of study.