Dr Dean-David Holyoake, Developmental Editor

“Remember before it happened?” She said, “You know the digi-moment thing.” 
I nodded, but couldn’t, “Yeah,” I replied and we both stared ahead. 

At ungodly hours I am now able to see relatives a million miles away. I regularly witness colleague’s horrific living room decoration and home furnishing. I marvel at how technology can blur the awful clash of Dralon™ and flowered pattern sofas with electronic party balloon motif and how we apathetically no longer care. I’ve become ritualistic, routinised and every hour check I’ve unplugged the webcam, unmute and hate my new waistline. What does she mean ‘digi-moment’? This may, in the big scheme of things be just a moment, but to suggest it is over or insignificant just wrong. Lockdown has changed more than a moment. Now, I complete my shopping online, give four-star driver reviews and run fingers through fashionable, but longer hair. My new routines, larger waistline and reluctant transformation a result of superhighways, microfibre and silicon so removed from my human condition that I would hardly call it a digi-moment. Lockdown deserves more than just a passing moment, more like a digi-monument I’d say. 

“It’s changed the way we all live and learn hasn’t it,” I said. 

Lockdown, lockdown and lockdown! 

I feel that I have a life which I don’t own 

What a dizzy journey walking to the unknown 

One minute I am hopeful and next minute I am down 

I lost my friends, my resilience and my mojo 

I live at home and I work at home as there is nowhere to go 

Lockdown! Lockdown! what an embargo! 

What a confusion what a vertigo! 

Am afraid of the future, am losing "the present" 

I have no feeling but like suffering from thirst 

Very tricky sphere like surviving in a desert 

I lost my confidence if I am completely honest. 

But as there is always but there is always another day 

That will keep all the muddle at bay 

Yes, there is another day 

And it will be a safe bay. 

Lockdown Experience 
Simon Yosef - Doctoral Student, Health 
University of Wolverhampton 

Although I didn’t realise at the time, beginning a part-time PhD in early February 2020, just weeks before ‘Lockdown 1’, was a little like a scene in an action movie where a character leaps over a rising drawbridge of a castle just in the nick of time. Upon reflection, I feel fortunate to have been able to have experienced an on-campus induction, which has served me well in the initial stages of researching my literature review. Living over 35 miles from campus, I always envisaged making use of online library services and possibly meetings, but little did any of us realise just how much these tools would mean to us in 2020-21. 

When applying for a PhD, I anticipated that I would learn new skills and improve established ones. As a mature student for whom IT regularly seems to ‘fight back’ I can confirm that I have now learnt many new things about how IT can assist connectivity with others (Nguyen et al, 2020) and facilitate access to resources, but that from time to time, like a much loved old car, it can and will let you down. I have also learnt that I am not alone in the world of IT ‘fight back’, and therefore to embrace its benefits, and be less worried by its hitches. 

Like a wrongly imprisoned person nearing the end of their incarceration, I am longing for a return to a lively campus, to see my supervisory team and attend real events as opposed to online ones. Nevertheless, I can’t help feeling the rush of online, UK wide academic events which emerged during the pandemic have enabled me to meet and make contact (Zheng 2020) with more people than I could ever have imagined in 2020-21 without expensive travel and event fees, and in a timesaving as well as environmentally friendly manner. Beginning to meet and grow into a research network is highly important. Technology made this possible not only for me, but for many others, thus it is only right to celebrate the innovative approaches (Sandars 2020) that evolved as a temporary, pragmatic response to the pandemic, as well as looking forward to all our post pandemic futures. 

References: 

Nguyen MH ,Hunsaker A and Hargittai E (2020): Older adults’online social engagement and social capital: the moderating role of Internet skills, Information,Communication & Society, DOI: 10.1080/1369118X.2020.1804980 

Sandars J, Correia R, Dankbaar M, de Jong P, et al. (2020) ‘Twelve tips for rapidly migrating to online learning during the COVID-19 pandemic’, MedEdPublish, 9, [1], 82, https://doi.org/10.15694/mep.2020.000082.1 

Zheng F, Khan N A and Hussain S (2020) ‘The COVID 19 pandemic and digital higher education: Exploring the impact of proactive personality on social capital through internet self-efficacy and online interaction quality’ Children and Youth Services Review Vol 119 DOI https://doi.org/10.1016/j.childyouth.2020.105694 

Castles, cars, networks and liberation 
Alison Etches - PhD Researcher, Education 
University of Wolverhampton 

My proposal for researching perceptions of the role of the Biomedical Scientist within patient outcomes involved face-to-face focus groups and interviews with stakeholders of the profession. Biomedical Scientists were, and continue to be, central to diagnostic COVID-19 testing (IBMS, 2020). Due to the impact of COVID-19, revised ethical documentation was submitted for online focus groups and interviews. The Delphi methodology that I used for data collection is known to be more successful if the researcher can develop a rapport with participants as this reduces the likelihood of attrition between rounds of data collection (Keeney, Hassan and McKenna, 2011). The greatest challenge of conducting focus groups and interviews online was how to build rapport with participants to encourage them to engage in subsequent rounds of the study. Utilising online video call technology in data collection has been considered ‘the next best thing’ to face-to-face meetings and participants prefer this to using the telephone (Archibald et al., 2019). 

The laboratory response to COVID-19 was significant, with additional staff and resources required to support the service (IBMS, 2020). In response, the Health and Care Professions Council (HCPC) opened temporary registers for students and former registrants (HCPC, 2020). Laboratory pressures inevitably impacted upon recruitment of participants as I was unable to recruit Biomedical Scientists for a focus group. Instead, I recruited five HCPC registered Biomedical Scientists for online interviews. This was beneficial because the richness of the interview data for the Biomedical Scientist group was combined with the focus group data from the students and academics on the BSc Biomedical Science programme. Integrating focus group and individual interview data can help to enrich conceptualisation of a phenomenon (Lambert and Loiselle, 2008). In addition, attrition rates in the study were relatively low, with 84% of participants completing both rounds of data collection. This is a low attrition rate for a Delphi study with some studies reporting attrition rates greater than 40% (Keeney, Hassan and McKenna, 2011). 

The COVID-19 pandemic impacted my data collection methodologies, meaning I had to conduct focus groups online rather than face-to-face. This was challenging as I lacked experience of conducting focus groups and was daunted by the need to build rapport with the participants without meeting them in person. Rapport is developed through establishing common ground, developing a bond and showing empathy (Zakaria and Musta’amal, 2014). Professionally, I had common ground with my participants through my role and empathy for the pressures of the COVID-19 pandemic within their role. The COVID-19 pressures also provided a topic of conversation to begin establishing rapport with the participants. At a challenging time for the Biomedical Scientist profession, online interviews provided convenience and flexibility for the participants as they were arranged at a mutually convenient time without the need to leave their workplace. This is recognised as one of the key advantages of online data collection methods (Archibald et al., 2019). Despite the challenges of researching online, it was important for me to maintain momentum with the study and not pause data collection. Although I had fewer participants than I had intended, the richness and quality of the data I have obtained means that it was beneficial to pursue data collection using online technologies. 

The COVID-19 pandemic has been a challenging time to be a doctoral student and has provided a test of resilience and determination to succeed. However, it has provided opportunities to study with fewer distractions and to utilise technology to conduct research remotely. 

References: 

Archibald, M.M., Ambagtsheer, R.C., Casey, M.G., Lawless, M., (2019). Using Zoom Videoconferencing for Qualitative Data Collection: Perceptions and Experiences of Researchers and Participants. International Journal of Qualitative Methods. 18, pp 1-8. 

Health and Care Professions Council (2020). COVID-19 Temporary Register. Available at: COVID-19 Temporary Register | (hcpc-uk.org) (Accessed 21/02/21) 

Institute of Biomedical Science. COVID-19 recommendations for laboratory work. Available at: COVID-19 - recommendations for laboratory work - Institute of Biomedical Science (ibms.org) (Accessed 21/02/21) 

Keeney, S., Hasson, F., McKenna, H., (2011). The Delphi Technique in Nursing and Health Research. Sussex: Wiley-Blackwell. 

Lambert, S.D., and Loiselle, C.G., (2008). Combining individual interviews and focus groups to enhance data richness. Journal of Advanced Nursing. 62 (2), pp. 228-237 

Zakaria, R., and Musta’amal, A.H., (2014). Rapport building in qualitative research. EPrints Universiti Teknologi Malaysia. Available at: http://eprints.utm.my/id/eprint/61304/1/AedeHatibMustaamal2014_RapportBuildinginQualitativeResearch.pdf (Accessed 24/02/21) 

Researching through a computer screen: the impact of COVID-19 
Kathryn Dudley - BSc(Hons), MSc, CSci, PGCert, FHEA, MIBMS - Doctoral Student, Health, 
University of Wolverhampton 

Covid-19 has had substantial suffocating impacts on our lives in diverse ways, be it our day to day lives, jobs, studies, exercise, local recreational activities, travelling abroad, festivities. Strictly time-bound life patterns transformed into less disciplined virtually operated living. To briefly shed light on these elements, I feel the urge to call for a new definition of Living and Learning in line with the altered constituents of our lives. Turning attention to the living aspect, my experienced, teaching professional self, transformed into a foreigner in the field of teaching where the use of conventional teaching methods became unsought. Thus, it became incumbent upon us, as teaching professionals, to utilize fashionable avenues of teaching digitally, and for this acquiring training on fresh or existing technological tools became mandatory. Exploring new virtual methods of teaching and the nonstop professional development through the extensive use of digital tools not positively impacted on health and domestic life. 

On the flip side, the lockdown regulations made teaching on-site defunct which provided me with the potential possibility of maximizing my personal commitments and occupying myself in writing literature for my thesis. Naturally, the absence of provision of visiting libraries and the chance to study in a scholarly environment barely reinvigorated. Similarly, restrictions on social interaction with the community of practice froze and disrupted the discourse that has challenged my philosophical underpinning. Embedding the virtual culture for professional demands became a nuisance to an extent that I could not allow myself to engage electronically for my research purposes. However, connections through MS Teams and Zoom have appeared to be effective that gave me an allowance to attend across the borders, Annual Progress Review, conferences and university seminars. 

It seems to be guaranteed that even after the departure of COVID-19 from our lives, life will experience a new normal phenomenon. Perhaps a new era, a small revolution in its own way. 

Living, Learning and Lockdown 
Ambreen Alam - Doctoral Student, Education 
University of Wolverhampton 

Lockdown 3.0 in the UK has coincided with my attempts to write a methodology chapter. This has meant grappling with the complexities of paradigms, ontology and epistemology whilst sharing responsibility for home schooling my daughter. Even when I’m off teaching duty the interruptions are seemingly constant. “Dad, do you want to play?”. “Dad, can I have a snack?”. “Dad…actually you’re not very good at maths, I’ll ask mummy”. The luxury of having long periods of time to read, write and reflect is a distant memory. 

Evaluating the potential incommensurability of post-positivism and constructionism whilst negotiating the hurdles of the primary school curriculum is no easy task, especially when my desk has been invaded by My Little Ponies. I suspect their appreciation of the literature is better than my own. I’m sure Denzin and Lincoln didn’t have to put up with this. What I have learnt, with a level of certainty not traditionally associated with qualitative research, is that studying for a PhD and teaching a 5-year-old are fundamentally incommensurable. 

I feel sure that my frustrations will resonate with parents everywhere who are trying to balance the demands of home working, home schooling and answering the door to the delivery driver. And yet, whilst progress has been dishearteningly slow at times, it has also been a joy to spend so much time with my family. There are other upsides too. Whilst my understanding of interpretivism is probably not what it should be, my phonics have really come on and if you ever want to know about the life cycle of a turtle, I’m your man. 

Reflections on the incommensurability of social constructionism and My Little Ponies 
Mark Elliot - PhD Researcher, Education 
University of Wolverhampton 

Covid 19 pandemic has influenced health and wellbeing research activities globally with many abruptly shutting down for safety reasons (Ataullahjan et al, 2020; Kozlowski et al, 2020). In- person participation, where essential studies were still running, was negatively affected (Cardel et al, 2020, Padala et al, 2020). I had to surmount the challenges posed by covid 19 pandemic by redesigning my doctoral research. Although the millennial generation (MG), my research subjects, are reputed to be digital natives and thus comfortable with the use of technology (Dahl et al, 2018; 2018; Fletcher and Mullett; McGloin et al, 2016), I had not contemplated the use of technology in the initial design of my data collection method. I wanted to collect “story artefacts” in form of hard copy collages so as to reflex on them and make ethnographic sense out of them (Cross and Holyoake, 2017). But face to face contacts became apparently impossible due to covid 19 lockdown. 

Through reflection, it occurred to me that I could collect the same data digitally using Skype. I thus modified my initial research proposal and applied for and was granted ethical approval based on the reviewed data collection method. Collecting data digitally helped to save the time and the money required for the participants to come down to the initially proposed data collection centre. This thus reduced respondents burden, a key reason for non-participation in health studies (Callinan, 2017; Scuderi et al, 2016; Ziegenfuss, 2010). 

This image which was digitally collected as a "story artefact" was provided by a participant as their representation of what apparent self-care looks like to them. I am currently working to construct metaphorical meanings from it. Suffice to stay that it demonstrates unequivocally that the data I wanted to initially collect in hard copies via face to face approach could be collected digitally as well. The MG are very busy with study or work and sometimes come across as hard-to-reach (Alsop, 2008; Baiyun et al, 2018; Winter and Jackson, 2016; Woodard et al, 2000). My experience with collecting data digitally made me to think that the problem reaching the MG may have to do more with the data collection methods utilised than their assumed unwillingness to participate in research. I recommend that even if life returns to normal from the covid 19 challenge, the digital technology should still be utilised as much as possible in health and wellbeing studies involving the MG (Cowey and Potts, 2016; Ransdell et al, 2011) 

Fig 1: A non-personal collage digitally collected from one of my research participants. 

References: 

Alsop (2008) The Trophy Kids Grow Up: How the Millennial Generation is Shaking Up the Workplace. San Francisco: Jossey Bass. 

Ataullahjan, A., Kortenaar, J., & Qamar, H. (2020).Towards more equitable global health research in a COVID‐19 world. Social Anthropology, 28(2), 224-225. 

Baiyun G., Ramkissoon, A., Greenwood, R.A. Hoyte, D.S. (2018) ‘The Generation for Change: Millennials, Their Career Orientation, and Role Innovation’, Journal of Managerial Issues, vol.30, no.1, pp.82–96. 

Callinan, Sarah. (2017). The Impact of Respondent Burden on Current Drinker Rates. Substance Use & Misuse, 52(11), 1522-1525. 

Cardel, M. I., Manasse, S., Krukowski, R. A., Ross, K., Shakour, R., Miller, Lemas, D.J., and Hong, Y. (2020). COVID‐19 Impacts Mental Health Outcomes and Ability/Desire to Participate in Research Among Current Research Participants. Obesity (Silver Spring, Md.), 28(12), 2272-2281. 

Cowey, A.E. & Potts, H. W.W. (2018) "What can we learn from second generation digital natives? A qualitative study of undergraduates’ views of digital health at one London university", Digital Health, vol. 4. 

Cross, V. and Holyoake, D.-D. (2017) ‘“Don”t just travel’: Thinking poetically on the way to professional knowledge’, Journal of Research in Nursing, 22(6–7), pp. 535–545. doi: 10.1177/1744987117727329. 

Dahl, A. J., D’Alessandro, A. M., Peltier, J. W., & Swan, E. L. (2018). Differential effects of omni-channel touchpoints and digital behaviors on digital natives’ social cause engagement. Journal of Research in Interactive Marketing, 12(3), 258-273. 

Fletcher, S. and Mullett, J. (2016) “Digital Stories as a Tool for Health Promotion and Youth Engagement.” Canadian Journal of Public Health, vol. 107, no. 2, pp. e183–e187. 

Kozlowski, H.N., Farkouh, M.E., Irwin, M.S., Radvanyi, L.G., Schimmer, A.D., Tabori, U. & Rosenblum, N.D.( 2020) "COVID ‐19: a pandemic experience that illuminates potential reforms to health research", EMBO Molecular Medicine, vol. 12, no. 11. 

McGloin, R., Richards, K. & Embacher, K. (2016). Examining the Potential Gender Gap in Online Health Information-Seeking Behaviors Among Digital Natives. Communication research reports, 33(4), pp.370–375. 

Padala, P. R., Jendro, A. M., Gauss, C. H., Orr, L. C., Dean, K. T., Wilson, K. B., Parkes, C.M. and Padala, 

K. P. (2020). Participant and Caregiver Perspectives on Clinical Research During Covid‐19 Pandemic. Journal of the American Geriatrics Society (JAGS), 68(6), E14-E18. 

Ransdell, S., Kent, B., Gaillard‐Kenney, S. & Long, J. (2011). Digital immigrants fare better than digital natives due to social reliance. British Journal of Educational Technology, 42(6), 931-938. 

Scuderi, G.R., Sikorskii, A., Bourne, R. B., Lonner, J.H., Benjamin, J.B. and Noble, P. C. (2016). The Knee Society Short Form Reduces Respondent Burden in the Assessment of Patient-reported Outcomes. Clinical Orthopaedics and Related Research, 474(1), 134-142. 

Winter, R. P. and Jackson, B. A. (2016) Work values preferences of Generation Y: performance relationship insights in the Australian Public Service. International Journal of Human Resource Management. 27(17), 1997-2015. 19p.1 Diagram,3 Charts. Database: Education Research Complete. 

Woodard, D.B., Jr. Love, P., and Komives, S.R. (2000) Students of the new millennium. In Leadership and Management Issues for a New Century. San Francisco: Jossey Bass, 92: 35-47 

Ziegenfuss, J.Y. (2010) "Embedded authorization form also reduces respondent burden", Journal of clinical epidemiology, vol. 63, no. 6, pp. 591-593. 

Millennial Generation Apparent Self Care 
How Covid 19 Lockdown Changed my Data 
Enemona Jacob, Dean-David Holyoake, Hilary Paniagua - Doctoral Student, Education 
University of Wolverhampton 

Writing a good thesis during a pandemic was not easy, I’d say. I was faced with enormous challenges of confinement related to a lack of freedom and social isolation. Working from home provided plenty of welcome distractions away from my study. I stayed focus and motivated as I threw myself into learning my thesis, chapter by chapter. For me, even in isolation, I remained connected to the combined support of my family, peers and supervisory team. The mock viva awakened my fears and may be eager to read and read!! Intertwined in my learning was messages: Stay alert, control the virus, stay safe or stay home, protect the NHS, save lives; a reminder that we exist in very serious times. 

I confronted the challenge of a good work-life balance very badly, gained pounds on the scales and had an inferior sleeping pattern as I worked early morning or very late nights. The virtual world and all its technology were a steep learning curve; having a contingency to avoid a disaster was essential. When V-Day arrived virtually on MS Teams, I rose above the emotional roller coaster and hovered in anticipation. The environment was prepared; the laptop charged, spare glasses, my thesis, prompts and cards and oh yes! a drink of water were all carefully arranged! The screen was ready, technology checked and working, the chair and supervisor was there on hand for support and ran through the process before I began my viva. Finally, I was in the moment, no pressure! I was on screen, and there were my three examiners. 

Let the performance begin!! The examiners wrapped me in compassion, the very topic of my thesis. I felt tranquilised and very much at ease. Questions were broad and narrow, deeper and deeper, we went. The time went quickly and then went slowly, as I waited for my decision. I didn’t and couldn’t eat, spoke to family and peers. As I joined MS teams, in those precious moments, I felt alone, although, at that moment, there were faces over all the screen. Congratulations, Dr Juliet Drummond, you have passed with minor amendments. The news brought me close to surrealism; as I received some verbal feedback, I tried to make notes of the amendments. All in all, it was a wonderful opportunity and a unique experience, full of meaningful exchanges of knowledge, to be treasured for many years to come. Merci to all my participants, supervisory team, lecturers, managers, star office, peers, friends and family; you have contributed to making my doctoral journey a positive one. 

Viva Le Lockdown 
Juliet Drummond - Professional Doctoral, Health 
University of Wolverhampton 

The pandemic that has restricted the movements and froze lives globally was treated diversely in my region, United Arab Emirates. The authorities invested in embedding E-learning's culture and assigned a budget for sanitizing streets, public places and laid easy to access Covid testing services throughout. Formerly, having moderate expectations to teach through the smart technological tool suddenly became mandatory. In addition to that, the non-stop arrivals of branded teaching tools to facilitate remote teaching took my career to the infancy stage. However, the learners' increasing interest made me realize that perhaps now was the time for teaching and learning to be evolved at this revolutionary rate. It seems unlikely to imagine that teaching institutes will revisit those former territories and pedagogies that are overtaken by the digitalized world. Nevertheless, the burgeoning popularity of electronic teaching platforms and the network may anticipate scrutiny in terms of cybersecurity and health-oriented concerns. 

Shedding light as a researcher, the lockdown has denied me the opportunities to hold meaningful debates with other professionals who has been providing me with new dimensions philosophically and forced me to explore and ponder my area of research. Reading, writing, preparing lessons and activities for my online lessons, became around the clock job. Ultimately, the designated time to skim through peer-reviewed articles and online research books became a secondary preference. The continuous writing spirit and the art of critiquing became rusty and I found myself in the phase when I have begun my doctoral degree and learnt to adopt academic writing tactics. The enthusiasm and motivation to complete my doctoral journey became an illusion. The positive aspect of this pandemic, however, is the online provision of the doctoral college’s workshops, sessions and conferences. Keeping up with social interaction boundaries, I intend to avoid haste in commencing fieldwork and therefore planning to tweak my doctoral development plan. 

Living, Learning and Lockdown 
Muhammad Zubair - Doctoral Student, Education 
University of Wolverhampton 

My research involved interviewing self-confessed perpetrators of domestic abuse. The interviews looked at understanding why such men, voluntarily attended psychologically informed intervention programmes for the desistance of domestic abuse. I hold a somewhat overly optimistic view that it is possible to end domestic abuse. I am not too sure whether that is something that would happen in my lifetime, but I am hopeful that someday domestic abuse will be a thing of the past. In the most simplistic sense, I believe most people need guidance on how to be in a relationship. 

I was intrigued whilst talking to the men and felt a sense of understanding of their experiences. However, this changed when news articles and media reports highlighted a significant increase in domestic abuse related deaths during lockdown. This left an intense feeling of shock and discomfort inside of me. During my research I needed to be empathetic and accepting towards the experiences of the men. Many of the men had lost contact with a child due to their abusive behaviours. It was hard not to be saddened by their emotive accounts of how they missed their children and desired nothing but to be able to see them again. But now I was reminded of the ugliness of domestic abuse and the very real extremes of what domestic abuse can lead to. Being in lockdown, having no escape, having no access to support systems and the fear of what could happen if the wrong thing was said or done. A very bleak image occupied my mind whilst I went over the interviews, transcribed and analysed my research. 

It might seem naive, that I was so surprised by the reality of domestic abuse resulting in death. But I also recognise, at times we create a ‘box’ in which we contain certain information, in order for us to be able to cope with the difficult information which lies ahead. This is what I did while I spoke to the men. How else would I been able to understand a man who had hit, stalked and controlled a woman but also was so very desperately trying to better himself for his child? 

The Ugliness of Domestic Abuse During Lockdown 
Tarnveer Kaur Bhogal - Counselling Psychology Doctoral Student 
University of Wolverhampton 

Earlier last year, the whole world came to a standstill. In March 2020, the United Kingdom (UK) experienced a nationwide lockdown, and society could not go into work, travel or meet individuals face to face. This was due to a deadly virus called "corona, also known as COVID-19". A message from the UK's Prime Minister Boris Johnson was broadcast daily on national television advising individuals to "stay at home, protect the NHS and save lives". This catchy slogan became embedded in the national consciousness in the pandemic's early days (McGuinness, 2020). The initial approach to communication about the virus was complacent (Sanders, 2020). This rapidly started to feel like a tape recorder set on replay as the words echoed around my household, and my family panicked with anxiety. 

Before the pandemic, I had never heard of the online video chat tools called Zoom or Microsoft Teams. These immediately became popular and the 'new norm' that everyone knew and talked about (Marks, 2020). This video chat platform swiftly became the highlight of my day as I was itching to communicate with work colleagues and lecturers to have virtual face-to-face contact with the outside world and structure my working day. Our communication method readily became so different, and I would feel nervous about seeing work colleagues behind a laptop screen; it was awkward to begin with. 

As months passed by, the UK's covid-19 death toll had gradually risen, and I began to experience a turmoil of emotions. I felt that things would not change anytime soon, causing me to feel hopeless about my future doctoral career. During this worrying time, I also continued working at HMP Whitemoor to support prisoners in managing their mental health difficulties. Some days felt massively anxiety-provoking, but I could bracket my feelings of worry by utilising grounding techniques and validating my irrational thoughts (Spinelli, 2005; Benedicto, 2018; Hazlett-Stevens, 2018; Hoffman & Gomez, 2017). 

A few weeks later, I began to find ways to self-motivate and reflect on my doctoral research thesis. I recalled research on the back burner as clinical duties and responsibilities were a greater priority within the National Health Service (NHS). I was keen to proceed with my research topic and felt passionate about completing what I had already started. I began to think creatively about making subtle changes to my research project and conducting data collection during unprecedented times, bearing in mind that the main priority was to keep safe and socially distant. As I brainstormed a few ideas around using video chatting tools to interview fellow research participants, I started to feel a sense of positivity entering into my body. I recognised that I had a plan B, and it left me feeling exhilarated. 

It was surreal, and I felt excited to virtually conduct research data collection and keen to add a new experience to my doctoral research journey. There was a space of inner enthusiasm and passion about my future which blossomed inside me, allowing me to adapt to a positive mindset. I kept reminding myself "to take one day at a time," these words supported me to manage my worry (Vivyan, 2018; Wells, 1995). In effect, I became my self-therapist, where I had used tools and resources to cope with a pandemic. I felt there was an opportunity to offer self-compassion and practise what I preached as a counselling psychologist in training (Gilbert, 2009). 

I am currently in the process of editing my research proposal, ensuring that practicalities have been considered to conduct research data collection in line with the UK's current government social distancing guidelines, alongside adhering to local NHS research and university policies. I hope to safely continue with my doctoral research journey during a time of uncertainty by utilising creativity and adapting to the unexpected. I have learnt a lot about myself in the year 2020, something that I will cherish for the rest of my life. I have learnt about my inner strengths, ability to persevere and draw upon my resilience. I have practised gratitude and focused on what I need to appreciate in life to strive each day. 

I have an image in mind that I would like to share and that "there will be light at the end of the tunnel". 

References

Benedicto, E. (2018). Mindfulness-based intervention in patients with generalised anxiety disorder, Relias Media, Retrieved from: https://www.reliasmedia.com/articles/142761-mindfulness-based-intervention-in-patients-with-generalized-anxiety-disorder 

Gilbert, P. (2009). Introducing compassion-focused therapy. Advances in Psychiatric treatment, 15, 199-208. 

Hazlett-Stevens, H. (2018). Mindfulness-based stress reduction for generalised disorder: does pre-treatment symptom severity relate to clinical outcomes? Journal of Depression and Anxiety Forecast, 1(1), 1-4. Retrieved from: https://scienceforecastoa.com/Articles/JDAF-V1-E1-1007.pdf 

Hoffman. S.G. & Gomez, A.F. (2017). Mindfulness-based interventions for anxiety and depression. Psychiatric Clinics of North America, 40(4), 739-749. 

Marks, P. (2020). Virtual collaboration in the age of the Coronavirus. Communications of the ACM, 63(9), 21-23. DOI: 10.1145/3409803. 

McGuinness, A. (2020). Coronavirus: How the PM’s slogans have changed. Sky News, retrieved from: https://news.sky.com/story/coronavirus-how-the-pms-slogans-have-changed-12040037 

Sanders, K. B (2020). British government communication during the 2020 Covid-19 pandemic: learning from high reliability organisations. Church, Communication and Culture, 5(3), 356-377. 

Spinelli, E. (2005). The Interpreted World: An Introduction to Phenomenological Psychology (2nd edition). London: Sage. 

Vivyan, C. (2018). Vicious Cycle of GAD and Worry. Get Self Help website, Retrieved from: https://www.getselfhelp.co.uk/gad.htm 

Wells, A (1995). Meta-cognition and worry: A cognitive model of generalised anxiety disorder. Behavioural and Cognitive Psychotherapy. 23: 301-20. 

“I think we all understandably get caught up at times in wanting 
certainty and yet I believe that it can indeed contribute… 
to a state of paralysis and lack of creativity” 
(Mason, 1993, p. 190). 

For my research, my interviews investigating the experiences of online negative comments for adults with learning disabilities were to be face-to-face. Prior to the pandemic, my research interviews had only ever been face-to-face or via the telephone, never using online video platforms. I was aware of my anxiety around online interviewing due to the unknown. However, rather than gripping solely to my certainty and staying in a state of paralysis, I delved into a position of ‘safe uncertainty,’ encompassing a way of being which prioritises both curiosity and difference (Mason, 1993). Through this, I became curious around the different online video platforms, taking the time to learn and become familiar with them, for example learning how to utilise the screen share function to share my images so I could creatively meet the unique needs of the individual with intellectual disabilities (Prosser & Bromley, 2012). 

Yet, further challenges that have emerged, where due to staring at a computer screen all day, I am beginning to experience ‘Zoom Fatigue’ (Fosslien & Duffy, 2020). In overcoming this challenge, I have prioritised self-care, an area historically neglected by myself, psychologists and those in the ‘helping’ professions (Rothschild & Rand, 2006). For me, this has taken the form of regular breaks away from my computer screen, walks outside in nature (Figure 1), which has been beneficial in giving me more energy to stay on focus. If COVID-19 has helped me learn anything as a researcher, it is the importance of a compassionate approach to self, others and research (Gilbert, 2010). 

References

Fosslien, L., & Duffy, M. W. (2020). How to combat zoom fatigue. Harvard Business Review, 29. 

Gilbert, P. (2010). The compassionate mind: A new approach to life’s challenges. London: Constable. 

Mason, B. (1993). Towards positions of safe uncertainty. Human Systems: The Journal of Systemic Consultation &: Management, 4, 189–200. 

Prosser, H., & Bromley, J. (2012). Interviewing People with Intellectual Disabilities. In E. Emerson, C. Hatton, K. Dickson, R. Gone, A. Caine, & J. Bromley (Eds.), Clinical Psychology and People with Intellectual Disabilities (pp. 105–120). Chichester, UK: John Wiley & Sons, Ltd. https://doi.org/10.1002/9781118404898.ch6 

Rothschild, B., & Rand, M. L. (2006). Help for the helper: The psychophysiology of compassion fatigue and vicarious trauma (1st ed). New York: W.W. Norton. 

Living, Learning and Lockdown 
Fiona Clements, MA MSc - Counselling Psychology Doctoral Student 
University of Wolverhampton 

The transmission of Covid-19 has been rapid through the global populace, invoking fear, illness and death upon millions. Our day to day journeying bought to a rather abrupt hiatus! With little time to process the speed of such drastic incarceration, with the loss to routines, pace and ways of living, time seemed to stand still encased in ‘bubbles’ of modified yet ‘enforced reality’. Rather like the respiratory virus, there was a feeling the world had paused for breath, whilst tragedy unfolded. For many, this existence undoubtedly involved significant periods of loneliness and isolation (Hwang et al., 2020), which may have greatly impacted on mental health (Pietrabisa and Simpson, 2020; Killgore et al., 2020). Conversely, others may have seized the moment to breathe life into new virtual ventures (Maritz et al., 2020). However, as I reflect from experience, it is the deafening sense of loss that is prominent; this ‘loss continuum’ being felt on a multitude of different levels with varying degrees of intensity and emotion. 

Indeed, the experience of loss is undoubtedly subjective, but what was prominent during lockdown were the taken for granted day to day rituals. For example, the school run, journey to work, and those benign corridor conversations with colleagues. Not to mention, the friendly handshake, hug and numerous other tactile gestures that are so integral to being human. Then, there is the loss of a loved one and the grief that ensues and Covid-19 has inflicted this in abundance, with the potential for prolonged impact on the health and wellbeing of those left grieving (Pearce, Honey and Lovick, 2021). Bereavement may bear a profound sense of emptiness, giving rise to a cocktail of feelings such as anger, frustration, guilt and sadness, not to mention a void that threatens to engulf the path. Thus, whatever form loss takes, it may run deep, cutting to the core of existential experience with a sense of ‘nothingness’; from which may come healing (Christ, 1995). As I pause and ruminate these emotions swirl, there are ripples of new insight unfolding, the silence lifts; and life appears to become more audible. A circularity of being that at times has been crippling brings clarity of mind, “a reality of metanoia” (Wright, 2005 p.193), bearing forth a renewed sense of hope. It is at the point of this new position that there is an unfolding awareness that the silence may have served to enable a new vision, whilst learning to have greater empathy for self and others. 

References

Christ, C. (1995) Diving Deep & Surfacing: Women Writers on Spiritual Quest. Boston: Beacon Press. 

Hwang, T., Rabheru, K, Peisah, C, Reichman, W., & Ikelda, M. (2020) Loneliness and social isolation during the COVD-19 pandemic. International Psychogeriatrics, 32 (10), 1217-1220. 

Killgore, W., Cloonan, S.A., Taylor, E.C & Dailey, N.S. (2020). Loneliness. A signature mental health concern in the era of COVID-19. Psychiatry Research, 290. https://doi.org/10.1016/j.psychres.2020. 113117. 

Maritz, A., Perenyi, A., de Waal, G., Buck, C. (2020) Entrepreneurship as the Unsung Hero during the 

Current COVID-19 Economic Crisis: Australian Perspectives. Sustainability 2020, 12, 4612. 

Pearce, C., Honey, J.R., Lovick, R. (2021) ‘A silent epidemic of grief’: a survey of bereavement care provision in the UK and Ireland during the COVID-19 pandemic. BMJ Open 2021; 11:e046872.doi:10.1136/bmjopen-2020-046872. 

Pietrabissa, G and Simpson, S.G. (2020) Psychological Consequences of Social Isolation During Covid-19 Outbreak. Front. Psychol. 11:2201. Doi: 10.3389/fpsyg.2020.02201 

Wright, S. (2005) Reflections on Spirituality and Healthcare. Whurr Publishing. 

EDITORIAL
Dr Hilary Paniagua
Editor-in-Chief

The 21st century has proved to be a challenging period however it can still be a dynamic and exciting time for research particularly where it is creative. For many years science disciplines have allied themselves only to a conception of knowledge that advocates procedural approaches and values associated with hard facts and replicability. Such thinking also presumes there is a fixed nature of subject matter that is independent of anyone’s particular prejudices and advocates propositions that are only supported and reinforced by empirical evidence. This traditional research thinking can no doubt be creatively devised but at the same time in its practice its aim can be to avoid creativity. In contrast there is now a transformative movement within research that embraces subjectivity and a belief that research can also be valued creatively through the lens of artistic practice. Such creative thinking about research is particularly useful at the start of a project, when all things are possible however it can also be used at every significant stage of the research process as well as in everyday research activities. This edition illustrates exactly this creative endeavour from its front cover through to its content of poems, limericks, pictures and posters, all of which have been created by Wolverhampton University’s research students and staff. If you have any reservations as to what is before you in this edition maybe I can leave you with the views of a JHSCI colleague?

“I have never worked in research, but I realise now how much work is 
involved and how students move through their doctoral journey. I think 
these are really nice reflections. It has been wonderful to take some time
out of a busy day to just sit and read these”

My portfolio unfolds through a series of letters. But why letters, you ask? Well, it is difficult to envisage a return to those days when handwriting and hand-written letters seemed so pivotal in the exchange of messages especially between people separated by time and place. I remember those days well when letters written by me on blue paper marked ‘air mail’ reached their destination at least a week after posting. I imagined my sister running to the front door at the sound of the postman’s cycle bell. She would then sit in the kitchen and read out my letter to the whole family, giving them news about my days in England. I imagined my mother listening intently whilst chopping vegetables and interrupting with questions about my plans to visit home. I imagined everyone wanting to take their turn at handling the letter afterwards.

Every day I would check my letter box for a reply, certain in the knowledge that very soon there will be an airmail addressed to me complete with the scent of home, the scent of Mauritius. The 1970s have now faded into a distant past, and hand- written letters sent and received lie in the darkness of a treasure chest, a time capsule. 

Letter-writing, referred to as ‘epistolary intent’, is an intention to communicate by letter with someone who ‘is not there’, motivated by the expectation of a response (Stanley, 2015). The letter, some would argue (Milne, 2010), also communicates many aspects of the letter writer’s personal characteristics. The recipient can sense traces of the writer such as their touch on the paper and their licking of the stamp. Similar intangible effects such as the aura or living hand of the writer is believed to radiate from their writing (Phillips, 2010). The more tangible attributes relate to the material aspects of the letter, that it can be read and re-read, passed on to others, destroyed or saved and kept. It can also be bought or sold or sought out by researchers or by those interested in its historical significance.

Despite these noteworthy characteristics, the letter is unlikely to continue to exist as a serious form of everyday communication. Epistolary seems destined to be fulfilled by other means. Everything is or will be typed or texted or twittered or emailed or attached to an email. Emotions will be expressed by means of emoticons and personalised signoffs. But despite its heralded demise, letter- writing has been used as a form of narrative therapy in counselling psychology (Mosher and Danoff-Burg, 2006; and Hoffman, 2008) and more recently Pithouse-Morgan et al., (2012) used letter-writing as a collaborative auto-ethnographic research method. They argued that letter-writing used in qualitative research generates self- reflexive data, the analysis of which enables participants to re-examine their own identities as well as their lived experiences.

Whilst I am drawn to the notion of letter writing as a reflexive auto-ethnographic research method, I am even more seduced by the nostalgia of those less tangible effects of letters particularly those written with affection: the thrill of receiving such a letter delivered by post, my name lighting up the envelope; the palpable sense of urgency and anticipation that it creates in me; the need to find a quiet corner removed from the rest of the world where I can open the letter in such a way that it speaks to no-one but me; the first words, Dear or My Dear, or My Darling, words that give me a deep sense of pleasure and make me believe that I exist or that I matter; sentences that carry me instantly to the letter writer or to places in my imagination; the freedom to choose to share its contents; and the desire to treasure it and keep it somewhere safe along with other precious letters.

Because of these not so scholarly reasons, I signpost my portfolio by means of letters I have written, letters I am writing and letters I should have written. The letters provide what Maxwell and Kupczyk-Romanczuk (2009, p.140) identify as the linking theme, the ‘over-arching pediment (roof)’ of the Greek temple holding together a row of columns, each symbolising a separate piece of work (please see Figure 1 below).

The columns and the pediment represent a coherent and connecting model for the portfolio, although I concede that reality is not necessarily orderly, coherent and simple. Instead it can be fragmented and chaotic with discontinuities (Heylighen, 2018), even more so in a Post-Covid- 19 world, a world in which a hand-written letter has the capacity to disrupt and deliver something unintended and sinister. On account of this, you the reader may refuse to accept anything sent on paper, at least until the danger of Covid-19 has passed and confidence in the magic of letters is restored.

Composed not with pen and paper but with sincerity, my first letter grows restless at the starting block. So, if you are sitting comfortably, allow me to begin.

My Dear …

References

Heylighen, F. (2018) Post-Modern Fragmentation [online]. [Accessed 13 August, 2018]. Available at: http://pespmc1.vub.ac.be/POMOFRAG.html

Hoffman, R. M. (2008) Letter Writing: A Tool for Counsellor Educators. Journal of Creativity in Mental Health 3(4) pp. 345 – 356.

Maxwell, T.W. and Kupzcyk and Romanczuk, G. (2009) Producing the professional doctorate: the portfolio as a legitimate alternative to the dissertation. Innovations in Education and Teaching International 46 (2) pp. 135 – 145.

Milne (2010), In: Stanley, L. (2015) The Death of the Letter? Epistolary Intent, Letterness and the Many Ends of Letter-Writing. Cultural Sociology 9 (2) pp. 240 – 250.

Mosher, C. E. and Danoff-Burg, S. (2006) Health Effects of Expressive Letter Writing. Journal of Social and Clinical Psychology 25 (10) pp. 1122 –1139

Phillips, S. (2010) Should you feel sad about the demise of  the       handwritten     letter?  [online]. [Accessed   August 13,  2018].     Available       at: http://aeon.co/ideas/should-you-feel-sad-about- the-demise-of-the-handwritten-letter

Pithouse-Morgan, K., Khau, M., Masinga, L. and Van De Ruit, L. 92002) Letter to Those Who Dare Feel: Using Reflective Letter – Writing to Explore the Emotionality of Research. International Journal of Qualitative Methods 11 (1) pp. 40 - 56

Stanley, L. (2015) The Death of the Letter? Epistolary Intent, Letterness and the Many Ends of Letter-Writing. Cultural Sociology 9 (2) pp. 240 –

Portfolio Through Letters
Yash Gunga Professional Doctoral Student
University of Wolverhampton

As a trainee Counselling psychologist, I identify with the discipline’s endeavour to address oppression and promote social justice. My research on the experience of Inflammatory Bowel Disease in South Asian Women moved me to such direction. Interviewing these women highlighted to me the many forms of oppression that one may experience in our society. Immersing myself in the interviews with my participants, I noticed myself asking: what does it feel to live with IBD? What does it feel to live with IBD as a woman within a culture, where women’s value is highly determined by the level and nature of care she can provide as a mother, a daughter, a daughter-in-law and a spouse?

 Delving deeper into my research data, I felt increasingly drawn into exploring the different levels of power associated with sociocultural characteristics that we all inherit from our context. I wondered about how the women thought and talked about IBD and how this influenced their views about themselves and perceptions of others. This led me to Michel Foucault (1926-1984) and his argument that power is based on knowledge that in turn reproduces. I then asked some more questions: what power is held within the women’s sociocultural discourses about femininity and womanhood, what knowledge do these discourses reproduce and with what effects? These are the questions that I am hoping to answer with my research and as a Counselling Psychologist contribute to a movement that challenges oppressive discourses.

I was thrilled when local artists gave shape and form to these questions in a collaborative Art’s Council funded exhibition “Living in silence” which was created from my research data. This display showcased artist’s interpretations      into      artefacts       including fashion, sculpture, animation, live poetry, and photography. The art destigmatised the condition of IBD   in   the   community and raised   awareness   of the significant psychological distress felt by participants. As one artist said she could see how the patient is feeling and “visualise the emotions, see the beauty in something traumatic”. Foucault famously said “What strikes me is the fact that in our society, art has become something which is only related to objects, and not to individuals, or to life (Foucault, 1984, p.350). This is an example of art relating to a life with IBD:

The following poem entitled “Dr Interrupted” is an expression of my anxieties about how drastically my life has changed as I pursue my Doctorate in Health and Wellbeing.

Dr interrupted

We had made majestic plans, you and I

Who knew like leaves they too would wither and die? A glimpse, a stare, look at us in our prime

But what a sight we have now become!

We can pick up the pieces, you say Things will get better if you stay But let me go and be free

Leave me to blow away in the wind, just me!

Most times I long for days gone by

So clear it was to see the reasons why Now I fear to get caught in a gust

This is the new norm, you say, you must adjust!

Wasted, worn and wafted around

I search for rest that can never be found Though it brightens my sky

To know tomorrow will soon come by.

But it is today that I wallow and woe 

I long to do so much more

Remember how we clung to hopes of bloom? 

Summer was here, but left us too soon.

Poet’s rationale

The emergence of the COVID-19 pandemic has meant that for the last seven months, as a researcher I have had to conceptualise, write and develop my data collection methodology in a creative and unique manner. Local, national and international quarantine measures have required a large scale adaptation to embrace alternative methodological approaches (Taster, 2020). Indeed, this unchartered moral territory has required a new energy to explore alternative solutions to data collection such as the analysis of personal diaries and reflections of participants to replace direct observation, poetry as self-narrative and use of online platforms (Torrentira, 2020).

References

Taster, M. (2020) Social Science in a Time of Social Distancing, London School of Economy Impact Blog, 23 March 20, available at: https://blogs.lse.ac.uk/impactofsocialsciences/ 2020/03/ 23/editorial-social-science-in-a-time- of-social-distancing/    (accessed  27 October 2020).

Torrentira, M.C. (2020) Online data collection as adaptation in conducting quantitative and qualitative research during the COVID-19 pandemic. European Journal of Education Studies. 7(11) pp78-87.

Dr interrupted
Jessie Allen BSc (Hons) MPH RNLD Professional Doctoral Student
University of Wolverhampton

Isolation
Blessing Chinganga Professional Doctoral Student
University of Wolverhampton

Creativity and participant anonymity was a strong feature of my doctoral thesis (which I have recently submitted) and as such I developed a composite character couple to merge the participants’ stories and re-story them, as this enabled a reduction in the risk of the participant’s identities and those of their families being exposed. Gutkind and Fletcher (2008) explain that in performances that are adapted from real or fictional narratives, a composite character is often created, which is a character based on more than one individual from a story. Once the composite characters were developed I wanted to utilise their story further, therefore I wrote a children’s book as I believe that it is important for all people to see their own reflection in mainstream media. When children with same-sex parents attend healthcare settings, there are no children’s picture books that can be used as a tool to ease their fears by reflecting same-sex parents (including dual heritage) and adopted children within a hospital setting.

The book was written to address that gap and to create a status quo so that children can see their family constellation and identity reflected outside of the family itself. The book is one of positivity and inclusion and the ethnicities and genders depicted within the book are representative of the participants within my study. The professionals shown within the book are purposely gendered to challenge gender-stereotyping within professions. The book is based upon a same-sex parented adoptive family being part of the normative and what children and their parents should expect when accessing healthcare. The aim of the children’s picture book is that it can be used as an educational tool to showcase diverse families to people of all ages and it can also be used by children who have same-sex parents that are attending healthcare settings to allow them to visualise themselves and to be represented. The near culmination of my doctoral journey has seen the book accepted for publication.

References:

Gutkind, L and Fletcher, H (2008) Keep It Real: Everything You Need to Know About Researching and Writing Creative Nonfiction (1st ed.). New York: W.W. Norto

A poem reflecting my thinking of the PhD journey so far. After just 18 months since starting this journey, the research study has become unruly and at times, heartbreaking. It’s been a transformative process of nurturing the research idea and the fighting the imposter syndrome that is embedded within this process. I am perplexed at how my idea becomes my teacher and I, a student of it.

You started as a simple
Sairah Miriam Shah, PhD in Education
University of Wolverhampton

“Stay home, stay safe” but what if home isn’t a safe place? COVID-19 restrictions and social distancing measures have led to more time in the home or in the same space as an abuser, increasing the risk for abuse and creating a new COVID-19 crisis. Individuals subjected to violence may be unable to reach out for help due to limited social contact, or they may not be able to seek support services or access a refuge. It's crucial we find new ways of supporting victims during this difficult time. During November 2020 I am raising money for ‘Refuge’ a charity which supports individuals experiencing domestic violence to ensure some help is there for those in need. 

I am in my second year studying the Professional Doctorate in Counselling Psychology at the University of Wolverhampton. I am currently finalising my research proposal for my thesis which will explore post-traumatic growth in those who have experienced domestic violence. The negative consequences of domestic violence have been well documented, and they can be far reaching, impacting significantly on the long-term health and emotional wellbeing of those affected (McGarry et al., 2011). However, a dearth of research suggests that exposure to trauma also has the potential to catalyse a host of positive changes such as improvements in personal, interpersonal and spiritual functioning, often referred to as posttraumatic growth (Steffans & Andrykowski, 2015; Draucker, 2001; McCann & Pearlman, 1990). Studies reveal that individuals can experience growth despite enduring highly stressful environments (Linley & Joseph, 2004). I aim to carry out a longitudinal mixed method design using questionnaires and virtual interviews with individuals who have accessed support from two    charities following domestic violence. This is to explore individuals’ perceptions of their recovery process and adaptation in the aftermath of domestic violence.

Personally, I have never experienced domestic abuse. One in 4 women and one in 10 men experience IPV, and violence can take various forms: it can be physical, emotional, sexual, or psychological.2 People of all races, cultures, genders, sexual orientations, socioeconomic classes, and religions experience IPV.

Long term post-traumatic growth in the aftermath of domestic violence
Nadine Denny BSc, MSc Trainee Counselling Psychologist
University of Wolverhampton

Abusive Men: A Small Attempt at Social Change
Tarnveer K Bhogal Counselling Psychology Doctoral Student
University of Wolverhampton

I took this photo as it represents my favourite season, Autumn; symbolising the return of cosy jumpers, pumpkin spiced lattes and the wonderful colours of the leaves, as they change colour and fall. My shoes represent that I am entering into a journey of change with my Doctoral research.

Summer is over, the leaves have changed, and it is apparent that COVID-19 is not going anytime soon. As such, I have had to adapt my research into cyber-victimization experiences for adults with intellectual disabilities. This means moving my planned recruitment from advocacy centres to online. Also, moving from the data collection in the form of face to face to online interviews using the participant’s preferred online platform. Whilst, I am comfortable with online research, I am aware that there are several challenges for disability populations reflected in the digital inequalities in access and use of information and communication technologies (Chadwick et al., 2019).

Yet, I am also mindful that Autumn leaves represent hope; where change can also bring opportunity. For example, online research has the benefits of reducing barriers for research participation including financial and geographical barriers (Saberi, 2020). Therefore, from another perspective, I can promote inclusivity by opening the research to a wider geographical area, the entire UK (Alhaboby et al., 2017). With the leaves in my photo vaguely akin to the UK shoreline, and with all the different colours, I am reminded of all the inclusivity which the online platforms can provide.

References

Alhaboby, Z. A., Barnes, J., Evans, H., & Short, E. (2017). Challenges facing online research: Experiences from research concerning cyber-victimisation of people with disabilities. Cyberpsychology: Journal of Psychosocial Research on Cyberspace, 11(1). https://doi.org/10.5817/CP2017-1-8 

Chadwick, D. D., Chapman, M., & Caton, S. (2019). Digital inclusion for people with an intellectual disability. In The Oxford Handbook of Cyberpsychology.

Saberi, P. (2020). Research in the Time of Coronavirus: Continuing Ongoing Studies in the Midst of the COVID-19 Pandemic. AIDS and Behavior, 24(8), 2232–2235. https://doi.org/10.1007/s10461-020-02868-4

The Season of Change
Fiona Clements Professional Doctoral Student
University of Wolverhampton

The Covid Thesis Year, 2020!
Janet Cash Lecturer in HR & Leadership Professional Doctorate in Education
University of Wolverhampton Experiences of Business Students during Online Lockdown Learning

“Autumn leaves don't fall, they fly. They take their time and wander on this their only chance to soar.”
– Delia Owens

During autumn there is a process of shedding to bring about the new where growth and change is experienced. Akin to this, much research supports the efficacy of Acceptance and Commitment Therapy (ACT) based Pain Management Programmes (PMP), however, this is based on analyses of pre-post changes in pre-defined outcome measures (Vowles, Wetherell and Sorrell, 2009; McCracken and Gutiérrez-Martínez, 2011; McCracken, Sato and Taylor, 2013). But how do individuals themselves give meaning to and experience change?

The present study explores this using Auto-Driven Photo-Elicitation (ADPE) whereby nine participants enrolled on a six-week digital PMP were invited to take a weekly photograph of a meaningful change to discuss during photo- elicitation interviews at week two, four and six. This method has gained popularity within health research and reports benefits by empowering participants to discuss and reflect upon what is individually meaningful, portray what may be difficult to express in words and explore everyday life that may be taken for granted or overlooked (Balmer, Griffiths and Dunn, 2015). Thematic analysis was used to analyse the transcripts and preliminary themes created. Findings support the use of ADPE as an engaging and valuable method for helping individuals with persistent pain conceptualise and articulate their pain management journey.

Alongside my participants I have used photography to capture and reflect upon my own research journey (Figure 1).

References

Balmer, C., Griffiths, F. and Dunn, J. (2015) A review of the issues and challenges involved in using participant-produced photographs in nursing research. Journal of Advanced Nursing, 71(7), pp.1726-1737.

 McCracken, L. and Gutiérrez-Martínez, O. (2011) Processes of change in psychological flexibility in an interdisciplinary group-based treatment for chronic pain based on Acceptance and Commitment Therapy. Behaviour Research and Therapy, 49(4), pp.267-274.

McCracken, L., Sato, A. and Taylor, G. (2013) A Trial of a Brief Group-Based Form of Acceptance and Commitment Therapy (ACT) for Chronic Pain in General Practice: Pilot Outcome and Process Results. The Journal of Pain, 14(11), pp.1398-1406.

Vowles, K., Wetherell, J. and Sorrell, J. (2009) Targeting Acceptance, Mindfulness, and Values- Based Action in Chronic Pain: Findings of Two Preliminary Trials of an Outpatient Group-Based Intervention. Cognitive and Behavioral Practice, 16(1), pp.49-58.

Adjusting the Lens on Change during Acceptance and Commitment Therapy based Pain Management
Suzanne Roberts BSc (Hons), PG Dip, MSc, MBACP, RN 4th Year Post Graduate Research Student
University of Wolverhampton (Professional Doctorate in Health and Well-Being)
Dr Debra Cureton, Professor Megan Lawton and Dr Sarah Sherwin

 Your course reflects passage through the sea, the ebbs and flows, ripples and waves

September 2018 ,A starting point ;gazing out in the calm blue waters, sun glinting on ripples mirroring the jewels of promise, reflecting the riches to come

Riding the waves of life, love and study, keeping afloat in your own personal boat Yet the clearest summer sky can change and then comes the rain

Ripples of anxiety and strife, rocking the boat, mirroring student life

Fishing for riches of study and practice success, angling for a catch and reward 

Sometimes coming up empty, the crushing defeat of failure and casting out again in the hopes of resubmission moving forward

Then came the tsunami, the crescendo of COVID, your boat is capsized, unexpected, brutal, Unprecedented, unforgiving and unrelenting, a tidal wave of fear and death,

Leaving destruction in its wake 

Forcing you to make choices in the flow, which way do you go

Which channel do you follow, agonies abound, and the conflicts in life create indecision and strife But you survived, you’re alive, changed, enriched, you have clambered back on board

You will all eventually get your reward; reach an oasis of calm, gently rocking in the waves Gather up, prepare, get ready for the next adventure and caper

Mentors and tutors have been guiding you to shore, away from the rocks, a beam of light illuminated your plight

We helped you navigate your way through choppy waters, the beam shining bright, perils are ignored, the path is made clear and free from harm 

Go forward, share lessons learnt, wisdom gained, in practice strive for change , support and transform

We have taught you to be a lighthouse in someone else’s storm

The Voyage of M18
Tracy Lapworth Professional Doctorate in Health and Well-Being
University of Wolverhampton

In my attempt to interview grandmothers who had sick grandchildren in a neonatal intensive care unit (NICU), I visited two NICU in the West Midlands at grandparents’ visiting times in the hope of recruiting participants for my study. In my naiveté, I assumed that there would be an abundance of grandmothers visiting their sick grandchildren on a regular basis. What I discovered instead, was that there were no grandmothers visiting either in the afternoon, evening or at weekend visiting times. These are two poems I wrote whilst I sat for many hours waiting for any grandmother to visit her grandchild.

Poems for the grandmothers who were not there.

‘Behind the scenes’: Grandmothers as silent heroes in the neonatal intensive care unit.
Hilary Lumsden Professional Doctoral Student
University of Wolverhampton

I have been collecting data from the study participants (millennials) on what the millennial generation apparent self-care looks like as part of my doctoral research. Until recently, I was ignorant of the possibility of the use of art based methods for health research (Norris 2020; Boydell et al 2016).

As I collected and reflected on the story artefacts, I began to appreciate the richness of this method. This made me to feel that qualitative studies help to access rich data that is normally unavailable or unacceptable for quantitative research (Bast et al 2013; Cross and Holyoake, 2017; Townsend et al, 2006). I am now in love with the use of art-based methods in doing health and wellbeing research. This is however a new experience for me as my previous research was laboratory based and driven by positivist considerations. I had always believed that a phenomenon must be about cause and effect and thus objectively measured. That for me was being “scientific”. But there is so much to explore and know about the meanings of apparent self-care than the restrictions of scientism would allow (Crawford 2017; Alexander et al 2014).

The use of both textual and graphic data to construct meanings of the social reality of people will help creativity and the unpacking of many interesting concepts in health and wellbeing. I have been reflexing a lot and feel that scientism had imprisoned me seriously in the past and gave me no space to explore social phenomena interpretively (Jiang 2018; Baron, 2019).

References

 Alexander G., Duarte A., García-González, L., Moreno,M.P. and Fernando D. V. (2014) "Implications of Instructional Strategies in Sport Teaching: A Nonlinear Pedagogy-based Approach." European Journal of Human Movement 32 (2014): European Journal of Human Movement, Vol.32. Web.

Baron, C. (2019) "THE RISE, FALL, AND RESURRECTION OF (IDEOLOGICAL) SCIENTISM." Zygon 54.2: 299-323. Web.

 Bast, A., Briggs, W.M., Calabrese, E.J., Fenech, M.F., Hanekamp, J.C., Heaney, R., Rijkers, G., Schwitters, B. & Verhoeven, P. (2013) "Scientism, Legalism and Precaution - Contending with Regulating Nutrition and Health Claims in Europe", European Food and Feed Law Review : EFFL, vol. 8, no. 6, pp. 401-409.

 Boydell, Katherine M, Hodgins, Michael, Gladstone, Brenda M, Stasiulis, Elaine, Belliveau, Burton, J. K., Moore, D. M. and Magliaro, S. G. (1996) ‘Behaviorism and Instructional Technology’. in Handbook for Research for Educational Communications and Technology. New York, N.Y.: Simon & Schuster Macmillan.

Crawford, R. (2017) "Rethinking Teaching and Learning Pedagogy for Education in the Twenty- first Century: Blended Learning in Music Education." Music Education Research 19.2: 195

Cross V, Holyoake D.D. (2017) ‘Don’t just travel’: thinking poetically on the way to professional knowledge. Journal of research in nursing. 22(6-7):535-45.

Jiang, Z. (2018) "Is the 'Intention' There? On the Impact of Scientism on Hermeneutics", European Review, vol. 26, no. 2, pp. 381-394.

Norris, J. (2020). A Walk in the Park: A Virtual Workshop Exploring Intertextuality and Implicit Powers Within Texts. Cultural Studies ↔ Critical Methodologies, 20(1), 26–34. https://doi.org/10.1177/1532708619885413

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Knowing Differently My Experience of Collecting Story Artefacts as Data for Health Research
Jacob Enemona Professional Doctoral Student in Health
University of Wolverhampton

All aboard!
Janet Mortimore Professional Doctoral Student
University of Wolverhampton

Doctoral process is a long and isolated degree

Still, we wanted to enter this course before our teaching could reach to its silver jubilee. We knew our professional practice and professional ideology has friction

Our positionality needed a new insight, became our mission

The very mental itch that has been bothering us at work

Following school’s policy, DfE guideline and Ofsted framework

Often put us into thoughts and forced into looking for reasoning

Always tried to search for sound answers however very weakening

First phenomenon, why do we divide students into ability grouping

We view this practice and considered it, quite educationally, polluting

Registering ourselves for a doctoral degree and delve into this phenomenon

We thought policymakers need to borrow researchers’ perceptions and related epiphenomenon

The other phenomenon under investigation

Is about the school leaders and upon them all the allegations

Whether it is instructional leadership, transformational style or other leaders’ traits

We develop interest in exploring true leader’s practice and debate

Ah! that first module really shifted our belief

The doctoral process was a challenge! and it was not such a relief

What is positionality, ontology and epistemology, did you say?

It was only Cresswell, Brayman and Silverman, who stopped us going stray

Eventually, started to like the philosophical thinking process

Even though failed in first assignment but learnt how to access

The wider resources, the valuable discourse with our module tutors

Those long doctoral sessions in Wolverhampton University was an investment for future 

The EdD WhatsApp group appeared to be such a buddy

The complexity of assessments diminished, and we learnt how to study

Delving into literature for module two, was an assignment

our perceptions began to receive alterations, and thoughts oozed out of old confinement

It, didn’t end here, before entering into the thesis stages

Module three was designed to record students’ understanding using distinct

gauges Use of artefacts, reflection and dialogue with other community of practice

This assignment certainly aligned effectively, great were assessment tactics

The three years’ worth of work is gradually making us a research native

We have learnt to innovate the existing phenomenon without being

imitative Critical analysis, evaluation and art of understanding methodology

Let us bet you; you will never find a creative course that may outmode your epistemology

Eye opening is the shift in our philosophy and identity

We grew confident that our research will bring professional serenity

Our views and beliefs have improved, rebuilt, reshaped and have got new features

We were fortunate, that our university has such great teachers

Don’t mistake us, not only the perceptions and views

The whole thinking pattern has reshuffled but some queries remain in queue

Evident is drastic innovation in academic writing and critical thinking

Little had we ever imagined that our queries will begin shrinking.

Doctoral Journey ……….
Ambreen Alam and Muhammad Zubair, EdD 4th Year Professional Doctorate Students
University of Wolverhampton

Abstract

This article aims to discuss the need for clinical education to embrace the use of narrative. It discusses the split – most evident in Anglophone countries – between the arts and the sciences, before discussing what can and cannot be known from the scientific method, and what can and cannot be known from narrative approaches. It concludes that narrative is the natural way to teach and learn and has the advantage that it can explore hypothetical situations in safety as well as both to learn and to convey values and attitudes while the hypothetico-deductive method can say what does happen but can shed no light on what should happen.

Introduction

Eva (2014) reminds us how Lasagna’s (1964) revision of the Hippocratic Oath tells us that ‘there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.’ (Lasagna, 1964: p11) In the course of this article, we consider how science and the arts were once wedded, before splitting in a manner which, most evidently in Anglophone countries, rendered them almost as strangers to each other. We move on to discuss in detail the need for narrative in clinical education and how this can be beneficial to teachers, learners, and patients and their relatives by permitting an exploration of ‘emplotment’ and hence hypothetical situations with full cognisance of all the actors and the impact of the scenario upon each and this in all its diverse manifestations.

Science and the arts

For a Renaissance scientist, there could never be any question of a division between the arts and the emergent sciences. Whether da Vinci, Harvey, Paracelsus or any of their contemporaries, the simple need to communicate their findings not only to their peers but more especially to their patrons meant that they had not only to be scientific in the sense of their explorations but also artists both in the sense of the graphic depiction of their work and in the verbal descriptions. An outstanding example of such versatility is Girolamo Cardano, physician by trade, but who produced in the course of the 16th century highly influential texts on ‘medicine, astrology, natural philosophy, mathematics, and morals … [and on] devices for raising sunken ships and stopping chimneys from smoking’ (Grafton, 2002: pxii) and whose Book of my Life (Cardano, 2002) gives an insight into how minds such as his worked.

It is in some senses ironical that the scientific descendants of these Renaissance minds might well find them somewhat unnecessarily verbose, elaborate and even obscure. The Renaissance man, and to a large extent woman, lived the ideal of the generalist who could reliably move in and out of diverse circles and engage in meaningful discussion across the full range of human experience and contemporary knowledge. 

Even as late as the Long Eighteenth Century could we find such eminent figures as Dr Samuel Johnson – a doctor of letters and not medicine as physicians had not yet gained a pre-eminence over the title (Hamilton, 1981; Strathern, 2005) – whose 1773 edition of his dictionary (first published in 1755) had an entry for the word science which he pointed out was derived from the Latin word scientia meaning knowledge (Johnson, 1773/1828). He then lists the meanings of the word science in his times as follows (Lyons, 2001).

1. Knowledge
2. Certainty grounded on demonstration
3. Art attained by precepts, built on principles.
4. Any art or species of knowledge
5. One of the seven liberal arts, grammar, rhetorick, logick, arithmetick, musick, geometry, astronomy

These liberal arts were close to the Medieval Trivium and Quadrivium which every aspiring Medieval physician who attended university [although most did not] would have studied prior to undertaking his [and almost never her] medical studies in a higher faculty. That the medical student would be Master of Arts prior to studying medicine was no coincidence as the Trivium and Quadrivium were deemed essential for the proper understanding of any learning in a higher faculty, whether this be Medicine, Law or Theology. The Arts were the gateway to further study and only by demonstrating a basis in them could be aspiring university-trained physician proceed further (Matheson, 1999).

 It is notable that Dr Johnson includes both what we would now recognise as science and the liberal arts under the same heading. The split came much later with the term scientists coined in 1834 in contrast to artists as students of the material world (Whewell, 1834) and by 1977, the fourth edition of the Penguin Dictionary of Science has only physics, biophysics, astronomy, chemistry, biochemistry, molecular biology, and mathematics and computing listed under science.

The split was underlined quite dramatically in the first examinations for the Indian Civil Service (ICS) in 1858 whose Part One examined the ‘subjects of a general education’ (Compton, 1968: p267), but sought quite openly to recruit ‘top Oxford or Cambridge honours graduates’ (p267), and hence focussed on Latin and Greek as taught in those universities. The result, unsurprisingly, was the domination of Oxbridge graduates among those who passed and the nearly total exclusion of graduates from Scotland’s five universities for whom the split between the arts and the sciences only came much later and whose knowledge of Latin and Greek was more functional than the models of parsing beloved in the two [out of then four] English universities (Bell and Grant, 1977). Despite this, as Midgeley (2009) reminds us, ‘

 Blake and Coleridge could discuss scientific problems with Faraday and Davy, … Darwin could write about Kant very sensibly … [and] TH Huxley wrote a book on Hume (Midgely, 2009: p27).

Nonetheless, the stance taken by the ICS showed that the trend was moving away from the polymath.

While Scotland continued its love of generalism, with school pupils intending for university being prepared across a range of both science and arts subjects, in England [and hence in the British Empire at large] early specialisation became the norm and eventually children as young as 14 were able to effectively drop virtually all sciences [or virtually all arts] and to funnel their studies until, without having yet left school, they were left with three, or exceptionally four, subjects which would only very rarely cross the arts/science divide.

The situation in England was made worse by a rapid growth in anti-intellectualism, as demonstrated in Hughes [1877] Tom Brown’s Schooldays where the eponymous Tom states that

I want to be A1 at cricket and football, and all the other games, and to make my hands keep my head against any fellow, lout or gentleman … I want to carry away just as much Latin and Greek as will take me through Oxford respectably (Hughes, 1857/1963: p282).

 As science moved from being a pursuit primarily of gentlemen of leisure [as were Lord Cavendish and the Honourable Robert Boyle, to name but two] and technology and engineering developed and became a major driving force for the British Empire, an ethic developed and thrived that opposed to anything that resembled physical labour (Gikandi, 1996). Latin and Greek were effectively useless in themselves and hence respectable for this very reason, while engineering and science had use but demanded, or at least implied, physical labour, however refined, and were thus to be disparaged as worthy only of the lower orders. Science and engineering were directly related to jobs; Latin and Greek were not. To make matters worse, science and engineering resembled jobs that one might prepare for by means of an apprenticeship and, in reality, were [and remain] subjects favoured at university by students from working class backgrounds. Even the massive growth of engineering in the UK during and after the Industrial Revolution could do nothing to change the Weltanschauung of the ruling classes. Even the accomplishments of engineers as great as Brunel were powerless in the face of this thinly veiled class discrimination.

Thus, we never see in UK history any phenomenon comparable to the prestigious Grandes Ecoles such as Napoleon established in France to train in the first instance civil engineers [as in case of the Ecole des Ponts et Chaussées].

The Second World War, otherwise a uniting force across many domains of UK society, exacerbated the division between the arts and the sciences with a shroud of mystery, necessary no doubt for the war effort, surrounding the ‘boffins’ and ‘backroom boys’ [i.e. scientists and engineers] upon whom the nation’s hopes were pinned but who were depicted as not only inevitably male and balding but also as totally incomprehensible to the general public, a situation aided by some of the less accessible public information films which assumed a level of nutritional knowledge well beyond that of even a well-educated public. It was thus in parody of the incomprehensible scientist that ‘Professor’ Stanley Unwin, a comedian in variety theatre and radio [and later television], found fame and fortune by literally talking incomprehensible gibberish. For example: 

Now, like all real life experience stories, this also begins once a polly tito, and Happiness Stan, whose life evolved the ephemeral colour dreamy most, and his deep joy in this being the multicolour of the moon. Oh yes. His home a victoriana charibold, the four-wheel folloped ft-ft-ft out the back. Now, as eve on his deep approach, his eye on the moon. Alltime sometime deept joy of a full moon scintyladen dangly in the heavenly bode. But now only half! So, gathering all behind him the hintermost, he ploddy-ploddy forward into the deep complicadent fundermold of the forry to sort this one out¹. 

Against this backdrop CP Snow delivered his 1959 Rede Lecture on the two cultures which are the arts and the sciences.

The two cultures

Snow pointed out that the sciences and the humanities come from different cultures and even reflected differing social classes with the greatest scientists often being of working class origin; and particularly so for those working in the applied sciences such as engineering (Snow, 1959). What he voiced was the reality in UK society and ‘a special instance of the lack of scientific literacy in society’ as a whole (Grayling, 2009: p27).

Snow’s lecture drew attention to these two cultures, and it was really for those trained in the humanities to take the sciences more seriously. He argued that, for example, the Second Law of Thermodynamics should be a cultural icon along with the works of Shakespeare (Midgely, 2009) in response to which Flanders and Swann rose to the challenge and, in First and Second Law, did a song celebrating the Second Law in a manner which was both entertaining and scientifically accurate. 

Heat is work and work's a curse And all the heat in the Universe

Is gonna cooool down ’cos it can't increase Then there'll be no more work and there'll be perfect peace

Really?

Yeah – that’s entropy, man!

At the time of Two Cultures lecture, school selection according to some measure of ability at age 11 via the 11+ Examination [12 in Scotland via the Qualifier] was almost universal across the United Kingdom and, at least as far as those destined to be the rulers of the future, the pinnacle of achievement was to graduate in the Classics from Oxford or Cambridge as it was from this group that much of government and especially the higher echelons of the Civil Service were drawn (Bell and Grant, 1977).

The same two cultures argument as employed by Snow can be applied to the cultures in and around clinical education where there is, for example, an uncomfortable juxtaposition of the scientific, where the patient and his/her condition are ‘objectified’ and one might even say dehumanised – though  this  may  be  the only  way  not  to  be paralysed by empathy with a sufferer’s pain – and the narrative, where the patient and their condition are a story, replete with characters, drama, suspense and some sort of hoped for – or feared – and then actual, dénouement. In the narrative, it is feelings and perceptions that come to the fore. The patient and their condition are central, but they are there as actors within the drama, subjective and potentially irrational but key to the proceedings.

The problem is one of how to introduce such narrative into medicine and a possible door is through increasing the understanding of the role that the arts in general and literature in particular can play in increasing the clinician’s understanding of what the patient is really going through and hence why they make the decisions that they do.

Evans (2003) argues that incorporation of literature into clinical education supports four ‘goods’:

1. An education (as opposed to training)
2. Ethics and communication skills
3. The development of personal values
4. A sense of wonder at embodied human nature

Unfortunately, Evans fails to make the case that the humanities are essential for any of these activities. There seems to be the recognition that it is in some way good for a clinician to know something of the humanities, but it is not clear what this should be. 

Part of the problem surrounds the idea of truth as embodied in the arts and in the sciences. Both cultures aim to understand the ‘truth’ but do so by different means. The question is whether these two approaches can be resolved.

The scientific approach

The basis of the scientific method is ‘objectivity’ which is often defined as things being true independently of the observer. However, a moment's reflection shows that this cannot be the case. If no human has ever observed something, then no human can know about it. The statement should read ‘independent of the choice of observer’, in itself a rather tall order and more of an ideal than an everyday reality.

Coupled with objectivity, there is empiricism. The empirical approach grounds all knowledge in sensory experiences (Hume, 1777/1977). The problem which philosophers have wrestled with through the ages is to discern the basis upon which this might be justified. Descartes, in his Mediations (Descartes, 1637/2007), put the sceptic’s case that senses could not be relied on due to two problems. The first was the problem of illusions and the second is how to distinguish dream from reality.

The justification for this grounding is ultimately pragmatic. The argument runs that if an animal's senses gave unreliable evidence about the real world, such as interpreting the presence of a lion as a rather unusual daffodil, then that animal would be, in Darwin's terms, less ‘fit’. In fact, people generally have such confidence in their senses that scientists usually publish without checking that others see the same image down the microscope.

The issue with illusions is interesting. Illusions are detected on the basis of triangulation, when two different lines of evidence give rise to two different conclusions. Again, we tend to know when our senses are most and when least reliable. One often quoted example is the issue of colour constancy which breaks down under extreme conditions of lighting or which falter under the weaknesses of human colour perception – an example of which pertains to one of the present writers who long possessed what he thought was a black coat, only for it to be revealed as being very dark blue when compared to a garment which was indeed black. An example of the breakdown of colour constancy occurs when red surface is illuminated by red light and so will appear white [or grey if the frequencies do not quite match]. Colour appearances are at their most reliable when viewed with sunlight at mid-day with a clear sky, conditions that most closely resemble the conditions under which our vision evolved, and very much unreliable when seen under the limited frequencies available with fluorescent tube lights. As Hume (1777/1977) himself pointed out, sensory data must, on occasion, be interpreted rationally.

This idea leads to the notion of an ‘objectivity’ defined as when the same opinion is offered, independent of the choice of observer. This works well [though not infallibly so] when it comes to primary sense data but could, in principle, be applied to any question.

Opinions on the colour of a flower will usually be accepted as objective, but not on such issues as who should be the next prime minister. Clearly, the opinion on the latter would be highly dependent upon the choice of the ‘observer’ and we can predict which opinions are those that can be considered ‘objective’ and which are not. Thus, the term is usually reserved to primary sense data and the hallmark of such is that the system has no memory although this is not quite true, as one can have ‘after-images’ but they are transient and fade. However, to return to the visual system, the perception of the colour red is not affected by what colours have been previously seen, even though vision itself is entirely subjective and potentially individual to the viewer. By contrast, one's opinion of a politician can be permanently affected by preceding events such as the Iraq war or Brexit.

 The hypothetico-deductive model and the sciences

The scientific method is often equated to the hypothetico-deductive process. This process is a key component of science, but it is just a component. The triumph of the hypothetico- deductive method is that it solves the logical basis of universal statements and of induction. The issue has always been as to how one can take the step from ‘all the swans that I have seen are white’ to the universal statement ‘all swans are white’. The straight answer is that one cannot (unless whiteness is part of the definition itself of a swan). The hypothetico-deductive method makes the observations that one can never prove a universal statement and never disprove a singular statement (Popper, 1959). No matter how many white swans one has seen, this does not prove that all swans are white. Conversely, one cannot prove that a black swan does not exist simply on the basis that you have not seen one as you cannot prove that you have inspected all swans. The scientific method works by postulating what may not occur and these are termed scientific laws. One then tries to disprove this by looking for forbidden events. The dichotomy in science is not true/false but consistent/false. Scientific laws are not in themselves provable, but they are consistent and open to being falsified.

 However, these laws, such as the Law of Conservation of Energy, do not explain what is actually occurring. Rather, they predict what will be observed, given appropriate conditions.

Good science is based on determining mechanism. Mechanism can never be directly proved and is only inferred or ‘constructed’ on the basis of the following reasoning. What one observes is events and if one wishes to prove that events A and B are linked then one needs to demonstrate four things:

1. If A then B.
2. If not B, then not A
3. Cause A to happen and B happens
4. Prevent B happening and A does not

These principles surface in many guises and under different names within sciences such as Koch's postulates in microbiology.

The limitations of the scientific method

The four steps that are required to demonstrate causality put severe constraints on the sort of events that can be investigated. In particular, they must be frequent, reversible or at least reproducible. The scientific method cannot be applied to rare and irreversible events which are just the conditions that apply to many of the most interesting events which involve humans such as 9/11 or World War II.

Humans clearly have memory and ethics alone make it unacceptable to even consider re-creating the same conditions to see if the same events recur

– even if the formidable practical problems could be overcome. Thus, there is a need for a different approach for this type of problem.

Narrative and the humanities

People have been telling stories since the dawn of time and it is one of the major ways by which we

1. Great literature has two key features: plot and characterisation (Booker, 2004). The first feature of a good story is ‘emplotment’ whereby a string of events are connected (Ricoeur, 1981). Heidegger postulated that narratives serve a ‘presencing’ function (Heidegger, 1971: p44) whereby events past or future, real or imaginary are ‘presenced’. It is easy to see how mirror neurones (Iacoboni and Dapretto, 2006) could be hypothesized to be a neural substrate for such a process.
2. Official
3. Invented (adapted)
4. First-hand (experiential)
5. Second-hand
6. Culturally common

Emplotment can be equated to mechanisms and so represent the potential for deep learning. Schank argues that knowledge consists of stories and what we recall are plots (Schank, 1990) though a good storyteller reinvents the details to make the story ‘come alive’ or presenced’. These stories come from five sources: 

These stories result in the formation of what Schank calls ‘scripts’; i.e. a set of expectations of what will happen in well-defined situations, and the aim of storytelling is to change other people's behaviour. In addition to script formation, the other key issue is indexing to allow recall of appropriate stories at the appropriate time. Indexing is done on the basis of facts or features in the story. 

In his view, intelligence then is the number and complexity of these scripts and of the indexing. This makes the hallmarks of intelligence to be observation and association and leads to the question of what are the features that lead to association.

Narratives are how we learn and communicate. We live in social groups and it is a great advantage if an individual can understand what another is thinking. The mere concept that another individual has a mind as well as ourselves is called ‘Theory of mind’ (de Waal, 2006) and it is postulated, and the evidence is being gathered, that this works by imagining how we would feel if we were in somebody else's shoes. This leads to the other hallmark of great literature – good characterisation, which allows the reader to feel as the character feels, think as they think and even act – in their mind – as they act. This is why literature and poetry are sometimes described as moral activities (Eagleton, 2007). 

It should be noted what narrative cannot do. While it can be used to speculate, it cannot prove mechanisms. Attempts to use narrative or discourse in this way has (a) formed the basis of the post-modernist approach, (b) has been highly influential and (c) is mostly of extremely poor quality (Gross and Levitt, 1998; Sokal and Bricmont, 1998) and is not a suitable alternative to the hypothetico-deductive method in situations where the latter can be applied, given that learning can have two distinct meanings. One is acquiring information from a teacher and narrative is good for ‘passing it on’. However, it does need to be distinguished from the other which is discovering and from situations when a scientist discovers information from the real world. Here, narrative fails (Sokal and Bricmont, 1998).

 Narrative medicine

Within medicine, there is increasing recognition of the importance of the narrative approach (Charon, 2006). In the 20th century, the scientific approach resulted in doctors treating patients increasingly like experimental subjects, culminating in the Tuskegee Syphilis Study Scandal, whereby 600 syphilis sufferers were denied treatment to see the natural history of the disease (this study also had distinct racial overtones as all the subjects were of African-American descent) (Heller, 1972). Such objectification, under the name of science, by concentrating on the frequent and the reproducible, ignores the unique and the personal. In contrast, narrative medicine gives insight into how individual patients make sense of their life and that by listening to them that one conveys respect and that, in itself, can carry therapeutic benefit.

This approach requires ‘close reading’ and this is a skill that requires development as well as the ability to listen. It also requires personal insight on the part of the clinician and an awareness not only of how s/he thinks but also of how patients may perceive them and their profession (Groopman, 2007). 

The second issue is that the sciences can shed light on what does happen but not on what should happen [to equate these two is termed ‘the naturalistic fallacy]. Accordingly, one would expect a narrative approach to be particularly valuable as it can engage with ought as well as does and all the while distinguish between the two (Jones, 1999). This exploration of hypotheticals and alternatives is what leads to the notion that good literature and poetry can be defined as being moral (Eagleton, 2007) meaning that it can affect behaviour. Miller puts it more strongly ‘Without story telling there is no theory of ethics. Narrative examples, stories ... are indispensable to thinking about ethics’ (Miller, 1987: p3). Narratives also show how far people will go in search of truth or results. They add the human aspect to human endeavour and maintain the human aspect in human suffering.

Narrative and education 

A popular paradigm for learning is experiential learning theory (ELT) as proposed by Kolb (A Kolb and Kolb, 2005) along with the learning style inventory (DA Kolb, 1976) and the umpteen variations on this theme. Kolb’s theory proposes that learning is a four-stage process that occurs in sequence of concrete experience (CE), reflective observation (RO), abstract conceptualisation (AC) and active experimentation (AE).

These stages are highly reminiscent of the hypothetico-deductive model of the scientific process of experiment, observation, hypothesis and prediction with a one-to-one mapping between the two models. This suggests that Kolb fell for a variant of the psychological fallacy that how we should think is how we do think! A systematic review of learning styles was highly critical of the whole field and in particular labelled the idea of the learning cycle as ‘may be seriously flawed’ (Coffield et al., 2004: p14). Even more suspect are attempts to map stages of the cycle to parts of the brain (Zull, 2002).

By contrast, Klein, in his research on how people make decisions (naturalistic decision making), found stories to be the best way to access this information and that stories were the medium by which experience was shared in the workplace (Klein, 1998). Work by Pennington and Hastie showed that jurors made sense of legal evidence by assembling it into stories so as to generate understanding and to facilitate recall. They also showed that the first story that the jurors constructed carried the greatest influence (Pennington and Hastie, 1993). Their findings are intuitively plausible. It is well known that we are all instinctively distrustful of a story that changes. It leads to the conclusion, in teaching, that getting the story right first time is of particular importance and this places a particular demand on the teacher that they have the necessary subject knowledge.

Conclusion 

The hypothetico-deductive method has proved supremely           triumphal        for       the       acquisition      of knowledge and the Kolb learning cycle is one example of the attempt to import the same method into education. However, this method was only fully understood until the 20th Century and is certainly not the natural method by which humans have acquired higher knowledge. Although we all start to acquire knowledge by interaction with the world – a process called play – this is a time- consuming method and, as soon as we can begin to use language, play is largely supplanted by the narrative approach, even when that leads to play! The narrative is the natural way to teach and learn. It has the further advantage in that the narrative can explore hypothetical situations in safety and is a particularly useful way both to learn and to convey values and attitudes over ethical issues. The hypothetico-deductive method can say what does happen but can shed no light on what should happen.

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Strathern, P. (2005) A Brief History of Medicine. London: Robinson.

The need for narrative in clinical education 
Dr David Matheson Reader in Education, University of Wolverhampton
Mr Alex Foss, Consultant Ophthalmologist, Nottingham University Hospitals

Anita Z Goldschmied, MRes, RNLD, Social Worker, Senior Lecturer, PhD Candidate
University of Wolverhampton

Dr Hilary Paniagua
Editor-in-Chief

Normality for all of us has become a thing of the past and lockdown a thing of the present. Who would have believed that the relentless march of COVID 19 would have reached our shores and caused so much devastation and heartbreak? All across the world people are scared, angry and uncertain and alongside these fears we see images of solidarity and an incredible commitment to fund raising and support to reach vulnerable people isolated in their own homes. Where would we be without the staunchness of workers behind supermarket tills and those who tediously stack shelves of much relished toilet paper, baked beans, flour and eggs often scarce commodities that have become a prized and hunted down aspect of our lives?

Our health professionals and care workers have shown a remarkable dedication in trying to tackle the virus in dangerous and challenging circumstances and many with the cost of their lives. Alongside the profound distress there is a growing understanding of the importance of research. In the NHS the Health Research Authority has a fast track process which means that COVID studies are being approved in as little as 24 hours. This fast process provides dedicated support to researchers to enable their study to be swiftly reviewed by a Research Ethics Committee and approvals specialists. If you want to request fast-track approval more detail about the process can be found in https://www.hra.nhs.uk/covid-19-research/fast-track-review-guidance- covid-19-studies/This service applies also to amendments to existing studies and to understand how and when to amend an existing study, either to incorporate COVID-19 or because of the impact of the virus. More details can be found in https://www.hra.nhs.uk/covid-19-research/covid-19-guidance-sponsors-sites-and- researchers/ Where there is a need to provide new information to research participants and record consent in COVID-19 research. For more information, read https://www.hra.nhs.uk/covid-19-research/seeking-consent- covid-19-research/

 Conversely research on a less urgent scale has been greatly affected and instead of quickly advanced there is now a need for its total rethink as studies with people are limited if not impossible. In our universities any academic activity is currently carried out at a distance and research teaching or supervision is now conducted remotely via e-learning or digital platforms. This issue of our Journal has pleasure in presenting some of the experiences of students at the forefront of this new age and I am sure readers will find this read at times moving, uplifting and edifying and maybe with some of them all at the same time.

Over the past few months, the world has come to face a deadly virus (COVID-19, also known as coronavirus) with everyone needing to take certain precautions in order to stay safe. Unfortunately, lives have been lost with some trying to survive and hope for the best. There are constant reminders of this deadly virus wherever we look and go: we are receiving emails from organisations with information and advice, the news is reporting rising numbers of deaths on a daily basis, and many are having to stay at home for an abnormally long time. Many have been told to self-isolate and some have been quarantined for several weeks. This virus seems to be spreading at a rapid rate, all over the world, especially here in the UK. We are all facing this global pandemic and we are all trying to understand how we can protect ourselves and our loved ones.

Every social platform, news programme, and internet search bar are a constant reminder of how this virus pandemic is unfolding every day. It is sometimes hard to distinguish factual news from false information. In their February 2020 ‘Situation report’, the World Health Organisation referenced the term ‘infodemic’ “an over-abundance of information – some accurate and some not – that makes it hard for people to find trustworthy sources and reliable guidance when they need it”.

As someone who is trying to get to grips with the current crisis and support my loved ones, this is something I am finding difficult. The COVID-19 pandemic and infodemic has become a part of my daily life and is something I have been reflecting on from the perspectives of being 1) a part time supply teacher being furloughed, 2) a PhD researcher in education, 3) a member of an affected community (city of Birmingham and from ethnic minority background) and 4) a member of a family with vulnerable individuals. There is some discord within these perspectives, which inspired me to write a reflective account on the impact of COVID- 19 on my research. 

Over the past 2 years, I have been researching teacher resilience and wellbeing as part of my, now completed, MA and current PhD studies. Resilience is often conceptualised as a group of factors supporting an individual to overcome adversities. My research has identified a few factors promoting one’s resilience, which have included: support from others (families and friends), spiritual influences, having a sense of self- efficacy and motivation to succeed (e.g. Black and Honeyman, 2020). Experiencing emotional support and being recognised for one’s strengths can lead to an individual feeling motivated to create a positive future.

Being a part-time supply teacher and a post- graduate researcher – both challenging roles - I have had to show a fair amount of resilience over a period of several years. Everything that I have researched and learnt about resilience is also very relevant to dealing with acute crises such as the current coronavirus situation and the effects of this for mental wellbeing.

Almost everyone has had to be resilient during the past few weeks and will have to continue to be over the next few days, weeks and months. There has been a lot of uncertainty around employment and safety, with several people losing their jobs and many being told to stay at home to stop the spread of the virus. Support networks are being lost or challenged, with the government advising all individuals to self-isolate and to not visit other family members. This has raised serious concerns about domestic and child abuse, with some using the current crisis as a reason to not have to visit or have visitors from other family members (NSPCC, 2020). And while many people have turned towards their religion and spirituality for comfort and support through difficult times (Shelton, Hein and Phipps, 2019), places of worship have been closed, making it difficult for some to come to terms with the realities of this virus.

 The pandemic situation has had a significant effect on my own personal resilience. My support network has been lost, as I am now unable to see my family in order to overcome difficulties, I have tended to use spiritual influences (religion) for guidance and motivation to be resilient. But it has been difficult being unable to attend my place of worship for support, and this has directly impacted my ability to continue studying. As well as keeping up with my PhD research, I have had to face uncertainty about how I will support myself financially in the immediate term. Being a part-time supply teacher has left me worrying about financial constraints, as schools have been restricted to serving the children of key workers, limiting opportunities for supply teachers to contribute.

However, these factors have motivated me to continue with my journey of research on teacher wellbeing. Now, more than ever, everyone is relying on teachers to care for children of key workers. But, where has teacher wellbeing come into play? There has been recent depoliticisation regarding teacher wellbeing during the outbreak of COVID-19. On the 19^th March 2020, the Department for Education published guidance for schools outlining a list of key workers. Teachers were regarded as key workers in this guidance, however there has been minimal effort to safeguard teachers’ physical and mental wellbeing. These ‘key workers’ are still expected to teach children who are stated as possibly being “carriers of the disease” (Ball, 2020). There is no “Personal Protective Equipment” (PPE) being provided to these teachers; the only protection the teachers have in order to overcome the current pandemic, are measures put into place by themselves. Not only that, schools were given no guidance on what to prepare if schools were to close for non-key worker children; they were expected to use their own initiatives and resilience to prepare home packs, lunches and safeguarding support.

The lack of support and consideration for the education system in the current situation has motivated me to discuss these issues within my PhD thesis. There is a lot of uncertainty around schools reopening and when this crisis will abate; a lot of questions are playing on all teachers’ minds: What about our own children? Am I still expected to come into school if I am deemed as vulnerable? Should I be seeing my own family? How will I travel to work? A key question on my mind is how are teachers expected to be resilient, without seeing families, without the support from the government, without the support from leadership (who are equally stressed) and while only being regarded as essentially child minders?

With a lot of ambiguity surrounding certain information about the severity of the virus and everyone’s levels of stress high, it is only normal to try to understand what is happening and how we should resolve the situation. Therefore, members of the public have been attempting to unite with one another through social media and other sources in order to access information and theories on the current crisis. These activities help determine our own decisions about what we do to manage our stress levels. Researchers have termed this “collective sense-making”; previous research has shown that individuals tend to use social media for minimising uncertainty during a pandemic (e.g. Zhang and Gao, 2014). I know that, like me, a lot of people, are taking part in the collective sense- making process.

 However, the process of information-sharing and discussion, especially over social media, can result in false information spreading which can be quite hazardous in leading to harmful choices and people causing danger to themselves and those around them. There has been a lack of trust in the UK government and how they have managed the virus so far. The current Prime Minister was the face of the famous quote “Stay at Home, Protect the NHS, Save Lives”, but was unfortunately admitted to hospital with COVID-19 related symptoms in intensive care. Seeing a country leader offer advice but still contracting the virus has led numerous people to engage in collective sensemaking, going online to use alternative sources of information to protect themselves.

Professor Susan Michie, a specialist in behaviour change, provided a critique on this matter: “Those in leadership positions should practise what they preach. If leaders do not adhere to their own recommendations, this undermines trust in them, which in turn can undermine the population’s adherence to their advice” (Stewart, Weaver and Proctor, 2020). This would consequently minimise public faith in authorised interventions and diminish the ability to recognise the most appropriate information. This can result in high levels of stress, poor decision making and low levels of resilience. 

Doubts have arisen in my own mind about self- isolating and how long to self-isolate for. It is certain that other teachers, who are expected to stay in schools to care for children of key workers, will also have doubts about self-isolation outside the workplace. Further doubts have arisen about my research ideas: are the factors related to teacher resilience and wellbeing I had planned to explore, such as leadership in schools, still most relevant and do I need to factor this crisis into my research plans? Given the relevance of resilience to the current COVID-19 crisis, it presents a new challenge for me to consider implications for my research plans as these unfold.

The ambiguity of government advice to teachers, the fact that everyone is facing the same crisis (leaders and teachers) and the sad reality that we are losing our loved ones and are unable to see them, are key factors that will be important in my current research. The views of teachers and leaders on the current crisis, the resources they drew on to deal with the crisis and how it has impacted their longer-term resilience will be something original to explore. Not only that, the views of educators and how they coped with current demands will provide guidance for schools if something like this were to happen again in the future.

Yet there are uncertainties over the viability of my original plans for field work. There has been reassurance from the government about schools reopening from September 2020, when I anticipate starting my research field work. Even if schools were to open in September, school policies regarding external visitors, like researchers, may change. Alternative methods of field work may need to be devised and I am uncertain about whether new methods, such as using webcams and online programmes, would provide me with the information I require. It is also uncertain whether my proposed participants will be allowed the time to participate in my research, as these will be busy periods for schools and teachers.

Further issues for my research have also come into play; the focus on wellbeing and mental health has been quite prominent in government policy and research over the past few years. Targets were set for this year to decrease the numbers of the UK population experiencing mental health problems and to improve the lives of everyone, including teachers. An example of such policy documents is the 2017 Green Paper for Transforming Children and Young People’s Mental Health Provision. This document set the target to provide the majority of schools with Education Mental Health Practitioners (EMHPs) by the year 2020. This is an example of the mental health targets that form the backdrop to my current research. However, due to the current crisis of COVID-19, these targets have been placed on hold until further notice. The policy, political, social and economic context (social inequalities) of my study has therefore changed and this will need to be factored into my research plans.

The problems in relation to social inequalities are still an issue in the current crisis. It has been found that those in society with the least resources and power suffer the most; there tends to be a widening of inequalities. There has been commentary on gender, socio-economic and ethnic inequalities in the current pandemic. For example, Apter (2020) pointed out the argument that the current pandemic will force women to “be driven back to their 1950s roles of cook, carer and cleaner”. With schools closing and people being told to work from home, women may be expected to do more housework and childcare and may be undermined as their income tends to be less than men’s. Moreover, concerns around race inequalities have also been noted by many. Haque (2020) wrote a summary of concerns surrounding those from ethnic minorities and vulnerability to COVID-19. It was stated that ethnic minorities were more likely to live in crowded houses, causing the virus to spread more easily. Further suggestions were made on those from ethnic minorities being less likely to overcome the economic crisis from COVID-19, as they were more likely to “be in precarious employment, including zero-hour contracts and agency contracts” (Haque, 2020).

It is vital that the impact of this virus on mental health and how others have coped with this adversity is researched. This focus is supported by other researchers, for example in the Lancet Psychiatry 2020 journal, many researchers all over the world published a joint report on the impact of COVID-19 on mental health. This report stated that there is a need to monitor mental health issues among all individuals, especially of those key workers (Holmes et al., 2020). The report further stated that “there is an urgent need for research to address how mental health consequences for vulnerable groups can be mitigated under pandemic conditions, and on the impact of repeated media consumption and health messaging around COVID-19”.

It has been further suggested that social contact is good for mental health and therefore those with existing mental health problems, such as anxiety, may find it more difficult to self-isolate (e.g. Teo et al., 2015). Furthermore, domestic violence is also a key consideration on the impact of COVID-19 on mental health. There have been reports by the charity called ‘Refuge’ (the UK’s largest domestic abuse charity) that there has been an increase of 700% in calls to their helpline (Townsend, 2020).

There is further concern around mental health outcomes due to the current pandemic. Indeed, one of the authors of the research report, Professor Rory O’Connor, has pointed to a link between previous virus outbreaks and poor mental wellbeing: “If we look at the Sars outbreak in 2003, we know there is evidence there that there were increased rates of anxiety, increased rates of depression and post- traumatic stress and, in some groups, there were also increased rates of suicide” (Davis, 2020). These considerations provide further motivation for me, as a researcher, to continue my research into resilience and wellbeing in the context of teaching.

Although there has been some negative impact of COVID-19 on my research and studying, it has been quite positive to my continuous academic self-development. Since the UK has been placed into lockdown, I have been able to place more focus on further study around the topic of wellbeing and resilience. The current pandemic has given a new lease of life to my research and has provided me with more current and alternative foci within my topic of teacher perspectives on resilience. My research mode has changed from part-time to full time, allowing me to delve deeper into relevant literature and broaden my knowledge about resilience. In the spirit of resilience, I have therefore made the best of a stressful situation, looked for positives and tried to turn it to my advantage in some respects through developing my understanding of resilience, through reading and through reflecting on the current context and my personal experience of this, for example through writing this article. These activities could, in turn, provide insights to support and advise to others when facing adversities.

 It is not known how long this pandemic will last and whether there will be a vaccination available to those who are infected. But it is known that people from different cultures, ethnicities and socio- economic backgrounds are coming together to lend a helping hand to each other. Moreover, the public are trying their best to support small businesses and charities, as well as the NHS. Not only the UK, but the whole world is experiencing the same difficulties in everyday life; the public are attempting to be resilient to support themselves, and their loved ones and neighbours. No religion, culture, ethnicity or background seems to matter in this moment in time, the one thing which does matter, is humanity.

Witnessing all communities and backgrounds come together to support each other through these unprecedented times, is something which I am in awe of. A positive outcome of this crisis may be the improvements in social cohesion. Now is the time for the world to unite, so that we can get through these difficult times. It is vital that we all continue to play our part and continue to try to see positives in a negative situation and under conditions of adversity, something which I am attempting to do. I conclude this reflection with this famous quote from Florence Nightingale, who has been an inspirational figure for British Society at this time: “I am of certain convinced that the greatest heroes are those who do their duty in the daily grind of domestic affairs whilst the world whirls as a maddening dreidel” (Florence Nightingale, cited in Mather, 2017).

References

Apter, T. (2020) What does the pandemic mean for gender  equality?   Available   at: https://thepsychologist.bps.org.uk/what-does- pandemic-mean-gender-equality         

Ball, J. (2020) ‘What scientists know so far about the effects of  coronavirus onchildren’, The Guardian, 23  March.    Available   at: https://www.theguardian.com/commentisfree/202 0/mar/23/scientists-effects-coronavirus-children- studies-carriers (Accessed: 18.04.20) 

Black, R. and Honeyman, A., (2020). Support for Staff: Building Resilience in Nurses. In Neonatal Palliative Care for Nurses (pp. 21-38). Springer, Cham.

Davis, N. (2020) ‘Urgent studies needed into mental  health  impact of  coronavirus’,   The Guardian, 15  April. Available     at: https://www.theguardian.com/world/2020/apr/15/ urgent-studies-needed-mental-health-coronavirus- lockdown (Accessed: 18.04.20)

Department for Education (2020) Guidance for schools, childcare providers, colleges and local authorities in England on maintaining educational provision.  Available   at: https://www.gov.uk/government/publications/coro navirus-covid-19-maintaining-educational- provision/guidance-for-schools-colleges-and- local-authorities-on-maintaining-educational- provision. (Accessed: 18.04.20) 

Department of Health and Department for Education (2017) Transforming Children and Young People’s Mental Health Provision: a Green   Paper. Available at: https://assets.publishing.service.gov.uk/gover nment/uploads/system/uploads/attachment_data/ file/664855/Transforming_children_and_young_ people_s_mental_health_provision.pdf (Accesse d: 18.04.20).

Haque, Z. (2020) Coronavirus will increase race inequalities. Available  at: https://www.runnymedetrust.org/blog/coronavir us-will-increase-race-inequalities  (Accessed: 27.04.20).

Holmes, E.A., O'Connor, R.C., Perry, V.H., Tracey, I., Wessely, S., Arseneault, L., Ballard, C., Christensen, H., Silver, R.C., Everall, I. and Ford, T., (2020). Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. The Lancet Psychiatry.

Mather, L., (2017). Burnout and sick leave due to mental disorders: heritability, comorbidity, risk factors and adverse outcomes. Inst för klinisk neurovetenskap/Dept of Clinical Neuroscience.

NSPCC (2020) Coronavirus (COVID-19) and keeping children safe from abuse. Available at: https://www.nspcc.org.uk/keeping-children- safe/reporting-abuse/coronavirus-abuse-neglect- vulnerable-children/ (Accessed: 27.04.20)

Shelton, C.D., Hein, S. and Phipps, K.A., (2019). Resilience and spirituality: a mixed methods exploration of executive stress. International Journal of Organizational Analysis.

Stewart, H., Weaver, M., Proctor, K., (2020) ‘Nonchalant: Boris Johnson accused of Covid-19 complacency’,     The      Guardian,  27  March. Available at: https://www.theguardian.com/world/2020/mar/2 7/nonchalant-boris-johnson-accused-of-covid- 19-complacency (Accessed: 19.04.20)

Teo, A.R., Choi, H., Andrea, S.B., Valenstein, M., Newsom, J.T., Dobscha, S.K. and Zivin, K., (2015). Does mode of contact with different types of social relationships predict depression in older adults? Evidence from a nationally representative survey. Journal of the American Geriatrics Society, 63(10), pp.2014-2022

Townsend, M. (2020) ‘Revealed: surge in domestic violence during Covid-19 crisis’, The Guardian, 12   April.   Available    at: https://www.theguardian.com/society/2020/apr/1 2/domestic-violence-surges-seven-hundred-per- cent-uk-coronavirus (Accessed: 27.04.20)

World    Health    Organization,  (2020). Novel Coronavirus (2019-nCoV): situation report, 3. Available at: https://www.who.int/docs/default- source/coronaviruse/situation-reports/20200202- sitrep-13-ncov-v3.pdf?sfvrsn=195f4010_6. (Accessed: 18.04.20)

Zhang, P. and Gao, D., (2014). Collective sensemaking in social media: A case study of the H7N9 flu pandemic in China. iConference 2014 Proceedings.

How COVID-19 has impacted my PhD research
Tayeba Khan - PhD Education
Researcher University of Wolverhampton

I am a final year student on the Professional Doctorate in Counselling Psychology at the University of Wolverhampton. Currently I am working on writing up my thesis on understanding the motivation of male perpetrators, for voluntary engagement on intimate partner violence treatment programmes. Alongside this, I balance two part time jobs offering psychological therapy in both a psychiatric hospital and a private company. I am lucky to have what I would consider to be an exciting and busy life managing such differing areas of my career and studies. However, during the current pandemic, it has been a challenge.

As much I knew I did not need to experience the same difficulties as my clients have in order to understand, I always thought that unless I share some commonality with their experiences, I could not truly understand them. Although I would have preferred not to have experienced and shared the anxieties which the world is currently experiencing at this moment in time.

I have worked with many clients who have struggled with anxiety of illness, disease and death. My initial thought would be to understand the root of the anxiety and to almost put aside the health condition they were anxious about. For instance, a previous client who I shall refer to as Helen, developed health anxiety after the death of her mother and deterioration of her elderly father. Due to a weak immune system and other underlying health aliments, Helen’s father had been hospitalised a few times due to health conditions such as pneumonia. I began therapeutic work formulating the impact of bullying, low life satisfaction, social isolation and explored her relationships with her parents and the impact of their many health issues in her own identity and purpose. Helen and I looked at all the usual issues, control, fear of death and fear of social interactions upon death of her father. I almost, although slightly unwilling to admit it, dismissed her worries of catching a cold and cough from me or others she passed (this was one of the ways her anxiety would manifest). Upon reflection, I realise that I missed a vital component of Helen’s therapeutic process.

Living in this pandemic, I cannot help but feel overwhelmed with anxiety due to very real, imminent health concern. Previous to this if anyone had asked, I would not have considered myself as a particularly overly anxious person. I would have said I am as anxious as the next person. I now can say I can begin to understand the real and imminent fear Helen felt whenever someone sneezed, coughed or breathed near her.

I work in a psychiatric hospital as part of a therapies team, amongst very skilled occupational therapists, social workers, and psychotherapists. The team is split into two, the adult team and adolescent’s team, who work in their respective wards. The team is a mixture of some very supportive, strong minded, intelligent and kind people. Normally I would find solace in and enjoy speaking with any one of the team, for both professional reasons and personal. However, approximately a week before COVID-19 was declared a pandemic, these people planted a seed of anxiety, fear and constant dread in my mind.

I went home on a Tuesday with ruminating and catastrophising thoughts. ‘What if my Mom gets it?’. What if we go to Turkey and can’t come back?’. I was due to fly to Turkey the following Tuesday. Subsequently the flight was cancelled the evening before, which I feel so grateful for now. But at the time I had the most automatic negative thoughts I have ever had in my life. The team all knew of my flight plans. One of the psychiatrists who I rarely speak to, also added to my fears by telling me in a very serious manner (a manner which I had not come across before), ‘do not travel, you will get stuck there’. At this point I was very worried about not being able to come back home if I did travel. For a week I could not sleep, felt fear and sickening sensation in the pit of my stomach every free moment I had during the day.

After the flights were cancelled, my anxiety shifted to my parents catching the virus, and the impact it would have on their health. My ‘herd mentality’ led me to even go and (I say this with my head held in shame) panic buy. I came home with two bottles of soy sauce, two packs of cotton buds, two packs of salted peanuts, two packs of dried pasta, three bottles of passata, four cartons of juice and anything else I could get my hands on. All other purchases made that day were reasonably sensible. I have never felt such fear in my life. Every day before going to sleep I would check the death toll. Something I would advise strongly against to any of my clients, but I could not stop myself. Sleepless nights and constant rumination, followed.

Once my own anxieties passed a little, I began reflecting on the meanings my clients held of living in this pandemic, whilst also living with psychosis, personality disorders, paranoia, OCD and other mental health difficulties. Though in my opinion, many of whom I work with deal with uncertainty with much resilience, this pandemic could either be non-relevant or possibly just the tip of the iceberg. Most of my clients on the hospital wards who experience psychotic episodes, have no awareness of the current reality and therefore very little of the pandemic and how it is impacting them right now. It seemed bizarre to me how some of my clients can have such little care about the pandemic, whilst I have sat with such anxiety.

However those who I work with in my private work, are feeling the pressures of being concerned about their own health and the health of their families. Along with this, they are feeling bored, frustrated and lonely in their homes. Disputes with family, difficulties in relationships, withdrawal and social isolation is impacting on these clients’  everyday lives. Their initial concerns (what they came to therapy for) no longer exist almost.

On the other end of the spectrum, some of my clients are left paralysed as a result of their anxiety. A hospital patient who was able to walk, talk and live a fairly normal (whatever normal is) life, is now bed bound, incontinent, mute and not eating. Almost in a catatonic state, the patient now resides in a bed of an acute mental health hospital. All because of this pandemic?

As well as my client work, my role within the hospital, involves reflective practise sessions for nursing staff. I run two sessions of reflective practise a week. I have become overwhelmed after every session of reflective practise since the word COVID-19 became the norm. I try to hold a positive and supportive presence for the nursing staff on the wards, however currently I am finding myself doubt and second guess my every move in reflective practise. I have become aware of a new phenomenon concerning the impact of COVID-19 on the lives of the hospital staff, blaming superiors. Naturally anxiety can at times lead to agitation, frustration and anger, however staff in the hospital seem preoccupied with the inconsistency, lack of and misdirection of PPE and wellbeing support. Managing the role of being understanding and empathetic to their very real concerns, I also hold the responsibility to supporting the staff in managing their frustrations towards authority.

In amongst all of this I feel a sense of fear but also feel the need to step up and take responsibility. This is why I came into this career. To help, support and treat people with mental anguish, distress and ill health. The purpose of my academic progress and development was for this purpose. This may possibly be the most important time in my career where I can help and work alongside my colleagues to support a nation who will inevitable be impacted and subject to mental ill health, on a large scale due to the Coronavirus.

With all of the above, how can I possibly focus on writing up my thesis?

Is this what health anxiety feels like?
Tarnveer Kaur Bajaj, BSc (Hons) MBPsS, Doctoral Student,
University of Wolverhampton

About me

I am a second year PhD research student at the University of Wolverhampton and my thesis surrounds the implications of different methodologies used to assess perceptions of child sexual offenders. I am employed part-time both at the university as a Psychology Demonstrator and elsewhere in the hospitality industry as a barmaid, I am also a parent. I am currently trying to find my way through a sea of uncertainty, anxiety and confusion, the “congratulations, Doctor” light at the end of the tunnel feeling dimmer and more elusive than ever.

 The emergence of COVID-19

COVID-19 has brought uncharted territory. I have never known schools and businesses forced to close, people being implored to stay in their homes, to not see family or friends to control and slow the spread of an invisible assailant. Therefore, when the news reports about COVID- 19 began to emerge, I believed the situation would unfold in the way previous epidemics have, e.g. SAARS, Ebola, Swine Flu. I imagined there would be guidelines on how to avoid contracting the virus, and if the worst should happen, that our healthcare professionals would have the knowledge and tools to help. But, maybe naively, I believed we would continue our daily lives unchanged. I believed I would still go to university, to work, I believed my son would continue attending school and that within a couple of weeks all of this would be a distant memory. I think this ignorance, the fact I did not want to accept that the world as I knew it would change so drastically so quickly, has contributed to the struggles I am facing during the COVID-19 lockdown period. I did not give myself chance to put strategies into place, to formulate a routine.

The paradox of COVID-19

From the outside, ‘on paper’, it seems as though the situation should work in my favour. I am lucky in the respect that my data collection is web-based. This means that, unlike some of my peers, I have not had to pause data collection or alter my methodology. I no longer have to go to work (physically), I can work from home as a Psychology Demonstrator (with lectures and student support transferred online), I cannot leave my home except for essential shopping or exercise, there are no school runs, no traffic to navigate, no parking spaces to find, therefore, what else do I have to do but work on my thesis?

 I have an abundance of work which requires nothing more than my time, and I have what would seem like the perfect environment to complete these tasks. However, the COVID-19 pandemic has brought more personal challenges regarding my doctoral journey.

Challenges of lockdown during COVID-19

Social Isolation, social comparison

At the vey beginning of my PhD, I was advised by those who have completed their doctorates that a PhD by research can feel quite lonely; although you have your supervisors there to advise and support you, it is ultimately down to you to become the expert in your field. I found this to be a struggle from the offset. I like to work with others, to talk about ideas; to have that company whilst working was always a huge benefit to me. Being in isolation makes my doctoral journey feel lonelier than ever.

It is difficult not to compare how you are functioning with how others appear to be. In academia it is no different. As a PhD researcher we were warned not to compare your progress with that of another researcher due to the individuality of the project, but in these times, it seems as though these comparisons enter into the mind without invitation which only compounds feelings of inadequacy.

Work/life balance 

A significant struggle during this period has been the inability to separate work from home. Ironically, I am physically home more, but I feel like I see my family less. Being a parent and a researcher, and a part-time worker has always taken a juggling act to balance. However, now, I am trying to ensure my son is emotionally supported, ensure he is fed, clean, entertained and stimulated. I find myself unable to relax and enjoy this extra time with him, I do not feel as though I can dedicate an afternoon to games, cooking or watching films as I feel guilty that I have so much of my thesis to work on with an upcoming review looming. It is a viscous circle. I am worrying as I have work to complete, but I cannot seem to motivate myself to work, therefore I am worrying when I am not working instead of allowing myself to relax or enjoy activities with my family.

The lack of a workspace has also been a struggle. Having no office space has meant that all my work (both for my PhD and my demonstrator position) has been undertaken in my family living room. The physical inability to remove myself from my place of work has meant that all my personal spaces have become merged with my work spaces; there seems to be no switching off, no escaping, which does not allow for sufficient time away to return to work refreshed and ready to tackle awaiting tasks. 

Unfortunately, the lockdown has meant that my other part-time role has been suspended until the lockdown is lifted. This has placed an added pressure in a financial regard. Having the responsibility to make ends meet to keep a roof over your head, and keep you family fed with a reduced household income in these uncertain times is a huge source of stress; the government aid not yet applying to those on 0-hour contracts.

COVID-19 and the novice researcher

Imposter! Am I capable?

The difficulties I have outlined regarding an inability to complete tasks, a loss of passion and motivation have led me to question my ability as a researcher. Pre-COVID-19 I would use the university space, I could work on my PhD, dressed in my ‘PhD student attire’ and assume that role. In that environment I was a doctoral student, I was confident (for the most part) that I was capable, and I was able to complete tasks that I had set out. As aforementioned, the inability to leave home, to don my mask, has brought feelings of self-doubt.

Imposter Syndrome is a phenomenon which received a lot of attention within academic literature (e.g. Clance & Imes, 1978; Langford & Clance, 1993; Sakulku, 2011). Characterised by an inability to attribute one’s successes and achievements to themselves, those who suffer from imposter syndrome often doubt their abilities and fear they will be exposed as a fraud, or ‘imposter’ and believe that others overestimate their competence (Sakulku, 2011). Despite reassurances from colleagues, the feelings of doubt are increasing exponentially the deeper into the pandemic we go. As I am now an apprentice researcher, I feel as though I should be able to manage my workload, that the skills and strategies I have developed and refined throughout my academic career should allow me to continue to work in an efficient and professional manner. The fact that this does not seem to be happening has left me with the question as to how I will function and thrive post-doctorate if I am struggling with the lack of a working environment and isolation; research is a lonely place after all. It is unclear to me whether these feelings are symptomatic of imposter syndrome, or whether my dream career is maybe not the dream I envisioned.

Guilt 

I feel guilty; I feel guilty that I am jealous of those who are still able to go to work, despite knowing they are risking their health and that of their families, I feel guilty that I am struggling when others are mourning, I feel guilty that I have managed to be lucky enough to have reached this point in my academic career and just a couple of weeks of lockdown has resulted in me being unable to find my motivation and drive, I feel guilty that my thesis is not getting the attention it deserves and needs.

Is everything all bad? 

Thus far, this reflection has focussed solely on the negatives aspects of being a researcher during COVID-19, however, there have been some notable positives. The use of technology has enabled video conversations with students and colleagues, slightly alleviating feelings of loneliness, departmental chat groups have allowed for some light-hearted chatter and to direct questions and worries easily. It is a time of great struggle, but knowing we are all in the same storm, if not the same boat, is of some comfort.

Concluding remarks

COVID-19 has brought many challenges to the research community. I was naïve in thinking that I could continue to work on my thesis during the nationwide lockdown with the same level of commitment and motivation. I was always a high achieving student throughout my undergraduate and master’s courses. What I did not anticipate was how the pressures of lockdown life would impact my functioning. The worries and struggles I have outlined have compounded to make the current situation one of the most difficult periods of my academic career.

When the pandemic is over, and it is nothing but a memory I hope that I can draw on these experiences, that the struggles of COVID-19 will have served to highlight the importance of certain aspects of life once took for granted.

References

Clance, P. R., & Imes, S. A. (1978). The imposter phenomenon in high achieving women: Dynamics and therapeutic intervention. Psychotherapy: Theory, Research & Practice, 15(3), 241.

Langford, J., & Clance, P. R. (1993). The imposter phenomenon: recent research findings regarding dynamics, personality and family patterns and their implications for treatment. Psychotherapy: theory, research, practice, training, 30(3), 495.

Sakulku, J.   (2011).   The   impostor phenomenon. The Journal of Behavioral Science, 6(1), 75-97.

The impact of COVID-19 on my doctoral journey
Laura Rhoden BSc, MSc, Psychology Demonstrator Doctoral Student
University of Wolverhampton

Abstract

My doctoral research focuses on student voice and the role of school governing bodies to find ways to listen, understand, and respond to the voices of students. This research takes a case study approach underpinned by participatory action research (PAR), involving a group of Sixth Form (16-18-year-olds) students as co- researchers. The research is based in one secondary school in England, where I am Chair of Governors, focusing on students and their realities in that location.

Some literature argues that conducting PAR, especially for doctoral research, is risky, time-consuming, and complicated. Also, Lenette et al. (2019) state that it is important to identify these challenges and are concerned that there is a reluctance from participatory researchers to highlight the difficulties experienced. They encourage more honesty to provide space for critical debate that will enrich the understanding of participatory research.

Therefore, this reflective piece attempts to give a candid account of the difficulties of PAR, including the challenge and potential implications of the COVID-19 pandemic on my doctoral research. Yet, I also argue that although PAR can present issues, especially for doctoral students, it could be an effective methodology to use in changing circumstances, because it is responsive and adaptable.

Introduction 

Spring term 2020 will be forever etched in my memory as the hardest term I have encountered so far in the secondary school where I am the Chair of Governors and a doctoral researcher. Four significant events happened: three governor resignations; a challenging Ofsted inspection; the unexpected death of the Assistant Head of Sixth Form; and the COVID-19 pandemic, which meant the school closed to the majority of students from 23 March 2020. Some literature highlights the difficulties of embarking on PAR for doctoral research (Zuber-Skerritt and Perry, 2002; Burgess, 2006; Klocker, 2012; Southby, 2017). Still, the problems I have faced this term, culminating with the COVID-19 pandemic, are unprecedented. Nevertheless, doctoral research can provide increased opportunity for critical reflection, insight and learning (Brady, 2017; Brady et al.,2018), which I aim to achieve with this paper and throughout my doctoral research. 

Research context and focus

 I have been a secondary school governor for over nine years. When our school became part of a multi-academy trust (MAT) in 2017, I was elected as vice-chair of the local governing body (LGB) and became chair in September 2019. Becoming part of a MAT has caused significant changes to our LGB. We were the founding school, so a number of our governors became members or trustees of the MAT. Therefore, our LGB depleted, and there were meeting and committee changes, including the loss of our student committee. The student committee was an opportunity for governors to connect with the student body through the student leadership team and hear directly from them and other students in the school. 

The UNCRC (1989) emphasises children’s rights, including their right to express their opinions about issues relating to their lives (Article 12) and ensuring their best interests are considered (Article 3). NASUWT (2016) argue that student voice practice should be inclusive, providing opportunities for all students to participate. Furthermore, the Governance Handbook (DfE, 2019), states that one key role of school governing bodies is that they find ways to listen, understand, and respond to the voices of students.

 As a governor, I realise the importance of continuously developing effective student voice practices. Also, from my own experience, there is a need for training and support for governors in how best to seek students’ views. However, I am concerned that student voice practice can be tokenistic and overlook some students, for example, "the silent-or silenced-students" (Ruddock and Fielding, 2006, p.228) and the "excluded middle" (Wisby, 2011, p.42). Therefore, my doctoral research aims to address these concerns by exploring the link between the school governing body and the student voice; recognising students’ agency by promoting their right to be heard. 

Research methodology

 My research takes a case study approach underpinned by PAR, involving a group of students as co-researchers and other students as participants. PAR is an inclusive methodological approach using a series of cycles involving planning, acting, observing, and reflecting (Kemmis, 1988) and “combines theory, action and participation” (Fals-Borda, 1987, p. 329). It enables the researcher to discover the voice, perspectives, and experiences of participants through close interaction and involvement with them (Burgess et al., 2006). It values the knowledge and experience co-researchers have from their everyday participation in their setting and recognises them as not just having a voice butas “change agents” (Rodriquez and Brown, 2009, p.19).

PAR supports my epistemological position that the researcher and participants can work together to create knowledge and fits with a participatory paradigm (Reason and Bradbury, 2001). The participatory paradigm advocates shared ownership of research, and the community analysing social issues and community action (Howell, 2013). It is collaborative, with the co- production of knowledge through joint understanding from lived experience (Costley, Elliot, and Gibbs, 2010), and endorses co- researchers and co-created findings (Guba and Lincoln, 2005). 

The case study is bounded in the natural setting of one secondary school in England, where I am Chair of Governors, investigating what it is like for students in this context by focusing on students’ participation and voice. 

Research progress so far 

In October 2019, I recruited eight Sixth Form students as co-researchers; two Year 13 (17-18- year-olds) students and six Year 12 (16-17-year- olds) students. The recruitment process was a lengthier activity than I anticipated, and it was even harder organising the research team to meet all together. In fact, we have not met as a whole research team because the Year 12 and Year 13 timetables were different, and messages did not always get through to meet in their tutor group time. Nevertheless, despite these ‘teething problems’, we chose our research team name (“Your Voice”) and planned cycle one of the research inquiry. 

PAR is developed in different cycles, and cycle one begins with an initial understanding of students' view of 'voice' with the question “What does student voice mean to you?”. We decided to put a research box in the school library for students to respond anonymously to our research questions. However, we had to wait for the approval of an ethics amendment before gathering student responses to our first research question. PAR projects can be a challenge when gaining ethics approval and may have to go back to the ethics committee several times to accommodate the different cycles of the research (Northway, Howard, and Evans, 2015). The authorisation to proceed was received in the middle of our school Ofsted inspection, which was followed by the unexpected death of our Assistant Head of Sixth Form. The next few weeks were tough in school as staff and students were upset and in shock. It was inappropriate to continue the research, so I put it on hold for a few weeks. 

Once ready to start again, we decorated the research box, made research information posters, and put up two displays to advertise the research with space for the research findings. Two of the research team planned to go in each year group assembly to explain our research. Also, research information for parents was ready to go in the school newsletter. It was then that COVID-19 became more of an immediate issue, especially once the World Health Organisation (WHO) declared it a pandemic on 11 March 2020. The research team could not promote the research project in the assemblies because understandably these were dominated by talks about COVID-19. All assemblies were then suspended to avoid large groups of children and young people in close proximately. The biweekly school newsletter, including the research information to parents, was not circulated. Instead, there were daily updates to parents about COVID-19 and advice on self- isolating from Public Health England and the Department for Education followed by the school closure to the majority of students from 23 March 2020. 

The potential impact of COVID-19 on my research 

It is hard, at this time, to measure the impact of this on my research, but I predict it will be significant. The two Year 13 student co-researchers left school without me being able to say goodbye or thank them personally for their contribution to the research team. The other six Year 12 student co- researchers I will see again, though I am not sure when. A summer term of potentially no face-to- face teaching due to the nationwide lockdown could mean that these Year 12 student co- researchers will have studies to catch up on. Also, they will be preparing for public examinations, so there may be less time available to be involved in the research study when school fully opens again. Nevertheless, from the outset, I thought I might have to recruit new members to the research team because there can be a lack of continuity of participants and change throughout the research process in levels of participant engagement with PAR (Grant, Nelson and Mitchell, 2008). For example, O’ Brien (2016), used PAR to investigate bullying in an independent day and boarding school and worked with a small group of students as co-researchers. She found that participation was fluid, and some young people withdrew from the research team after cycle one, so more students were recruited for cycle two. Furthermore, Brady (2017), in her doctoral research on young people’s participation in health services, found that two young advisors opted in and out over a period of time depending on their availability and circumstances. 

The other potential impact is student research responses and the direction of the study. The COVID-19 pandemic has created instability, anxiety, and fear. Things that we took for granted are on hold for an indefinite time, such as going to school, work, and seeing family and friends face- to-face. The research study aims to give students a voice, and the outcome of what they want to voice may be different because of the COVID-19 pandemic. "' [T]oilet and chips' issues" (Whitty and Wisby, 2007, p.312) may seem irrelevant and insignificant. Some students will have lost loved ones to the virus or been ill themselves. Students may feel stressed and be concerned about their studies and examinations, friendships, and the future due to a significant period of time out of school and away physically from friends. Childline (NSPCC, 2020) cite children and young people’s main concerns between 21 January 2020 to 8 April 2020. They include mental health, including feelings of depression, anxiety, and suicidal thoughts; family relationships, including arguments, financial pressure and worries about family members contracting the virus; and doing schoolwork at home, including finding it hard to concentrate, a lack of motivation and worrying about future prospects. 

PAR as an effective methodology for unforeseen circumstances 

Despite the challenges of conducting PAR research, it could be argued that PAR is an effective methodology to adjust to these unprecedented times. Participatory research should be responsive and adaptable and does not need to follow a predetermined route (Groundwater-Smith, Dockett and Bottrell, 2015). Klocker (2012) highlights the flexibility of PAR and how the research focus can change from the initial research proposal and ethics application, especially with doctoral research. Due to academic regulations, doctoral candidates have to submit documents, including the research focus and questions, for approval before participants are recruited. Yet, uncertainty and fluidity can be built into the research proposal (Klocker, 2012).

Participatory research is done with participants and not on them as objects and enables participants to have a say in decisions, and the course the research takes (Reason and Bradbury, 2008). Therefore, my research proposal and ethics application reflected the nature of PAR as an emerging process dependent on the student co-researchers and the direction we as a research team want to take the investigation. Fortunately, no data has been collected, so as a research team, we are in a strong position to change the research focus and direction if we decide this is necessary. Hence, there is an opportunity, due to my chosen methodology, to adapt and reflect the changing and challenging times we are living in.

Conclusion

Lenette et al. (2019, p.175) invite researchers "to engage in reflections on the difficult and risky aspects of participatory research", and I have attempted to reflect on some of the issues I have faced so far. Conducting PAR gives me the researcher, as part of the research group, access to knowledge that I may not have got through traditional research (Kidd and Krael, 2005). PAR is an adaptable, responsive methodology and arguably an effective methodology for these challenging times. It has the potential to give the student co-researchers and wider school student body the opportunity to have their voice heard, but what that voice will look like is uncertain. Moreover, whether these voices will be different because of the COVID-19 pandemic is as yet unknown.

References

Brady, L.-M., Templeton, L., Toner, P., Watson, J., Evans, D., Percy-Smith, B. and Copello, A. (2018) ‘Involving young people in drug and alcohol research’, Drugs and Alcohol Today, 18(1), pp. 28- 38.

Brady, L.-M. (2017) ‘Rhetoric to reality: an inquiry into embedding young people’s participation in health services and research’, PhD, University of the West of England. Available at: http://eprints.uwe.ac.uk/29885 (Accessed: 25 April 2020).

 Burgess, J. (2006) ‘Participatory action research: First-person perspectives of a graduate student’, Action Research, 4(4), pp. 419-437

Burgess, H., Sieminski, S. and Arthur, L. (2006) Achieving your Doctorate in Education. London: Sage.

Costley, C., Elliot, G. and Gibbs, P. (2010) Doing Work Based Research. London: Sage.

Department     for     Education     (DfE)     (2019) Governance Handbook: For academies, multi- academy trusts and maintained schools. Available at: https://assets.publishing.service.gov.uk/ government/uploads/system/uploads/attachment_ data/file/788234/governance_handbook_2019.pdf (Accessed: 13 April 2020).

Fals-Borda, O. (1987) ‘The Application of Participatory Action-Research in Latin America’, International Sociology, 2(4), pp.329-347.

Grant, J., Nelson, G. and Mitchell, T. (2008) ‘Negotiating the Challenges of Participatory Action Research: relationships, Power, Participation, Change and Credibility’, in Reason, P. and Bradbury, H. (eds.) Handbook of Action Research: Participative Inquiry and Practice. Sage: London, pp. 589-601.

Groundwater-Smith, S., Dockett, S. and Bottrell (2015) Participatory research with children and young people. London: Sage.

Guba, E.G. and Lincoln, Y.S. (2005) ‘Paradigmatic Controversies, Contradictions, and Emerging Confluences’, in Denzin, N.K. and Lincoln, Y.S. (eds.) The Sage Handbook of Qualitative Research. 3^rd edn. Thousand Oaks, CA: Sage. pp.191-215.

Howell, K.E. (2013) An introduction to the philosophy of methodology. London: Sage.

 Kemmis, S. (1988) ‘Action Research’, in Hammersley, M. (ed.) Educational Research and Evidence-based Practice. London/Milton Keynes: Open University in assoc. with Sage. pp.167-180.

Kidd, S.A. and Krael, M.J. (2005) ‘Practising Participatory Action Research’, Journal of Counselling Psychology, 52(2) pp.187-195. 

Klocker, N. (2012) ‘Doing participatory action research and doing a PhD: words of encouragement for prospective students’, Journal of Geography in Higher Education, 36(1), pp.149- 163.

Lenette, C., Stavropoulou, N., Nunn, C., Kong, S.T., Cook, T., Coddington, K. and Banks, S. (2019) ‘Brushed under the carpet: Examining the complexities of participatory research’, Research for All, 3(2), pp.161-179. 

NASUWT (2016) Student Voice a guide to supporting and promoting good practice in schools.   Available        at: https://www.nasuwt.org.uk/uploads/assets/upload ed/918afd4a-1c6a-4b21-a1886844969183a5.pdf (Accessed: 12 August 2019).

 Northway, R., Howarth, J. and Evans, L. (2015) ‘Participatory research, people with intellectual disabilities and ethical approval: Making reasonable adjustments to enable participation’, Journal of Clinical Nursing, 24(4), pp. 573–81.

 NSPCC (2020) What children are saying to Childline        about   coronavirus.    Available        at: https://learning.nspcc.org.uk/media/2195/what- children-are-saying-to-childline-about- coronavirus.pdf (Accessed: 20 April 2020).

 O’Brien, N. (2016) ‘To 'snitch' or not to 'snitch': using PAR to explore bullying in a private day and boarding school’, PhD, Anglia Ruskin University. Available at: https://arro.anglia.ac.uk/700970/ (Accessed: 13 April 2020).

Reason, P. and Bradbury, H. (2001) ‘Introduction: Inquiry and Participation in Search of a World Worthy of Human Aspiration’, in Reason, P. and Bradbury, H. (eds.) Handbook of Action Research. Thousand Oaks, CA: Sage, pp.366-380.

 Reason, P. and Bradbury, H. (2008) ‘Introduction’, in Reason, P. and Bradbury, H. (eds.) The Sage Handbook of Action Research: Participative Inquiry and Practice. 2^nd edn. Thousand Oaks, CA: Sage, pp.1-10.

Rodriguez, L. F. and Brown, T. M. (2009) ‘From Voice to Agency: Guiding Principles for Participatory Action Research with Youth’, New Directions for Youth Development, 123, pp.19-34.

Rudduck, J. and Fielding, M. (2006) ‘Student voice and the perils of popularity’, Educational Review, 58(2), pp. 219-231.

Southby, K. (2017) ‘Reflecting on (the challenge of) conducting participatory research as a research-degree student’, Research for All, 1(1), pp.128-142.

United Nations (1989) Convention on the Rights of the Child (UNCRC). Available at: https://downloads.unicef.org.uk/wp- content/uploads/2010/05/UNCRC_PRESS200910 web.pdf?_ga=2.143389040.417759904.15656185 16-2115390771.1565618516 (Accessed: 13 April 2020).

Whitty, G. and Wisby, E. (2007) ‘Whose voice? An exploration of the current policy interest in pupil involvement in school decision‐making’, International Studies in Sociology of Education, 17(3), pp.303-319.

Wisby, E. (2011) ‘Student Voice and New Models of Teacher Professionalism’, in Czerniawski, G. and Kidd, W. (eds.) The student voice handbook: bridging the academic/practitioner divide. Bingley: Emerald Group Publishing, pp. 31-44.

Zuber-Skerritt, O. and Perry, C. (2002) ‘Action research within organisations and university thesis writing’, The Learning Organization, 9(4), pp.171-79.

The impact of COVID-19 on my doctoral research: some reflections
Tracey J W Price (BEd; MEd; MA), Anglia Ruskin University Faculty of Health, Education, Medicine and Social Care Professional Doctorate in Education (EdD)

 Abstract

This paper offers critical reflections on the impact of the pandemic COVID-19 on Doctoral studies and research from the perspective of a Trainee Counselling Psychologist.

Introduction

COVID-19, coronavirus, lockdown, pandemic, virus, deaths, frontline, Italy, Spain, China, NHS, doctors, critical, ventilators, oxygen, masks, panic, vulnerable, isolation and since yesterday the words ‘Boris Johnson’ the UK Prime Minister and ‘intensive care’ (BBC News, 2020e). These are just a subsample of some of the words in the newspaper and media headlines that we are continually bombarded with on a daily, hours and minute-by-minute basis on our phones, tablets, computer screens as part of our new daily life; where the UK is facing COVID-19 (coronavirus disease) which is termed the ‘invisible enemy’ by American President, Donald Trump (The Guardian, 2020). As such, our current worldwide situation has been equated with wartimes and hence led the Queen to deliver a direct address to the public, an event which last took place during World War Two (WW2) (BBC News, 2020b, 2020c).

Provisional Existence

Due to the comparison to WW2, a quote by an existential psychiatrist Viktor Frankl (1946) who wrote about his experiences of life within a concentration camp seems fitting “A man who could not see the end of his “provisional existence” was not able to aim at an ultimate goal in life” (p. 79). Whilst, the horrors Frankl experienced do not compare to my current situation; I would argue that Frankl’s notion of a ‘provisional existence’ sums up my current situation in relation to thinking about how my studies including my research have been impacted by COVID-19. Life feels suspended, like I was on a train journey towards achieving the ultimate goal, my Doctorate and the train has stopped. I have no idea when the train will commence and start heading closer again towards my destination and this makes for difficulty in staying motivated to work in my confined train carriage. With concern to research, it has been agreed with my research supervisors that data collection will be put ‘on-hold’; which is necessary due to social-distancing measures currently in place and due to the uncertainty around COVID-19, it is not possible to set a date at present for data collection. Overall, the action plan for research is to take a pragmatic approach in managing my research amid the current situation; this feels appropriate and is thus, consistent with the pragmatic paradigm being adopted for my mixed-methods research (Creswell & Creswell, 2018).

As Frankl (1946) advocates, in order to survive difficult times we must find meaning in life; where for myself my meaning comes not only through the Doctorate, but family and health which has recently come to the forefront, possibly obscured previously by only focusing on the Counselling Psychology Doctorate, which includes my research work. However, despite having an action plan in relation to my research, I am aware that I still feel high levels of anxiety and worry, not only regarding the ongoing uncertainty around my Doctorate and research, but also in relation to my loved one’s and my own’s health. From a cognitive behaviour therapy (CBT) viewpoint, my anxiety could be seen as an intolerance to uncertainty (Buhr & Dugas, 2002). As a result, I am finding myself responding by constantly looking up information online about the virus trying to gain some certainty in the sea of uncertainty. This could be explained in relation to my coping strategy for processing health information. Where I am engaging with a monitoring coping style which entails scanning external threat cues; as opposed to a blunting coping style, which is associated with the avoidance of threat cues (Aguirre, 2017).

However, when I came across the article by the BBC, “‘Lockdown can be especially difficult’ for those with learning disabilities,” I started to reflect on how this situation may have impacted the research population for my thesis, adults with intellectual and developmental disabilities (IDD). Where the article highlights a response from learning disability charity, MENCAP in relation to COVID-19. The charity comments that individuals with IDD who are already isolated and struggling are finding lockdown especially hard; particularly with the little social contact that they already have being restricted even further with the lockdown (BBC News, 2020d). Which in a way leads me to argue that the current situation provides more support for the current research into online risks for adults with IDD; where an understanding of risks can support ‘digital exclusion’ for this population (Chadwick et al., 2013, 2017).

Online Risks

Whilst the internet has enabled greater communication abilities than ever before and has provided the public access to a wealth of information regarding COVID-19, it has allowed for online scams to take place. Recently, there has been a reported increase in online scams than usual, where COVID-19 is the topic of interest (BBC News, 2020a). Reflecting on my own experience, I am in the privileged position of being able to read critically on the internet and have a good understanding around risks including online scams. Therefore, I am able to differentiate between factual information and information which may be presented to spread fear or ‘scaremongering’ about the virus. Yet, considering that part of a diagnosis of intellectual disability individuals have an impairment in functioning involving abstracting thinking, reasoning and problem-solving (American Psychiatric Association, 1998, 2013). It has been identified that individuals with intellectual disabilities can be particularly vulnerable to fraud and untrustworthy information which may present online (Salmeron et al., 2016) and other online risks including bullying, offensive pornographic content, stalking, sexual exploitation, marketing scams and hacking have already been investigated empirically within this population (Chadwick et al., 2017). In addition, persons with IDD, when they are subject to online risks, are rarely adequately supported by the criminal justice system (Chester, 2018; Jones, 2007). Therefore, despite little being known about counselling psychologists who work with persons with intellectual disabilities (Jones, 2013); it is important that we identify areas of support in relation to online risks. For example a recent study found that a training programme helped students with an intellectual disability to read more critically online including to choose trustworthy web pages; in order to address the need for greater literacy skills in this population to benefit from the internet (Delgado et al., 2019).

Impact on Other Areas of Study

With concern to my university studies and clinical placement in mental health, these have moved from face-to-face to online work through applications such as Zoom (Zoom Video Communications, Inc., 2020). Whilst, I am comfortable with this transition, as I know it is essential for the safety of myself and others, and the guidance that regulatory bodies for counselling and psychology have produced for working online has helped greatly (British Association for Counselling & Psychotherapy (BACP), 2020). I remain aware how this situation may negatively impact individuals with IDD. Online therapy for individuals with IDD such as CBT can be effective, studies have shown that a training programme for this population may be needed for them to fully access the benefits of online therapy (Cooney et al., 2017). However, these training programmes are obviously hindered by the COVID-19 quarantine. 

Even more concerning is the access inequalities; where reflecting on the ‘digital divide,’ figures have shown that 31% of disabled adults have not accessed the internet (Chadwick & Wesson, 2016) and therefore will not be able to access any psychological support during this time. Moreover, mental health support is particularly important for this population as people with IDD are at a greater risk of mental health difficulties than the general population (Cooper & Bailey, 2001). In other words, individuals with IDD may be severely disadvantaged in their access to mental health support during this time, reflecting a mental health inequality.

In addition, humans are relational beings (Cooper, 2009); therefore, human’s relational needs are limited with social distancing. Individuals with IDD may be even more isolated during this time with limited social networks already and no or more limited internet access to receive relational connection. As such, social isolation and loneliness are associated with poorer mental health and physical health consequences, making the IDD population especially vulnerable to this (Leigh-Hunt et al., 2017).

In sum, I think these reflections highlight the sheer magnitude of inequality for individuals with IDD during this time. It also makes me feel lucky that during this scary and anxiety-provoking time for many people, I have applications like Whataspp, Skype, Zoom, Facetime, Instagram, amongst others, to enable me to stay in contact with loved ones, something which is missing from lives of many individuals with IDD.

References

Aguirre, K. M. (2017). Monitoring And Blunting Coping Style Effects On College Student Processing Of Health Information Via Social Media.

American Psychiatric Association (Ed.). (1998). Diagnostic and statistical manual of mental disorders: DSM-IV ; includes ICD-9-CM codes effective 1. Oct. 96 (4. ed., 7. print).

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). American Psychiatric Association. 

BBC News. (2020a, March 13). Coronavirus: How hackers are preying on fears of Covid-19. BBC News. https://www.bbc.co.uk/news/technology- 51838468

BBC News. (2020b, March 17). Coronavirus: ‘We must act like any wartime government’. BBC News. https://www.bbc.co.uk/news/av/uk-/coronavirus-we-must-act-like-any- wartime-government

 BBC News. (2020c, April 5). Coronavirus: Queen tells UK ‘we will succeed’ in fight. BBC News. https://www.bbc.co.uk/news/uk-52176222

 BBC News. (2020d, April 6). Learning disability couple ‘struggling to cope’ apart in isolation.

BBC News. https://www.bbc.co.uk/news/uk- england-birmingham-52128055

BBC News. (2020e, April 7). Coronavirus: Boris Johnson moved to intensive care as symptoms worsen.   BBC    News. https://www.bbc.co.uk/news/uk-52192604

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I made a choice to be a nurse and entrepreneur knowing and anticipating the challenges that lay ahead. I never, not in my wildest dreams, thought I would ever have to face a crisis such as the current Covid-19. This virus has been deemed a global emergency (WHO, 2020). While disease epidemics have plagued human societies since the earliest days of recorded history there is clearly a lack of parallels to the current crisis (Baker et al., 2020). This disruption in my normal day-to-day life is more than just a slight hiccup, it is unfolding rapidly and each day feels more and more light a fight for survival, both emotionally and physically. The purpose of this paper is two-fold. Firstly, to look at what this has taught me about myself and secondly about the world that I now find myself living in. 

My experience of this pandemic can be best described as being multi-faceted. COVID-19 constitutes a catastrophic experience that is at once individual and collective, intimate and yet so public. My life is structured that way too. I am a 46-year-old woman who is a mother, wife, nurse, entrepreneur, athlete and doctoral student. My basketball coach, Pete, a world-renowned NBA legend Hakeem Olajuwon when I was introduced to him at a recent youth camp in the city of Birmingham asked me “How do you manage to do all that? You should write a book “. That was thrilling to hear from my sporting idol and at the time I remember thinking maybe I should. Recently, I was inspired to turn my experiences into a film. I took lessons in screenwriting and revelled in my new found form of expression. The very idea of turning my experiences into a big block-buster film was fitting to these strange times when it has become difficult to distinguish the real form the hyperreal (Baudrillard, 1983). The proliferation of dark images that associate the COVID-19 outbreak with the end of the world as we know it is hard to ignore.

I was going to do more than just soul-searching to get through these strange times. Autoethnography requires that I analyse not only mine but other people’s lives in order to connect the personal experiences to bring out the culture and emerging themes (Ellis and Bochner, 2000; Silverman, 2000). It was going to be difficult to turn away from connecting with other people, even if they are convinced that the sky is falling.

I had at last clarified the direction I wanted my research and thesis to take and was considering ethics and getting ethics approval, looking forward to face to face contact with my supervisory team that would guide me as I plot just how I would succeed in getting this thesis and resultant movie blockbuster into existence. I was excited to share the stories of my life as a black nurse entrepreneur living in England and looked forward to others learning from my experiences. Besides, this is how I learnt so much about so many things that I was battling to understand and make sense of. At the top of the list is Victor Frankl’s reflections of life in a concentration camp (Frankl and Kushner, 2006). When I read his book entitled Man’s search for meaning” I knew I had to share it with others. So, I bought a few more copies and gave to friends and family.

 Prior to the outbreak I felt that I was finally taking control of both my professional and personal life. Family life and my satisfaction as a wife and mother was at an all-time high. My academic life was on lift-off too. I had just finished my literature review assignment and landed myself a research assistant job with the University and could not be happier getting stuck in with arranging my very first conference, arranging venues and making sure our guest speaker would be taken care off. Life was full of great promises.

Being a parent during the lock-down has been challenging and draining too, juggling responsibilities of being the teacher, dinner lady and playground supervisor. I was not alone in this. Parents across the world have been reduced to hoarding toilet paper, leaving empty supermarket shelves in an attempt to make sure the family has sufficient durable goods to last lockdown (Pagel et al., 2020).

But, I am torn between being thankful that at least my youngest son is safe at home albeit on his PlayStation and worrying about my first-born son in America. After his college closed and orders given for all campus dwellers to vacate, most international students headed to the airports, but my son refused to do the same. I could sense the looming travel restrictions. Fear of the importation of the virus from abroad led to quarantine measures and advice from the government to stay at home (Public Health England, 2020).

“I don’t want to come home”, he said when I had yelled hysterically down the phone for him to get himself here before the airports all shut down. He chose not to and followed up on our conversation with a text saying, “I don’t want to come home mum ”. The broken-hearted emoji punctuated was just precisely how I felt. He wants to pursue his dreams of making it as an athlete and I suppose it’s my fault for drilling it into him and his brother that “boys you should always follow your dreams”. All I can do is accept his decision and pray he follows the quarantine laws of that land.

As an entrepreneur, the impact on my company is not my greatest concern. At the top of my list is the deep desire to get to the other side with all my employees and clients safe and well. If I can get that done, then I would have succeeded. Because of the nature of the sectors that my businesses operate in it makes it necessary for me to keep going and carry on as usual and except nothing is usual about Covid-19.

Three weeks into lock-down and almost half of my employees are not working. Some have young families and for their health decided to self-isolate as advised by the authorities (HM Government, 2020). Others with pre-existing conditions have done the same, or in the case of one full timer, been admitted into hospital for an operation.

Prior to the Covid-19 outbreak I had resolved that I was going to be exit the health and social care market due to the lack of funding and low profitability and I had even set a date for my freedom from the responsibilities that come with owning and running a care business. “Golden Monday”, was what I wrote in my diary. This date was to be my Independence Day. So I thought. Once the pandemic hit and lock-down happened, all that changed. I have found myself on the frontline, literally leading my team of home care workers from one client to another. The older people we support and care for are always happy to see a familiar face, even if half the face is covered with a mask. This is living my purpose and three weeks into the lock down and I am now only just getting used to the feel of the mask on my face but revelling in the thought that I am making a difference.

Since the pandemic I have found what Victor Frankl was referring to in his book. I also now believe that when you are driven by purpose the universe conspires to make sure you get what you want. This is my favourite quote from The Alchemist, a book by Paulo Coelho that I am re- reading for the third time. Reading this story of a shepherd in search of his treasure at this time of Covd-19, has a different meaning for me and has led me to wonder if and when life gets back to normal, will I still be in the frontline of health and social care? This remains to be seen.

References

Baker, S.R., Bloom, N., Davis, S., Terry, S. (2020) Covid-Induced Economic Uncertainty [online]. National Bureau of Economic Research. Cambridge, MA. [Accessed 4 May 2020]. Available at: https://www.nber.org/papers/w26983.pdf>

Baudrillard, J. (1983) Simulations. New York. USA: Foreigner Agent Series. Semotext Inc.

Ellis, C., & Bochner, A. P. (2000). Autoethnography, personal narrative, reflexivity: Researcher as subject. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of Qualitative Research (pp. 733-768). London: Sage.

Frankl, V. and Kushner, H., 2006. Man's Search For Meaning. Boston, Mass.: Beacon Press.

HM Government (2020) Novel Coronavirus: Guidance for Primary Care. [online] . Available at: https:www.gov.uk/government/publications/wn- cov-guidance-for-primary-care>

Pagel, M., and Yannelis, C. (2020) How does household spending respond to an epidemic? Consumption during the 2020 COVID-19 Pandemic. National Bureau of Economic Research: Camridge, MA.

Public Health England (2020) Coronavirus (COVID19): Latest information and advice [online].   Available at:<https:www.gov.uk/guidance/wuhan-novel- coronavirus-information-for-the-public#history> 

Silverman, D. (2000). Doing qualitative research: A practical handbook. London: Sage

Covid-19 and 1 – Reflections of a nurse entrepreneur during the lock-down period
Jessie Allen BSc(Hons) MPH RNLD Professional Doctorate in Health Student
University of Wolverhampton

On March 23^rd, 2020, the UK government instituted a full-scale lockdown in response to the worldwide COVID-19 pandemic. People would only be permitted to leave their homes for the following purposes:

1. Shopping for basic necessities, as infrequently as possible;
2. One form of exercise a day – for example a run, walk, or cycle – alone or with members of your household;
3. Any medical need, to provide care or to help a vulnerable person;
4. Travelling to and from work, but only where absolutely necessary and where work cannot be completed from

In the days prior to the start of the lockdown, I left a role at one professional football academy based in the North of England and relocated to start a PhD undertaken in conjunction with another professional football academy based in the Midlands. Through doing so, I have had a unique insight into the response of two English football academies to this unprecedented situation. The present article offers a brief commentary on the potential implications of the COVID-19 lockdown for academy players athletic identity and wellbeing. Observations will be presented along with reference to relevant literature in order to draw lessons from the COVID-19 lockdown in the UK for athletic identity, and prepare for future eventualities which share the characteristics of: i) people staying at home; ii) social distancing; and iii) the closure of places of work; in this instance football academies. 

In the UK, all domestic football leagues and cups have been postponed until further notice, which also includes the cessation of training across all clubs. Through daily media reports, the impact COVID-19 on those involved in the industry at first team level (Premier League, 2020), is well known, but there has also been a profound impact on football academies across the country. There have been varied responses of football clubs in the face of this crisis. For example, as of the 20th of April, many clubs (e.g., Newcastle United, Norwich City, Derby County) have placed staff on ‘furlough ’ following announcement of the government coronavirus job retention scheme, whilst others continue to pay employees their full salary (e.g., Manchester United, Arsenal, West Ham United). Irrespective of response, the COVID-19 pandemic has left players having to adapt to prolonged periods of self-isolation. Many players within academies across the country, especially within the Youth Development Phase (U12 to U16) and Professional Development Phase (U18 to U23), will have been a part of an academy for many of their formative years. During this time, an ‘athletic identity’ may have developed, defined as ‘the degree to which an individual identifies with the athlete role’ (Brewer, Van Raalte, & Linder, 1993, p. 237). Through their participation within sport, a player is making a social statement about who they are and how they want others to think of them.

Specifically, Brewer et al. (1993, p. 238) propose that this is a cognitive structure that ‘guides and organizes processing of self-related information’ as well as a social role. This therefore implies that ‘athletic identity’ is largely derived from the feedback from others (e.g., parents, coaches, teammates) which for many players, given the current lockdown, has been missing. This pandemic is a situation like no other, but comparisons could be made to that of a nonnormative transition in sport such as a forced retirement due to injury. A transition results in a change in assumptions about oneself and are generally unpredicted and involuntary events, such as COVID-19, where players must adjust to life without sport for a prolonged period (Schlossberg, 1981).

The cessation of training has meant that players ‘athletic identity’ may be challenged, which therefore may have implications on players wellbeing. For example, research by Kim and Moen (2001) highlighted that a dramatic change in lifestyle can be accompanied by a shift in subjective well-being. This new lifestyle will be void of their usual routine, whilst players will also be missing their sporting environment and the competition that accompanies this, which can leave players with a feeling of emptiness in their lives (Stephan, 2003). Research has also highlighted that such transitions can lead to a loss of personal control over a player’s life, considered a key factor of enhanced well-being (Lang, & Heckhausen, 2001). Therefore, how academies respond to this pandemic is critical when you consider the impact such a transition could have on an individual.

Within academies across the country, in an attempt to broaden an individual’s identity beyond an athletic identity, there are many proactive programmes in place for players that focus on both the development of non-sport specific skills, as well as how skills developed within the sporting context can transfer into other areas such as academic study (Bailey, Hillman, Arent, & Petitpas, 2013). Over recent weeks, staff within academies have come up with novel ways of supporting not just the players, but also their own identities as coaches, by organising team meetings through apps such as Zoom and Microsoft Teams. These have ranged from general catch ups, to quizzes, to technical and physical challenges to provide competition that many players currently miss. Through doing this, not only have staff and players developed their skillset and their ability in using this means of communication, but feedback has highlighted other positive outcomes. For example, coaches and players have discussed the increased feelings of connectedness with one another, a critical factor in a positive coach-athlete relationship (Jowett & Poczwardowski, 2007). This finding has also been found in the education setting where the use of technology has led to improvements in the teacher-student relationship (Pollock & Amaechi, 2013). Inter-personal relationships can provide a psychological resource to protect individual’s health and wellbeing, particularly in times of adversity (Praharso, Tear, & Cruwys, 2017). As we begin to move out of the enforced lockdown, could we see such technologies become a more common means of communicating within sporting academies, further developing creativity, as well as enhancing the relationships and wellbeing of those involved? In considering the use of such means of communication, due consideration must be given to safeguarding and confidentiality issues, especially when working with those under the age of eighteen.

 The lockdown resulting from COVID-19 has highlighted the importance of those involved within football maintaining interests and skillsets outside of a sporting/football domain. It has also emphasised the importance of remaining connected to those around us, so that potential issues related to wellbeing during such situations may be minimised.

References

Bailey, R., Hillman, C., Arent, S. and Petitpas, A. (2013) Physical activity: an underestimated investment in human capital?. Journal of physical activity and health, 10(3), pp.289-308. https://doi.org/10.1123/jpah.10.3.289

Brewer, B. W., Van Raalte, J. L., and Linder, D. E. (1993) Athletic identity: Hercules' muscles or Achilles heel?. International Journal of Sport Psychology, 24(2), pp.237–254.

Jowett, S., and Poczwardowski, A. (2007) Understanding the Coach-Athlete Relationship. In Jowette & D. Lavallee. (ed.), Social Psychology in Sport. Champaign: Human Kinetics, pp. 3–14.

Kim, J. E., and Moen, P. (2001). Is retirement good or bad for subjective well-being? Current Directions in Psychological Science, 10, 3, pp.83– 86. https://doi.org/10.1111/1467-8721.00121

Lang, F. R., and Heckhausen, J. (2001). Perceived control over development and subjective well- being: Differential benefits across adulthood. Journal of Personality and Social Psychology, 81(3), pp.509– 523. DOI: 10.1037//0022-3514.81.3.509

COVID-19: A commentary on implications for Academy Football players athletic identity and wellbeing
James Maurice, Professor Tracey Devonport Bsc Psychology, Msc Sport and Exercise Psychology, Qualification in Sport and Exercise
Psychology (QSEP), Unniversity of Wolverhampton

Abstract

Covid-19 is currently a major pandemic and concern globally. The epidemic has led to the adoption of quarantine and isolation measures at a historically unprecedented scale worldwide. In this paper, I use autoethnography to present a personal narrative about my experience with Covid-19. I problematize conceptions and fears of the coronavirus and narrate my stories from what is known about the virus to date. I will also reflect on how academics and professionals on campus can more effectively work with students currently experiencing Covid-19

Keywords: Covid-19, autoethnography, narrative, self-isolation, coronavirus, lockdown

Background

Historically plagues, pandemics, epidemics (PPE) and outbreaks through biblical times to date have had devastated effects on communities, societies and countries worldwide. PPE are defined according to the severity of the disease, or whether it may be simply described as often producing many illnesses and deaths, remains ambiguous (Doshi, 2011). PPE have wiped out populations, undermined economies and crumbled the foundations and values of human existence. The Plague of Justinian (541 - 750 AD) is thought to have killed between 30 million and 50 million people, perhaps equal to as much as half of the world's population at the time, Black Death (1347- 1351) smallpox plague (bubonic) spread throughout Europe, killing approximately 25 million people, the Spanish Flu, also known as the 1918 influenza pandemic an outbreak of a H1N1 virus infected around 500 million people in the early 21st century. The pandemic was responsible for killing over 50 million people globally (www.history.com). The first identified influenza virus was isolated from a pig in 1931 (Shope, 1931), while the human 1918 virus from a frozen corpse was itself sequenced between 1995 and 2005 from pathology specimens (Taubenberger, 2007).

Before this current PPE (Covid-19), perhaps the worst, are the Bubonic Plague and the AIDs outbreak in the 1980’s. According to World Health Organisation (WHO), in 2018 the global number of people living with HIV was 37.9 million, compared to 24.9 million in 2000. Covid-19 is a pneumonia of unknown cause detected in Wuhan, China which was first reported to the WHO Country Office in China on 31 December 2019 and declared a Public Health Emergency of International concern on 30 January 2020. As of today, 5^th May 2020 coronavirus cases reported: 3,658,266, Deaths: 252,264,504 Recovered: 1.202,905 (WHO). These figures are staggering and climbing by the day as there are no treatment nor vaccinations available for the virus to date. According to Morens and Taubenberger (2018), signs and symptoms (fever, muscle aches, respiratory complaints) have remained unchanged over centuries. Deaths from influenza-associated pneumonias, with high mortality young and old persons and pregnant women, have repeatedly been documented. In the UK, the over 70’s and people with underlining conditions are the most vulnerable, although a five-year old boy is the reported youngest to die from the virus to date. To stop the virus spreading the UK government measures include social distancing and lockdown (closed schools, pubs, restaurants, cafes, gyms and other businesses) which commenced on 23 March 2020. The governments slogan is Stay Home Protect the NHS Save Lives.

 My autoethnographic narrative

My goal in writing my story as an autoethnographic narrative is to add my own nuanced perspective on Covid-19 by taking a road that leads to one of possible multiple destinations in Health and Wellbeing research (Eisner, 2008, p. 22). This narrative expands a circle of communication and “advances human understanding” (Eisner, 1997, p. 5). As Ellis (2007) stated “Doing autoethnography involves a back-and-forth movement between experiencing and examining self and revealing the broader context of the experience." Epistemologically narratives are both a way of telling about our lives and a means of knowing (Richardson 2000) The reader is invited to me in co-construction an understanding of the experience Covid-19 no matter how little. Each reader brings his or her own perspective to this understanding.

January 2020 – The beginning of a new term

I returned to the UK from Florida mid-January after attending the ‘Doing Autoethnography’ International Association of Autoethnography and Narrative Inquiry 2020 annual conference between 2^nd and 5^th January where I presented a paper that is under consideration for publication. At the same time, students and staff were returning to campuses from all over the world after the Christmas break to resume teaching and learning. As a Campus Support Officer in a top London university, my role involves providing welfare and guidance to students living on and off campus and to signpost them for further support according to the needs. My team operates 7 days a weekday and nights.

Before the Christmas break, I was signed off work for two weeks after suffering from what my GP termed ‘Lower resp tract infection’. I was placed on antibiotics and recovered in time for my trip to the US. However, on my return to work in January,

I experienced a flu-like illness and started coughing. This happened as the news of the coronavirus outbreak in China was developing. I asked myself was this a sign or/and symptom of coronavirus? Although I recovered from the scare, I continued to monitor the situation. 

March 2020 – The arrival of coronavirus

As the infection continued to spread globally with high reported numbers in Italy and Spain, and minor cases in the UK, the Government announced that the nation is prepared to cope with Covid-19. On 11 March 2020, the World Health Organization declared the outbreak a pandemic. As the virus is unknown, the general advice from medical and health care professionals was to wash hands with soap for at least 20 seconds signing ‘happy birthday to you…’ twice and avoid touching mouth nose and eyes as the this ‘deadly pneumonic disease’ is for real. On campus the same messages were relayed to students and staff via posters, social media, websites and word of mouth.

On arriving at work on 13 March, my team leader asked. “Hey, John have you heard?” “I replied heard what? No”
With a smile on her face “Go get settled…I will debrief you at the handover meeting” she said.

It was the unwelcome arrival of coronavirus on campus the team leader told us at the handover meeting. Apparently, a guest arriving from abroad visiting a student tested positive to Covid-19 and have been both isolated along with other students residing in the same block of flats. We were then instructed to contact them regularly via telephone and cover the course of the weekend, we will need to provide them with breakfast and dinner by placing them at the front of the resident respective door entrances. We were reassured that there are no risks of contacting the various and that Public Health England are monitoring situation. I must confess, I was not comfortable with the arrangement as we had limited information and no time to prepare physically and mental for the task. Moreover, we were not provided with any protective gear. On that same evening, my colleague and I did our first round as we owe the students a duty of care. As we were unprotected, I was concerned that I may have encountered Covid- What ensued next was texts messages between my manager and myself, expressing my concerns. Excerpts below:

Dear Boss,

The saga that went on overnight was not pretty. I am aware and appreciate that our residents (including staff) a duty of care. However, personally I was not happy attending affected residence despite the low level of risk to the virus. I have underlining health conditions such as diabetes and high blood pressure and should not be exposing myself to any risk at all for the sake of my family and others. During the hand over yesterday evening, we were advised that we do not need to make contact with those isolated. We were then lumbered in when the reception staff refused to deliver to doors. I think this is unfair considering the fact that we only knew about the situation when we arrived at worked. With little information about the situation at residence, I can’t say much, but I think the set-up needs to be reviewed and not put staff and other students at risk. Those isolated can order their own on food online and reception staff deliver to respective doors.

COVID-19 is spreading fast in the UK despite the containment. Who knows where it's going to strike next? I am concerned. Thanks for your understanding.

Regards John

Dear John,

Thank you for getting in touch about this. The actions that you and colleagues carried out last night were in the best interests of duty of care to students and were very much out of necessity. For that I am truly appreciative. Of course, my duty of care within the remit of my job is to strike a balance between duty of care to students and that of duty of care to staff.

Given this continual and dynamic overview, PHE has determined that there is currently no further risk to staff or students in the building, given the containment of the one affected party. There is currently no confirmation that these are diagnoses of Covid-19. Unfortunately, we’re being forced into this situation in order to be confident of the health of the students in isolation In my view, this is paramount. Again, I want to reiterate that I would not ask you and or any colleague, to enter a zone that would pose a health risk against any express advice/risk assessment by Public Health England. They’ve all asked me to pass on my thanks to you, and the wider team for the actions carried out thus far. Please also accept my assurances that if this situation changes to the point where we are not able to manage it as a service, it will be fed back to Public Health England to manage this dynamic change. We have reiterated that we are at the maximum capacity of what we are able to provide.

Regard

Boss

In the meantime, I welcomed my boss response with an open mind while respecting his ‘duty of care’ responsibility to staff and students. I then further requested for up to date information on the situation daily in order to keep us informed while off-duty which he promised via the university website. Meanwhile, as tension, fear and uncertainty continue to grow in public, the UK government continue to advice those with symptoms to self-isolate for 7 days with family members up to 14 days. On Monday16^th March, at approximately 10.00 am, we received a call from my daughter’s school to pick her up immediately as she has developed a fever with high temperature (a symptom of coronavirus). Over the preceding weekend, my daughter had attended rehearsals and performance for a street-dance competition. Was she infected at the show? Following the government’s guideline, all members of the household will need to self-isolate at home. That we did while continuing to monitor the situation. While self-isolating, I continued to work remotely from home via telephone, skype, Microsoft team and lately zoom. Thinking I have contacted Covid-

19 made me feel stressed, anxious and scared sometimes about my own health and the health of my household. Each time I cough comes with anxiety about the virus as it is difficult to switch off thoughts and feelings. But as the days go by with the lockdown and social distancing, working from home remotely and writing papers, I now feel a bit relaxed that I am free of Covid-19. However, until a reliable test is carried out, I may still have the symptoms of the virus.

April 2020 – And the beat goes on

Since the earliest known case of coronavirus caught within the UK was documented on 28 February 2020 and gradual rise of infections became a norm, causing 1,500 cases by March 16. The UK Government declared a countrywide lockdown on 23^rd March which has kept most of the population confined to their homes to date, with people only able to leave for exercise or to collect necessities. As of the time of writing this paper, reported confirmed cases stands at 190,584 with 28,734 death. As number of national and international students remained on campus caught up in the lockdown restriction, part of my role is to continue to contact and support them as I to work remotely from home. I also seized this opportunity to work on my thesis module towards Professional Doctorate in Health and Wellbeing. I have also submitted peer-reviewed papers for publications.

Final comments

There is no doubt that the strain of Covid-19 is felt politically, economically, socially around the world. Lockdown measures introduced by various governments are met with scepticism and uncertainties, economies are shrinking with jobs losses, and the social distancing measures are not just pulling friends and families apart, but causing a lot of mental health issues, anti-social behaviours and criminal activities such as child abuse and domestic violence. The only winner at the moments is technology (internet, smart phones, laptops, skype, zoom, Microsoft Teams etc.). Nevertheless, all is not doom and gloom. There are some achievements made from previous outbreaks. For example, serologic testing in 1901 came into use in the 1910s and has become a basic tool to diagnose and control many infectious diseases. Alzheimer’s Disease discovered in 1907 the brain’s cortex was significantly smaller and upon microscopic evaluation and was found to have widespread, abnormal fat deposits in blood vessels. The successful treatment of diabetes with insulin led to the 1923 Nobel Prize in Physiology or Medicine being awarded to John J.R. Macleod and Fredrick Banting. In 2005, an international regulation was introduced by WHO to fight viruses. More recently, the 2009 flu pandemic vaccines were influenza vaccines developed to protect against the pandemic H1N1/09 virus. In the UK, in addition to Covid-19 testing kit made available to frontline NHS workers, universities and scientist are racing to develop a vaccine clinical trial with volunteers before the of April 2020. Is there is light at the end of a tunnel? Only time will tell. But the devastation Covid-19 has caused will go down as one of the worst pandemics in post-modern times.

This autoethnographic style of writing has empowered me to recount my lived professional and personal experience over the past few months as I navigated around Covid-19 and its impact on the society. My intention is to unsettle, criticise and challenge taken-for-granted meanings and socially scripted performances by global leaders.

Secondly, I present political, workable, collective and committed viewpoints that should provoke thinking. I hope that this narrative is found useful in any endeavor that tries to make a ‘new sense of situations of uncertainty’ (Schon, 1983, p.61) as we all reflect on the importance of social distancing, implementation of quarantine measures and most importantly inadequate preparation and transparency by the relevant agencies as the worst is not over yet.

"I saw and felt the power of autoethnography as an opening to honest and deep reflection about ourselves, our relationships with others, and how we want to live. I saw and felt the reciprocal relationships between knowing and feeling, self and other, author and respondents." (Ellis, 2013, p.10)

References

Doshi, P. (2011). The elusive definition of pandemic influenza. Bull World Health Organisation,  89:532-538.Educational Researcher, 26, 6, pp. 4-10.

Eisner, E. W. (1997). The promise and perils of alternative forms of data representation.

Eisner, E. W. (2008). Persistent tensions in arts- based research. In M. Cahnmann-Taylor & R. Siegesmund (Eds.), Arts-based research in education: Foundations for Practice, pp. 16-27. New York, NY: Routledge. 

Ellis, C. (2007). Telling secrets, revealing lives: Relational ethics in research with intimate others. Qualitative Inquiry, 13, pp. 3-29.

Ellis,    C.    (2013).    Carrying    the    torch    for autoethnography. Handbook of autoethnography, 9, p.12. https://www.history.com/topics/middle- ages/pandemics-timeline https://www.who.int/gho/hiv/epidemic_status/cas es_all/en/ International health regulations (2005). 2nd ed. Geneva: World Health Organization, 2008.

Morens, D. M., & Taubenberger, J. K. (2018). The Mother of All Pandemics Is 100 Years Old (and Going Strong)! American Journal of Public Health, 108(11),  pp.1449–1454.https://doi.org/10.2105/AJPH.2018.304631

Richardson, L. (2000). Writing: A method of inquiry. In Handbook of Qualitative Research, ed Denzin and Y. Lincoln. London: Sage.(2007). Discovery and characterization of the 1918 pandemic influenza virus in historical context. Antiviral Therapy, 12, pp. 581–591.

Schon, D. A (1983). The reflective practitioner. How professionals think in action, London: Temple Smith.

Shope, R. E. (1931). The Etiology of Swine Influenza. Science,73, 1886 pp. 214–221.

Taubenberger J., K, & Morens D., M. (2006). 1918 Influenza: the mother of all pandemics. Emerging Infectious Diseases, 12, pp. 15-22.

Taubenberger, J., K, Hultin, J., V, & Morens D.,

Introduction

Covid-19 has inflicted suffering around the World and being Chinese, studying and working in the UK. I knew that this plague had the potential to break families and cause significant losses to all walks of life. I am the founder of Mirror Beauty a small business located in Downtown Coventry, so it was a prerequisite to connect with students and console them as most of patients are Chinese students. This paper firstly gives fundamental understandings to Covid-19 and its brief in 2020 and secondly presents the issues observed by me which is pertinent to Chinese students in the U.K. responding to Covid-19. Lastly it introduces the actions that have been practised by myself and my beauty parlour in response to the lockdown and I hope this information will be beneficial to other practitioners in the beauty industry.

History of contagious virus

Plagues are part of the worlds history and the Black Death was one plague introduced to the

U.K. from 1348 and it killed a quarter of the U.K.’s population over four years. In 1918 the Influenza Pandemic (Spanish flu) was a more recent pandemic which resulted in 228,000 deaths in the UK. alone and became the reason for the end of the First World War (Johnson 2016). During 1968 to 1969, the Hong Kong Flu was the main culprit behind the death of 80,000 people and the Asian Flu outbreak killed 33,000 (1957-1958). After the 21^st century, the pandemic of SARS and MERS luckily was not linked to any deaths in the U.K., but in 2009 the influenza pandemic (H1N1) was with reported to kill a minimal number of deaths with 457 cases comparatively (See figure below).

Today the world is faced with its Covid-19 outbreak and this has severely impacted on all walks of life. Since January 21^st, a large amount of confirmed cases has been widely reported in Wuhan City China, and many families lost their loved ones. In Europe, Italy was the first country to suffer a high number of deaths and became the epicentre of the coronavirus. It was followed by France, Germany, Spain and finally spread to the United Kingdom with over 130,000 of British confirmed with infectious virus Covid-19 and around 30,000 deaths attributed to this so far (NHS.com 2020). Covid-19 has a high mortality rate of around 10%, and it is a fatal disease that can cause a person’s respiratory system to fail as it primarily attacks the lungs of the human recipient. During the Covid-19 outbreak, the amounting infections overwhelmed the N.H.S and in turn this overwhelms other areas such in plastic surgery and the beauty business. From February to the lockdown, the writer experienced many issues regarding patient problems and business.

Issues Observed

Chinese students studying within British universities number over 100,000 annually and Chinese students undertaking education at middle or high schools across Britain number 15,000, this represents a large proportion of individuals. Based on my limited information, it is proposed that such students are vulnerable groups, particularly those younger oversea students because they are unable to access necessary facilities during the lockdown and struggle to take care of themselves. During the lockdown, some Chinese students were found to be rejected either by a boarding school or a homestay accommodation. Chinese students are no more a danger to the British public than anyone else they are obedient to political orders and follow the governmental instructions strictly; Most of my patients (Chinese oversea students) firmly stay at home, and they only go out for shopping necessities. Some of them have been found to have stayed at home for almost two months without going out at all, and they have abandoned schooling, meetings. eating out, outdoor exercises, travelling and other activities during the lockdown helping us to contain the fervent spread of this virus. However, all this self-imposed lock down and isolation can impact profoundly on their mentality.

Students are concerned about their health and safety issues, particularly during the virus outbreak and any misinformation about them can cause even more undue stress on them. In January three students contacted me to discuss their concerns about the coronavirus as their family members had warned them of the dangers of Covid-19 and the prediction that it would kill many people, but the British government did not warn people before March 2020. A report from the New York Times claimed that Chinese students were fretting about the lack of British containment policies indicating that ‘over in China, there were a lot of control mechanisms in place, but not here yet.’ and universities were not acting decisively to virtualise learning programme either in time (Muller 2020). Students in the U.K. from February started to worry about the British public going into social and public places without a face masks and many people crowed in groups, which were threatening people’s health and promoting the spread of the virus (Hereinuk.com 2020). I find that Chinese students were one of the first groups to wear masks and undertake social distancing in public. For instance, before the lockdown, I tried to isolate myself from others because suggestions and media exposures from China were warning me to do so, but at the time my classmates thought I was making a fuss.

Staying in an alien land is difficult due to problems of homesickness or loneliness which means friendship and classmate-ship is important and could help individuals overcome panic states, isolation and other psychological troubles. Most of the Chinese students are in their twenties, which means they lack life experience and need to have supports from friends and others. When the lockdown was stringently implemented, Chinese students were isolated from each other mostly without any good networks other than the internet or mobile phone. This is a tough situation for those who feel lonely. Girlfriends or boyfriends were forced apart during the Covid-19 lockdown, causing strain on their relationship. It is presumed that some young students (teenagers) were suffering more from this situation than other groups because they have to take care of themselves. During the lockdown rumours of racism and other extreme behaviours (e.g. bullying, sarcastic words or misconducts) would pose threats to young students psychologically. Some politicians labelled them as the problem behind the cause of Covid-19 causing prejudiced xenophobia, discrimination, violent opinions and disturbing thoughts about those of an east Asian origin. For instance, despite the official name given by WHO, Donald Trump, the president of United States of America, named Covid-19, the China Virus and claimed that this was because the virus originated from China (Gaudefroy and Lindaman 2020). This entails the exacerbation of racism to east Asian in the U.S.A. Meanwhile, media coverage has exacerbated the situations and promoted the chaos (Harsanyi 2020). All these things have compounding effects on Chinese students, which influences their feelings and emotions. Since March the Chinese government has closed most of its borders and cancelled many flights, which disturbs Chinese students’ plans and precludes them from going back home rendering life even more difficulties for them.

 Some Chinese students in the U.K. were forced to undertake a part-time job in order to survive, but during the lockdown period their employers now find it impossible to keep them on and they now are suffering severe financial problems due to unemployment. Despite that, some students may have financial problems because of the impact of Covid-19 within the Chinese domestic economy; their sponsors (usually families) have problems now with being able to provide tuition or stipends for them in time. For instance, some shops, stores, and restaurants were compulsorily closed during the lockdown, and many people were out of work due to the virus impact.

The gap is evident between the needs and support from friends, schools, governments and other organisations. Some of my friends complained that the support from the university was not useful. Many universities have not provided sufficient information about Covid-19 to alert their international students about what is happening. In contrast, others have problems in coordinating international students with their lecturers or supervisors by virtual learning. Besides Chinese students may others experience difficulties in communicating with N.G.O.s, schools or governments or other institutions efficiently and consequently they feel isolated and helpless during the lockdown. 

Actions 

Responding to Covid-19, I have prepared for anti- virus combat and made some changes subject to study and work. For the business, through work arrangement, parlour cleanness and maintaining, and patient management, I have managed to control the business, save the cost and relieve the financial pressures. And for the individual, to manage time, study and psychological state, I have arranged the lockdown in life properly.

Work rescheduled 

In terms of the operation of my beauty parlour, the scheduled operations and treatments are my essential businesses. Patients’ accumulative aesthetic plan still need to be carried out and any scheduled necessary and chronic plastic surgeries and treatments are now delayed, but some others have gone ahead. In light of this personal protective equipment (P.P.E.) is vital including face masks (ordinary or medical level) and the parlour’s rules are that these patients are seen by a doctor one by one in an isolation situation. This is in line with another plastic surgeon’s practice (Armstrong et al., 2020). In accordance with the UK. governmental restrictions, after 23^rd March and lockdown, all but essential businesses had to close immediately (Barr 2020). Beauty parlours were not allowed to open during the lockdown period, thus any unnecessary operations and treatments had to be rescheduled accordingly. Abiding with the lockdown policy from the government, the writer’s workshop was closed after March 23. In this manner, firstly, it helped the social distancing of clients, and secondly, it catered for clients’ needs; thirdly, it followed the administrations from the U.K. government. Besides adhering to lockdown, the parlour also alerted the risks of Covid-19 to others by sharing guidelines and precautions through social media and email marketing.

Parlour cleanness and maintaining

 The beauty parlour could be seen to be at risk during the Covid-19 and in order to keep a healthy and sanitary environment, the following actions have been done before the closing. 1. the place was deep cleaned with a high standard of care by using disinfection spray to clean every corner of the parlour such as handrails, chairs, beds, receptionist desks and so on; 2. we ensured our clients had disinfected towels and individualised sterilised equipment; 3. to prevent the spread of coronavirus we had removed magazines and newspapers from the parlour and told customers to bring their owns to stop cross-contact infections. To maintain this small business, based on U.K. financial support for businesses the beauty parlour has asked for a grant of up to £10,000 to help and receiving this is fundamental to us surviving.

Patients management

 To stay in contact with patients is a necessity and during lockdown, the whole nation is under panic and frustrated with a hopeless future; thus, if surgeons or other aesthetic practitioners can maintain contact with patients this will help to stimulate a positive mood. I believe that if a good connection could be reached, the doctors could effectively keep in touch with their patients and provide some professional beauty suggestions to patients during the lockdown. Also some useful daily advise or tips during the Covid-19 could be effectively distributed to patients.

 Preparedness

I was informed about the risks of Covid-19 very early on this year as I went back to China during January. I stayed in China for 15 days and was fortunate enough to fly back to the U.K early in February before any flight cancellations and I was not exposed to Covid-19. Prior to the lockdown (March 27), I had prepared food, books, and other living necessities to pass the subsequent miserable days. When staying away from Covid-19 having sufficient food ensured the that I was able to stay at home. Instant foods, canned foods, eggs, meat and precooked meat were bought in bulk; reducing the need for me to go outside and shop. In addition, books and articles were bought for study and passing time. I have bought three books which have been a god send providing me with fun and learning and a positive side of lockdown. I was also able to obtain some exercise apparatus such as dumbbells, a treadmill and a rope which were fitting for domestic exercises and helped to support my emotional wellbeing. With proper preparation, every day is now arranged fully, and I have established a good habit and routine. During the lockdown, the gym and other body exercise facilities were shut down, which is not available for practice so I have had to take advantages of the house garden and stairs to do my body exercises as normal and everyday i will do push-ups, squats, burpees to keep the fitness. Some home-used tools are beneficial to maintain health.

Academic study and distant learning

 At the moment I am undertaking modules on the Professional Doctorate in Health and during lockdown I have attempted to study and read, and books and articles have helped me during the quarantine period. This is a good time now to prepare for my dissertation and write other papers, and I have had space now to complete a research proposal and undertake my assignments that are due. For my aesthetic courses organisers have also relocated their modules online which has facilitated another means of distant learning for me.

Being Chinese as well as medical I have actively taken part in a series of activities organised by the Chinese Students and Scholars Association in Britain to help Chinese students in Coventry. Since April 2^nd I have been a volunteer and helped to deliver health packs containing an anti-epidemic guide and medical kits given by the China Embassy here in the UK (Yurou 2020). I also attempted to provide guidance and health instruction to other students to improve their knowledge and awareness of Covid-19. 

Summary and implications

Covid-19 stresses us all and we should strive to combat this. We all have to be very careful and mindful during this outbreak, and for the majority of aesthetic practitioners, the only thing we can do is to stay positive and confident. I am not and expert on viruses and only have a general understanding about Covid-19 from the news but I find that students are vulnerable to Covid-19. Many experience difficulties and are subject to safety, monetary and mental issues as they struggle for support. Regarding any preparation for Covid- 19 I hope my experiences may give ideas to others in the beauty business and other individuals in a similar position to myself.

References

Armstrong A., Jeevaratnam J., Murphy G., Pasha M., Tough A., Conway-Jones R., Mifsud R.W., and Tucker S., (2020) ‘A plastic surgery service response to Covid-19 in one of the largest teaching hospitals in Europe’, Journal of Plastic, Reconstructive & Aesthetic Surgery, https://doi.org/10.1016/j.bjps.2020.03.027

Barr S. (2020) CORONAVIRUS: WHEN MIGHT THE UK LOCKDOWN COME TO AN END?

[online]  available  from https://www.independent.co.uk/life-style/health- and-families/coronavirus-lockdown-uk-remove- end-review-schools-when-government- a9453246.html <accessed by April 24, 2020>

 Gaudefroy J. V. and Lindaman D. (2020) Donald Trump’s ‘Chinese virus’: the politics of naming [online]       available          from https://theconversation.com/donald-trumps- chinese-virus-the-politics-of-naming- 136796<accessed by April 25, 2020>

 Harsanyi D. (2020) Covid-19 Is the Chinese Government’s Curse upon the World [online] available from https://www.nationalreview.com/2020/03/Covid- 19-is-the-chinese-governments-curse-upon-the- world/<accessed by April 25, 2020>

Hereinuk (2020) Archives and articles [online] available from http://www.hereinuk.com/date/ 2020/03 <accessed by April 24, 2020> 

Johnson B. (2016) The Spanish Flu Pandemic of 1918 [online] available from https://www.historic- uk.com/HistoryUK/HistoryofBritain/The- Spanish-Flu-pandemic-of-1918/ <accessed  by April 24, 2020>

Muller B. (2020) Western Universities Rely on China. After the Virus, That May Not Last. [online] available from https://www.nytimes.com/ 2020/03/21/world/europe/coronavirus-chinese- students-uk.html <accessed by April 24, 2020>

NHS (2020) SARS (severe acute respiratory syndrome) [online] available from https://www.nhs.uk/conditions/sars/ <accessed by April 24, 2020>

Yurou (2020) Chinese embassy provides health packs to Chinese students in Britain [online] available from http://www.xinhuanet.com/ english/2020-03/25/c_138914720.htm <accessed by April 24, 2020>

I am a second year PhD student exploring dyadic coping among spousal carers of partners living with dementia. In laying the foundations for my research, I have spent eighteen months attending and supporting two dementia cafés’. During this time, I have focused on better understanding dementia and its implications for spousal carers. I have also focussed on building a rapport with carers of those living with dementia so that they feel comfortable with my presence and to develop their trust in me. This is an important part of researcher integration which is all too often overlooked and can strengthen qualitative research findings (Collins & Cooper, 2014).

In this article, I reflect on the way in which COVID-19 has highlighted an area of research practice for which there are competing perspectives. As a qualitative researcher, one body of literature suggests that I should seek to connect emotionally with participants, and these emotional reactions should then become part of the process (Gilbert, 2001), whereby, researcher emotions should be recognised as insightful, a source that offers distinctive value, and can be examined and featured within the research (Mitchell & Irvine, 2008; van Heugten, 2004). However, a second body of literature suggests that strategies for emotional distancing be adopted if the research topic is potentially emotionally challenging (Sanjari et al., 2014). It is argued that emotions are irrational, impacting the outcome of the research, and social science researchers posit that research be conducted objectively (Holland, 2007). If emotional disconnect was the accepted recommendation, could I do this? With no clear consensus either way, COVID-19 has brought about personal reflection with regards this consideration. During this pandemic I have observed increased social isolation among the carer population. I am a member of social media groups used by these carers. They have used these forums to express their stressors, fears, and concerns during COVID-19, and as such, I find myself exposed to highly emotive situations.

 Largely practiced in qualitative research, reflection is fundamental in exploring one’s own values, experiences, established beliefs and expectations relative to the research area and participants (Adler, 1993). Reflection is also used to legitimise and validate research procedures (Mortari, 2015). To become a reflective learner (and practitioner), it has been proposed that commitment and a desire to ask questions about oneself and associated practice are required (Driscoll, 2007). In preparing this reflective article, the second author (Tracey Devonport) offered support through reflective conversations which helped to identify and challenge assumptions, and present reflections in writing. In brief, I shared feelings having read carer exchanges on social media concerning their experiences during COVID-19 – I was asked to think about my emotional attachment to prospective participants and whether this might help or hinder the research process? In working through these reflections, I was asked questions that encouraged deeper thinking regarding describing the carer context, outcomes for carer and cared for, and then to plan possible interventions and how these might influence outcomes for carers and others.

Over time, I have developed undeniable emotional attachments to my prospective participants. Indeed, I believe I have created something comparable to a therapeutic alliance. Defined as the feelings and attitudes that therapist and client have toward one another and how these are expressed (Norcross, 2010), the quality of interpersonal relationships are important as they support the attainment of honest responses. This then supports the identification of patterns or themes, both specific and generic that help better understand the research phenomena under investigation (Horvath, 2005). As a researcher I must be aware of my emotional involvement with participants and the potential impact this has on the research process and outcomes. I am the instrument of data collection when interviewing participants (Hammersley & Atkinson, 1995). As such I seek to provide a conversational space in which participants feel they can express themselves freely (Owens, 2006), when exploring thier experiences, beliefs, motivations and dynamics. Central to this process are strong interpersonal skills and emotional maturity (Collins & Cooper, 2014). So, I ask myself, is a degree of emotional detachment necessary (Fox, 2006) or if I were unemotive would I fail to engage participants? If I were to be overly emotional, would this result in emotion fatigue or suggest a lack of impartiality and influence responding (Watts, 2008)?

Research with potentially vulnerable participants of a qualitative nature leads to practical dilemmas (Watts, 2008). Literature refers to the traditions of science where one must be neutral and objective, where researchers most specifically, in the social sciences, adopt a stratified separation of thinking but not feeling (Campbell, 2002). Examining the experiences of carers for those living with dementia presents a risk of eliciting intense emotions for both participants and myself as researcher (Sanjari et al., 2014). In reflecting on this consideration, I believe that emotional engagement outweighs potential risks for both myself and my participants The research findings produced may have considerably more depth (Kidd & Finlayson, 2006), and although there may be different motives for emotional engagement for participants and the researcher, it contributes to a process that is stimulating, cathartic and helpful (Newton, 2017). As argued by Corbin and Morse (2003), it is the ethical awareness and the skill of the researcher that is decisive in making judgements regarding benefits and risk.

References

Adler, S. (1993). Teacher education: Research as reflective practice. Teaching and Teacher Education, 9(2),  159-167.https//doi.org/10.1016/0742-051x(93)90051-h

Campbell, R. (2002). Emotionally involved (p. 10). Routledge.

Collins, C., & Cooper, J. (2014). Emotional Intelligence      and      the       Qualitative Researcher. International Journal of Qualitative Methods, 13(1),  88-103.

https://doi.org/10.1177/160940691401300134 Corbin, J., & Morse, J. M. (2003). The unstructured interactive interview: Issues of reciprocity and risks when dealing with sensitive topics. Qualitative inquiry, 9(3), 335-354. 

Driscoll, J. (Ed.). (2007). Practising clinical supervision: A reflective approach for healthcare professionals. Elsevier Health Sciences 

Fox, J. (2006). “Notice how you feel”: An alternative to detached concern among hospice volunteers. Qualitative Health Research, 16(7), 944-961.

Gilbert, K. (Ed.). (2001). The emotional nature of qualitative research. CRC Press Hammersley, M. (2007). Ethnography. The Blackwell encyclopedia of sociology. Methodology, 10(3), 195-209. Research, 15(1-2), 3-7

Mitchell, W., & Irvine, A. (2008). I'm okay, you're okay?: Reflections on the well-being and ethical requirements of researchers and research participants in conducting qualitative fieldwork interviews. International Journal of Qualitative Methods, 7(4), 31-44.

Mortari, L. (2015). Reflectivity in Research Practice. International Journal of Qualitative Methods, 14(5),           160940691561804.

https://doi.org/ 10.1177/1609406915618045 Newton, V. L. (2017, March). ‘It's good to be able to talk’: An exploration of the complexities of participant and researcher relationships when conducting sensitive research. In Women's Studies International Forum (Vol. 61, pp. 93-99). Pergamon.

Norcross, J. C. (2010). The Therapeutic Relationship. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The Heart and Soul of Change: Delivering What Works in Therapy (p. 113–141). American Psychological Association.

Owens, E. (2006). Conversational space and participant shame in interviewing. Qualitative Inquiry, 12(6), 1160-1179.

Sanjari, M., Bahramnezhad, F., Fomani, F. K., Shoghi, M., & Cheraghi, M. A. (2014). Ethical challenges of researchers in qualitative studies: the necessity to develop a specific guideline. Journal of medical ethics and history of medicine, 7, 14.

Van Heugten, K. (2004). Managing insider research: Learning from experience. Qualitative Social Work, 3(2), 203-219.

Watts, J. H. (2008). Emotion, empathy and exit: reflections on doing ethnographic qualitative research on sensitive topics. Medical Sociology Online, 3(2), 3-14.

Objective Researcher or Emotional Being?
Kelly Warwicker BSc, MSc, Psychology Demonstrator, Doctoral Student Tracey Devonport (PhD, CPsychol, CSci, FBASES, FHEA), BASES accredited sport scientist (scientific support), HCPC registered sport and exercise psychologist, Professor of
Applied Sport and Exercise Science University of Wolverhampton

Dr Dean-David Holyoake, Developmental Editor

The New Mission
Advice to Contributors

A new year, a new decade and so many new year resolutions to break. Yep, here we are again promising ourselves super-human attempts at self-improvement. Perhaps like me you’ve re-joined a gym, thrown out the crisps and biscuits, promised yourself to drink only 4 nights a week and learn Russian to impress the woman in the opposite flat. Maybe you’ve even decided to take your academia seriously and write for 15 minutes every day instead of nostalgically lamenting how the years easily fade. How it is now 2020 and you’ve still not completed that article for JoSCHI. Aha, I hear you cry, I see his secret agenda. I can see how, like some Soviet propaganda he’s trying to make me feel bad and frightening me with threats of the gulag and Cossack dancing unless I contribute to the writing revolution. Well, this may be the case but what do you say we agree on a new covenant? How about today, right now you write for 15 minutes, join a writing group and see what happens. For our part here at JoSCHI, we’ll attempt to rewrite our ‘opportunity’ constitution and commitment to help you get the most out of your pen. Unlike a Russian doll you don’t have to be full of yourself just commit to make yours an inside job.

Click here for ABBA SOS (1975) (from previous editorial) https://www.youtube.com/watch?v=89w-L3aICj4

Introduction

Over recent decades, there has been increasing attention paid to negative attitudes and stigma and discrimination experienced by people with mental health problems (Angermeyer & Dietrich, 2006; Evans-Lacko, Corker, Williams, Henderson, & Thornicroft, 2014; Gabbidon et al., 2013).

Negative attitudes towards individuals with mental illness have also been found in health professionals (Bjorkman, Angelman, & Jonsson, 2008; Gras et al., 2015; Rao et al., 2009) including psychiatrists (Chaplin, 2000) and other mental healthcare workers (Hugo, 2001; Nordt, Rossler, & Lauber, 2006). The use of negative language (Sartorius, 2007) or inappropriate diagnostic labelling (Schulze, 2007) by health professionals, is likely to both increase the stigma experienced by service users and to reinforce the negative attitudes held by many members of the general public (Caldwell & Jorm, 2001). 

Research into negative attitudes held by health professionals towards people with mental illness has often focussed on looking at particular characteristics of the individual sufferer, for example gender or ethnicity (McKenzie & Bhui, 2007; SHSA, 1993). However it has been suggested that attitudes towards people with mental illness can also be affected by factors relating to the health professional, such as ethnicity (Silton, Flannelly, Milstein, & Vaaler, 2011, (Schafer, Wood, & Williams, 2011)), gender (Angermeyer & Dietrich, 2006), and personal or family history of mental health problems (Corrigan, Markowitz, & Watson, 2003). However, most of these studies have either focussed on a single health professional discipline or have failed to examine possible differences between different disciplines.

Several scales have been developed to assess attitudes to people with mental health problems; however these have largely been validated in non- professional populations, or have been specifically developed to explore attitudes in one particular professional group (Gabbidon et al., 2013; Svensson et al., 2011; Van Brakel, 2006). The MICA v4 Scale was developed by Gabbidon et al. (2013) to look at attitudes towards mental illness held by healthcare professionals and students in any discipline.

 The aim of this study was to compare the attitudes of medical and nursing mental health professionals towards individuals with mental health problems and to identify factors associated with positive or negative attitudes. It was hypothesised that healthcare workers with a personal or family history of mental health problems would be less likely to hold negative attitudes due to social contact or experience.

 Method

All psychiatrists working in five different Mental Health NHS Trusts in England and all nursing staff (including healthcare assistants) working in a large South London Mental Health Trust were invited to participate in a brief online survey by email. Potential participants were identified by a medical staff member in each of the trusts and contacted using internal email mailing lists

Measures

Participants were asked to complete the Mental Illness: Clinicians’ Attitudes (MICA) Scale v4 (Gabbidon et al., 2013). The MICA v4 is a 16 item scale which can be used to assess healthcare professionals’ and students’ attitudes towards people with mental illness. Each item is scored on a six point scale from ‘strongly agree’ to ‘strongly disagree’. Items 1, 2, 4-8 and 13-15 are reverse scored, as per the MICAv4 scoring guidelines. A total score is then calculated by adding the results for items 1 to 16. Questionnaire items are also grouped into 5 factors (as identified by Gras et al, 2015 and described in Box 1) and an average score for each factor is calculated. Higher scores indicate more stigmatising views.

In line with previous research, a score of ≤3 (indicating somewhat (dis)agree), was used to indicate a moderately positive attitude, whilst a score of ≤2 indicated a positive attitude (Gras et al., 2015). The MICA v4 has been validated with nursing students and other healthcare workers. It has been found to have good internal consistency and inter- item correlations, good face validity and acceptable convergent validity.The authors of the MICA v4 gave permission for an electronic version of the questionnaire to be created.

Participants were also asked to provide some demographic details including: age, gender, marital status and ethnicity, as well as current job title and degree of experience working in mental health. Ethnicity was initially categorised into five groups, reflecting the broad ethnic groups used by the Office of National Statistics (2012), however due to the small sample size, for the purposes of meaningful analyses, this was further reduced to the three most common categories in our sample (White, Black, Other). Finally, participants were asked to state whether they themselves, or a family member, had ever experienced mental health problems. A sample size of at least 30 participants in each professional group was required to provide sufficient information regarding the distribution of attitudes in this sample.

Statistical analysis

Data was analysed and scored using SPSS v23 for Windows. Categorical socio-demographic variables were compared between professional groups using Pearson χ² hypothesis tests. The association between the socio-demographic variables and the five factors of the MICA v4 and the total score was explored using one-way analysis of variance (ANOVA). In order to explore the presence of interaction effects between professional group and socio-demographic variables on attitudes to mental illness ANOVA models in Table 2 were refitted adding in the respective interaction effect and the two independent variables as main effects.

Results

190 responses were received. In total 19 participant’s responses were excluded due to missing data, relating to at least one response, leaving 171 participants. Participants who omitted demographic information, were also excluded from relevant analyses.

Characteristics of participants

Table 1 shows the Characteristics of Participants. There were significant differences between professional groups. Compared to the nursing sample, the doctors had a more even gender distribution (p=0.002), were younger (p<0.001) and were less ethnically diverse (with a significant majority of Caucasian respondents) (p<0.001). Significantly more doctors than nurses reported a family history of mental health problems (p=0.001).

Thirty seven (37%) doctors were core trainees, 26 (26%) were higher trainees and 35 (35%) were consultants. Thirty one (43%) nurses were healthcare assistants, 7 (10%) were staff nurses, 4 (6%) were charge nurses, 10 (14%) were nurse practitioners, 14 (19%) were community mental health nurses and 6 (8%) were in managerial roles.

Attitudes of doctors and nursing staff towards people with mental illness

Across the whole sample, significant differences were found between ethnic groups (Black, White and Other) on the overall score on the MICA (p=0.046) and on Factor 1 (p=0.010). Borderline significance was found on Factor 2 (p=0.060), with Black and ‘Other’ group participants scoring higher on these factors, indicating more negative attitudes towards people with mental illness.

Participants with a family history of mental health problems tended to report less negative attitudes on the MICA (p=0.058), Factor 1 (p=0.089) and Factor 3 (p=0.086), although results failed to reach significance level of 0.05.

Interactions   between   professional   group   and socio-demographic variables

Due to significant demographic differences between medical and nursing groups as demonstrated in Table 1, further analyses tested for interaction effects between professional group and socio-demographic variables for each factor of the MICA4.

There was a significant interaction between ethnicity and professional group with respect to factor 1 (p-0.005). Whilst Black doctors had the lowest scores on factor 1 (mean 1.5: 95% CI 0.6, 2.4), Black and ‘Other’ nursing staff scored much higher (mean=2.7: 95% CI 2.4, 3.0 and mean=2.6:

95% CI 2.2, 3.1 respectively). There was a further significant interaction between ethnicity and professional groups on Factor 2 (p=0.032). Black doctors had the lowest scores (mean 1.667: 95% CI 1.0, 2.4), whilst Black and ‘Other’ nurses scored higher (mean 2.2: 95% CI 2.0, 2.5 and mean 2.5:95% CI 2.2, 2.9).

There was a significant interaction between ‘Previous History of a Mental Health Problem and professional group with respect to Factor 2 (p=0.023). Mean scores on Factor 2 were similar for doctors who had had a mental health problem and those who had not (previous history mean 1.9: 95% CI 1.7, 2.1; no previous history mean 1.8: 95% CI 1.7, 2.0). However, nursing staff, who had personally experienced mental health problems scored much lower than those who not personally experienced mental health problems (mean=1.7: 95% CI 1.4, 2.0 versus mean 2.2: 95% CI 2.0, 2.4). Very similar results were also found in respect to Factor 1, although the interaction failed to reach significance (p=0.054). 

There was a significant interaction between Family History of a Mental Health Problem and professional group with respect to Factor 1 (p=0.006). Similar mean scores on Factor 1 were obtained for doctors regardless of any reported family history of mental health problems (family history present mean 2.1: 95% CI 1.9, 2.3; no family history mean 2.1: 95% CI 1.8, 2.4). However, nursing staff with a family history scored much lower than those with no family history (mean=1.9: 95% CI 1.6, 2.2 versus mean 2.6: 95% CI 2.4, 2.9).

 Discussion 

This study set out to explore the attitudes of mental health professionals working in psychiatry towards people with mental health problems and factors affecting them. 

Average scores on the MICAv4 were low, indicating moderately positive or positive attitudes towards people with mental health problems in this sample. However, the study identified certain key differences between doctors and nurses working in mental health settings.

Nursing staff from Black and Other ethnic groups held more negative views about mental illness and were also less likely to endorse the need to acquire knowledge about mental health problems, when compared with White nursing staff. Attitudes of medical staff in the field were not, however, affected by ethnicity. Our findings are with regard to nursing staff are consistent with Schafer (Schafer et al 2011) who also found less positive attitudes towards people with mental illness amongst Black and ethnic minority nursing students, compared with White nursing students. No research has specifically examined whether this ethnicity effect is also found in doctors.

Whilst a personal or family history of mental health problems did not result in significantly lower scores on the MICAv4 overall, when considered according to professional group, we found that nursing staff with a family or personal history of mental health problems tended to hold less negative attitudes towards people with mental illness and less negative attitudes with regard to gaining knowledge about mental health problems, compared to those with no family or personal history. Medical staff attitudes were not influenced by personal or family history of mental health problems. Other studies have found an association between having a personal or family history of mental illness and less negative attitudes towards others with mental health problems in a lay sample (Corrigan et al., 2003) and nursing sample (Martensson, Jacobsson, & Engstrom, 2014). But again this effect has not specifically been examined in doctors.

 The differential impact of ethnicity and family and personal history of mental health problems on attitudes of doctors and nurses towards individuals with mental illness, warrants further exploration. Significant numbers of mental health nursing staff in London originate from low and middle income countries (Yar, 2001) where there is very limited research into attitudes towards patients with mental health problems (Thornicroft et al., 2016) and training in equality and diversity issues is not necessarily as integrated within training as in the UK. However it is not clear why the variation according to attitudes is not apparent amongst Black and Minority Ethnic doctors.

It is possible that having a family or personal history of mental health problems may reduce stigmatising attitudes through the knowledge or experience that is associated with this. This may be relevant in the nursing group where exposure to mental health problems in self or family led to less negative attitudes. Doctors’ attitudes could be influenced by length and breadth of medical training resulting in less negative attitudes in this group regardless of their personal experience of mental health problems. Location of nursing and medical training may also be an important factor when considering attitudes. Training in the UK now routinely incorporates equality and diversity training and education around mental health, which may not be the norm for training delivered in other countries.

Previous research has suggested that female nursing staff tend to hold significantly less stigmatising views of patients with mental health problems than male nurses (Chambers et al., 2010). However, we found no difference in attitudes according to gender, amongst the doctors, or the nurses.

Mental health professionals are important advocates for their patients. Whilst negative attitudes do not automatically translate into discriminatory behaviour and adverse treatment, they may affect the professional’s ability to promote recovery and social inclusion. Alongside stigma and discrimination, negative attitudes have been described as a barrier to recovery amongst those with mental health problems (Chambers et al., 2010) and may result in worse outcomes (Alvarez-Galvez & Salvador-Carulla, 2013; Schomerus et al., 2015). Negative views of mental illness have also been associated with self-stigma in mental health patients (Evans-Lacko, Brohan, Mojtabai, & Thornicroft, 2012). It is possible that exposure to people with mental health problems and education and training around mental health could reduce negative attitudes in healthcare staff, improving health outcomes for those using mental health services (Schomerus et al., 2015). The precise nature of interventions that are effective in challenging negative attitudes warrants further exploration.

This study has several limitations. Numbers were relatively small and so when carrying out analyses, there was the possibility of Type II errors. A selection bias is possible due to the method of data collection. We are unable to report a response rate because we did not have access to the individual email addresses of potential participants and do not know how many staff received the invitation. The small number of participants meant that broad categories were used for demographic variables for the purpose of analysis, particularly with regards to ethnicity, where each group (Black/White/Other) could represent diverse populations with significant heterogeneity. Nurse participants were all from one Mental Health Trust, which may limit generalisability of results.

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Bjorkman, T., Angelman, T., & Jonsson, M. (2008). Attitudes towards people with mental illness: a cross-sectional study among nursing staff in psychiatric and somatic care. Scandinavian Journal of Caring Sciences, 22, 170-177.

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Chambers, M., Guise, V., Valimaki, M., Botelho A., Scott, A., Staniuliene, V., & Zanotti, R. (2010). Nurses' attitudes to mental illness: a comparison of a sample of nurses from five European countries. Int J Nurs Stud, 47(3), 350- 362. doi:10.1016/j.ijnurstu.2009.08.008 (2013). Mental Illness: Clinicians' Attitudes (MICA) scale-psychometric properties of a version for healthcare students and professionals. Psychiatry Res, 206(1),            81-87.

Chaplin, R. (2000). Psychiatrists can cause stigma too. Br J Psychiatry, 177, 467.

Corrigan, P., Markowitz, F. E., & Watson, A. (2003). An attribution model of public discrimation towards persons with mental illness. Journal of Health and Social Behaviour, 44, 162-179. 

Evans-Lacko, S., Brohan, E., Mojtabai, R., & Thornicroft, G. (2012). Association between public views of mental illness and self-stigma among individuals with mental illness in 14 European countries. Psychol Med, 42(8), 1741-1752. doi:10.1017/S0033291711002558

Evans-Lacko, S., Corker, E., Williams, P., Henderson, C., & Thornicroft, G. (2014). Effect of the Time to Change anti-stigma campaign on trends in mental-illness-related public stigma among the English population in 2003-13: an analysis of survey data. Lancet Psychiatry, 1(2), 121-128. doi:10.1016/S2215-0366(14)70243-3

Gabbidon, J., Clement, S., van Nieuwenhuizen, A., Kassam, A., Brohan, E., Norman, I., & Thornicroft,doi:10.1016/j.psychres.2012.09.028

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Hugo, M. (2001). Mental health professionals' attitudes towards people who have experienced a mental health disorder. J Psychiatr Ment Health Nurs, 8(5), 419-425.

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Supplamentary material

Box 1. Five factors of MICAv4 Sample size

Table 1. Characteristics of participants

Table 2. Analysis of each factor on the MICAv4 according to demographic characteristics of participants using one way ANOVA

Ethical deliberation is a central imperative throughout all research inquiry, interweaved with deep connections to our humanity (Turner, 2013). The intention here is to offer a reflective account of salient ethical issues unique to autoethnographical research. Autoethnnography is a narrative qualitative approach that draws on the lived experience of the author, in order to examine often difficult socio-cultural issues and give space for exploration, representation and interpretation of such. Thus the central character situated at the heart of the knowledge quest is ‘myself and I’, a point to which I will return. 

Firstly, I aim to focus on an important thread of axiological debate that would appear unique to autoethnography; that of, ‘relational ethics’. Indeed, it is difficult if not impossible when talking about myself to disentangle the ‘I’ from ‘others’, who may be intertwined in my lived experience and reality (Ellis, 2007; Chang, 2008; Roth, 2009; Turner, 2013). Relational ethics centres on the importance of being ‘true’ to self, without compromising others. Arguably, there is variance to this idea in a socially “constructed ontology”, where my thoughts may differ to another’s (Turner, 2013 p.220). When thinking along these lines the inquiry was a construction and interpretation of events that were layered and informed by the voices of relational others, to provide texture to my story.

As with all research the fundamental principal of confidentiality has to be maintained to provide anonymity of individuals or specific contexts within the data. However, this contention does become problematic when referring to siblings (Ellis, 2004; 2007; Tullis, 2013; Turner, 2013; Adams, Holman-Jones and Ellis, 2015). For this purpose, I strived to be ethically mindful of personal responsibility towards others, relative to ‘alterity’ or the capacity to do good (Levinas, 1987). Mechanisms that enabled such capabilities hinged around accountability, a recognition of my “narrative privilege” (Adams, 2008) and my “narrative conscience” (Poulos, 2008 p.46). In line with Porter- Abbot (2008), I remained cognizant that my narrative could be mechanism for power and authority. Ultimately, I held accountability for what was disclosed about self and others but with the power rubric in mind; the practice of both ‘process consent’ and ‘member checking’ were implemented. The former to ensure voluntary participation throughout (Denshire, 2013; Adams, Holman-Jones and Ellis, 2015) whilst the latter enabled discussion of inaccuracies and reflection on any differences that emerged (Biscomb, 2012).

Furthermore, it was important to be mindful of not publishing anything I would find uncomfortable showing to those referred to within the text. However, this has potential to become difficult when sharing stories relating to the memory of someone who is now deceased. Arguably, the making of decisions on what to tell of those deceased carries ethical issues. The processes discussed above helped in the decisions of what and how to tell. Indeed, the upmost care was taken to share only what my siblings were happy with, and working to promote the fundamental principles of beneficence and non-maleficence at all times.

Notably, as indicated above, not all the data involved siblings and as the research evolved, ‘Myself and I’, became the prominent site for the inquiry. Moreover, what became apparent on the journey were the many layered complexities that have potential to surface whilst doing autoethnography. With this in mind, it was important to pay attention to these unanticipated ethical issues arising in the course of the research which may serve to ensure “that emotional labour is performed” (Jarzabkowski, 2012 p.10) through cultivating a heightened sense of emotional awareness towards self and others. This required my ongoing attention at all stages of the process in order to question, reflect, search and challenge intentions (Ellis, 2007).

Similarly, as alluded to above seminal proponents contend that ethical issues are highly important in relation to ‘myself and I’. For this purpose, consideration has to be given at all stages of the research process to the possibility of revealing a vulnerable self. As indicated by Adams, Holman- Jones and Ellis (2015 p.65) “you become the stories you write” and in line with Tolich (2010), should be viewed as an ‘inked tattoo’ or permanent marking which cannot then be removed. For this reason, at the outset of my research I considered the medium of a composite character (Ellis, 2004) as a layer to protect and provide less visibility to my vulnerable self. However, as I was exploring the personal lived experience of mental health stigma; a topic in need of more openness and much talk, I decided against this; instead taking the cautious decision to display my ‘inking’ loud and proud. The explorative process included attention to my own self-care. For example, supervisory meetings, debriefs, along with ongoing attention to reflexivity through journaling were useful mechanisms of support (Muncey, 2010; Adams, Holman-Jones and Ellis, 2015; Tullis, 2013).

Finally, autoethnography is a highly subjective methodology, that through the doing of then became the product of an inquiry where ‘myself and I’ were pivotal, yet also deeply entwined with relational others in a co-constructed reality. From this personal reflection on my research practice, I hope to have conveyed an overview of some of the ethical complexities inherent within the genre, along with highlighting their equal importance to all other research approaches.

References

Adams, T. E. (2008) A review of narrative ethics. Qualitative Inquiry. 14(2), pp. 175-194.

Adams, T., Holman Jones, S. and Ellis, C. (2015) Autoethnography: Understanding Qualitative Research. Oxford University Press.

Biscomb, K. (2012) Three generations of Lancashire women. Asia-Specific Journal of Health, Sport and Physical Education, 3(3), pp. 253-265.

Chang, H. (2008) Autoethnography as Method.Walnut Creek, CA: Left Coast Press.

Denshire, S. (2013) Autoethnography, Sociopedia.isa, [online] [Accessed 10/8/17] Available at DOI: 10.1177/205684601351.

Ellis, C. (2004) The Ethnographic 1: A Methodological Novel About Autoethnography. USA: Alta Mira Press.

Ellis, C. (2007) Telling Stories, Revealing Lives: Relational Ethics in Research with Intimate Others. Qualitative Inquiry, 13(1), pp. 3-29.

Hoelson, C. N., and Burton, R. (2012) Conversing Life: An Autoethnographic Construction. The Qualitative Report, 17(1), pp. 92-119. [online] [Accessed                      08/9/14]            Available    at http://nsuworks.nova.edu/tqr/vol17/iss1/4.

Jarzabkowski, L. (2012) The Nexus Between Emotional Labour and Ethical Practice in Educational Research. Research Intelligence. Issue 118.

Levinas, E. (1987) Time and the Other. Translated by Cohen, R.A. Pittsburgh: Duquesne University Press.

Muncey, T. (2010) Creating Autoethnographies. London: Sage Publications.

Porter-Abbott, H. (2008) The Cambridge Introduction to Narrative. Cambridge MA: Cambridge University Press.

 Poulos, C. (2008) Narrative Conscience and the autoethnographic adventure: Probing memories, secrets, shadows, and possibilities. Qualitative Inquiry, 14 (1

 Roth, W.M (2008) Auto/Ethnography and the Question of Ethics. Forum: Qualitative Social Research, 10(1), Art 38.

Tolich, M. (2010) A Critique of Current Practice: Ten Foundational Guidelines for Qualitative Health Research, 20(12), pp. 1599–1610.

Tullis, J. (2013) Self and Others: Ethics in Autoethnographical Research in Holman- Jones, S., Adams, T. and Ellis, C. Handbook of Autoethnography. USA: Left Coast Press. pp.244- 261. 

Turner, L. (2013) The Evocative Autoethnographic I: The Relational Ethics of Writing About Oneself. In. Short, N.P., Turner, L and Grant, A. (eds) Contemporary British Autoethnography. Sense Publishing. pp. 213-229.

‘MYSELF AND I’: Ethical reflections on autoethnographical research
Dr Lucy Pursehouse, Senior Lecturer
University of Wolverhampton, UK

Executive Summary

The aim of this case study is to explore factors that affect work-based learning (WBL) for trainee nurse associates. It will focus on a pilot work-based Nurse Associate, foundation degree that I teach on. The objective of the TNA programme is to support students’ to develop skills, understanding and personal attributes; which would improve their employability. The programme is underpinned with a constructivist- collaborative-andragogy and experiential approach as well as blended learning.

This case study identifies a range of factors, which affect student learning in a work-based context. An initial diverse group of one hundred students were enrolled to a pilot programme. The students are employees of the partner organisations. It is important to note that the students have extensive experience as health care assistance. Furthermore, the majority are mature students, who came into higher education through widening participation who generally had a historical negative experience of education. In order to address these issues inclusivity was central to the curriculum design in anticipation of the learners needs. Furthermore I gave due recognition, to the work place as a legitimate site for experiential learning (Kolb, 1984). Having said that, the harsh reality is that, there are numerous organisational and cultural barriers to work-based learning that need to be carefully managed (Evans, Hodkinson and Unwin 2005).

Pedagogic-andragogy theories relevant to work-based teaching and learning will be explored and the challenges and opportunities this presents. Four main findings from the case study, namely; Inclusivity: the holy grail for work-based learning, Students; a key partner in work-based learning, Clarity of expectations and finally Quality assurance challenges in work-based learning will be discussed in more detail.

The context of this case study is specific to health care however; the findings, themes and messages are not context specific and could be applicable to any work-based learning environment.

Key words: Inclusivity, Experiential learning, Andragogy, Work-based learning, Employability

Introduction

This case study is based on level 5 trainee nursing associate work-based foundation degree, which is being piloted at a large university in the west midlands. Higher Education England (HEE) following the Shaping Care Review, which recommended a work-based programme for a nurse associate role to address shortfalls in nursing workforce (HEE, 2015), commissioned the course. A local University in the West Midlands in collaborated with nine NHS partners set up a trailblazing work-based learning programme, which I have the privilege to teach.

Work-based learning presents both opportunities and challenges for students, universities and employers. This case study will focus on supporting and fostering work-based learning for students from non-traditional routes into higher education. It will explore opportunities and challenges of creating an environment conducive to an adult learning approach. I will evaluate the programme’s effectiveness in supporting WBL using a reflective approach; I hope this will enable personal growth through experiential learning which would improve my teaching practice for the benefit of learners as well as contribute to the body of knowledge on work-based learning.

Work-based learning is a contested term; for the purpose of this case study it will be used to refer to a collaboration between students, university and employers to create university level learning opportunities across university and the work place using an andragogic approach (Boud and Solomon, 2003), (Knowles, 1984). According to Evans, Hodkinson and Unwin, (2005) the work place has enormous potential as a site for learning. Its main advantage is that it meets the needs of learners, improves employability and contributes to in- house workforce development. In this case study I designed sessions that would not just extend the knowledge of the individual, but to meet the work force needs of the employer (Boud and Solomon, 2003).

This intrinsic case study research (Baxter and Jack, 2008) and reflective narrative (Gibbs, 1999) explores opportunities and challenges of work- based learning in a health and social care context. However, the lessons learnt, could be applied to work-based learning in other context; considering apprenticeships are high on the government agenda (DoE, 2018). In this case study, as a lecturer I take an insider’s view, using a constructivist methodology; where truth is relative, and is built on the premise that knowledge is socially constructed. Constructivist paradigm rejects the notion of epistemic objectivity and applauds the subjective perspectives of individuals (Baxter and Jack, 2008). Baxter and Jack (2008) further opine that, participants are able to tell their stories through close collaboration between researcher and participants.

In this case study, I have used data from a variety of sources that is already available to me in my teaching role, including student feedback. Confidentiality will be maintained at all times, throughout this case study (NMC, 2015).

Across all participating organisations, there was consensus to actively champion the new role. Generally, students were excited and motivated about embarking on this personal and professional transformational learning journey; however, there were challenges to achieving this at times. Students on the TNA course attend university once a week and are at work for four days, with a discretionary study day. The programme’s strategy is to widen participation into higher education for students who would otherwise not qualify through traditional routes. Therefore, I adopted an inclusive and collaborative approach to teaching and learning. This was underpinned by experiential learning which valued student prior experience (Kolb, 1984).

Findings

Inclusivity: the holy grail for work-based learning

A key finding from this case study is that TNAs students are not a homogenous group, they are diverse in many dimensions. The majority of students came into university through widening participation in higher education (non-traditional route); most left school with limited qualifications and some had special learning needs such as dyslexia. This affected student learning, Al Hassan (2012) opines that it is important to understand what influences student learning. Al Hassan likens it to piecing together a puzzle whose many parts must come together before the true picture emerges; the learner’s individual characteristics, the context in which learning takes place and teaching strategies used affects students’ learning. Inclusivity pedagogy formed the bedrock of my teaching practice; various strategies are used in teaching and assessing students. According to Florian and Spratt (2012) pedagogy is the knowledge and skills required by teachers to inform the decisions they make about their practice. Inclusive pedagogy is an approach to teaching that aims to raise the achievement of all learners, while safeguarding the inclusion of those who are vulnerable or marginalised (Florian and Spratt, 2012).

In terms of inclusivity, I used a range of teaching and assessment strategies. I also provided significant scaffolding support for learners, through individual and group tutorials to enable students to progress on the pedagogy – andragogy continuum. This individualised support was important in meeting student needs; however, inclusivity needs to be implemented sensitively, in a way that protects students from stigmatization (Waterfield and West, 2005). Furthermore, anecdotal evidence suggests students found it difficult to maintain work-life balance, which affected how they engaged with the course demands. In order to address these challenges I used blended learning strategies, learning resources are made available on-line through Canvas to enable all learners to engage with course content at their convenience.

Despite the challenges outlined above the students had a wealth of experience and seemed to excel when I used an experiential learning approach, which according to Dewey (1938) incorporating students’ experience into teaching and learning is a powerful way to motivate and engage learners, this was achieved by reflecting on scenarios from clinical practice and debates.

Students: a key partner in work-based learning

The planning, developing and running of the TNA trailblazing programme is time consuming and requires a high degree of coordination. The collaboration between the university and employers required clear communication to clarify objectives. According to Ball and Manwaring (2010) universities and health care providers have a different language and culture; so for work-based learning to be successful, mutual understanding and effective communication is an essential step in building partnerships that work. Having said that I quickly realised that, actually; the most important partner is the students, without which there will be no work-based programme to talk about.

It is important to recognise students as an equal and important partner in work-based learning. Students’ views and feedback is actively sought, and as a teacher, I adopted the use reflective practice to co-produce learning with students. Vygotsky (2005) highlights the benefits of teacher- student collaboration in enhancing active learning. Student feedback indicates that this is an effective strategy for active and deep learning. Collaborative working with students is beneficial as it uses familiar work context to support learning and also uses familiar work tasks to assess learning (Ball and Manwaring 2010), (Mezirow, 1991).

I treated students as adult learners and equal partners. Initially most students struggled to get theirs heads round the concept of (andragogy) self- directed-adult learning (Knowles, 1984). Student- centred-adult-learning approaches within an inclusive ethos underpinned the teaching approaches on the TNA programme. Andragogy approach recognises that students as adult learners would commit to learning when goals and objectives are seen as realistic and important to the learner. Furthermore, it was identified that students’ motivation increased when learning objectives are related and relevant to clinical practice (Ball and Manwaring, 2010). According to Knowles (1984), adult learning is a humanistic approach based on self-directed and autonomous leaners, with the teacher as a facilitator. My experience on this course is that pedagogy – andragogy is not a case of either or, but is context dependant and rather dynamic and on a continuum (Merriam, et al 2007).

Furthermore, mentors in work placements are an important partner in facilitating student learning by selecting appropriate learning strategies to integrate learning from clinical practice and academic experience (NMC, 2015), (Briggs and Tang 2011)

Clarity of expectations 

Although all the three partners (students, employers and the university) had varying expectations of the TNA course, I will only focus on student expectations and how this affected their learning. At the beginning of the university taught sessions the majority of students seemed to be caught-up in a ‘disorientation dilemma’, and expected to be ‘spoon fed’ by lecturers through chalk and talk sessions (Mezirow, 1991). However, there were a small number of students who seemed to have the Dunning-Kruger effect (illusionary superiority)  based on  the wealth  of clinical experience they have. This later group of students had a sense of ‘I know it all’. It felt like they had come to university for validation of their knowledge (Kruger and Dunning 1999). These two types of learners engaged differently with learning. On the other hand, while in the work environment the TNA’s role could easily be blared. Some students are put under pressure to continue functioning as health care assistant in times of staff shortages and not full transition into a work-based TNA learner. The impact of this lake of role clarity and demarcation resulted in students missing out on learning opportunities in clinical practice. According to Bond and Solomon (2003), WBL requires effective partnership between learners, employers and HEI to foster student learning.

Some learners found that they were not getting the desired level of support from both the university and employers; students were not sure who to contact for help when they had issues with work- based modules. Furthermore, some employers were reluctant to release students for prolonged periods of study.

I believe as a teacher my role is to design and deliver courses that are constructively aligned and in the case of WBL, it has to apply to both employer setting and HEI. This promotes deeper learning in students; as it allows learners to see the link between learning outcomes, course content and assessment task in both contexts (Briggs and Tang 2011). Furthermore, academics and employers should work in partnership to provide on-going pastoral care for learners as this can enhance student engagement with the course and reduce drop rates. The TNA course was based on the belief that education is transformational; it provides opportunities for individual personal, professional growth and improves employability.

Quality assurance challenges in work based education

Experiential Learning Approach is central to teaching and student learning in this case study (Kolb 1984). Students for the TNA programme are drawn from diverse clinical settings ranging from primary care (GP practices) to community teams

(District nurses) and acute in patients (hospitals). One of the challenges is ensuring quality and consistent learning and assessment across different work placements. Quality assurance of work-based teaching and assessment needs to be developed and managed across different placements. One of the findings in this particular case study is that, even though practice mentors had been trained to support nursing students; because the programme was rolled out at pace some mentors were unfamiliar with the new role of trainee nursing associates, which created some confusion. Students also found it frustrating having to explain the practice assessment document (PAD) to their mentors. Winter (1994) goes further by arguing that that there can be quality assurance problems in work-based learning, as identifying and assessing intellectual qualities of work place practice can be difficult.

Tulbure (2012) supports the notion of experiential learning by arguing that learning is more than just the presenting and acquisition of content, but is the interaction between content and experience where each influences the other. According to Kolb (1984), the Experiential Cycle is an ideal approach to educating adults as it touches learners with different learning styles. I used blended learning by making module content available on Canvas, making use of interactive face-to-face lectures and seminar groups, using regular formative assessment and feedback.

Discussion 

This case study identified four key findings; inclusivity: the holy grail to work-based learning, Students a key partner in work-based learning, Clarity of expectations and finally Quality assurance challenges in work-based learning.

 Inclusivity is a requirement in widening participation to higher education (the entire students came through non-traditional routes) and making a business case for inclusivity by design is more cost effective rather than addressing issues on a case by case because that would be benefit all students. Complying with the disability legislation is the bare minimum, not all students declare their disabilities for fear of stigmatisation. Making lessons inclusive and student-learning-focused, gives every student the opportunity to fulfil their potential. However, the challenge of delivering sessions that are inclusive and accessible to all students is that it is resource intensive.

Students are an important partner in WBL. As a teacher my role is to facilitate student learning and acknowledging that student bring a huge amount of experiential knowledge from clinical practice, which they can draw from. Therefore, I have an expectation that students co-produce knowledge as equal partners; students have a valuable contribution to make in their learning. Peer learning through problem based learning and group work is a useful strategy in encouraging students to contribute and collaborate in knowledge production. Action learning sets and coaching are useful strategies that can be used to enhance social and collaborative dimension to learning with the teacher as facilitator. These sessions can be delivered jointly between the university and the practice partners. 

This trail blazing programme was launched at pace, this required communication and close collaboration between partners. This was a challenge as managing the expectations of all the key partners can be time consuming; it required time commitment for regular meetings. In order for the student voice to be heard, student representative formed an integral part of the course review team. If work-based learning is to be effective in meeting its objectives the student voice needs to audible and taken into consideration. Students’ representation is important in capturing the students’ lived experience through the course. The challenge is that this can be time consuming for the student representatives. This can be overcome by finding novel ways such as having representatives from all.the partner organisations who can alternate attending meetings.

There were challenges in quality assurance for work-based learning across the university and work placements. The TNA is a generic course, which covers all branches of nursing, the diversity of learning opportunities required a strategy to ensure student learning and assessment was consistent across the board. Several strategies were used; each student was allocated a personal tutor and a mentor for the duration of the course. The university also employed practice educators who worked closely with mentors in clinical practice. This ensured students had consistent support. Practice educators are a useful resource for students, mentors and lecturers.

Conclusion 

In conclusion, this case study has shown that despites its challenges, WBL present a great opportunity for using the work place as a learning resource; which would improve student employability. The university has a shared responsibility with employers for teaching, which is excellent for linking theory to practice. WBL is beneficial to employers in addressing skill shortages by growing their own workforce. In order to support and foster WBL for students, appropriate learning provision and a diversity of well-supported placements with skilled mentorship is essential. Furthermore; Inclusivity, an adult- learner approach underpinned with experiential learning strategies with clear expectations is key in supporting and fostering effective learning in a work-based context. The words of the great philosopher Confucius seems to sum up WBL well, ‘I hear and I forget. I see and I remember. I do and I understand’.

References

Al Hassan, A., M. (2012) Factors Affecting Adult Learning and Their Persistence: A Theoretical Approach. European Journal of Business and Social Science, Vol 1(6) 150-16 

Ball, W. and Manwaring, G. (2010) making it work: A guide to work-based learning. www.qaa.ac.uk cited on 1.2.18.

Baxter, P. and Jack, S (2008) Qualitative Case Study Methodology: Study Design and Implementation for Novice Researchers. The Qualitative Report, Vol 13 (4) 544-559.

Biggs, J and Tang, C. (2011), Teaching for Quality Learning at University, McGraw-Hill and Open University Press, Maidenhead.

Boud, D. and Solomon, N. (2003) Work-based learning: a new higher education? London: McGraw-Hill Education.

Department of Education (2018) Approving Apprenticeship Standards. Cited 25.3.18 www.consult.education.gov.uk

Dewey, J. (1938) Experience and Education. New York, Macmillan.

 Evans, K., Hodkinson, P. and Unwin, L (2005) Working to Learn: transforming learning in the workplace. London: Kogan Page.

Florian, L. and Spratt, J. (2012) Inclusive Pedagogy: A framework for interrogating inclusive practice. European Journal for special needs education. Vol 28(2), 119-135.

Gibbs, G (1999) Using assessment strategically to change the way students learn, in Brown, S. and Glasner, A (Eds.) Assessment Matters in Higher Education, Buckingham, Open University Press, 41-53.

Higher Education England (HEE), (2015) Nursing Associates. www.hee.nhs.uk cited 20.3.18

Knowles, M. (1984) Andragogy in Action. San Francisco: Jossey-Bass 

Kruger, J and Dunning, D. (1999) Unskilled and Unaware of it: How difficulties in recognising one’s own incompetence lead to inflated self- assessments. Journal of personality and social psychology. Vol 77(6): 1121-1134.

Kolb, D. (1984) Experiential learning. Englewood Cliffs, NJ: Prentice-Hall.

Merriam, S., Baumgartner, L. and Caffarella, R. (2007) Learning in Adulthood: A comprehensive guide. San Francisco: Jossey-Bass.

Mezirow, J. (1991) Transformative Dimensions of Adult Learning. San Francisco, Jossey-Bass.

 Nursing and Midwifery Council (2015) The Code; Professional standards of practice and behaviour for nurses and midwifes. Nursing and Midwifery Council: London.

 Tulbure, C. (2012) Learning styles, teaching strategies and academic achievement in higher education: across sectional investigation. Procedia- Social and behavioural science, Vol 33 398-402 

Vygotsky (2005) Vygotsky’s philosophy: constructivism and its criticisms examined. International Education Journal, 6(3), 386-399.

Waterfield, J and West, B. (2005) Inclusive Assessment in Higher Education: A resource for change. Plymouth: University of Plymouth.

Winter, R. (1994) Work-based learning and Quality assurance in higher education. Assessment & Evaluation in higher education, Vol 19(3): 247- 257.

Supporting and Fostering Work-based learning for
Trainee Nursing Associates (TNA)
Griffin Ganga, Senior Lecturer
University of Wolverhampton, UK

Dr Dean-David Holyoake, Developmental Editor

Noticing ABBA and Dead Wood 

I’m sure the gardeners amongst us will know what I mean when I say ‘dead wood’. I’m also certain that ABBA fans can sing SOS. So, if nothing else, Gardeners World is in a pair of Knowing Me, Knowing You safe hands. But, all of this frivolity reminds me that there is a stack of stuff in my life that requires cutting out in order to Save Our Souls. For some time now I’ve been intending to do some trimming of my own metaphorical garden, but have, due to laziness, tended to opt out. I prefer to call it minimal interference and like much of the Journal of Health and Social Care Improvement’s approach, allow contributors space to grow, emerge awkward opinion and tackle issues beyond the ‘what you see is what you get’ ethos standards of many on-line journals. You see, with a sharp sickle in my editorial right hand I am more than able to scythe down opinion but that’s not what the Journal of Opportunity does. In fact, here on the editorial board, we prefer to don white flares, glittery high-heels and repeatedly pout at one another whilst recognising that taking a chance is better than a winner taking it all. So we hope to encourage more of you to send us your articles. Anyhow, all this wittering and chopping brings us to this edition. 

In this forest, there is plenty on offer from a broad multidisciplinary contribution. The wise words of Carol Cullen, Wendy Nicholls and Magi Sque keep ahead the Waterloo that is obesity, whilst Jonathan Beckett focuses on the serious issue that is the Mama Mia of other eating issues known as Prader–Willi Syndrome. These original research articles are not the only Name of the Game as they are joined by a Super Trooper article contributed by Emma Dudzinski who writes quite rightly about the needs of a growing elderly population. In between we have a commentary by Anita Z Goldschmied who, in her usual manner, makes comment as to how no one ever hears the tree fall in the woods. Now, if all of this ABBA revivalism has got you wondering about tentative connections then look no further than the link below and answer this. How come Benny Anderson has his back to the rest of the band? Answers to appear in the next edition, but we reckon its no walk in the woods, especially if it’s not dead. 

Click here for ABBA SOS (1975) 

Abstract 

This study developed a substantive theory to explain maintained weight loss. Individuals who live with the classification of severe obesity often experience physical and psychological ill health and the frequency and severity of comorbidities make weight loss increasingly difficult. Whilst short-term interventions in treating obesity are successful, long-term maintenance of weight loss shows limited success. Participants began losing weight from a B.M.I. of 35 or above, reached their goal weight and maintained this weight loss for at least one year. Seven semi-structured interviews were carried out and analysed using Charmaz’s (2006) grounded theory approach. 

Data was analysed and a substantive theory of ‘Emergent Self’ was constructed, which explained participants’ views and feelings. The emergent self was the most pervasive core category from seven categories; ‘Normalizing’, ‘Controlling’, ‘Isolating’, ‘Seeking’, ‘Gaining’, ‘Analysing’ and ‘Choosing’. 

Findings revealed that as participants experienced a process of psychological awareness within a favourable environment their reliance upon food for emotional coping and avoidance reduced. The environment provided; hope for recovery, identification with others, openness and honesty to share, self-acceptance and access to a non-judgemental supportive community of like-minded individuals. The participants facilitated a life-long way of achieving maintained weight loss. These findings can be used to inform weight management programmes. 

Keywords: Maintained weight loss, Severely Obese, Weight management, Grounded theory, Substantive theory 

Introduction 

Obesity is very prevalent in today’s society on a worldwide scale. Compared with metabolically healthy normal-weight individuals, obese persons are at increased risk for adverse long-term outcomes even in the absence of metabolic abnormalities (Kramer, Zinman & Retnakaran, 2013). Obesity increases the chances of serious mental and physical conditions (Must, Spandano, Coakley, Field, Colditz & Dietz, 1999) including; depression (Faith et al, 2011), high blood pressure (De Pergola, Nardecchia, Guida & Silvestris, 2011), high cholesterol (Andersen, Kendall & Jenkins, 2003), diabetes Type 2 (Kyrou & Kumar, 2010), heart and kidney disease (Liu, von Deneen, Kobeissy & Gold, 2011), stroke (Toss, Lindahl, Siegbah, & Walletin, 1997) and respiratory disorders (Jubber, 2004). The frequency and severity of comorbidity increases further for those individuals living with the classification of severe obesity, making weight loss increasingly difficult through poor mobility and a higher risk of mortality (National Institute of Clinical Excellence [N.I.C.E.], 2006). Whilst society adjusts to individuals with severe obesity, the implementation of wide scale factors contributing to the amelioration of this condition appear limited (National Obesity Observatory [N.O.O.], 2009). 

A healthy diet and increased exercise are considered to be the basis to weight loss yet attrition rates are high on weight management programmes implementing these (Grave, Suppini, Calugi & Marchesini, 2006; Teixeira et al, 2004). The reasons for this attrition call for further investigation. As weight and comorbidities increase NICE (2014) guidelines suggest that individuals should be referred to a specialist, Tier 3 weight management programme to receive medical, psychiatric, psychological and dietary assistance in addition to exercise advice. Whilst this approach appears comprehensive NHS England, 2014 state that the clarity around the service that each NHS practice implements and the efficacy of Tier 3 specialised obesity services are variable, with the absence of such services in many areas. For those individuals who have a B.M.I. of ≥ 35 with comorbidities bariatric surgery is recommended. Surgery itself presents risks (Apovian, Garvey & Ryan, 2015), however consideration is being given to lowering the threshold for bariatric surgery to a BMI of 32 (N.I.C.E., 2014). It is of significant importance to remember that obesity is itself primarily a preventable condition and when we consider that people are spending a lifetime experiencing obesity and the negative consequences it brings to the individual it is vital to understand more about achieving non-surgical long-term weight maintenance (Wadden & Butryn, 2003; Wing & Phelan, 2005). 

A meta-analysis of nutritional and behaviour-focused weight management interventions suggests that diet and exercise remain largely unsuccessful with half (Wadden & Butryn, 2003) to three quarters (Anderson, Konz, Frederich & Wood, 2001) of participants usually regaining their lost weight within five years. The rationale for individuals being unable to sustain their weight loss long-term remains unclear. Theoretical explanations have been presented which have focused on biological, behavioural and psychological determinants (N.O.O., 2010). Contributory factors to obesity from a biological perspective include having a genetic disposition (Nammi, Koka, Chinnala & Boini, 2004; Wilding, 2011); damage to a particular area of the brain which controls satiety and hunger signals (Thaler et al., 2012); an instinctive biological drive - eat to survive (Van Buren & Stinton, 2009). Many people may originate from a long line of descendants who have been obese or severely obese and whilst a biological factor may be an element of their obesity, this may also be explained as a learned behaviour dependent upon cultural, environmental or emotional factors (Collins & Bentz, 2009). Schachter's (1971) externality theory of obesity suggests that some individuals are hypersensitive to external food-relevant stimuli, while being hyposensitive to internal signs of hunger and satiety. Individuals therefore respond impulsively to the sight or smell of food which can be particularly detrimental in an abundant, high-calorie obesogenic environment. High external eaters have been identified, through the use of neurological mapping of the brain, in producing strong cravings in response to exposure to food which encouraged overeating (Nijs, Franken & Muris, 2009). Similar activation of the brain area has been identified in substance dependent patients to indicate cravings (Field, Munafo & Franken, 2009). With such a strong biological or behavioural instinct to eat when high-calorie food is readily available it is understandable that individuals find it challenging when asked to join a weight management programme to alter and reduce their eating. Another theory to explain the failure of maintaining long-term weight loss focuses on restraint theory which suggests that the individual uses cognitive control to significantly reduce food consumption. This process can be maintained in the short-term whilst supported by a weight management programme but is difficult for individuals to maintain long-term (McGuire, Wing, Klem & Lang & Hill 1999). An explanation for this failure to achieve maintained weight loss has been attributed to individuals requiring food as a means of affect regulation (Zijlstra et al, 2012) to help cope with various kinds of psychological stressors (Buckroyd & Rother, 2007). When this coping mechanism is withdrawn by changing the individuals diet/eating behaviour without addressing the psychology of what food means to each individual it is too difficult to sustain long-term. This perceived failing from those who are not successful in altering their food intake can result in greater psychological ill health (Miller & Jacob, 2001). Bi-directional associations with obesity and mental health have been made (N.O.O., 2010). Obesity has been linked to depression (Cunningham et al, 2012), anxiety disorder (Toups et al, 2013), psychosis (Wilding, 2011), bipolar disorder (McElroy & Keck, 2012), and post-traumatic stress disorder (Pagoto et al, 2012). Obesity has also been linked to having an insecure attachment (Mazzeschi et al, 2014) and a traumatic childhood (Hughes, Power, Fisher, Mueller & Nicklas, 2005). An individual’s propensity to be isolated and sedentary when experiencing mental ill health, coupled with side-effects of medication which often increase weight, creates a cyclical pattern that is difficult for the individual to break but some individuals have achieved breaking these cycles (N.I.C.E., 2014). With an influence from positive psychology this research looked at what facilitated successful individuals to lose and maintain their weight from being severely obese. In order to obtain this in-depth, ideographic information of each individual’s perspective as well as seeking to obtain a substantive theory of maintained weight loss; Charmaz’s (2006) grounded theory was used. 

Methods 

Participants 

Ethical approval was obtained from The Wolverhampton University Faculty of Education, Health and Wellbeing Ethics Sub-Committee Board and from a National Health Service [N.H.S.] Regional Ethics Committee via N.H.S. Proportionate Review with the relevant N.H.S. Research and Development Site Specific Assessment. 

Purposive sampling identified two participants who had finished an NHS weight management programme and one individual who attended Overeater’s Anonymous [O.A.] with two further participants from O.A. via snowballing effect. Two further participants were identified through the researcher’s word of mouth. The initial inclusion criteria looked for participants who had maintained an intentional weight loss of at least 10% of their original weight for at least one year. The criteria was tightened following four interviews, to participants who had reached their goal weight and maintained that weight for at least one year. It was identified that participants with 10% weight loss were found to be fluctuating in weight or were still losing weight and therefore were not keeping an existing state/maintenance of weight loss. 

Recruitment for the two N.H.S. participants entailed sending a recruitment pack to the N.H.S. Service. The Service sent out a participant pack to 27 individuals who met the initial inclusion criteria. The pack contained a letter of introduction with contact details of the researcher and an information 

participants obtained via word of mouth, one of which was an O.A. member, were passed the researcher’s contact details. When they made contact they were then forwarded the introductory letter, information sheet and consent form. Recruitment extended to advertising an A4 poster in gyms, health centres, emailed to sports centres, sports clubs, B-EAT website and advertised in a newspaper. The last three participants were recruited from O.A.; study information/contact details were circulated to their branches. 

A total of seven adult participants took part in this study; three men and four women aged between 31- 61 years of age (mean = 49). Table 1 provides a summary of the participant’s demographic information detailing weight/height and BMI and comorbidities at the time of commencing weight loss. One participant had a BMI of 31.6 at the start of her weight loss therefore did not reach the inclusion criteria. This participant was included because she had managed to maintain a healthy weight for 18 years whilst suffering from depression. All identifiable information was changed throughout the study to ensure anonymity of participants. O.A. participants wanted it known that it was their personal view they presented not those of O.A. 

Semi-structured interviews were conducted after obtaining informed consent and completing the data collection form; the first four interviews were at each participant’s home. The researcher adhered to a lone-worker’s policy. A further interview was carried out by telephone and the last two were by Skype (non-video), due to the distance involved in achieving face to face interviews. Interviews lasted between 43 and 93 minutes and were recorded on a hand-held dictaphone. An interview schedule was used as a guide to ensure the objectives of the study were met whilst using open ended questions to encourage participants to talk openly about their experience of achieving maintained weight loss. Each interview was transferred to a security coded laptop and transcribed verbatim by the first author as soon as feasible. Interviews were listened to at least three times to ensure an accurate transcription and to become immersed in the data. Pre and post interview reflective field notes were made to provide context for the interview and to record impressions and interactions of the participant and researcher. A debrief sheet was given to the participant at the end of each interview which detailed the aims of the study along with contact details of national charities related to eating disorders and listening services. 

Data was analysed using Charmaz’s (2006) grounded theory with the aim of obtaining a substantive theory to contribute towards future weight loss interventions. Analysis involved gerund (line by line) initial coding to ensure the process from the data was obtained. Initial coding was then elevated to form focused codes and then categories. Memoing was recorded throughout each stage of the analysis ensuring openness of the researchers’ thought processes and interpretations. Constant comparison of all the data/focused codes/memoing ensured that the categories developed could be identified as grounded in the data (Elliott & Lazenbatt, 2005). Analysis revealed seven categories which formed a storyline of maintained weight loss. The seven categories integrated to form an eighth core category of ‘Emergent Self’. 

Theory of Emergent Self showing the storyline and category integration; ‘becoming prominent the conscious knowledge of one’s own character, feelings, motives and desires’ 

Results 

The ‘Emergent Self’ showed the individual becoming consciously aware of their own character, feelings, motives and desires. This psychological self-awareness placed the individual in a position of being able to understand their response to difficult emotions and to begin to address these emotions in a more positive way so that they did not need to avoid them by using food. 

The storyline focused on the underlying process that was occurring for the participants as they achieved maintained weight loss and the factors which influenced and prevented this process. The categories identified are discussed along with excerpts from the participants’ interviews to illustrate the construct of their experiences to maintained weight loss. 

Normalizing – Responding to patterns of behaviour in childhood 

The majority of participants were able to identify patterns of emotional and behavioural responses to food which they first experienced in childhood. Examples included; being given large portions as a child because their parents were overcompensating for their own lack of food in childhood, having to clear their plate of all food, having second helpings therefore not learning satiety or overriding hunger signals. Patterns of emotional associations with food focused on; one participant who was living in an abusive family and secretly being given sweet food to make everything seem better. She continued using sweet food in this way when she was taken into care. Another participant was shown love from her parents through food rather than verbal and physical affection; 

“Food was very important for our family…like the currency; you know it was like love on a plate really.” (Claire, Line 122) 

Logical reasoning is often used to reduce food intake and/or change to healthier food in weight management programmes but it is questioned whether the strength of the emotional attachment to a type of food is addressed. 

“I I knew that whatever happened to me if I could get something sweet to eat I would be OK…..calmed me down…” (Claire, Line 129) 

This view was expressed by Claire when she reflected on attending a slimming club; 

“When I look back now it was crazy, there was no psychological feeling component to why we’re we’re all fat, it was just about well if you just do this with your chicken satay or whatever it was, it was just crazy superficial talk …...” (Claire, Line 195) 

Controlling – Avoiding thoughts and feelings 

Participants spoke of difficult life events and how they responded to them with food. Charles grew up believing you could buy love, as an adult he got into debt and he identified how he would use food to avoid his negative emotions day or night; 

“I’ve stuffed kinda feelings down you know” (Charles, Line 454) 

“I used to find that if things are blocking my head if I got up during the night for the toilet or anything like that I’d visit the fridge” (Charles, Line 631) 

This study was able to compare those who had reached their goal weight to those who had lost 10% of their weight and were still fluctuating. Those who had lost 10% of their weight spent a lot of time creating an external focus; measuring and recording weight, monitoring exercise and food and measuring portion sizes. Participants who had achieved maintained weight loss identified this external focus as something they also used to do which became a barrier to achieving maintained weight loss. 

“I mean I did an awful lot of overeating…I also did an awful lot of thinking about it too…or planning how I was going to lose the weight, I spent a lot of mental energy on all of that so the fact that I don’t have to do that anymore…..I live differently.” (Claire, Line 504) 

They identified that the internal process of being self-aware; what they were thinking, feeling and ultimately how they were behaving was what facilitated their maintained weight loss. They had to learn how to manage difficult emotions without the use of food or avoiding through the use of external focus. 

Isolating – Feeling ‘abnormal’ and alone 

Being unable to manage their emotions and having to use food to help avoid these feelings was found to leave the individual with a wish to avoid being with themselves; they did not like the person they had become. Linda shows how she would use substances to avoid having to be with herself; 

“I just loved eating and loved food and then found alcohol, I loved alcohol and I couldn’t get enough of that. Do you know… it was always like something to make me feel different about myself….a sense of just not being able to sit with yourself and so you have to do something to try and not sit with yourself.” (Linda, Line 534) 

This negative self-image was shown to increase the need for using food, or any substance to such a degree that the individual felt to have lost control over themselves and the substance. This created a negative cycle which the participants found very difficult to move away from and resulted in isolation and in some cases poor mental and physical health. 

Participants spoke of negative cycles which were exacerbated by attending slimming clubs where maintaining control and record keeping were encouraged and the occasional treat was monitored. Participants who had achieved maintained weight loss found that they had to abstain from the food they could not eat in moderation; in the same way that an alcoholic would abstain from alcohol. Participants who attended the weight loss programmes were able to lose weight in the short term but found that the weight would return after leaving the programme. 

“Every time I lost weight I would then put that weight back on and I always put on more, um so in some ways I sort of dieted myself up to twenty two and a half stone” (Linda, Line 112) 

This cycle left participants feeling immense shame and self-blame choosing to isolate themselves. Participants had a feeling of being abnormal and separate from the rest of society. Their shame led them to secrecy around their eating which often made seeking help difficult to do. 

Seeking – Reaching levels of desperation in wanting help 

“It was so secret, I was so ashamed. The sense of shame I had was huge so to go to a normal doctor I just don’t know how they do that but some people do but I couldn’t do that.” (Claire, Line 587). 

All the participants highlighted mental or physical ill health that led them to begin their weight loss process. Four of the participants had reached the point of desperation in seeking help either because they had not been able to ask for help or the help they received had been unsuccessful. 

Gaining – Obtaining self-acceptance and self-awareness 

Lacking awareness of why the individual was overeating prior to successful intervention was prevalent in all of the participants’ interviews. Being in an open and supportive environment allowed the participants to identify with others, obtain a sense of inclusion therefore no longer feeling alone or abnormal. 

“I was very much a Jekyll and Hyde really I suppose… I’d put on a big front for everybody but inside I was really quite depressed and unhappy but I never let anybody know – I’m much more open and I’m very very different…just much more real I suppose.” (Claire, Lines 548/564) 

The participants found that by listening to others talking openly and honestly, they received a sense of hope for a better future around food. They were immersed in a community of like-minded individuals who provided support and acceptance for as long as they required it. Whilst experiencing this support they were encouraged to be autonomous and take responsibility for any decisions they made. As participants achieved positive mental health through self-reflection and analysis, their focus around food changed; they no longer used food as a means of coping or avoiding. They were able to then achieve maintained weight loss and as they recovered they were encouraged to then help others. 

Analysing – Looking objectively at your own patterns of thoughts, feelings and behaviours 

Participants were identified as journaling daily how they thought and felt which they would then look at objectively. If the participant was unable to see another way of looking at their emotions, possibly due to feeling overwhelmed by them, they could seek support from another individual. The process allowed exploration of themselves on a regular basis to manage their thoughts and feelings. Linda explained that she had always responded to everything with extreme emotion, that there was no middle ground or moderation. 

“I felt like everyone else had some sort of instruction manual for life and that I just hadn’t got my copy because I felt very over sensitive very emotional…things just touched me really hard, like very deeply um even as a young kid.” (Linda, Line 518) 

Regular monitoring of her emotions prevented them from dominating her life and she was therefore able to live her life more successfully and peacefully. Linda indicates that her main focus was not the weight but more on trying to manage extreme emotion and how it made her feel. Claire also states that weight was not her primary concern; 

“It wasn’t just about the weight ever it was about me and inside me.” (Claire, Line 555) 

Choosing – Taking it seriously one day at a time 

Maintained weight loss requires a life-long approach and cannot be treated in an on-off way. The participants who had maintained weight loss were abstaining from the foods that they could not eat in moderation, a day at a time. This helped the participants stay in the present moment. They reflect daily their thoughts and feelings. Once maintaining their weight they do not dwell on the past or think too far into the future. This helps them cope with the feeling of loss from not having the food they crave in their lives, so that they do not feel overwhelmed. 

“If you’re told you have to do you have to stop something for the rest of your life there’s quite a panic…..you must be willing to go to any length which is what I was at the time you know…. That’s every day of the week regardless of birthdays, Christmas or any special events. Never alter, never intend to.” (Charles Lines 62/540) 

Abstinence needs constant awareness by the individual; Linda found abstaining from high amounts of sugar in foods very difficult to do because sugar is presented in high quantities in many foods yet it is not obviously apparent. She has to remain constantly vigilant not to trigger her overeating off accidentally. 

Discussion and Summary 

The aim of this study was to provide insight into the facilitators of maintained weight loss from the perspective of individuals who had severe obesity and now have achieved maintained weight loss at goal weight. Analysis revealed the importance of psychological wellbeing in achieving maintained weight loss and how this can be obtained, by looking at attachment, self-awareness, self-esteem, self-acceptance, affect regulation and reflection. Weight itself became a secondary concern for the participants. 

Initially this research questioned whether 10% intentional weight loss for individuals with severe obesity should be used to define maintained weight loss. This study found that this is not a suitable definition. Consideration should be given to future research seeking individuals who have ‘intentionally achieved their goal weight; sustained for at least one year’.  

Childhood experiences were a prevalent antecedent of obesity reported by the majority of participants, whether this was due to behavioural or emotional conditioning. This was supported by previous research where individuals experiencing poor attachment or a traumatic childhood use food as a way of regulating emotions (Hughes, Power, Fisher, Mueller & Nicklas, 2005; Larsen & Diener, 1987; Mazeschi et al, 2014). This highlighted the necessity to be aware of individual differences in history taking for clinicians and an understanding of the meaning that food had for each individual. Individuals may not be aware of how they began their relationship with food and as adults may not fully understand their use of food. Adults were found to be aware that they were overeating but were not aware of the reasons why. Avoidance of difficult emotions was a significant factor in this study, it revealed the difference between those who had maintained weight loss and those who had achieved 10% weight loss but were still fluctuating. Individuals with severe obesity were found to have difficulty experiencing negative affect compared to those who had achieved maintained weight loss and were using cognitive reappraisal for difficult situations in their life in addition to using expression of affect in reflective process (Moore et al., 2008). The latter interventions allowed the participant to gain self-awareness. The need for affect regulation in the treatment of individuals with severe obesity has been recognised (Abilés et al., 2010; Buckroyd & Rother, 2007; Zijlstra et al., 2012) and is a significant barrier to achieving maintained weight loss. 

It was possible to identify negative cyclical patterns of behaviour around food. Food was used as a distraction from feeling a failure in life or a wish to escape from the person they had become. Food itself then becomes the object of their failure often following attendance at weight management programmes where they were unable to achieve weight loss maintenance. The individual then gets caught up in a vicious cycle negotiating self-blame, failure, shame and distress (Heatherton & Baumeister 1991; Klein, 2004; Owen-Smith et al, 2014; Throsby, 2007). Consideration needs to be given to recognising the implications of referring individuals with obesity and severe obesity to weight management programmes that alter and restrict diet without consideration to the individual’s psychological relationship with food and their affect regulation and self-esteem. Successful maintenance of weight loss for these participants was established through greater psychological awareness and self-acceptance in an environment that provided constant support and encouraged autonomy and responsibility. The importance of a form of constant support has been essential for the participants in this study and other studies (Gupta, 2014; Jensen et al, 2014). Ensuring adequate support both during and following an intervention programme is a significant gap in treatment. Participants were able to benefit from continued community support from like-minded individuals who had succeeded in achieving maintained weight loss and knew from their own experience the type of support required. 

Whilst other studies have shown how affect dysregulation is associated with severe obesity (Berg et al, 2015; Haedt-Matt & Keel, 2011; Zijlstra et al, 2012) none have used an ideographic approach with individuals who have achieved maintained weight loss from being severely obese or produced a grounded theory to maintained weight loss. The inclusion of male participants has been limited in previous studies this is felt to be due to affect regulation only been seen as a female requirement. This study has shown that men benefit from greater psychological awareness and particularly self-acceptance. Limitations of this study focused on whether the level of saturation of the data with relevance to theoretical concepts was 

achieved due to the limited number of participants found who met the revised inclusion criteria. Saturation of the data was achieved in terms of repeated constructs being observed. It is recommended that future studies obtain participants of both sexes who meet the amended criteria; this may ensure that saturation of theoretical concepts is achieved. Future prospective studies into the aetiology of severe obesity could focus on the childhood relationship between the participant and main caregiver, with particular reference to their attachment style and the use of food in this relationship. Research could also extend to the adult and their psychological relationship with food. This is an area that has been researched in obese individuals but greater insight would be beneficial for severely obese individuals. 

The overarching findings obtained from this research with regard to facilitating maintained weight loss converge towards the core category of the ‘Emergent Self’. Recognising that by addressing the individual’s underlying psychology behind their disordered eating facilitates change for greater self-awareness and greater self-acceptance. 

Supplementary material

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If you are one of those few people who feels maintaining a healthy weight is a constant battle, then Carol, Wendy and Magi article can be a constructive read that summarises various theories of both obesity and the difficulties of maintaining our weight. Their paper gives due consideration to the complex issue of humans’ relationship with food. They discuss, how we are never in full control, and as life in the forest, the capacity to maintain a healthy weight is an effect of the myriad interactions between networks of elements that compose them such as childhood experiences. Yet, they suggest, the concept of “Emergent Self”, a psychological self-awareness of why and how we respond to those capacities and the potential effects might be a way to achieve success and a sense of control. Maintaining weight is a life-long task, not a one-off, and the paper concludes this. However, the beauty of complex ecosystems is that they remind us, there might be no one model that fits for all, and the same person might benefit from varied approaches at a different phase of their journey. 

Abstract 

This paper is a narrative account of a life experience of managing Prader–Willi syndrome (PWS). This research takes the form of a singular case study, using interview to highlight what life may be like for an individual with PWS, taking the perspective of a mother of an adult. The singular case study approach is justified due to the unique and original insight it brings; the singular, specific offering illumination upon general. 

Issues of living with PWS – the management of food, desiring to excessively eat, not knowing the importance of maintaining personal hygiene and not being able to be gainfully employed are pertinent issues facing those with PWS. Finally, in the wake of this, this paper notes how some of these issues may be addressed and offers suggestions for those with PWS, their carers and practitioners. 

Key words: Prader–Willi syndrome, narrative, qualitative, health and wellbeing. 

Introduction and context 

This paper presents a narrative life account based on an interview with a mother whose daughter has Prader–Willi syndrome. In so doing it offers an original insightful account of Prader–Willi syndrome (PWS). This work explored themes and detailed issues related to the difficulties associated with personal care, relationships and eating habits. The research concerns Bridget (pseudonym), who is 35, lives with her father (George) who has type one diabetes and looks after him, acting as a carer. This research uses an extended interview for data collection - interviewing Bridget’s mother (Sarah), who lives separately from Bridget and George. Bridget has Prader–Willi syndrome (PWS) - a rare genetic disorder due to loss of function of chromosome 15, inherited from her father (Waters, 2004). PWS is a complex neurodevelopmental disorder. Individuals with PWS have their own specific strengths and weaknesses but all tend to have a propensity to particular physical and mental health difficulties (Whittington, 2011). The condition causes continual hunger, excessive appetite and behavioural difficulties. Hence, if the individual consumes excess calories then they are more likely to suffer with weight gain and subsequent obesity problems. This could increase the likelihood of developing heart disease alongside respiratory problems, as well as type two diabetes, which could be fatal. (Hernandez-Storr, 2016). 

Methodology 

This research used ‘storying’ (Lewis, 2011) to gather qualitative thick description to describe a perception of the experiences associated with Prader–Willi syndrome (PWS). Moreover, Lewis (2011:505) notes, story is a ‘principal way of understanding the lived world.’ By encouraging personal narratives, specific life-transforming events can be shared, which offer enlightenment and some generalisability to other situations (Denzin, 1989; Ercikan and Roth, 2009). The use of singular case study was selected due to the in-depth account and the power of the life story narrative within an organisation and set of relationships (Yin, 2013). In so doing, this research asked Sarah to describe her experiences with a reflective notion of the holistic impact this had upon her and Bridget. 

Although the single case study has to be handled with caution due to reliability issues (Cohen et al, 2017), tentative generalisability can be applied to which Interpretive Phenomenological Analysis (IPA) has been employed. This approach seeks to evaluate phenomenological description to the perceptive explication of the interviewee’s sentiments. By encouraging personal narratives, specific life-transforming events can be shared. The use of IPA is to allow for the emersion of rich data to shape the analyses of the work of small-selected samples, such as those interviewed. Smith (2009) notes phenomenology’s philosophical, interpretive approach begins with the individual seeking to attach meaning to life experiences without pre-conceived theoretical notions. The interviewers then elicited strands of meaning from the participants’ account; as an idiographic examination of each point was made to create wider deductions – follow up non-structured questions were used to check understanding - IPA acknowledges the role of the researcher in the process, whilst still employing interpretive analysis to subjective experiential data (Duncan et al., 2001). Moreover, the researcher was not removed from the context of the data collection procedure so the potential impact of the inter-subjective dynamics occurring between participant, data and analysis process must be noted (Finlay and Gough, 2003). Consequently, the researchers sought to use Erben’s schema of using imagination in the interpretation of the data sets, whilst being mindful of the overarching contextual dynamics, such as societal, educational and cultural factors, occurring within the participants’ life story (Erben, 1998). The potential impact of power-relations on participant responses during data collection was minimised by reiterating the sincerity of the researcher in listening and respecting the participant’s experiences and emphasising a feeling of equality between researcher and participant. In addition, it was important to emphasise that no judgements were being made, especially with the sensitive nature of the matters raised. The researchers suggested that this may offer potential empowerment to share life accounts which may inspire or help other people. 

Research aims 

Data from the interview, of which the salient points were transcribed, coded and thematically analysed. In narrative analysis participants re-tell life experiences, seeking to attach meaning to specific events of significance. Judicial caution was applied noting the subjectivity of what was said as much ‘memory work’ was involved, which needs to be situated within a context (Willig and Stainton-Rogers, 2017), hence the use of IPA. The interview guide was framed around a set of themed ideas which developed into questions, an approach of Roller and Lavrakas (2015). Sarah was asked to describe her experiences of managing Bridget’s PWS in the past, but more, at present (being the foci of the study). The key questions explored were: 

• How does Prader–Willi syndrome (PWS) impact upon a life? 
• How would you describe your experiences of caring for Bridget as a girl and as a woman? 
• What approaches did or do you take with Bridget? 
• What do you see the long-term picture looking like? 

Research Data 

The demands of PWS were highlighted in the pertinent points transcribed and thematically analysed using IPA in the section below, applying the ‘bottom up’ approach, generating codes from the data. 

Sarah said that Bridget, due to the condition of PWS, would have a high metabolism, keep eating and have no concept of when she was full. Therefore, she would ‘continuously look for food’. As a young girl locks would have to be put upon the cupboard doors to ensure she did not snack between meals or when nobody was around: ‘Bridget would have to have locks on the cupboards downstairs in case she got up in the night and ate things in the cupboard.’ 

As she had no concept of when she was full, she would eat all the time, put on weight and had recently become in the region of 26 to 30 stone. Sarah reported that Bridget had difficulty managing personal hygiene due to carrying excessive fat and attended social gatherings, church services and other events smelling of body odour This causes people to avoid her due to the magnitude of the unpleasant odour and she consequently becomes even further isolated. Sarah noted how if ever she was invited around for coffee or Bible study after church a special individual study for her as some people refused or had been put off from coming by her smells, all the house would smell stale and odorous. She would put a rug over the sofa to stop the smell seeping through and would detox all the surfaces after she had been. Whatever the weather, Sarah would be forced to leave the door open for around half an hour after she went to prevent the smell lingering. 

Sarah additionally recounted how the suspension of her car was affected after several occasions in which she gave Bridget lifts to and from her house to church, hospital or work: ‘The garage said that there was something not right with the suspension and I know it was after taking Bridget’. On some occasions she had broken furniture in the church, at home or in public. Bridget at times got sensitive when things like this occurred. However, when the subject of weight management and looking after yourself was raised she would ‘zone out and not listen’. On occasions she had been with a friend to weight watchers but had not sustained enthusiasm for any period of time or committed herself to losing a significant amount of weight with help and support. 

Bridget does not currently work and has a low intellect / IQ. She had begun a floristry course at a local college but had terminated it due to the assignments, which she found unmanageable. With her weight problem she finds certain jobs challenging. Working in a supermarket, for example, would be difficult because cravings for food would arise from scanning edible items at a checkout. She also would find some jobs difficult to do such as working in a supermarket, scanning items of food on the checkout due to the feelings of cravings for food. This, Sarah suggested, would be ‘cruel as she would always be seeing lots of items of food pass her by.’ However, she would also find corner shop work difficult due to the physical space she would need to work in; taking up more space than a single person behind the counter. 

Sarah did not know what the future would hold for Bridget. Lots of employment avenues seemed to be shut for her as her IQ was low and she would have mood issues, affecting social relationships. Spending long periods of time at home was not deemed by Sarah to be helpful for Bridget; Sarah recommended that having a goal in life would benefit Bridget. Her father had prompted her to put her name down on the council list for houses so that when he died she would have somewhere to live. He had also encouraged her to take some exercise and she held a step-count monitor which she sought to increase each week. In relation to the long-term picture, Sarah was quite upset to try and picture what would become of Bridget in the future; ‘I don’t really know what will become of Bridget, it’s so hard to think of what she can do or will do.’ 

Discussion 

As collated from the participant’s responses. The main problem identified by Sarah related to Bridget’s excessive appetite which consequently led to: 

• • Weight gain 
• • Obesity and associated health problems 
• • Issues with bathing / personal hygiene 
• • Problems with employment (also impact of low IQ) 

Each will be considered in turn: Weight gain caused by over eating is a significant cause of heart disease and mortality (Caldwell and Taylor, 2013). Moreover, PWS is associated with relentless weight gain in adults with untreated PRS (Holm et al., 1981:273). Consequently, regular exercise and management of diet are key features emerging from this narrative, which need to be addressed to help support Bridget. 

Butler et al. (2006:415) notes: The basic premise of intervention acknowledges that at no time can a person with Prader-Willi syndrome be expected to voluntarily or independently control his / her food consumption. … an exercise program, activities of daily living, chores, and personal hygiene are all supported by the therapeutic milieu. 

Therefore, controls on diet, such as training on how to cook meals from raw ingredients (if capable) or purchase ready meals which are nutritious and healthy are important in helping an individual with PWS. The above sentiments of Butler et al (2006) suggests that someone with PWS will never be able to be completely independent? Will they require a carer to visit them? Perhaps training in buying healthy ready meals will only benefit people with this condition so far? As unchecked, individuals may consume excess calories of foods which provide little nutritional value and compound weight gain. For Bridget, as a young person, having locks on cupboards meant that, although it may appear oppressive, she did not over eat after mealtimes. As Sarah said ‘she could put five stone on in a year otherwise.’ However, the locks of cabinets appeared only a short-term solution, a long-term approach designed to help manage compulsiveness or hunger suppression tablets or hormonal / thyroid medication is potentially required. 

Obesity and the interconnectedness of other health issues are key features of PWS (Eiholzer, 2001). Therefore, ensuring rigorous but empowering actions to monitor the types of food eaten on a chart could provide a useful tool to monitor consumption. Being open at health care sessions with practitioners and being held to account with others such as at Weight Watchers is potentially a good way of learning the importance of how many calories are in different foods and ensuring weight is managed and reduced over time. Sarah noted now she did not even expect to see Bridget alive after 30 years old because in the last few years she had fluctuated in weight and most recently put on several stone in a matter of months. This was, in Sarah’s view, due to the lack of accountability Bridget felt she had towards her father and mother now as an adult. Sarah makes the case for intervention for this eating problem happening much earlier on so that she has the opportunity to train herself into good habits from an earlier age. 

Issues with personal hygiene can be associated with the condition and therefore managing practical issues into a step-by-step approach helps; dressing, personal care and so forth (Waters, 2004). It is clear that a key feature emerging from this narrative is the smell that Bridget makes when she does not adhere to matters of personal hygiene attendance. A rigorous approach to emphasising the importance of washing thoroughly and of smelling fresh appears to be needed as potentially this may not be fully understood by Bridget due to a low IQ. This is also impacted by inability to reach certain areas of her body due to excess fat/skin folds, that these habits need to be developed early on because, despite low IQ, the mind might be trained for long-term coping mechanisms. 

Problems getting and maintaining a job are key features of the sentiments of Sarah. ‘The employment scripts of knowing and following the “rules” of a job setting and knowing and using the “politics” of a job…’ (Reynolds and Fletcher-Janzen, 2007: 1611) are difficult to grasp for those with PWS in a competitive market for employment. However, jobs which combine both exercise and routine and do not require analytical deductions, working out change or problem solving are likely to be suitable for Bridget. Supported employment opportunities can help individuals with PWS (Goldstein and Reynolds, 2005). Moreover, Butler et al. (2006) suggest cleaning, lawn mowing and restaurant work as potential jobs for those with PWS. These types of jobs, and others such as: warehouse work, gardening, shop assistant, would allow Bridget to move and therefore, get exercise and feel a sense of purpose. I would caution the sentiments of Butler et al. (2006), suggesting the restaurant job may be detrimental to health, due to the contact she would have with food, potentially making her desirous to excessively eat) here, seeing as restaurant work would challenge the very nature of the difficulties that the condition brings. 

Conclusion 

PWS impacts upon the life choices and trajectory of those with the condition and those associated with looking out for them. In this narrative account it is unclear what will happen to Bridget in the future, particularly when the support of her parents is no longer available. James (2010) reports on a Canadian approach to PWS for middle-aged persons in which their dreams and ambitions are recognised and supported. Additionally, accommodation with nearby call-staff is another effective idea in supporting individuals with PWS. The tenets of this approach is recognition of need whilst at the same time noting that developmental disabilities and genetic differences should not ostracise the individual from the wider world. 

It is important from the discussion of the salient points raised through IPA that Bridget seeks help and is accepting of Sarah’s advice in the key matters of weight management and loss, personal hygiene and employment. However, it could be questioned: is she accepting of advice? Is the problem more that she zones out? This work underlines the importance of listening to unique perspectives of what life is like for those with PWS and of those around them. This research is of importance because it highlights a rare condition and provides a first-hand account of the problems faced on a daily basis, which adds to the minimal existing literature on individuals affected by this condition. Additionally, it accentuates the wider problem of lack of management for the condition, which sees lack of training for individuals with PWS in their younger years consequently being unable or unwilling to seek the support they need to deal effectively with the issues that arise within their adult years. 

This study is justified because it illuminates the problems faced by people with PWS and offers a powerful insight into the world of PWS. It further provides original insights with generalisability for others involved in the care and provision of those with the condition. It finally presents a call for more research in this area in relation to life-training skills to aid people’s management of the condition. 

References 

Butler, M., Lee., P. & Whitman, B. (2006). Management of Prader-Willi Syndrome, New York: Springer. 

Caldwell, M. & Taylor, R. (2013). Prader-Willi Syndrome: Selected Research and Management Issues. London: Springer. 

Cohen, L., Manion, L. & Morrison, K. (2017). Research Methods in Education. Oxford: Routledge 

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James, T. (2010). Prader-Willi Syndrome: Growing Older, Courtenay: Poplar Publishing. 

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theory, method and research, London: Sage. 

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Yin, R. (2013). Case Study Research: Design and Methods. London: Sage. 

Johnathan’s detailed narrative is an important reminder of using a methodology that keeps people and their experiences at the centre of inquiry. The link between the tendency of overeating and Prader-Willy Syndrome is a well-known and researched issue in the scientific arena. However, we often forget the personal, both in terms of living with or caring for someone with such a condition. Have you ever wondered whether there are overweight animals in the forest? Or whether animals overeat? The paper answers the question. They have no health and social care system in place to provide them with food once they are so overweight that cannot go and find food anymore. So, whilst they could and occasionally do overeat life in the forest ensures they will quickly become fit and lean compared to their own body and not to an artificially composed ideal for all. The paper highlights pressing issues around employment and health problems whilst offering some interventions that might seem restrictive at first. Yet, once we considered the benefits of living in the forest, we find that the locked cupboard is an ecosystem all of its own. 

Introduction 

Older people are the main users of health and social care services in Great Britain (Department of Health [DH], 2001; Howse, 2007). The number of older people in the UK is increasing and projected to increase to almost a quarter of the population by 2045 (Office for National Statistics, 2017). This will place further pressures on health and social care services at a time of increasingly scarce resources; and requires local authorities to consider new and innovative ways of working to meet these needs. Thus there is a responsibility for occupational therapy to demonstrate the effectiveness of its services for older people in social care settings. 

Many older people have long term conditions that result in limitations in physical activity and function (Melis et al, 2008). Maintaining functional ability is important, not only to enable a person to carry out independent activities of daily living, but to also reduce caregiver burden and influence the wellbeing of both (Peters et al, 2013). Difficulties performing activities of daily living such as bathing or mobilising at home represent significant events that may trigger the need for personal assistance or relocation to a family member’s home or residential facility (Gill et al, 2006). Moreover, functional difficulties are associated with a reduced quality of life, fear of falling, functional decline and depression (Spillman, 2004; Feng et al 2014). 

Glendinning et al (2008) highlighted that interventions with a focus on activity, independence and successful ageing are more effective than those based on a dependency service provision model. This is supported by the Adult Social Care Outcomes Framework 2013/14 (DH 2012) which focuses on delaying and reducing the need for care and support. The Care Act (2014) placed a responsibility on local authorities to provide preventative services to defer the need for expensive, institutionally based, interventions in times of crisis. The Royal College of Occupational Therapists (RCOT) (2017) demonstrated how involving the older person in decision making, seeing the whole person, and focusing on what they can do, results in a better quality of life for the older person, reducing their need for long term care. 

Occupational therapists play a fundamental role in promoting function and independence by removing barriers, adapting or modifying physical environments and offering support, guidance and education for individuals and caregivers. This paper offers two case study examples of an innovative service, in a local authority in England, combining the expertise of both occupational therapists and assistant practitioners. All names are replaced with pseudonyms to preserve the anonymity of participants. 

Motivations for a new approach to service delivery in Adult Social Care 

The motivations for a new service delivery model came from increased pressures on the locality’s social work waiting list whilst there was capacity in the occupational therapy and assistant practitioner assessment service. In line with the Care Act (2014) prevention principles, we looked for service improvement which would embed a culture of promoting independence for clients whilst motivating the team by generating innovative ways of working. Furthermore, we hoped to contribute to budget savings by reducing commitments to long term packages of care whilst managing expectations and perceptions of the social care remit by the public. 

Methods 

Project Model 

Combining the concepts of ‘occupational therapy first’, ‘strengths based assessment’ and ‘promoting independence and prevention’, we nominated two pairs of occupational therapists and assistant practitioners to focus on new referrals coming into the department, requesting a package of care, where there were no existing services. These cases would have normally been assessed by a social worker. 

We aimed to utilise the occupational therapy functional assessment, creative use of resources, a strengths based approach focusing on the person’s own capabilities and wider support network, and knowledge of local voluntary, third sector and community resources to prevent, reduce or delay the need for funded care. We used the occupational therapy and assistant practitioner skill mix to combine the holistic functional assessment skills of an occupational therapist with the support planning skills and community based knowledge of an assistant practitioner. The occupational therapist would also lead any complex issues or mental capacity assessments. The visits were joint, both practitioners contributing to one assessment avoiding duplication in recording, with the expectation that there would be little or no reduction in the numbers of cases seen. 

Ethical approval was not necessary as this was audit and service evaluation. The activity was usual service improvement hence explicit informed consent was not required. 

Findings 

Case Study: John 

John is diagnosed with Alzheimer’s disease and arthritis affecting his back. He lives with his wife, Mary, his main carer. John was referred to Adult Social Care requesting support with bathing, after becoming stuck in the bath. 

Assessment 

The Occupational Therapy and Assistant Practitioner (OTAP) assessment took place at John’s home with his wife and son present. This was a familiar environment for John and enabled functional abilities to be observed within his home setting. 

The assessment used a holistic biopsychosocial approach focusing initially on the reason for referral (bathing difficulties), but also exploring the impact of John’s long-term conditions on other aspects of his daily living routine using discussion and observation. Having two practitioners present enabled the occupational therapist to spend time alone with John observing his mobility and transfer technique, whilst the assistant practitioner completed a carer’s assessment with Mary, assessing her needs and the impact of her caring role. Littlechild et al (2010) identified that assisting family carers was one of three main important features for promoting or maintaining service user independence. 

John had reduced balance but was mobile with a walking stick. He had difficulties with bath and toilet transfers and experienced balance problems on the stairs and when transferring in and out of the property. Mary reported that John became disorientated at night in the dark, and could be verbally aggressive. 

Intervention 

The occupational therapist ordered a bath lift, additional banister rail and two toilet frames to increase independence and safety at home. Following the prevention principles of the Care Act (2014), information and advice was provided for the family to explore grab rails and a half step at the front access. This promoted wellbeing by increasing the ability to exercise choice and control and is a vital component to prevent or delay a person’s need for care and support (DH, 2017). 

Mary was regularly travelling by taxi to collect John’s medication which was time consuming and expensive, the assistant practitioner suggested exploring a medication delivery service. Mary asked for support managing her husband’s verbally aggressive behaviour and support from the Mental Health team was advised and information regarding the Alzheimer’s Society provided. Cohen-Mansfield (2001) suggest people with dementia behave in an agitated manner when their needs (for example for social interaction) are not correctly perceived and addressed by caregivers. The assistant practitioner suggested referral for a volunteer to provide John with some social stimulation and providing Mary with a break from her caring role. A referral to Assistive Technology was made for motion sensor lights, and a sensor to alert Mary when her husband gets out of bed, to address disorientation at night time. 

Outcomes 

John and Mary felt the provision of equipment made a positive difference to John’s independence and safety reducing his likelihood of falls on the stairs. Mary also reported that John needed less support to complete activities of daily living with the equipment in place, as found by Sainty et al (2009) who showed equipment provision made people feel safer and more independent, reducing the need for support. Here, provision of equipment, onward referrals and information and advice prevented the need for funded care and the joint OTAP approach enabled a carer assessment and occupational therapy assessment to be completed within the same appointment. This reduced visits and waiting times, enabling a holistic and empowering process for both service user and caregiver. 

Case Study: Sarah 

Sarah had a stroke one year ago resulting in language, comprehension and expression difficulties. She can only read and write a few words and experiences difficulties with managing her correspondence. Sarah lives alone, with no family or friends able to support this task. Her speech and language therapist requested a social care assessment, for a personal budget, to enable Sarah to employ a personal assistant to support her with correspondence. 

Assessment 

The OTAP assessment took place at Sarah’s home with her speech and language therapist present supporting communication. The occupational therapist and assistant practitioner used gestures and short phrases when communicating with Sarah, giving her additional time to respond, to help improve her participation in the assessment. 

Questions were addressed directly to Sarah, using the speech and language therapist only when necessary, ensuring a person-centred approach (Morris et al, 2015). 

In the assessment, Sarah demonstrated difficulties accessing her over bath shower, right sided weakness and reduced sensation, in addition to expressive and receptive aphasia. 

Intervention 

The assistant practitioner requested a long-term volunteer to support Sarah with managing her correspondence and explored local support groups that she might attend. This is supported by Ch’ng et al (2008) who suggest engagement in new activities and social support appear to be key factors in post-stroke adjustment. More time in the home is experienced by people as they age, however, accessing the community and being involved in social activities remains essential for health and wellbeing (DH, 2014). 

The occupational therapist trialled bathing equipment to assist Sarah to access her over bath shower; however, this remained difficult and the shower was not temperature controlled. A thermostatically controlled level access shower was recommended via a Disabled Facilities Grant (DFG), to enable safe and independent access to bathing facilities. 

Outcomes 

The volunteer provided long term support with correspondence preventing the need for funded care. A level access shower with shower chair was installed enabling independence with bathing, this was an additional need, not highlighted in the initial referral. As Gill et al (2006) note, it is important to restore and maintain independent bathing for older adults, to prevent further deterioration in functional ability. The joint OTAP approach enabled eligibility for the DFG to be identified early which would not have otherwise happened as the referral was for a social work care assessment, not occupational therapy. If the social worker had identified the need for an occupational therapy assessment, further delays would have occurred due to the waiting list. Powell et al (2017) found delays in referrals for adaptations mean that help may come too late to maintain independence. Timely housing adaptations consequently have scope to promote autonomy and reduce demands on families and formal services (Allen and Glasby, 2013). There is potential here for significant cost savings and improved preventative outcomes for service users and caregivers. 

Discussion 

Wellbeing is recognised as important in the Care Act (2014), it is vital that local authorities refocus, creating social care services that help older people to do as much as they can for themselves, for as long as they can. To meet the challenges of the future, services must intervene early, help people retain or regain their skills, and prevent or delay deterioration wherever possible. This may mean a period of intense support or home adaptation, however once goals are achieved, support may be safely reduced or even withdrawn. 

The joint OTAP service delivery model meets needs through low level equipment, information and advice, education, voluntary and third sector interventions, signposting, DFG adaptations, carer’s assessments and short-term interventions from reablement services. Anecdotal feedback from service users suggests moving away from a dependency service provision model is ‘enabling’ and ‘giving control back’. 

Practitioners felt positive and motivated by the model, and reflected on the development of their 

skills. Assistant practitioners reported observing the service user in their own environment, led to an evidence-based understanding of risk, and increased knowledge on how to meet needs without a care package not revealed by a static talking and listening approach to assessment. Occupational therapists reported feeling they worked more proactively and were able to apply clinical reasoning in practice at the time, rather than reflecting back on practice after the visit. Workers felt key factors for success were the strong joint working partnership and seeing service users in their own environment. 

As the majority of cases seen were those with no current services, it is difficult to accurately reflect the savings achieved. A visit from two practitioners may be perceived as an expensive approach, however analysing the referrals and estimating a predicted spend based on that information and average costs of care, showed a predicted saving. Over six months 84% of cases seen using the OTAP approach were met without funded care or resulted in a reduction of care. No second assessments were needed and the length of visits was no greater than a single practitioner case. The organisation predicted an annual saving of one million pounds by using this approach, suggesting that finding innovative ways to enable people to continue to participate in daily life can provide more effective use of public money. 

Most cases seen, using the OTAP approach, were referred for social work intervention, but have benefited from equipment, adaptations and focused advice around managing conditions and daily routines. This joint approach is predicted to reduce the number of internal referrals to occupational therapy from social workers and assistant practitioners, potentially preventing the need for a second assessment, and the need for the person to repeat their story. 

The RCOT (2017) recommends that occupational therapists are employed to develop person and community-centred approaches, ensuring older people live independently for as long as possible in their communities. This report also suggests service design should allow occupational therapists to adopt a more preventive and enabling approach. The joint OTAP model exemplifies these recommendations by promoting a holistic and strengths based intervention. 

Conclusion 

This service evaluation outlines two examples of using the OTAP approach within an Adult Social Care setting. The implications for practice are the opportunity to reframe how we approach assessing and provide for people with care and support needs. Taking a preventative approach; giving information and advice, developing resources and working with communities, occupational therapists and assistant practitioners have worked collaboratively to prevent, reduce and delay the need for funded care. This led to significant predicted savings and maintenance of independence and wellbeing for service users. 

Anecdotal feedback suggests this is an empowering approach for service users which motivates practitioners and expands their knowledge. Eligibility for DFGs was identified in a timely way, with reduced internal referrals to occupational therapy. Availability of this service has been increased with plans to implement this approach across other localities. 

References 

Allen K, Glasby J (2013) ‘The billion dollar question’: Embedding prevention in older people’s services – ten ‘high-impact’ changes. British Journal of Social Work, 43, 904-924. 

Care Act 2014, c.23. Available at: http://www.legislation.gov.uk/ukpga/2014/23/contents/enacted (Accessed 2 August 2018) 

Ch’ng AM, French D, Mclean N (2008) Coping with the challenges of recovery from stroke: Long term perspectives of stroke support group members. Journal of Health Psychology, 13(8), 1136-1146. 

Cohen-Mansfield J (2001) Nonpharmacologic interventions for inappropriate behaviors in dementia: A review, summary, and critique. The American Journal of Geriatric Psychiatry, 9(4), 361-381. 

Department of Health (2017) Care and support statutory guidance. Available at: https://www.gov.uk/government/publications/care-act-statutory-guidance/care-and-support-statutory-guidance (Accessed 2 August 2018) 

Department of Health (2014) Compendium of factsheets: Wellbeing across the lifecourse. Ageing Well. Available at: 

www.gov.uk/government/uploads/system/uploads/attachment_data/file/277584/Ageing_Well.pdf (Accessed 2 August 2018) 

Department of Health (2001) National Service Framework for Older People. London: Department of Health. 

Department of Health (2012) The Adult Social Care Outcomes Framework 2013/14. England. Department of Health. 

Feng L, Nyunt MSZ, Feng L, Yap KB, Ng TP (2014) Frailty predicts new and persistent depressive symptoms among community-dwelling older adults: Findings from Singapore longitudinal aging study. Journal of the American Directors Association, 15(1), 76.e7-76.e12. 

Gill TM, Guo Z, Allore HG (2006) The epidemiology of bathing disability in older persons. Journal of the American Geriatrics Society, 54, 1524-1530. 

Glendinning C, Clarke S, Hare P, Maddison J, Newbronner L (2008) Progress and problems in developing outcomes-focused social care services for older people in England. Health and Social Care in the Community, 16, 54-63. 

Howse K (2007) Health and social care for older people in the UK: a snapshot view. Working paper 607. 2nd edition. Oxford Institute of Ageing. Available at: http://www.ageing.ox.ac.uk/files/workingpaper_607.pdf (Accessed 2 August 2018) 

Littlechild R, Bowl R, Matka E (2010) An independence at home service: the potential and the pitfalls for occupational therapy services. British Journal of Occupational Therapy, 73(6), 242–250. 

Melis RJF, van Eijken MIJ, Teerenstra S, Van Achterberg T, Parker SG, Borm GF, Van de Lisdonk EH, Wensing M, Rikkert MG (2008) A randomized study of a multidisciplinary program to intervene on geriatric syndromes in vulnerable older people who live at home (Dutch EASYcare Study). The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 63A, 283–290. 

Morris MA, Clayman ML, Peters KJ, Leppin AL, LeBlanc A (2015) Patient-centred communication strategies for patients with aphasia: Discrepancies between what patients want and what physicians do. Disability and Health Journal, 8, 208-215. 

Office for National Statistics (2017) Overview of the UK population: March 2017. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/articles/overviewoftheukpopulation/mar2017 (Accessed 2 August 2018)

Peters M, Jenkinson C, Doll H, Playford ED, Fitzpatrick R (2013) Carer quality of life and experiences of health services: A cross-sectional survey across three neurological conditions. Health and Quality of Life Outcomes, 11, 1–8. 

Powell J, Mackintosh S, Bird E, Ige J, Garrett H, Roys M (2017) The role of home adaptations in improving later life. Available at: https://www.ageingbetter.org.uk/sites/default/files/201712/The%20role%20of%20home%20adaptations%20in%20improving%20later%20life.pdf (Accessed 2 August 2018) 

Royal College of Occupational Therapists (2017) Living not existing: Putting prevention at the heart of care for older people in England. Available at: http://3clw1r2j0esn1tg2ng3xziww.wpengine.netdna-cdn.com/wp-content/uploads/2017/07/ILSM-Phase-II-England-16pp.pdf (Accessed 2 August 2018) 

Spillman BC (2004) Changes in elderly disability rates and the implication for health care utilization and cost. The Millbank Quarterly, 82(1), 157-194. 

Emma’s article and the case studies remind us that providing older adults with health and social care interventions in the 21st Century is like navigating a forest and finding our way out but doing it in a way that also enhances the ecosystem. And this is not a small task when we consider the complex interacting organisms and the physical environment. Can one professional have all the skills to assess, plan and provide interventions in such a complex network? Well, the Care Act (2014) places a statutory duty on local authorities to promote independence and reduce dependency on care and support provision. The article offers a service delivery model that utilises skill-mix to optimise care both in terms of efficiency and effectiveness. It invites us to reflect on how we draw the boundaries between disciplines. What skills should professionals possess? Could any other professionals be involved? How have they ensured no duplications are recorded? And if they have different tasks to perform then what are the actuals benefits of carrying out an assessment in one time rather than through two separate visits? Probably further investigations and pilots could explore such details.

Dr Hilary Paniagua, Editor-in-Chief 

Get ready for GDPR as a new era of data protection is about to start

On May 25th this year the Data Protection Act will be replaced by the European Union’s (EU) General Data Protection Regulation (GDPR), a framework with has succinct rules that have greater scope, harsher penalties and actionable fines for those who do not comply with its rules regarding the handling and storage of personal data. The context of this Regulation aims to strengthen privacy rights while at the same time facilitate digital innovation within the EU. The GDPR also aspires to resolve the sometimes conflicting values of privacy and innovation. It aims to do this by coordinating different privacy legislations across the EU and by creating various exemptions for different types of research within in its mandate, Even though this new framework will come into place as Britain starts the process of leaving the EU, the Great Repeal Act means that the GPDR is likely to become part of British law which will ultimately have an impact on research and transform the way researchers manage personal data within its new elements. Research however is in a good position within its outlines as it permits organizations that process personal data for research purposes to evade some restrictions on secondary processing and on managing sensitive data as long as they have appropriate ethical standards and safeguards in place.

Furthermore under the regulations organizations can find themselves in a unique position where they are able to overrule a data subject’s right to object to the processing of data or the subsequent destruction of personal data. In its endeavours to encourage innovation the GDPR can also permit organizations to process personal data for research purposes without the data subject’s consent and in some cases even transfer personal data for research purposes to third countries that do not provide a satisfactory level of protection. The GDPR strives to facilitate a Digital Single Market across the EU and in doing so exempts research from the principles of limitations in storage which will allow researchers to process personal data beyond the purposes for which it was first intended. Researcher will also have to consider the new rules in terms of gaining consent as this infers “any freely given, specific, informed and unambiguous indication of the data subject's wishes by which he or she, by a statement or by a clear affirmative action, signifies agreement to the processing of personal data relating to him or her”. Consent can no longer be affirmed from silence or from inactivity. Opting out for recruitment purposes therefor is no longer permissible and removes this option; researchers can no longer presume any agreement to take part unless participants have specifically agreed to it. The new regulations are far from straightforward and the NHS Health Research Authority issues specific guidance for researchers which is aimed specifically at researchers, sites and sponsors managing individual research projects. This guidance is published as a living document that will be updated over the coming weeks so researchers would be advised to review it when submitting research now to the NHS.

Journal of Health and Social Care Improvement 2018 February Issue Vol 1 (4) i-ii

Abstract

Background: This paper illustrates important factors for recovery from co-occurring mental health and substance misuse conditions. Individuals with co-occurring conditions face challenging recovery trajectories; however, little is known about how these people can heal holistically. The purpose of this paper was therefore to explore the essential elements relevant for recovery and to identify any gaps in research.

Methods: A critical review was conducted; six studies were selected and scrutinised.

Results: Although this review reiterated that recovery is a unique and personal process, several shared factors were found to be of significant support. Strong themes surrounding education, social support, spirituality and productivity were identified as imperative to recovery.

Key words: Mental illness, Substance misuse, Co-occurring conditions, Dual diagnosis, Recovery, Dual Recovery

 Introduction 

This review seeks to scrutinise six research studies surrounding mental health and substance misuse recovery. The paper will summarise the search strategy, critically appraise the methodological approaches, conduct a thematic analysis, discuss the findings in relation to health and social care practice, and provide possible areas for future research. 

When an individual has two or more medical conditions, it is referred to as a dual-diagnosis, comorbidity or co-occurring conditions (National Institute on Drug Abuse, 2010). Co-occurring mental health and substance misuse issues are becoming increasingly common; it is estimated that mental health and substance abuse issues affect 1 in every 5 individuals (Ross et al, 2015). Individuals with co-occurring conditions arguably face more difficult recovery trajectories since they often have a multitude of factors to face. Just one condition can have a profound impact upon a person’s life; two interacting conditions could therefore be overwhelming (Rassool, 2006). Rassool (2006) reports that individuals with a dual diagnosis are at an increased risk of homelessness, HIV and self-harm, investigating the elements of recovery is therefore essential. 

The current understanding of comorbidity is inadequate; the evidence base surrounding the effectiveness of treatment approaches and the suitability of services is limited and little is known about how a person can heal holistically (Hogan et al, 2015; Schulte et al, 2008). This investigation will identify any important aspects relevant for recovery and any gaps in research. 

Literature search 

The University of Wolverhampton’s library catalogue and a range of EBSCO host databases (Academic Search Complete, CINAHL, MEDLINE, PsycINFO, the Psychology and Behavioural Sciences Collection) were employed for the search strategy. 

The keywords ‘substance abuse’, ‘mental illness’ and ‘recovery’ were initially used, which produced 1692 results. In order to limit the search, the author selected articles published between 2011-2017 with full text only, this produced 504 results. Two studies were selected from the surface, which then provided alternative keywords. At this point it proved advantageous to be aware of ‘Boolean logic’; the principles behind search engines where simple words such as AND, OR and NOT can be used to limit and broaden the results. The search was refined again to include the terms ‘dual diagnosis’ or ‘co-occurring’ or ‘comorbidity’, which produced 111 results. Another study was selected from the surface, however a number of studies surrounding homelessness were present so the author excluded these from the search and further limited the results to those with references available, producing 20 results. One further study was selected from the list but the other sources were unsuitable. The library catalogue was then searched using the keywords ‘dual diagnosis’, ‘recovery’ and ‘experiences’. After refining the results by content type and publication date, the final two studies were selected. 

Methodological Approach and Research Methods 

Each study justified the relevance of the research, clearly stated its aim and adopted a design appropriate for addressing said aims. Five studies employed a qualitative approach (Brekke et al, 2017; Cabassa, Nicasio and Whitley, 2013; Edward and Robins, 2012; Hipolito, Carpenter-Song and Whitley, 2011; Thomas and Rickwood, 2016), which is suitable for exploring the subjective experience of recovery. Qualitative research aligns with interpretivist ontology; it assumes that individuals construct their own reality and therefore seeks to conduct studies within natural social settings in order to understand personal thoughts and feelings (Bowling, 2009). 

Qualitative approaches have proven advantageous in exploring sensitive subjects (Bowling, 2009); researchers interact with respondents, which allows for rapport to be built and thus produces detailed data. Nevertheless, when the inquirer interacts with participants it has the potential to influence the data-collection and interpretation (Gerrish, 2011). Qualitative research could therefore be criticised since it cannot guarantee objectivity and there is no way to ensure that the data has been construed correctly (Sarantakos, 2005). Robson (2002) argues that although there is a need to represent reality, it ought to be acknowledged that ‘reality’ can differ depending on the perspective (Cowan, 2009). 

One study adopted a mixed-methods approach (Green et al, 2015); employing qualitative methods to explore personal perceptions, with quantitative methods to seek some objectivity and provide socio-demographic data. Quantitative approaches align with positivist ontology; which assumes that reality is concrete and argues that certain characteristics can be accurately measured (Badewi, 2013). In quantitative research the inquirer is independent; there is no interaction with participants to prevent any bias. The use of both quantitative and qualitative methods can complement one another and provide more accurate, in-depth data (Tashakkori and Teddlie, 2003). 

Five of the studies acquired ethical approval from the appropriate boards and obtained informed consent from respondents (Brekke et al, 2017; Cabassa, Nicasio and Whitley, 2013; Green et al, 2015; Hipolito, Carpenter-Song and Whitley, 2011; Thomas and Rickwood, 2016), which usually indicates righteous research since it suggests that 

ethical issues have been considered and steps have been taken to ensure that participants rights are protected. Ethical considerations are integral to any research design, however, although researchers must attempt to avoid causing harm, Sarantakos (2005) highlights that there is no one agreement among academics as to what harmful exactly constitutes; that which researchers may consider harmful might differ to the respondents view; for some, merely engaging in a particular subject matter could cause distress. One study offered financial incentives to those who participate (Hipolito, Carpenter-song and Whitley, 2011), which could be criticised for being cohesive. People should not be persuaded or pressurised into participating; there are concerns that payments prevent financially disadvantaged groups from providing freely given consent (Ethics Guidebook, 2017). 

One study was exempt from ethical review since the research did not require any interaction with respondents, furthermore informed consent was not obtained but instead the authors argued that it was implied since the data derived from public domains (Edward and Robins, 2012). Denscombe (2010) declares that internet-data is not straightforward and states that there are occasions where it is neither possible nor practical to obtain consent. Moreover, all of the studies do appear to have acted in the interest of both beneficence (done for the greater good; to benefit others) and non-maleficence (done in a way which prevents harm from participants) (Earle et al, 2007). 

The sample, including the selection strategy, is another imperative aspect of research (Moule, 2015); when well designed it encourages unbiased and robust results (Wilmot, 2005). Two studies did not discuss details of their sample (Edward and Robins, 2012; Thomas and Rickwood, 2016). This was warranted for Edward and Robins (2012) due to the very nature of their research. Conversely, Thomas and Rickwood (2016) completely failed to acknowledge how or why they selected the particular participant for their case study, leading to questions surrounding credibility. 

One study used probability sampling and randomly selected participants from a healthcare centre within strata defined by gender and diagnosis (Green et al, 2015). Hek, Judd and Moule (2003) highlight that this allows researchers to achieve a representative sample of a smaller size, however, this was not the case with this particular study since the sample was so large and solely consisted of members of an insurance plan, thus excluding those without insurance, furthermore the majority of the participants were white, thus eliminating the experiences of other ethnicity’s. Although probability sampling is often portrayed as the ideal method for generating a representative sample, Denscombe (2010) notes that it does not necessarily lend itself to studies surrounding substance use or the homeless since this information is not readily available as there is no database documenting every individual who uses illicit substances or is homeless. Non-probability (purposive) sampling can still generate a strong sample, although it relies heavily upon good practice (Denscombe, 2010). Purposive sampling was appropriately used within one study (Cabassa, Nicasio and Whitley, 2013). 

Volunteer samples were used within two studies (Brekke et al, 2017; Hipolito, Carpenter-song and Whitley, 2011). Parahoo (2006) states that self-selected samples are some of the weakest and contends that they are used merely out of convenience. Nevertheless, Brekke et al (2017) justified their recruitment methods; since the study sought a sample diverse in age, gender and duration since contact with services, distributing flyers in relevant locations appears apt. Unfortunately, the same cannot be said for the second study since the volunteers were residents within a recovery community (Hipolito, Carpenter-Song and Whitley, 2011). Wissen and Siebers (1993) discuss ‘un-coerced voluntary participation’ and question exactly how voluntary participation can be within a captive population such as a hospital or care home (Parahoo, 2006). They note a number of reasons 

why people in such places may volunteer, for example: they may feel morally obligated, they may fear reprisal if they refuse, or they may fear being labelled as uncooperative (Wissen and Siebers, 1993, in Parahoo, 2006). With these considerations in mind, it is plausible to claim that the validity of the data could be compromised. 

All but one of the applicable studies acquired a suitably sized sample for their data collection methods (Brekke et al, 2017; Cabassa, Nicasio and Whitley, 2013; Hipolito, Carpenter-song and Whitley, 2011; Thomas and Rickwood, 2016). Although there is no set standard sample size, Lapan, Quartaroli and Reimer (2011) note that low levels of participants are able to provide in-depth, meaningful data; a large sample is therefore not necessary. One study claimed that it conducted in-depth individual interviews with 177 participants (Green et al, 2015), but it could be argued that this was unwarranted. Kvale (1996) contends that large samples are not suitable for interview studies; it can cause confusion during the data analysis and prevent the penetrating themes from being clearly identified (Trainor and Graue, 2013). 

A diverse range of data collection methods were utilised, each one was justified by the researchers and suitable for the study. One study used photo-voice (Cabassa, Nicasio and Whitley, 2013); where participants take photographs of their personal experiences and then discuss them in photo-elicitation interviews and group dialogues. Using visual materials is a creative way to capture the reality of recovery, which compared to most conventional methods, is unobtrusive and empowering (Creswell, 2014). Although the data could be difficult to interpret, employing individual elicitation interviews somewhat eradicates this issue. 

One study stated that focus groups and observations were employed for data-collection (Hipolito, Carpenter-Song and Whitley, 2011), however it failed to provide any further information on the observations. The focus groups were particularly fitting as it aligned with routine practices in a residential recovery community; respondents were therefore accustomed to sharing their experience in a group format. The group dynamics have the ability to stimulate discussion and generate governing themes relevant to recovery (Bowling, 2009), but there is a risk that more powerful personalities can dominate discussions and express their experiences at the expense of others (Parahoo, 2006). 

Klapowitz (2000) compared the data of focus groups and individual interviews and found that interviews are more suited for sensitive subjects; interviews were revealed to be 18 times more likely to raise delicate discussions (Parahoo, 2006). Three studies suitably employed interviews (Brekke et al, 2017; Green et al, 2015; Thomas and Rickwood, 2016), whilst one conducted a documentary analysis (Edward and Robins, 2012), which can be seen as an alternative to both questionnaires and interviews (Denscombe, 2010). Denscombe (2010) declares that documentary data should not be taken at face value, nevertheless this was acknowledged by the authors, who used a quality criteria checklist to select data and provided a clear audit trail to enhance credibility. 

All of the applicable studies audiotaped the data-collection process, which raises reliability (Keats, 2000). This was suitable for four of the studies (Brekke et al, 2017; Cabassa, Nicasio and Whitley, 2013; Green et al, 2015; Thomas and Rickwood, 2016), however it could be argued that it is not so fitting for use with focus groups (Hipolito, Carpenter-song and Whitley, 2011). Audio-recording a number of participants could prove difficult during the data analysis stage, which could result in misinterpretation. 

A detailed description of the data analysis process was provided by each study. One study (Edward and Robins, 2012) read and reviewed statements until they reached saturation; the point where no new information emerges (Given, 2008). Saturation suggests that a concept has been thoroughly 

examined and indicates quality data collection (Trainor and Graue, 2013). Five studies used coding to categorise key themes (Brekke et al, 2017; Cabassa, Nicasio and Whitley, 2013; Green et al, 2015; Hipolito, Carpenter-song and Whitley, 2011; Thomas and Rickwood, 2016), four of which were assisted with analytical software (Brekke et al, 2017; Cabassa, Nicasio and Whitley, 2013; Green et al, 2015; Thomas and Rickwood, 2016). Kaefer et al (2015) contends that analytical software makes a study more transparent and trustworthy. Furthermore, it is able to illustrate patterns of data that might not be identifiable with manual methods (Costa et al, 2017). Nevertheless, these programmes can be complex. Regardless of which data-analysis method is decided, researchers require particular skills and abilities. Although four studies stated that the authors were suitably qualified (Brekke et al, 2017; Cabassa, Nicasio and Whitley, 2013; Edward and Robins, 2012; Green et al, 2015), two did not disclose any background information regarding the researchers (Hipolito, Carpenter-song and Whitley, 2011; Thomas and Rickwood, 2016), which can lead to questions surrounding suitability. 

Sufficient information was provided by each study and was presented logically to support the findings. Five of the studies engaged in some form of peer debriefing or member checking activities to enhance credibility (Brekke et al, 2017; Cabassa, Nicasio and Whitley, 2013; Green et al, 2015; Hipolito, Carpenter-Song and Whitley, 2011; Thomas and Rickwood, 2016), two of which employed a range of researchers, clinicians and other relevant personal to increase rigour (Brekke et al, 2017, Green et al, 2015). 

Thematic Analysis 

After analysing the findings of the six studies, a number of factors relevant for recovery were identified (See also appendix 2 – themes table). 

Recovery routes 

The studies acknowledged a range of recovery routes. Several respondents reported that they reached recovery with the assistance of formal treatment programmes (Green et al, 2015), however some studies identified programme related problems. Respondents reported receiving mixed messages from clinicians, mental health medications impacting upon their ability to attend appointments, or being kicked out in the first instance of relapse (Edward and Robins, 2012; Green et al, 2015). A number of participants noted that they had a natural recovery, whereby they reduced substance use or reached sobriety by themselves, without help (Green et al, 2015). Reaching sobriety was found to be important for initiating the recovery process (Green et al, 2015; Hipolito, Carpenter-song and Whitley, 2011), but gaining complete control over substance use and symptoms was found to be just one pathway to recovery, rather than the very essence (Brekke et al, 2017). Some participants cited continued controlled substance use, even if it went against clinician’s advice (Edward and Robins, 2012; Green et al, 2015). 

These findings demonstrate the diversity of recovery; it illustrates the unique and individual aspects of each person’s healing process and suggests that there is no set standard route to be taken. 

Coming to terms with the conditions 

Recovery was revealed to entail coming to terms with conditions, this involved: acknowledging and accepting the existence of both the psychiatric and the substance abuse issues and developing a deeper awareness of oneself, ones illness and the impact that drug and alcohol use can have. Themes of acknowledgement, acceptance and awareness were identified across five studies (Brekke et al, 2017; Edward and Robins, 2012; Green et al, 2015; Hipolito, Carpenter-Song and Whitley, 2011; Thomas and Rickwood, 2016). 

Some respondents reported using substances to self-medicate, thus masking their mental health issues (Hipolito, Carpenter-Song and Whitley 2011); recognising the reality of the situation was 

revealed to be the first step for recovery. Likewise, Edward and Robins (2012) found admittance and acceptance to be important aspects; some statements reflected that recovery could not commence without treating both conditions. Acknowledgement also referred to the unravelling of traumatic events; recognising how a painful past might influence the present enabled individuals to move forward with their lives (Brekke et al, 2017; Hipolito, Carpenter-Song and Whitley, 2011). 

An awareness of the condition and the effects of drugs and alcohol were also found to contribute towards recovery. Respondents reported that they had no idea what they were doing to their bodies (Green et al, 2016); learning about it helped motivate them to change. Self-awareness of triggers and strategies for symptom management were also found to be significant (Hipolito, Carpenter-Song and Whitley, 2011; Thomas and Rickwood, 2016). 

These findings imply that the identification of both the mental health and the substance abuse issues is imperative and the statements suggest that treating them together is more successful. The findings also indicate the importance of enquiring about traumatic events. Trauma is usually a very personal and private matter, but professionals should support people to explore their past; otherwise it could hinder the recovery process and prevent people from progressing forward (Rosenberg, 2011). Finally, an awareness of the conditions was found to be fundamental; therefore both services and service-users need to be educated on the impact and interactions of mental health and substance use. 

Social support 

Giving and receiving social support was identified as important for recovery across five studies (Brekke et al, 2017; Cabassa, Nicasio and Whitley, 2013; Edward and Robins, 2012; Green et al, 2015; Thomas and Rickwood, 2016). 

Peers were found to have a positive influence on self-control (Edward and Robins, 2012) and participants said that social networks were able to shift unhealthy behaviours with encouragement and reinforcement (Cabassa, Nicasio and Whitley, 2013). Socialisation was found to aid recovery by reducing isolation and depression (Cabassa, Nicasio and Whitley, 2013), however respondents reported difficulty feeling accepted in the community as a substance user (Brekke et al, 2017). Having someone to talk to was identified as imperative (Brekke et al, 2017; Thomas and Rickwood, 2016) and participants stressed the significance of simply being around other people in similar situations (Green et al, 2015). Peer support was found to increase people’s awareness of addictions (Brekke et al, 2017) and providing that support for peers enabled individuals to feel valued and needed (Cabassa, Nicasio and Whitley, 2013). 

These findings demonstrate the social dimensions of recovery; peers can have an immense impact upon a person’s self-control and self-esteem, both of which are essential elements. It is therefore important that professionals are aware of this and provide support group services and peer-led initiatives where possible. 

Spirituality 

Spiritual sustenance was found to play an important role in recovery across four studies (Brekke et al, 2017; Cabassa, Nicasio and Whitley, 2013; Green et al 2015; Hipolito, Carpenter-Song and Whitley, 2011). Spirituality was found to serve as a valuable source of hope (Hipolito, Carpenter-Song and Whitley, 2011) and a number of respondents reported that they relied on their religion or faith as a source of strength for sobriety (Cabassa, Nicasio and Whitley, 2013). Prayers, meditation and reading religious texts were cited as being used as a healthy release from stress, and spiritual services were found to give individuals a sense of direction (Cabassa, Nicasio and Whitley, 2013). Some participants stated that what had helped them was of a religious nature (Green et al, 2015), others noted that understanding the bigger picture and recognising the concept of a higher power provided them with a sense of dignity and meaning (Brekke et al 2017; Green et al, 2015). In one study 

participants said that they kept spiritual experiences secret from professionals for fear of it being seen as a symptom (Brekke et al, 2017). 

These findings highlight the healing aspects of faith. Since spirituality can be such a significant factor for some people’s recovery, it is imperative that professionals adopt a non-judgemental attitude, which allows individuals to be open and talk freely. Again, support groups might be a suitable suggestion since they often incorporate elements of spirituality within the sessions. 

Being productive/having purpose 

Recovery was revealed to involve being productive and finding purpose within four studies (Brekke et al, 2017; Cabassa, Nicasio and Whitley, 2013; Edward and Robins, 2012; Thomas and Rickwood, 2016). 

Respondents described recovery as feeling useful and remaining occupied (Brekke et al, 2017; Edward and Robins, 2012); having something to do or somewhere to be was identified as important, even if it just meant getting out of the house for a while (Edward and Robins, 2012). Cabassa, Nicasio and Whitley (2013) found life achievements to be central to recovery; going back to school, completing qualifications or finding employment restored a sense of self-worth and purpose. The same was echoed within Brekke et al (2017); recovery was defined as ‘mastering life’; practising skills and gaining greater experience to accomplish personal goals. 

Community involvement provided individuals with a sense of connectedness and feelings of normalcy (Edward and Robins, 2012), contributing within the community was also associated with feeling valuable (Brekke et al, 2017). 

These findings posit that community participation is pivotal for recovery. Services that provide support with education and employment could have a promising, positive impact, although they may not prove practical for everyone. Individuals with co-occurring conditions may benefit from reablement services; which seeks to support people to regain skills and confidence with a range of assisted activities (Care Quality Commission, 2012). 

Application to Health and Social Care 

Overall, the findings demonstrate a need to develop a deeper awareness of co-occurring conditions. Mental health and substance abuse issues are extremely prevalent and people with co-occurring conditions are likely to present within contexts other than just healthcare (Baker and Velleman, 2007), educational programmes aimed at both professionals and the public should therefore be employed to promote awareness. Promoting awareness promotes the recovery process; the studies showed that individuals must come to terms with their conditions (Green et al, 2016; Hipolito, Carpenter-Song and Whitley, 2011; Thomas and Rickwood, 2016); they should be supported to learn about the impact of and the interactions between their mental health and substance abuse issues, but this cannot take place unless all agencies have an adequate awareness themselves. 

Acknowledging the existence of both conditions was found to be the first step for recovery (Edward and Robins, 2012), however many people self-medicate (Hipolito, Carpenter-Song and Whitley 2011), which masks the true extent of their troubles. Individuals are often unable to recognise that they have co-occurring issues (Baker and Vellemen, 2007). Identification is imperative to recovery since co-occurring conditions often interact, an implication for practice could therefore be the suggestion of routine screening within mental health and substance misuse services. The criminalities surrounding substance use sees people reluctant to tell professionals their problems; policies and procedures should therefore be developed to promote trust. Service-users should feel at ease and simple screening interviews and self-report questionnaires should be implemented (Baker and Velleman, 2007). 

The studies showed that there is no set standard recovery route (Brekke et al, 2017; Green et al, 2015; Hipolito, Carpenter-song and Whitley, 2011); what works for one person may not work for another, therefore there should be a range of treatment options on offer. The findings suggest that support groups might be most suitable for this client group since they can provide social and spiritual sustenance. Since the studies suggested that being productive is pivotal to recovery (Brekke et al, 2017; Cabassa, Nicasio and Whitley, 2013; Edward and Robins, 2012; Thomas and Rickwood, 2016), community based interventions should also be considered; societal participation has shown to reduce the severity of distress and any community involvement can give individuals a greater capacity to cope (Tew, 2005). Talking therapies should always be an available option; trauma is cited as a commonality amongst individuals with co-occurring conditions (Brown et al, 2013) and ignoring it only hinders healing. 

Identifying Future Research Needs 

The six studies have contributed greatly to the comprehension of co-occurring conditions and have identified a number of important issues relevant for recovery, nevertheless there are several limitations surrounding the samples. Some samples seem to be biased as they only selected particular groups of people (Green et al, 2015; Hipolito, Carpenter-song and Whitley, 2011; Thomas and Rickwood, 2016), furthermore none of the studies investigated the experience of individuals in the United Kingdom. Hipolito, Carpenter-song and Whitley (2011) note that meanings of recovery may differ depending on ones socio-demographic status, studies should therefore be conducted within the United Kingdom and they should seek a diverse sample comprising of different ages, genders and ethnic groups. 

Some studies identified programme related problems (Edward and Robins, 2012; Green et al, 2015); more research is therefore required to expand on any barriers to recovery. 

Conclusion 

Overall, the studies have shown that although recovery is an extremely personal process, there are a number of shared elements that can be of significant support. Education encourages recovery by raising awareness and allowing individuals to come to a clear understanding about their conditions, learning new skills keeps people productive and can also provide a sense of meaning and purpose. Community participation and peers can have a positive influence on a number of levels, however some statements suggested that substance users struggled to feel like they fit in. Spirituality was found to be another important influence, but it tends to be overlooked within traditional treatment services. Peer-led support groups have therefore shown to be particularly promising for this client group since they incorporate elements of spirituality and socialisation within the sessions. 

All of the studies have methodological strengths and weaknesses, although there were questions surrounding the suitability of some approaches, the author argues that the appropriate steps were taken to ensure authenticity and validity, thus allowing for this data to be added to the already existing knowledge of co-occurring conditions. 

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Appendix

Appendix 1: Search summary 

Databases used: 

- Academic Search Complete 

- CINAHL 

- MEDLINE 

- PsycINFO 

- Psychology and Behavioural Sciences Collection 

- University of Wolverhampton Library Catalogue 

Keywords used: 

- Mental illness 

- Substance abuse 

- Dual diagnosis OR Co-occurring OR Comorbidity 

- Recovery 

- Experiences 

Study selection process: 

- ‘Substance abuse’, ‘mental illness’ and ‘recovery’ = 1692 results, 

- Limited to articles with full text only, published between 2011-2017 = 504 results (two studies selected from the surface). 

- Keywords ‘dual diagnosis’ OR ‘co-occurring’, OR ‘comorbidity’ included = 111 results (one study selected from the surface). 

- Search refined to exclude the terms ‘homeless’ OR ‘homelessness’, limited to articles with references available = 20 results (one study selected). 

- University of Wolverhampton Library catalogue searched using the keywords ‘Dual Diagnosis’, ‘Recovery’ and ‘Experiences’ =24,806 results. 

- Limited to journal articles with full text available, published between 2012-2017 = 4,779 results. 

- Limited by subject terms; studies = 536 results (two final studies selected). 

Appendix 2 Themes 

Appendix 3 Studies 

Co-occurring Mental Health and Substance Misuse Recovery, a Critical Review
Authors Jodi Ward
Faculty of Education, Health and Wellbeing, University of Wolverhampton

Correspondence: email: jvward93@gmail.com 

 Journal of Health and Social Care Improvement 2018 February: Issue Vol 1 (4) 1-14

Abstract 

Gender and race can be regarded as the major organizing principles of the labour market, with disability, age and sexual orientation being factors that also influence employment patterns and outcomes (Kirton and Greene 2010). These five dimensions of diversity are the main sources of employment discrimination and disadvantage. 

This paper explores the male nursing student’s experience and considers whether male discrimination and disadvantage takes place as they are a minority group within nursing. The research used a mixed methods approach. It was conducted using semi-structured qualitative interviews on twelve respondents and two qualitative focus groups containing six respondents. A quantitative email questionnaire sent to two hundred student nurses was also used. The respondents were from a wide range of backgrounds, ages, cultures and levels of training. The findings showed that the male student nurses experience was very mixed. This included issues relating to perceptions, attitudes, roles, barriers, challenges, negative experiences and effects all relating to being a minority group subject to gender discrimination. Influences other than gender were noted to have an effect on their male experience such as age, culture, life experiences, confidence, personality and character traits. This research also identified possible solutions to how male experience could be improved and what the benefits would be of having more male nurses in the profession. 

Key words: male discrimination, sexual predator, unmanly, resilience, peer support 

 Introduction 

There have been many different definitions and approaches to equality over the years. The main approach being based around the liberal and radical ideas which came about from the equality agenda of the 1970s-1980s. In the 1990s and onwards the equality agenda (policies and practices of equality and equal opportunities in organisations) moved towards diversity approaches. The principle of diversity being to maximise individuals potential with a move away from the negative aspects of older equality agendas by using employees diversity such as ethnicity to add value to organisations. The hope was that this new approach of promoting equality would lead to profit aligned with organisational objectives. However, despite this new way forward many organisations can still meet their objectives either without workforce diversity or without actually valuing diversity (Kirton and Greene 2010). This leads to inequalities and there is still a need to develop policies to redress discrimination and disadvantage. Because of this it is important for diversity management policies to grow from and onto existing equality policies and Acts, rather than replacing them (Kirton and Greene 2010) such as the new Equality Act (2010). 

It is widely accepted that there are six main equality and diversity strands: gender, race/ethnicity, disability, sexual orientation, age and religion. Gender and race can be regarded as the major organizing principles of the labour market, with disability, age and sexual orientation being factors that also influence employment patterns and outcomes (Kirton and Greene 2010). These five dimensions of diversity are the main sources of employment discrimination and disadvantage. 

This case study considers male discrimination and disadvantage in nursing education and looks at the reasons why men go into nursing. It examines the perceptions and attitudes within nursing towards male student nurses and considers the educational environment and pre-registration nursing course as a whole. It also looks into male personal experiences of discrimination and how they manage and cope with. Other experiences are also highlighted in the form of the barriers they come across and the reactions they get from others. There is a final consideration as to whether the male student nurses experience could be improved and in what areas. Consideration is also given in terms of how male student nurse numbers could be increased and why this would be beneficial to the profession as a whole. 

Research Design 

The research philosophy based on this study is a mixture between positivism and interpretivism. Business and management research often reflects this dual perspective, perhaps reflecting the stance of realism (Saunders et al 2007). Data is usually collected in the form of descriptions using non mathematical procedures when interpreting and explaining research (White 2002). There are a number of reasons to combine these two types of philosophy (White 2002). For example deciding to carry out a questionnaire after investigating a subject from a qualitative perspective or after studying changes in an organisation a survey is carried out to gain opinions about a particular aspect (White 2002).Ultimately looking at the same problem from a number of viewpoints is an excellent way to verify interpretation and draw conclusions (White 2002). Triangulation is the term used to describe this combining of qualitative methods with the idea being to increase the quality of the research (Cooper and Schindler 2008). By using a variety of methods, results give far more information about the topic under investigation (White 2002), particularly if the results from the different methods point to the same inferences; this in turn strengthens the whole argument (White 2002). Mixed methods also overcome any limitations of using one method particularly when wanting to provide a better understanding of a phenomenon (Bryman and Bell 2011). 

Interviews were adopted for this study because they are a popular form of data collection and can provide a rich source of material (White 2002). The main advantage is that they can be used in a variety of contexts, situations, and in conjunction with other research methods (White 2002). They are not without disadvantages as they can be time consuming, suffer from problems of bias (White 2002). There is always the danger that the interviewees could want to please the interviewer and as a result not tell the truth (White 2002). For the purpose of this research a semi-structured interview was used as this gives the interviewee a great deal of leeway in how to reply (Bryman and Bell 2011), particularly as questions can be asked as the interviewer picks up on things making the interview process more flexible (Bryman and Bell 2011). Twelve interviews were carried out on male students from the ages of eighteen to forty and from year one, two and three of the pre-registration adult nursing course. Sample sizes for qualitative research vary by technique but are generally small as in this research. Nonprobability sampling (Cooper and Schindler 2008) was used where little attempt is made to generate a representative sample. The type of nonprobability sampling used was purposive whereby the researcher chose participants arbitrarily for their unique characteristics (Cooper and Schindler 2008). 

This study also utilised focus groups so that the people with similar experiences could be interviewed in a relatively unstructured way about that experience (Bryman and Bell 2011). The focus group has become a popular method for researchers examining the ways in which people in conjunction with one another construe the general topics of research interest (Bryman and Bell 2011) and can be used to define problems and facilitates individuals to work together to identify potential problems (Hutt 1979). They also allow the researcher to develop an understanding about why people feel the way they do (Bryman and Bell 2011), and allows people to probe each other’s reasons for holding certain views. This method can be more interesting than the 

sometimes predictable question followed by answer approach of interviews and is more naturalistic. The participants were selected because they were male nursing students and they were encouraged to discuss and share their points of view without any pressure to reach a consensus (Kruegar and Casey 2000). 

Two focus groups were chosen with six participants in each as focus groups typically involve groups of six to twelve (Bryman and Bell 2011). Morgan (1998) recommends smaller groups as participants are likely to have a lot to say on the research topic, especially when they are emotionally preoccupied with the topic. When the moderator reaches the point that he or she is able to anticipate fairly accurately what the next group is going to say, then there are probably enough groups already (Calder 1977). So these two groups were felt to be sufficient. 

The interview questions and focus group questions were semi-structured in nature, with open questions being asked around different themes. These themes were centred on the reasons/motivations/characteristics that underpin nursing, the perceptions and attitudes of others towards male nurses and how students coped with them. The male student’s personal experience of the educational environment and how students felt their experience could be improved. With open questions, respondents were asked questions and could reply however they wished (Bryman and Bell 2011). The reason to use open questions was so respondents could answer in their own terms and allowed unusual responses to be derived. The questions did not suggest certain kinds of answer but were derived from the research, they were useful for supporting the research or exploring new areas or ones in which the researcher had not thought of before or had a limited knowledge of as recommended (Bryman and Bell 2011). The reason for this structure was to incorporate flexibility and therefore gain rich data and information. 

An email questionnaire was also chosen and a non-random (non-probability) sampling was used as it is impossible to determine accurately the sampling frame. The survey was sent to two hundred male nursing students as it was a cheap method that allows for a large sample spread over a wide area, and is convenient for respondents (Bryman and Bell 2011). This used closed questions only and was more generic in its themes, so as to gain views that would prove or disprove the findings. The reason to use closed questions was because it was easy to process the answers and they enhanced the comparability of the answers making it easier to show relationships between variables and comparisons (Bryman and Bell 2011). 

List style questions were used which offered the respondent yes/no responses (Saunders et al 2007). They are essentially useful when ensuring the respondent has considered all possible responses (Saunders et al 2007). It was important to make sure the responses were defined clearly and meaningfully so that respondents were more likely to answer (Saunders et al 2007). Making questionnaires easy to answer is attractive and encourages the respondents to fill and return them (Saunders et al 2007). To achieve a high response rate an introduction was given on the first page of the questionnaire in addition to the covering letter. The limited time frame of the research meant that this survey was only a snapshot of students from one University. As Saunders et al (2007) states a short snapshot can be used to explore a particular phenomenon or phenomena at one particular instance. 

A pilot study was undertaken as this should be done with a group similar as possible to the final population so that respondents will have no problem in answering the questions and there will be no problems in recording data (Saunders et al 2007). This involved showing the questionnaire and all the possible questions that were going to be asked to three people. Undertaking a pilot allowed for some assessment of the questions’ validity and the likely reliability of the data to be collected (Saunders et al 2007). The pilot did not identify any apparent problems and the questionnaire was deemed to make sense i.e. it had face validity (Saunders et al 2007). 

Data Analysis 

The interviews and focus groups were recorded allowing them to be transcribed and reviewed later (Bryman and Bell 2011). Note taking instead would have been disruptive as respondents need to stop whilst writing something down (Bryman and Bell 2011) and the nuances of language can be lost if the researcher has to rely on notes (Bryman and Bell 2011). Content analysis was used to analyse the findings of the interviews and focus groups as this seeks to quantify content in terms of predetermined categories and in a systematic and replicable manner 

(Bryman and Bell 2011). Content analysis was chosen as it follows a systematic process for coding and drawing inferences from texts (Cooper and Schindler 2008). In the case of this research thematic data units were coded, which uses topics contained within texts illustrating they represent higher level abstractions inferred from the text and its content (Cooper and Schindler 2008). In other words the responses to an open ended question may reflect a certain theme and essentially, what is being sought is a categorization of the phenomenon or phenomena of interest (Bryman and Bell 2011). 

Since the nature of the research was only a snap shot, detailed statistical analysis was not required (White 2002). Univariate analysis was used as this allows for the analysis of one variable at a time (Bryman and Bell 2011). A frequency table was produced to provide the number and percentage of people belonging to each of the categories of the questions (Bryman and Bell 2011). Diagrams were used to display the data as they are among the most frequently used methods of displaying quantitative data (Bryman and Bell 2011) their chief advantage being that they are relatively easy to interpret and understand (Bryman and Bell 2011). Pie charts were mainly used as this helped to show the relative size of the different categories and also brings out the size of each slice relative to the total sample (Bryman and Bell 2011). 

Following on from the data analysis the findings were categorised into three main themes which were- 

1. The experience of male discrimination 

2. The resilience of a male nurse 

3. The way forward 

These will now be discussed in turn. 

The experience of male discrimination 

Male students face problems because of their gender within nurse training which has been identified within the literature before (Keogh and O’Lynn 2007). Ironically being a male was used as an advantage at times as male students were expected to be assertive and to assume leadership roles and to take on extra jobs such as assisting with heavy lifting and transporting patients. However this also meant that they were often more closely scrutinised and “under a microscope” and these expectations were not really congruent with a course curriculum that was aimed more towards the needs of the female sex (Kelly, Shoemaker and Steele 1996). As a consequence in order to gain access to other jobs it was often cited that they had to be “extra professional” in their demeanour and approach. Respondents reported the perception of being in a ‘girly job’, again confirming that male nurses require the perceived attributes of a female nurse. Not only were these concepts evident within the nursing profession, but many of the male student nurses’ reported their families shared a similar perception, again questioning their reasons for why they were wishing to enter the nursing profession. Ultimately they felt discriminated against and as a result of this they had to cope with social isolation and unequal clinical opportunities compared to that of females. One such example of this related to receiving conflicting instruction around the use of human touch which was more female orientated. The latter correlated to the literature presented by Evans (2004) and Fenkl (2006) whereby male nurses continue to be stereotyped and the feminisation of the profession limits their full participation. They expressed issues of self-doubt and the perception of being treated very differently in their clinical experiences and clinical opportunities from that of female nurses. 

The findings suggest that student’s felt there were many barriers to becoming a nurse, which included a fear of being perceived unmanly and not getting a client’s acceptance because of this. The stereotyping of student nurses as being ‘gay’ and the concept of homosexuality was predominant with male student nurses being asked frequently about their sexual orientation. This was a strong theme that arose across all three data collection methods. There are parallels in this research to the work undertaken by Genua (2005) who examined the stereotypes amongst male nurses and they concluded also that men can be labelled as gay or effeminate All respondents concluded that they had all been asked by their mentors regarding their sexual orientation with some stating it was ‘homophobia but can’t be proved’’ or they had said ‘don’t you want to do a real man’s job?’ Additionally all respondents disclosed that they would openly state to people anything other than the fact they were a nurse. It was felt that there was a distinct lack of male role models or male mentors in nursing to pave the way ahead for them and this would have made the situation easier. 

Labelling male nurses as gay or effeminate can be considered as a social control issue because nursing 

is defined as a woman’s profession (Evans 1997). It is evident when examining male student nurses that questions regarding their sexual orientation is not only embedded within the profession in training but it can follow them throughout their nursing career (Genua, 2005). Genua (2005) further suggest that being a male nurse will limit their eventual choice of speciality looking for jobs where there is little requirement of the need to touch or deliver intimate care at the bedside. Contrary to this Williams (1995) argues that male nurses who present themselves as ‘suitably masculine’ have consequently benefitted in tangible ways. One such instance relates to the fact that they gain higher level positions in nursing where there is an emphasis on leadership skills, technical competence and an unconditional dedication to work- qualities typically associated with masculinity. This is also noted at a nurse education level where it could be argued that male student nurses are also treated preferentially. It is therefore argued, the division of labour based on gender, has resulted in men being channelled into areas of specialisation considered more congruent with masculinity. These areas, in addition to their historical association with masculine traits such as physical strength, also reflect the superior value of men and everything masculine in patriarchal culture (Evans 2004). 

It was clear throughout the discussions of the focus groups and interviews that the male students had been excluded from certain types of placements, gender specific care and from certain gender specific procedures whilst on their nursing programme. There was a general feeling amongst the respondents that they were excluded from optimising learning opportunities due to being male even though there were male midwives and male medical practitioners present. 

The aforementioned has a clear correlation between the existing literature and the research findings; however the phrase ‘sexual predator’ occurred frequently throughout all methods of data collection and this had not been something that has been highlighted before in the literature. Being thought of as a “sexual predator” was brought up with undertones relating to being asked about their sexual orientation all the time. They felt that many who asked did it in a covert way to hide their homophobia rather than in a more overt ways previously. The students felt this was due to changes in society and the fears of today based on the need to be politically correct. This was supported with a respondent stating ‘won’t ask to look after young female patients as there is an image of being sexual predators despite it being ok for male doctors’. All the respondents felt that the media had a role to play in bring about this attitudinal change, it related to how television programmes reinforce the notions of sexual predators being dangerous and gay. 

It seems that the perceptions of male nurses predominantly relate to being seen as homosexual and necessitating female traits and characteristics. These perceptions are in line with the current research and are not only in existence within the profession, but also stretch to society’s perception including family and friends and the media. The term ‘sexual predator’ appears to be a new immerging concept that has not previously been sighted within the current available literature and this concept may be influenced through current media channels. 

The resilience of a male nurse 

In order for male student nurses to manage the levels of discrimination that they encounter, the findings suggest ‘resilience’ plays a fundamental coping strategy in their day to day working activities. Integral to this notion is the idea that personality and characteristic traits are important facets in producing resilient practitioners. Fundamental to being resilient was the belief that students had to have the trait of being able to ‘get on with people’ and do that little bit extra and particularly that above their female counterparts as they ‘must impress’, and be able to ‘lift heavy stuff’, they were always ‘needed for some muscle’, ‘to manage difficult and aggressive people’, this in turn gained dividend in terms of much respect from others. 

Despite the literature review and findings from this study suggesting male student nurses require feminine behaviours and are labelled as being gay, it is suggested that they also need the prerequisite of masculinity. Furthermore male nurses are expected to be more assertive, assume leadership roles and take on increased duties such as heavy manual handling, managing difficult situations and transporting patients. There was an overriding consensus that the male students were expected to undertake all this on a regular basis and to use this to the advantage of the workplace. They were asked frequently to assist pregnant nurses, manage violent 

and aggressive patients under the influence of alcohol or illicit drugs, chaperone female nurses for safety and expected to look after prisoners. Male student nurse appeared to have an extended role and this extension also appeared to be apparent within the higher education setting whereby male student nurses were also expected to take on the enhanced leadership roles at the university such as student representation. 

Respondents also acknowledged that way they were treated was not a bad thing as the man’s role is essentially to be gallant and there were advantages ‘it is about chivalry and so feel it is the role’, ‘this was fine as just want the job done’, ‘everyone remembers you’, ‘stand out more’ and ‘must have positive attitude then have positive experiences’. The students also recognized that in order to be successful they needed to be able to adopt certain traits they perceived as belonging to females including being caring, sensitive, social, clean, tidy, friendly, good listener, open, generous, emotional, multi-tasker, calming, empathetic, compassionate and helpful. This is cognisant with Grant (1988) identifying female qualities such as nurturance, compassion, sensitivity, cooperativeness, affection, gentleness, interpersonal sensitivity and interdependence as important traits for male nurses to have. Khan et al. (2011) also acknowledged that instead of attributing these notions a female traits adopted by males it is more that there can be differing levels of masculinity and that this is more consonant with the expression of emotion, openness to experiences and acceptance towards the diversity of men’s sexual preferences. Arguably the traits attributed to males such as independence, self-reliance, autonomy, aggression, leadership, initiative, competiveness, ambition and analytical thinking are essential qualities need to survive or become a leader in today’s ever changing NHS. Nonetheless, some may argue that such characteristics of success are not without consequence as in the male nurse situation they are underpinned by homophobia, disadvantage and discrimination; it may be easier and more rewarding to want to be true to oneself and successful because of it. 

Adopting this stance would also alleviate some of the problems the male student nurses experienced such as feeling that they needed to perform to a higher level than their female counterparts in order to be accepted and valued. Whilst some saw this positively others highlighted how this can be challenging and very isolating at times and recognised the importance of having a support mechanism around them. 

There was a prevailing agreement amongst all respondents that being able to socialise and discuss day to day practices with other male student nurses was vital in order to progress positively through the nursing curriculum. The male student nurses who did not have this opportunity to socialise and discuss issues with male peers felt more isolated and lonely with one respondent stating ‘he had been depressed and required counselling because of this’. Undoubtedly, this provided some indication that some respondents felt a degree of role strain. This was compounded by a perceived lack of support from some mentors and female academics. Male students relayed that they had the additional burden of having to work a little harder to prove themselves due to being a minority group with one respondent stating they felt ‘pressure to stand out and to perform well to give a better image of males and encourage more to come into the role’. Role strain was not experienced by all as they suggested they just needed to ‘just band together as male students so not noticed’ or it was ‘down to how you bond with the group’. These responses are congruent with holding a particular personality strength alongside the ability to take advantage of peer support. Interestingly, the ideology of having some form of peer support, whereby socialisation and discussions can take place, seems to strengthen the male student nurse resilience which has not been noted in previous research. 

Overall, the respondents described themselves as having both male and female characteristics which were seen as separate not interchangeable attributes amongst the sexes. The trait male nurses felt they possessed were felt to be adaptive rather than inherent. Furthermore it is evident that male students need to be resilient in training to deal with the challenges they face as men and social support plays an important part in this resilience. 

The way forward 

There is a clear necessity and professional obligation to provide more male nurse mentors to act as future role models to students and this could potentially improve the male nurse experience. There was a strong correlation across the three types of data collection methods that student nurses who have 

experienced male educators have received a much more positive experience and felt better supported within the course. Students feel that this move alongside the introduction of specific male mentorship programmes should be considered with much more intent. Likewise in training students institutions need to be cognisant of the strong feminist image nursing portrays and how this can discriminate against males. Programmes and education has to be specifically designed to promote equality amongst the sexes. Respondents highlighted that by not addressing their needs this resulted in ‘no guidance on the appropriate use of touch’, and ‘limitations for male students during obstetric training’. Educators themselves should be more aware of their audience and act appropriately as reported by a respondent ‘lecturers need to stop calling everyone ladies or calling out morning girls’. This behaviour by lecturers further compounds the feelings of social isolation by male students. Nurse educators who are aware of gender issues and avoid gender bias in texts and historical frameworks of practice can better facilitate learning and prepare male nurses to move from a sense of being oppressed to being empowered professionals (Anthony 2004). 

Students also highlight that recruitment into nurse training is faced with powerful barriers to prevent males from applying. This includes the powerful professional representation of nursing with its symbolic image of the female uniforms, titles and language. It is widely acknowledge within the literature (Alvesson and Billing 1992) that most jobs in society and most work areas in organisations have some sort of gendered image. Symbolism is closely connected to the degree to which the job is disproportionally occupied by one sex. The media has a strong part to play in reinforcing this female image of nursing and actively promotes the stereotype of male nurses as gay. Many of the respondents felt that the general public viewed nursing as the ‘Carry On’ films or ‘Holby City’. Furthermore it was noted by the respondents that nursing was not actively encouraged by career advisors, teachers or parents during their secondary education as it was seen as a more female profession. 

Attrition and academic failure rates for men who enter into the nursing profession are high (Keogh and O’Lynn 2007) and it is clear that students do not always experience a training environment that is conducive to their needs as men in a female oppressed profession. The findings suggest as found by Ryan (2009) that men and women have different learning styles. Male students generally display the assimilator style of learning valuing rationalism and objectivity and they prefer didactic learning. However, a learning style most commonly seen in nursing is the reflector (Honey and Mumford 2000) which is preferred mostly by female students. As a result male students generally have to adapt to a more female orientated style of learning (Ryan 2009) which can impact negatively on their performance and their socialisation into the profession (Keogh and O’Lynn 2007). 

It is evident that men in nursing have great difficulties within their training and there is a need to offer strategies to retain learners and find solutions. Nurse educators must use strategies and tactics to make male student nurses feel they are accepted and have valuable talents and traits that they bring to the profession. In order to provide appropriate education and training for student’s attitudinal change is required. The biggest shift must come from nursing leadership in changing nursing culture within the profession to become more sensitive of the gender needs of students. Awareness of media influence is also important in bringing about change. It is recognised that powerful methods such as the media and organisations can influence the existing symbolism of nursing positively creating a new cultural/societal image of the male nurse. 

Conclusion 

This research study set out to examine the male nursing student’s experience and it has confirmed that the male student nurse experiences are complex. The findings to this research study have been based upon a mixed methodology utilising three data collection methods increasing the reliability, validity and trustworthiness. Nonetheless, this study is based upon respondents from one higher education institute and is therefore too small to make generalisations to the wider population of male student nurses. 

Gender discrepancy, bias and discrimination exist within nursing with male student nurses reporting many barriers and stereotypes. It is evident that male student nurses are perceived to be unmanly due to the feminine characteristics they sometimes hold. 

Feminine traits within male students however can actually complement their pre-existing masculinity and this can be fundamental to delivering patient care effectively. 

There seems to be a cultural and societal acceptance that men entering the nursing profession are ‘gay’ with their sexual orientation being questioned frequently, not only within the clinical setting but also within the structure of their family and friends. This issue appears to amplify the sexism approach within the clinical environment impeding the types of placement or learning opportunities chosen. A new emerging theme of male student nurses and nurses being a ‘sexual predator’ has not been cited in previous research and was unexpected to the researcher. Again this is most likely to be related to societal constructs and the current legal frameworks within the UK. Male student nurses need resilience to work within a heavily dominated female profession and value receiving emotional and social support in order to thrive. Despite numbers increasing, male nurses still remain a minority group with many experiencing some form of role strain. 

In response to these findings it is recommended that a number of changes are required to eliminate the problems males experience when entering into nursing. The media could be influential in altering current stereotypes allowing public perceptions to change. This would certainly challenge the pre-existing symbolism attached to nursing whereby societal influences have perpetuated the development of nursing as a predominately female gender specific profession. This societal perception of nursing ultimately deters some male applicants from seeking admission to nursing programmes. Initially this calls for more improved career advice to be made available within secondary education and lastly higher educational clinical and academic environments require an attitudinal shift embracing the presence of male learners. More male mentors are required and therefore the introduction of male mentorship programmes is advisable. Certainly an increase to male nurses and male mentors would be beneficial to improving the efficiency, diversity and service delivery of the NHS offering a breadth of choice and flexibility to patients. A proactive approach addressing both the internal organisation and the external recruitment of men needs to take place if gender diversity in nursing is to happen so as to more effectively provide care to an increasingly diverse population. 

References 

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Trials and tribulations of male student nurses 
Author: Paul Jackson 
Faculty of Education, Health and Wellbeing, University of Wolverhampton 

Correspondence: email: P.Jackson3@wlv.ac.uk 

Journal of Health and Social Care Improvement, 2018 February. Issue Vol 1 (4) 15-23 

Abstract 

This study described the lifeworld of one ‘chronic pain patient’, Shelly whose disability living allowance (DLA) was withdrawn. The aim is to explicate the existential impact of this withdrawal when she presented her lived experience of this phenomenon in her narration. As I listened to Shelly’s problem soaked narratives through a relatively unstructured interview, an emerged behind the scene voice of travail became louder through the narratives. The existential phenomenological analysis reveals an experience of erosion of Shelly’s sense of identity, a daily toil and laborious lived body in the context of her life activities and relationships. The narratives also revealed the patriarchal approach of ‘the system that be’ that were compounding and even making the voice of travail louder, eroding autonomy, promoting feeling of helplessness and suffering. These findings were discussed in the context of previous studies. Following the discussion, a reflexive account of the research relationship and how the process of analysis has impacted on this researcher was provided to promote a more transparent accounting of the relational centred methodology and how I came to my interpretation. Findings from this research lend support to the idea of the ontology that fully embodied and integrate with our being in the world, bridging the gap and weaving together a new way of understanding the body-subject and how it experiences and copes with its vulnerability in the world 

Key words: Chronic Pain, Disability Living Allowance, Life world, Travail, Embodiment 

Introduction 

The wave of austerity and unfavourable economic climate which swept across Europe towards the end of 2009 (Norman & Uba, 2015) led the United Kingdom government to embark on budget cutting and a series of sustained reductions in public spending in 2010. This austerity measure has continued up to the time of writing this article, with the aim of reducing the budget deficits and public debts through closure programmes to either abolish or withdraw funding. The first focus was public bodies funded by the government known as quasi-autonomous non-governmental organisations (Quangos) and later, incapacity benefits, organisations such as the National Health Service (NHS), leading to varied consequences (Morris, 2010; Hills, 2015). The Disability Living Allowance (DLA)/attendance allowance advisory Board, and the Appointments Commission were returned to Whitehall departments (Morris, 2010). 

Some researchers have presented arguments that justified the government’s closures and benefit cut programmes. Allen & Radev (2006) presented that keeping the Quangos promotes lack of transparency and lack of accountability for the tax payers’ money. It was also reported that in the UK, about 3,000 people go on to the incapacity benefit scheme every week and a mere 300 ever return back to work (Frank & Chamberlain, 2001; Phillips, 2006; Waddell& Burton, 2006). Specifically, the Taskforce on Pain in the work place have argued that benefit payments could compromise the motivation to return to work and recommended that medical benefits for Chronic Pain (CP) should cease at six weeks in order to encourage early mobilisation and return to work (Ministerial Task Force for Health, Safety and Productivity- MTFHSP, 2004). These forms of arguments have led to the setting up of a stringent definition of disability based on substantial limitation in a major life activity, similar to what happened in the US and Canada in the past (Friedland, 1999). 

The issue of cuts to benefits for disabled people is not a popular topic among the people and was well contended (Action for M-E, 2016; Morris, 2010; DeGood & Kierman, 1996). However, the Department of Work and Pension (DWP) announced the scrapping of the DLA and an introduction of a new support programme, arguing that £2 billion in savings is expected from ending the DLA (Age UK, 2013). Hence, from April 2013, a new benefit called Personal Independent Payment (PIP) replaced the old DLA (The Disability rights, 2013) and it came to force on February 2013, under part 4 of the welfare reform act, 2012. This led to the reassessment of people obtaining the old DLA and new applicants by the new disability assessors trained and commissioned to carry out this assignment under the DWP (Age UK, 2013). 

Although the eligibility criteria for the DLA have not changed for the PIP, it has now become more stringent as disability is now based on substantial limitation in a major life activity (DWP, 2013) similar to the US definition (Friedland, 1999). Eligibility criteria also demanded claimant ‘to have had these limitation/difficulties for 3 months and expect them to last for at least 9 months’ (Tu & Ginnis, 2012; DWP, 2013) with the exemption of only the terminally ill who are not expected to live more than 6 months (DWP, 2013). Concerns were raised that this way of defining disability could invalidate the eligibility of those with fluctuating disability or whose conditions are episodic and might not fit the orthodox ways of body construction as well/unwell, healthy/unhealthy, abled/disabled (Action for M-E, 2016; Lightman, Vick, Herd & Mitchell, 2009). 

As the PIP came into force, the guidance note stated that claimants will be regularly assessed to re-establish their eligibility and identify the help needed (DWP, 2013). Hence, people living with chronic pain and other chronic conditions were re-assessed, leading to many losing their DLA status as they could not fit well to the new disability definition. 

The current study focused on the lived experience of withdrawn DLA of a person living with a chronic pain condition. Chronic pain is a condition characterised by persistent or episodic nociceptive pain of a duration or intensity that adversely affects the function or wellbeing of the patient. Chronic pain is defined as pain that persists or recurs for more than 3 months over a 6-month period (IASP, 1986 & 2016). It is estimated to exert the highest cost of economic burden as a major cause of disability across the world (Phillips, 2006). It is also regarded as the most common medical cause of long term sickness absence annually (Phillips, 2006; Allen, Hubbard& Sullivan, 2005) and could have a profound negative impact on the quality of life of the Chronic Pain Patients (CPPs) in addition to its economic impact (Eriksen, Jensen, Sjogren, Ekholm & Rasmussen, 2003). Without adequate treatment, the CPPs are often unable to work or even carry out the simplest of tasks leading to problems such as depression or stress (Eriksen et al., 2003; Ekman, Jonhagen, Hunsche & Jonsson, 2005). Moreover, the condition might fluctuate and may not fit well within the framework of able/disabled and healthy/ill whereas other types of disabilities could be inferred from an inability to function on a daily basis in the work place or elsewhere (Beatty, 2005). 

The struggles of the CPPs to legitimize their chronic illness and achieve a sick role have been well documented in literature. Werner, Isaksen and Malterud, (2004) interviewed ten women who were CPPs about their condition, they revealed how they perceived skepticism, distrust and struggle for the medical legitimisation of their condition as they sought treatment. A systematic review by Newton, Southall, Raphael, Ashford and LeMarchand (2013) showed how feeling of disbelief (also known as de-legitimation in literature) could lead to emotional distress such as depression, guilt and anger among the CPPs. The CPPs could also perceive challenge to their integrity which could subsequently affect their individual’s self- identity, as well as isolation resulting from loss of relationships (Newton et al, 2013). There is however a gap in literature particularly in the UK regarding the impact of the withdrawn DLA from the CPPs who were previously found eligible for it. 

The current study explored what it is like for a chronic pain patient (*Shelly) whose DLA was withdrawn. 

Method 

The central question of this research project is: how does a chronic pain patient who has been entitled to Disability Living Allowance perceive the withdrawal of their benefit; and how does this affect the account of their sense of self or identity? 

The study adopted a qualitative method with the specific aim of understanding how a chronic pain patient is thinking and feeling about the policy change that she directly experienced/affected her. A relational centred, existential phenomenological research method was adopted (Finlay & Evans, 2009; Finlay, 2011). It focuses on exploring the lived world of one woman, to understand the process within two phenomena, that is, the experience of having benefit withdrawn as a chronic pain patient; and to provide the researcher’s own reflexive process as impacted by the experience of the woman. Although the main focus of this study is to describe Shelly’s experience, as a reflexive researcher, the researcher also provides information on how her own psychological process creates opportunity for further exploration of Shelly’s experience. This process of phenomenological inquiry is in line with phenomenological and existentialist approaches, which allows for this very personal way of working with the client’s predicaments. Thus promoting close resonance with client’s experiences and needs (Creswell, 1998; Finlay & Payman, 2013). Attempt was made to stick close to Shelly’s experience, but yet not limiting it only to the empirical as I sought to capture both her experience and the research process as it unfolded in an embodied, experiential relational way (Finlay & Payman, 2013). 

This research follows an idiographic approach, making no assumption of inter-subjectivity or shared realities across different individuals who might also be in the same condition. This opposes the positivistic oriented nomothetic approach by which impression and interpretations are based on averaging data obtained from large samples where resulting statistics can only apply to an average person, not to a particular individual. 

Bracketing 

As a clinical psychologist who also received training in pain psychology, I have worked within a pain management clinic and have some knowledge of clinical and psychological features of chronic pain syndromes. My usual practice tends more towards positivistic orientation using scales/inventories and psychological measures to assess feelings, thoughts, emotions, beliefs and other psychological states of my clients. I then would consider this information in the context of a clinical interview, conducted before formulating hypothesis and establishing the aetiology of my clients’ problems. In my role as clinical psychologist, my interview techniques will usually be carried out with some preconceived ideas and theoretical underpinnings. I am quite aware that this orientation is contrary to the research method adopted for this study. I had to work hard to “bracket” these presuppositions and my natural, positivistic and reductionism epistemology in order to attend genuinely and actively to my participant’s views and feelings. My trainings as a psychotherapist and a qualitative researcher significantly assisted me on my effort to ‘bracket’ and be attuned to my co researcher (Shelly). 

Literature was delayed till after data collection in accordance with Hamil and Sinclair’s (2010) suggestion to avoid phrasing questions or analysing data for themes already existing in the literature. Chan, Fung and Chien (2013) suggested that this will help to address the problem of researchers’ pre-understanding of the research questions and subsequently enhance ‘bracketing’. 

Ethical approval 

Ethical approval for the study was obtained from the ethics committee at Manchester Institute of Psychotherapy. After ethical approval, the potential co-researcher was sent information sheets and a consent form and was afforded an opportunity to ask questions about the study before she confirmed her agreement to participate. She was assured of anonymity, confidentiality and the right to withdraw at any stage of the study. At the beginning of the interview, a verbal consent was also obtained from the participant. Detailed process of withdrawing the transcript was provided on the information sheet. My co-researcher was informed of an opportunity for one psychotherapy session, which had been arranged for her with a qualified psychotherapist without charge as compensatory for her time, if she wished. A mutual place for the interview was also agreed on before the interview. 

Participant (co-researcher) 

Shelly, a 47-year-old Caucasian lady, is an acquaintance that I met in a charity cafeteria where I used to volunteer to serve. She had become a friend and will freely discuss her family problems, pain problems, as well as her current visits to the hospital and her doctor’s impressions with me. Undoubtedly, a mutual trust became established between the two of us as she began to see me as someone who listened to her and whom she could share her problems with. I believe that this might have promoted her free attitude to share her personal and interpersonal details in the discussions that emanated from this interview. 

My co-researcher is a mother of one daughter (aged 24years) and she has two grandchildren (boy and girl). She has the diagnoses of Fibromyalgia, sciatica back pain and asthma. She had been on Disability Living Allowance (DLA) for over ten years before a ruling in 2013 ‘took her off’ the DLA list. She is currently on employment and support allowance (ESA) and has been placed on trainings at different locations. 

Data collection- interview 

Prior to the interview, an information leaflet and an informed consent form were completed by the co researcher who also provided a verbal consent. An in-depth interview guided only by the topic of the discussion was adopted for this study. This method is deemed useful to enable the researcher to have complete data, tone and implied meanings. Questions asked were open ended intended mainly as cues to elicit talk from the woman. The interview lasted for 90-minutes and was recorded with the co-researcher's consent. The woman was debriefed after the interview. A week after the interview, my co-researcher also dropped a written poem for me to further express her feelings and thoughts (appendix 1). This poem formed part of the materials analysed below. 

Analysis 

A relational phenomenological analysis (RPA) was adopted to analysis the data. The tape was listened to and transcribed to text which was then hermeneutically analysed. The transcript was read a number of times by which point the investigator became very familiar with the material. The transcripts were examined for identity related themes, some resulting from the woman's direct account. As this process continued, the researcher continues to engage in interpretative analysis with the text and transcript in an attempt to unravel the meanings contained in the woman's account and how this account impacted on the researcher. I had endeavoured to pay close attention to what was explicitly and implicitly communicated by my co researcher as she constructed a narrative around her meaning of her DLA withdrawal and her experience with the ‘system that be’. 

Results and discussion 

Broad theme: A voice of Travail 

Travail is a word that comes from the Latin word, trepalium, meaning “instrument of torture”. Thesaurus on line and Oxford dictionary (2014) described it as’ to work strenuously, especially when arduous or involving painful effort, toil, tribulation or agony or anguish. While the closest English word is toil, travail means you are not just exerting monumental effort but suffering as you do so’. It seems that I clearly and loudly heard the voice of travail echoing in the voice of my participant as she described her experience of benefit revocation in this project. Shelly was asked about what the revocation of her DLA means to her now. She responded by querying “the point in life” and described herself as being “at the bottom of the sea, drowning” in conversation below: 

Seriously, I do, yeah. Of course I do. I've been trying to keep my head above the waters, but feeling like I'm drowning. I think I'm at the bottom of the sea and I'm drowning. 

Shelly’s hyperbolic metaphor of being ‘at the bottom of the sea drowning’ touched the existential issue of life and how she is struggling to keep alive. As if choked, this was echoed again in her poem (appendix 1) when she said, “their policies are burning me,” “can’t you ease up a little and allow us to breathe and heal?” How long the struggle, the labour or toil will be to keep alive ‘at the bottom of the sea’ or in the struggle ‘to breathe’ is hard to imagine. Her next conversation further described her experience and how she feels about it. Shelly resonated “I just want an end to it. Sick and struggling, exhausting and tired, trying to just get on with life”. 

Shelly also showed her feeling of helplessness and anguish as she further described her experience of the withdrawn benefit this way; 

“I have nowhere to turn, as I get disfigured by the state”. 

Now that the benefit is withdrawn, she is “a lamb in a jungle, tied up in a post and just left there” to “become a super lunch, a super food for the lions and tigers.” Chronic pain itself has its own challenges for Shelly, as it exerts its debilitating effect and limits her ability to engage in meaningful occupations, leading to diminished quality of life (Newton et al, 2013). Studies showed how it causes stress on all components of a person’s life including family, health, psychological status, spirituality and socioeconomic circumstances. It might appear sensible that Shelly’s narratives show laborious struggle to keep alive if the impact of her chronic pain is combined with the impact of the benefit withdrawal. Shelly’s story presented the State as the “torturer” and herself as “the instrument of torture”. 

Should the government be labelled ‘torturer’ for striving to save money and ‘rehabilitate’ the people previously living on benefits back to work? Previous studies have shown strong empirical evidence in support of back to work programmes for people with musculoskeletal chronic pain (for example, Waddell, Burton & Kendall, 2008; Waddell et al 2006). These studies also showed that the principles of remaining at work could be applied to most people with common musculoskeletal disorders and this could have significant positive impact on their psychological wellbeing (Waddel et al 2008; 2006). It can be argued that the government’s duty is to save money especially at this period when the government is battling with increased national debt and the recovering of the collapsing economy. 

But while the policy sounds beneficial to the nation, how is this to Shelly? Shelly, standing from an alienated position, described her agony and laborious trial under the heavy hand of ‘their burning’ policy. Other major issues promoting travail for Shelly are further illustrated in the four major subthemes uncovered from the interview which will be discussed in turn. 

Subthemes: 

1. Paternalism ideology promoting travail. 

A significant theme from Shelly’s narrative centres on how her relationship with the state could be captured by Paternalism Ideology (PI). PI is defined as the interference of a state or an individual with another person, either with or against their will with a claim that the person interfered with will be better off or protected from harm (Dworkin, 2010). Below is Shelly’s narrative of how she has been on benefits: 

“, they put me on sickness benefit. I was on it for, I could say twelve-years actually, for I was on sickness benefit, due to the fact of being ill… 

Yes, I was on Sickness benefit and income support as well. Which didn't give me a great standard of living at all but at least, I could at least pay one or two bills”. 

Forrat (2012) described state benefit gesture as soft paternalism where the state assists the disadvantaged through the provision of public housing, and gives money to the poor in the form of various benefits. Classical neo-economists (Beaulier & Caplan, 2007) were the prominent critics of the welfare state as they felt that soft paternalism divides the society into the elites and the masses, where the latter need guidance and protection and the former are capable of providing it (Murray, 1990; Hernstein & Murray, 1994; Sowell, 1996 & Chavez, 2002). They argued that the welfare state perversely harms the very people it is intended to help. The classical neo-economic viewpoint appears to be the far right. Beaulier et al, (2007) argued that giving money to the poor reduces their incentive to enter the work force, has ill-effect on their judgement, promotes self-control problems and failure to acquire experience, and eventually left people at lower class level. They thereby suggested a reduction of the size of welfare benefits, limiting their duration, restricting eligibility, and even abolition. 

Shelly’s next narrative appeared to deviate from the above arguments as it seemed the benefits have helped her to a point where she has been pursuing an online degree programme but had to stop it after her DLA status was withdrawn. 

“But it's like, you know, I was doing a degree to get myself up so that I could eventually come off the benefit one day, may be going into teaching mathematics. But that was my dream, they've kicked the dream from underneath my feet. They sent me to “Learn –Direct”…, for me to do some training with them or whatever. And it's compulsory and if I don't go, I'm going to lose all my benefits, So I'll be left with nothing. …….So they bag you up into a corner, they'll bully you and you are already not well. So, what will this do, this exasperates the problem you've got. So no wonder you know, I'm just gonna feel down and depressed, and feel like what the heck is this all about. So, yeah........”. 

Shelly’s narrative here appears to show how the state could move from the soft paternalism to the hard one and how she also defied the reasoning and critical arguments of the classical neo-economists (Murray, Hernstein et al, 1994; Sowell, 1996; Chavez, 2002). She was pursuing pre-degree programme so that she “can eventually come off the benefit one day” but had to stop to create more time to enable her meet the conditions for receiving the ESA from the government. Shelly’s DLA seems to be for survival since she has no other means or source of income and she called the absence of her DLA a ‘hard time’. To Glaeser (2006), the welfare programme is like the state giving more choice to the citizens and withdrawing the choice could be more costly and intrusive. Therefore, Shelly’s DLA withdrawal might have opened Shelly up to this cost and intrusion. But the replacement will fall well within the hard paternalistic orientation defined by Glaeser (2006). 

It sounds puzzling that Shelly was not supported with her dream of earning a degree, but this fits with the idea of a new paternalistic welfare state, which assumes that service users lack certain capacities and require supervisory programs to guide them towards self-sufficiency (Ben –Ishai, 2012). This is incompatible with the obligation of a “Just state” (Ben-Ishai, 2012) that fosters autonomy. Shelly used the word ‘compulsory’, and the metaphor “bagged you to a corner and bully you”, and another metaphor, “because I'm jumping through their hooks and I have to do whatever they tell me to do” to describe her relationship with the state. The last metaphor depicts a helpless fish in pain, on the hook of the fisherman to be disposed as the fisherman wishes. Shelly’s rich use of metaphor described the state with the characteristic of hard paternalism, thus confirming Glaeser’s (2006) idea that soft paternalism involving welfare, will later increase support for hard paternalism. 

It’s hard to know whether the state-sponsored programme that Shelly was co-opted to will achieve its set goals, but what is clear from this data is the evidence of her struggle to keep up with the state’s expectation against her will because Shelly’s original dream has been “kicked off underneath her feet”. Shelly traced her current psychological status of ‘feeling down and depressed’ to her experience with the state as though in ‘déjà vu’ when she said ‘so no wonder I’m just gonna…’. There is also a sense of alienation and persecution by the power that be, still reinforcing the idea of hard paternalism. She said: 

“Yeah, I'm getting punished for being ill. That's what I have said from the beginning. I'm being punished for being ill. I'm a criminal for being ill. I am guilty I'm ill. I'm just waiting for them to pass more sentences.” 

It appears she felt she was receiving punishment from two angles, referring to her pain and the state that is also ‘punishing’ her ‘for being ill’. Here is her description of this metaphorically; 

“Yes, and they are punishing me for having the illness. Yeah. “I'm between the devil (is this her pain?) “and the deep blue sea” (is this the state?). 

This depicts her as an ‘object of torture’, echoing the voice of travail. 

The ambivalence relationship of my co-researcher to her DLA/ESA also ‘leaped out’ in the excerpt above like ‘I hate you (that is, ‘you are not enough’), don’t leave me’ (‘but I need you’) phrase (Kreisman & Straw, 2010). On one hand, she felt really sad that her DLA has been stopped, but on the other, she laboured hard to meet the criteria for ESA which appears not enough for living. She recounted about her present situation 

“I have to do away with some things to buy food. I have to do away with gas and electricity. That means there has been some few weeks I have to do away with Gas and electricity and I have no gas to cook. I've not got anything to cook. It's just robbing Peter to pay Paul. You know, Ermm.. I have got phone to pay and every fortnight, I have to pay my phone bills and then on top of that pay the rent. So that week, I might be left with like £20 to £30 to last for two weeks. And it's not a case of I'm going on partying on a Friday and Saturday if I could. I'm not buying any luxury, I don't buy, you know, there is nothing that I buy that is considered as any kind of luxury or whatsoever. Just normal things. Pay the bills. That's it.... (Silence). I'm trying not to get into debt with the bills because the last thing I need is the bailiff hanging out at my door…. because that really will be the end. ...” 

Without the next major theme identified from Shelly’s narrative, one would wonder what her motivation to continue with such insufficient amount for sustenance is rather than seeking a job. 

2. Embodiment (Disappointing Body). 

The phenomenological definition of embodiment defines it as an effect where the body, its sensorimotor state, its morphology or its mental representation play an important role in information processing (Korner, Topolinski and Slack, 2015; Glenberg, 2010). This framework calls for unification and the analysis of those processes arising from the recurrent, dynamic interactions of behaviour, brain, bodily processes and changes in the physical and social world. It has its philosophical route in Merleau-Ponty’s (1962) phenomenology of perception which proposed that the body is our general medium from having a world. There is the assumption that thoughts, feelings and behaviours are grounded in bodily interaction with the environment (Glenberg, 2010). The collection of themes below describes how Shelly experienced her body phenomenologically as well as how this interacted with her behaviour, thoughts and feelings to promote her travail. 

Body creating barrier to employment 

As Shelly was experiencing a persistent pain condition which has gone sciatica, she described her body as creating a barrier to employment or ability to remain on job in this narrative. Shelly’s thought is presented in her statement below; 

“Often, yeah, I mean I'll love full time job, I'll love it, but I know that I can't do it, because my health won't let me, so I'm limited to few hours a day, and it’s about finding that kind of job. 

This is because of the uncertainty she often feel from her body: 

And then, how am I going to do it, because I can't say it’s between the hours of whatever and whatever, I am feeling okay, and in which day I'm going to be really in pain and be feeling uncomfortable and not feeling great whilst I'm doing whatever I'm doing”. 

On how the health condition affected her, she narrated how she braved her pain to do things but ending up amplifying the fluidity of her body and her discomfort. She described how hard to predict what is best to do without experiencing tremendous pain in her excerpt below; 

“Because (of) my health condition (it) is hard for me to do anything for any long period of time, I can't sit down for any long period, I can't stand up for too long, I can't walk for too long. Er, mmm it’s a mismatch of all these three things, sitting down, standing up and walking that be. …….. I can stand up for five minutes and walk to two metres, then you are able to walk, and then.....” 

Again, she described this uncertainty regarding her body’s ability to carry out actions dictated by her nervous system (Konner et al, 2015); 

“……yeah, that is it. Yeah. Because you can see me today, I can be walking, feeling a little bit okay. …. And then the next time you see me, I could be holding on to the walls, trying to drag my feet along. So, then the wall becomes my best hold because I had to hold onto it to get to anywhere I need to go”. 

This narrative explains why she has been on the DLA for 12 years as her condition does not seem to fit the work environment expectations. Patel, Greasely and Watson’s (2007) reported perceived overarching barriers to return to work among unemployed chronic musculoskeletal pain patients to include financial and physical uncertainty, as well as their pain condition. Shelly seems to have described a disabling pain condition that will require a special provision to fit the work environment. However, Siebers (2011) noted how difficult it may be for a ‘disabled’ person to fit in to the work environment if they will require special provision that will make the ‘business owners bend over backwards to accommodate access that able bodied persons take for granted’. 

The bodies-at-odds/body Fluidity 

In an attempt to further understand what it is like to be Shelly, she provided further insight to what goes on in her body daily; 

“Shooting pain, sometimes… you try to massage it, and the pain…, it’s like you are not relieved from that pain. …you usually getting, let’s say 10 being the worst pain and 0 being none, but you are either getting 5 or you getting 10. Walking up the stairs, my God man, it’s like. … I feel like mountaineering. My God! It’s only stairs. I use to walk or run up to 50 stairs and I feel nothing. Now I can hardly finish walking up one stairs! You know, you have pain in your chest because you get asthma as well. You try to cope with that, and then you get one thing going, then another thing going, then another, then another, just bugging you down and just stopping you from, even trying to move normally, you can't. 

Shelly’s narrative described someone with the diagnosis of fibromyalgia, a condition characterised by a widespread pain and tenderness; and which legitimised her right to DLA for about 12 years. Despite medication, she still experienced ‘sciatic’ back pain which “causes lots of pain most of the time”. Shelly’s narrative described a body that is disappointing and “at odds” with her expectations (Vicks et al, 2010; Thomson, 1997). Scarry (1987, in Smith, 2006) described the journey that a fibromyalgia patient might have gone through to obtain a doctor’s diagnosis of the condition as laborious. It appears she must have been relieved when her physician labelled her condition, since fibromyalgia has no organic causation (Scarry, 1996 in Smith, 2006). However, getting fibromyalgia diagnosis is one thing; living with the condition is another. Since the medical knowledge and practices are built upon the conceptualisation of the body as a material functioning system, consisting of muscles, bones, tissues, nerves and chemical substances (Boyd, 2012; Bullington, 2009), this therefore makes a condition with no organic causation difficult to treat. Bullington (2009) found it puzzling to see how people turn to the health care system to seek help for a variety of psychosomatic/psychosocial problems, allowing their bodies objectified and to be treated like a malfunctioning machine without considering their lived experiences. 

In line with Leder’s (1990) and Phinney’s(2002) observations that chronic pain can thwart the meaning and reordered the life stories of sufferers, Shelly’s story showed how her illness condition has “thwarted and reordered” her meaningful life stories. Shelly described how she “used to walk or run up to 50 stairs and feel nothing”, but now, her chronic pain condition has placed the painful body in focus, rupturing the natural connection of the body to the world and diminishing her articulation of self and the world. The body that was once taken for granted to the point that it disappears from immediate awareness has now become visible and unfamiliar (Leder, 1990). It appears that Shelly would benefit more from a therapeutic process that could re-insert the body into the flow of experience, where the body disappears into its natural science in order to allow the world to once again unfold (Bullington, 2009). 

Shelly’s description of her condition has also amplified what researchers have previously been observed as common experience of people living with chronic pain conditions with regards to the fluxing body (Lightman et al, 2009; Fisher, Emerson, Firpo, Ptak, Wonn, & Bartolacci, 2007 & Friedland, 1999). In a world that emphasise categorical orientation or what Longhurst (2001) called binaries of the body as, for example, able/disable, health/ill, this might create a dilemma and generate controversies around the individual who is experiencing a fluxing or fluctuating body. The description of the body as either/or creates a situation described by Lightman et al (2009) as bodies-at-odds. This creates discomfort because the individual possesses the ability to live sometimes as healthy, sometimes ill, sometimes able, and sometimes disabled. In essence, Shelly’s narrative showed a contending sense of self outside the mainstream culture and her own culture due to the issue of the unstable body (Sandahl, 2003). Unfortunately, little attention has been paid to the fact that many people experience fluctuations in impairment or episodes of wellness within disability studies and disability-related policy and legislation (Phinney, 2002; Lightman et al, 2009; Siebers, 2011). 

3. Sense of self-worthlessness and loneliness 

Pertaining to her sense of self, Shelly described herself as a ‘no class person’, a ‘nobody’, a ‘nothing’. ‘Sense of self’ and her ‘feelings’ became inseparable. 

I am a no class person. That is how I feel. I am a no class person….. 

Previous studies also noted the narrow medicalised view of the suffering of individuals living with chronic pain and how often they experience a sense of loneliness as they observe their former self-image crumbling away and without the simultaneous development of a new image (Charmaz, 1983; Cannella, Lobel, Glass, Lokshina & Graham, 2007). It appears Shelly’s DLA was serving as a form of recognition of her suffering from her pain condition, validating herself and helping to save her sense of self from total collapse. Now that the benefit is withdrawn, her sense of self plummeted and she saw herself as worth ‘nothing’. 

4. Insensitivity- what employer is going to employ you? 

Shelly sarcastically recounted her disappointing experience of not been able to secure a job due to the insensitivity of employers towards her health problem, she asked; 

“What employer is going to employ you? Cause they just want workers, they are not interested in your health, so to find that certain number of hours per day to do the work, I'm looking but I've not find in much look” 

However, the most prominent insensitivity felt by Shelly appeared to be from the state health assessor whom she said did not show her any recognition: 

“They sent me to see a medical professional, which didn't acknowledge anything that I was saying. …Just typing away on the computer…. She didn't look at me. She didn't listen. They just made up their own mind and basically signed me off, Ermmm, and she wrote up to the *DSS and got me signed off. She said I was fit for work.......And clearly my medical record says that I am not fit for work. But this lady thinks I am”. 

……….”The whole situation of it all right from the very start that they send me to the health care professionals, the obnoxious arrogant attitude from her, the obnoxious and arrogant attitude from the judge, and just...... you know, I'm ill, I'm not a criminal. So, they make you feel that you are nobody”. 

Shelly described a feeling of not been accounted for by the judge, the state agents and the medical assessor who authorised the removal of her 12 years old benefit without considering the implication of this on her. Her description of the health professionals here appear to fit the paternalistic way of working by medical professionals decried and detested by Coulter (1999) and Glenton (2003). These authors commented that medical professionals reproduce knowledge which support their social position as educated experts and justifies the treatment they give to patients with no consideration of the agentic position of the patients. Anndale & Clark (1996) called this type of positioning ‘patriarchal model of thinking and behaving’.Shelly responded to this by feeling let down by the system; that ‘nobody listens’; and subsequently that she has ‘nowhere to turn,’; ‘trapped in a system she cannot fight.’ Anndale et al (1996) and Luke (1974) noted that the pervading patriarchal models of thinking and behaving could become inherently dominating, controlling and objectifying and lead to power display 

Reflexivity 

The use of a relational phenomenological approach enabled me to capture the richness of the lifeworld experience of how a policy adopted for the generality of a society affected the lived experience of an individual. As data continued to emerge from the researcher-participant relationship, I was aware that a co-creation was taking place in the embodied dialogical encounter (Finlay, 2009). I was aware that the intersubjective space between us was allowing each of us to impact one another causing an intermingling in the pre-analytic participation as we both actively engaged in an interactional encounter (Finlay, 2009). Adopting the principles of Finlay’s relational phenomenological approach where I engaged in open presence, embodied inter-subjectivity, dialogic co-creation and the entangled selves to understand another’s (Shelly’s) personhood has brought new realities to me about how ‘the power that be’ could use hard and soft paternalism, to generate impact that could create and maintain unhealthy dependency within the society (Jones, 1996; Coulter, 1999). 

Considering the difficulty of my co-researcher to break her circle of ‘torture’, I had noticed a discomforting feeling at one point during the interview, an aroused feeling where I felt the helplessness of having “nowhere to turn” in the face of ‘burning’ circumstance. As my feelings of discomfort escalated, this dialogue ensued between me and Shelly, 

R: I really felt like crying when you said that… 

Co researcher: Yeah (eyes turned red, position adjusted) ... Oh don't cry because you let me cry as well. You know, it’s one of those things…. .....So, yeah.....…….. 

I was aware that what I said could have re-directed the focus from Shelly to me as I empathise with her. But I was glad that instead of this, it seemed to help her to experience her inner and repressed emotion. The process of my reflexivity and supervision revealed how my own childhood experience of hardship and difficulties in my early academic journey had suddenly emerged as a parallel process as I listened to the narrative of my co-researcher. This has brought alive the complexity of the intersubjective space where the past selves surface to interact with those present. Rather than becoming preoccupied with my own emotions and experiences, I have stayed close with my co-researcher as our dialogues brought new realities into being from her lived experience. We seemed to become entangled where the “feel like crying” became a commonality, bringing the question, ‘was the crying mine or hers’ or ‘was it for me or for her’. This is where reflexivity, adequate supervision and use of bracketing become essential tools in relational phenomenological approach (Finlay, 2009). However, the significant issue here is that it appears that this interpersonal dialogue with my co-researcher seems to meet a fundamental need to experience shared reality in me. It seems the commonality of an inner state has been appropriately motivated and there is a successful connection of shared reality (Echterhof, Higgins & Levine, 2009). 

Conclusion and recommendations 

The themes from Shelly’s narrative showed how the withdrawal of her DLA and her enlistment in the government’s programme has not ‘rehabilitated’ her, but has instead increased her pain and kept her on within the system for longer. This at the end will seem to cost more than any financial saving in line with previous researchers’ observations (Good, 1992; Glenton, 2003). As a therapist who adopts transactional analysis in my approach of working with clients, the recurring theme from Shelly’s narrative of not being heard, being punished, not acknowledged or understood seems to fit into the description of the parental injunction of ‘don’t exist’ and ‘don’t be important’ toxic messages from the Parent ego states (Goulding & Goulding, 1976) and classified as part of the survival injunctions in TA terms (McNeel, 2000). Bollas (1987) proposed a similar concept of lived relationships that leaves shadows in our living body from how we were handled as a baby, how we were attuned to. The end result of this injunction could be depressive/suicidal thoughts or feeling of worthlessness (I don’t matter) and an existential life position of You are Okay, I am not Okay (the victim positioning) with the childhood decision/belief of ‘I am never going to be heard’ and a sense of hopelessness. 

This idea has been noted to underlie fibromyalgia and other chronic pain conditions. Appel-Opper (2008a,b) noted that ‘some childhood experiences will be ‘unthought’ and ‘unsensed’ by the person concerned, but remain living in the body waiting to be heard by some-body’ and manifest itself as psychosomatic problems. The whole Shelly’s experience appears as an impasse (Goulding & Goulding, 1976), a circle of woe, unending movement from sorrow to woe, a voice of travail. I conclude, like Appel-Opper (2008a) that in this impasse condition, ‘there is also something like a hope, ‘a healthy striving’ in the body that one day ‘some-body’ will be able to listen, to see the invisible and just to be there’. 

It is interesting that my participant has never been referred for psychological intervention or psychotherapy. This has implication for the need to include psychotherapeutic services within pain management. I believe that the state will benefit more from promoting autonomy and involving the individual in the decisions that concerns them than the use of power. Lukes (1974) argued that the use of power may avert open grievance or actual conflict, but the latent conflicts which consist in a contradiction between the interest of those exercising power and the real interest of those they exclude remains. Like Tomasini (2013) reiterate, there is need to consider the idea of the ontology that fully embodied and integrate with our being in the world, bridging the gap and weaving together a new way of understanding the body-subject and how it experiences and copes with its vulnerability in the world. 

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Appendix 1 

My co-researcher’s poem handed over to me after the interview. 

Poem written by Shelly the co-research 

Hard times are here, I have nowhere to turn, as I get disfigured by the state. 

Their policies are burning me, they don’t care, (it) is our fate. 

Don’t be ill (unwell) in this country, they sweep you all the same 

You for your illnesses are to blame 

I hope someday things will have to change, and people treated with dignity again. 

Is it not the responsibility of the policy makers to include everyone? 

Yet folk like we (us) are made a victim. 

Can’t you ease up a little and allow us to breath and heal? 

After all we are human and we do suffer and feel. 

 Abigail Olubola Taiwo 

 University of Wolverhampton 

Correspondence: a.taiwo@wlv.ac.uk 

Schroeder, C. S. and Smith-Boydson, J. M. (2017) Assessment and Treatment of Childhood Problems. Third Edition. New York: The Guilford Press. 648pp. ISBN: 978-1-4625-3070-0 Price: £48.99

Key words: child psychology, child psychiatry, psychiatric nursing, paediatrics, educational psychology

The purpose of this exceptionally well written book is to provide evidence-based ways to assess and treat children’s behavioural and emotional difficulties which are frequently encountered in clinical settings. The book is aimed at a wide range of healthcare practitioners working in child psychiatry, child psychology, psychiatric nursing, educational psychology and paediatrics. Academics and lecturers delivering postgraduate courses and researchers with specialist interest in abnormal child development will also benefit from owning a copy of this book which will hold currency for years to come. What this third edition offers is a decade and a half of advances in assessment and treatment of developmental psychopathology. The contents page provides a very good overview of the substantive content of the book; an excellent basis for knowing when to dip and out as the clinical situation demands. The organisation of the book draws the reader in from the basic foundations including the risk and assessment of childhood psychopathology (Part 1), to managing common childhood problems (Part 2) and finally to managing stressful life events (Part 3), the book becoming increasingly more in-depth and complex. The structure of each chapter is not identical, but key themes include subject identification and classification, characteristics, assessment, treatment and case study examples. A good range of assessment instruments are included in the appendices which will be of use to researchers and clinicians. The reference list runs to 65 pages, which is a large portion of the total page numbers, indicative of extensive background research required the authors’ to develop the book. The magnitude of previous research studies cited in the book gives a strong sense of authority to claims made. However, a critical reading reveals no mention of the criteria for acceptance of previous research studies. A fourth edition could remedy this by the addition of a brief chapter on how the literature was sourced and what inclusion and exclusion criteria were applied to evaluate the validity, robustness and worthiness of previous research for inclusion in the book. The book is designed for the American market so readers outside of the USA should be mindful of the many differences in terminology, culture, ethnicity, statistics, and legislative differences between states and between the USA and the UK. Caution should therefore be exercised in transferring some of the content to the UK context. The only limitations I can see include a dearth of visual materials which could make this a hard read for some readers, and the font size is rather small, so for the reader who may have reading limitations or visual challenges, there may be some difficulty in accessing the book. The book is of great importance and significance to the many disciplines where child development and adjustment is concerned. I will certainly recommend the book to researchers and practitioners in childhood development, masters and doctoral level researchers, practitioners and lecturers on the Professional Doctorates in Counselling Psychology and Health and Wellbeing in my institution.

Contact: Dr Angela Morgan, C.Psychol, PhD, PGCE, FHEA, BSc Institute of Community and Society, Faculty of Education Health and Wellbeing University of Wolverhampton WV1 1DT UK Email: Angela-Morgan@wlv.ac.uk

I am writing this piece today with deep sadness for the loss of one of our founder board members Vinette Cross, not only with the desire to pay tribute to her but more from the need to do so. This acknowledgement is the Journal’s chance to say thank you for the way you have enriched the lives of students, colleagues, authors and readers with your creativity, understanding and insight. For me your greatest gift was your eloquence and poetry which you used imaginatively to inspire and instruct others. Your desire to challenge convention whilst not letting go of your wisdom or mischievousness is irreplaceable and will be missed. Your contribution to the Journal and the journey of others was always underpinned by originality and vision which will never be forgotten. There is the world of the flesh, and there is the spirit world. When the flesh is gone the spirit forever remains.

Their voices speak to those who know how to listen. Wisdom is born in the heart, and then spoken.

Wolf Clan Song

Abstract

There are a number of government reviews and white papers, which discuss how universities have a major role in providing students with employability and graduate attributes. By embarking on a literature review to assess these requirements and an examination of the research undertaken with employers, students and universities, this review was able to identify that universities must continually monitor their programmes and assessment methods to ensure they are delivering the employability skills and graduate attributes required by local employers. This suggests that universities should consider undertaking research in their region to identify the specific needs within their local business communities.

Key words: Employability, Embedding, Skills, Local Employers, Graduates.

Introduction

Every job, regardless of level, needs a range of skills and knowledge. There is an expectation of the degree of skills a university student will have when they leave university. These are known as employability skills or graduate attributes. They may include technical skills, the ability to take the initiative, the ability to be a team player, good quality communication skills or have passion and flexibility (BIS, 2015). However, OECD (2016 p.50) indicates that one in ten graduates have poor “basic skills” which could result in them never repaying their student loans. This may explain why over one thousand graduate jobs were not filled in 2015 within the top 100 graduate employers. (Higherfliers, 2016) There is a long history of Government reviews, white papers and initiatives to address these issues and expectations of employers, students and universities. This literature in context review will examine this history. It will move on to how students, employers and universities manage and deliver these expectations. It will conclude with a research question that could add further help and assistance to assure that graduates of vocational educational providers, leave with the skills and attributes required by local employers.

Government policy

There have been many government reports and white papers in the last 19 years that have debated the issue of employability and the role Higher Education (HE) especially universities, had to play in ensuring their graduates left with the skills needed by employers. ‘The Dearing Report ‘(1997), ‘Lambert Review ‘(2003), Leitch (2006), Students at the Heart of the System (2011), Wilson (2012) all highlighted aims and objectives they expected Universities to implement. However, employability was first highlighted in The Robbins Report, (1963). The report identified four main aims of HEI’s The first aim was ‘”instructions of skills suitable to play a part in the general division of labour” (Robbins, 1963, p.6). The committee felt that this needed to be the first identified aim to ensure it was not forgotten. They believed the work of HE’s should have a distinct direction regarding the development of individuals (Robbins, 1963). Two papers had been written examining the effect this report had on education 50 years later. One by the London School of Economics and Political Science (2014) and the other by David Willets (2013) who was the Minister for Universities. Neither report discussed how this first aim had been implemented.

The employability theme continued into the next major report regarding HE provision by Dearing in 1997. Throughout the 400 plus page report Dearing constantly referred back to the role universities needed to play in ensuring their graduates were equipped and proficient with the skills needed to ensure economic growth. The theme of employability was not just a strand throughout the report; there was a whole chapter dedicated to the topic. Chapter 9, p.130 stated, “learning should be increasingly responsive to employment needs and include the development of general skills, widely valued in employment.” The chapter went on to examine employers’ views and their beliefs regarding the skills and attributes they wanted and expected to employ their graduates with (Dearing 1997). However, eight years later, only 37% of employers felt the graduates they were employing had those skills that had been identified. (Manpower 2005 in Lauillard 2007)

In contrast to the findings of the Manpower survey, the Lambert Review (2003) suggested that employers were happy with the skills of many of their graduates. The Lambert Review (2003) was the first of its kind to examine the relationship between businesses and universities. Whilst the report mainly focused on research and development, it did discuss how students felt work placements were of value and how future students could benefit from knowing how graduates had progressed in relationship to pay and employability. However, employers expressed concern regarding how their needs and the courses offer by some universities did not match.

The review made a number of recommendations such as all universities should publish undergraduate and post graduate employability for each department to help students make an informed decision regarding their future. They also wanted HEFCE to guarantee their next review would take into consideration the needs and views of employer led bodies and the public and voluntary sector. (Lambert 2003)

In 2010, six years after the original recommendation from the Lambert Review and as part of a long term review between the Department of Business, Innovations and Skills and the Higher Education Funding Council for England, (HEFCE) all universities were “invited” to publish an ‘employability statement’ on the Unistats web site. Unistats is the official government website that provides information to enable prospective students to compare different universities from information provided from the National Students Survey and the Destination of Leavers Survey (Unistats 2016). The reasoning behind this was to enable students to have a greater understanding of the success of previous students. However, the invite was compulsory and all universities had to respond. (HEFCE 2010)

When the coalition government published their white paper in 2011, “Students at the Heart of the System” it built on the Skills for Sustainable Growth (2010) white paper. The main emphasis of The Skills for Sustainable Growth paper (2010) was around apprenticeships and Further Education, (FE) with HE mentioned as the progression for both pathways. However, there was no specific direction regarding what HE was expected to delivery or how. Unfortunately, in 2014, OECD reported that there was “limited provision of post-secondary Vocational Education Training”. This suggested that this part of the White paper has not materialised. In the Students at the Heart of the System paper, the government identified they wanted the Quality Assurance Agency (QAA), the National Council for Graduate Entrepreneurship and National Consortium of University Entrepreneurs to liaise with HE to provide students with opportunities to acquire enterprise skills. The government also requested Professor Sir Tim Wilson to conduct a review in the same vein as the Lambert review (2003) examining the working relationship between industry and universities. (BIS 2011)

The Wilson Review (2012) was not as heavily based on research. It identified a wider range of measures need to strengthen the relationship between the universities and businesses. The review identified that students needed to have greater access to pertinent work experience during their time at university to increase their graduate attributes. To reinforce the work experience element it was recommended that “skills development” should be incorporated within degree courses and recorded for future development and employers. Wilson supported the government’s recommendation about entrepreneurial skills but Wilson wanted this to be delivered within the curriculum in the same way as general skills development. To support these recommendations, Wilson wanted the university careers services to create a link between the local business and the university. These links were to identify placement opportunities and develop the programme to deliver the skills and attributes wanted by the businesses. (Wilson 2012).

In the latest business-university review, the Dowling Review (2015) made 32 recommendations. None of which were to do with skills or attributes needed. The skills were addressed in a separate 245 page report from Department for Business, Innovation & Skills (BIS) entitled “Understanding Employers Graduate Recruitment and Selection Practices” (2015). This was a very comprehensive report about what employers wanted and expected of students and how they felt the input from universities was imperative in making a difference to the quality of skills and attributes of students. The report also discussed how small and medium employers’ felt there was a skill discrepancy between their needs and what universities perceived they needed. 

The history of reviews and legislation suggests that even though employability skills had been identified by many as a responsibility of universities, it may not have be executed in the manner employers and students wanted or needed. After examining the various reviews and white papers, it would appear that universities were seen as the place where students learnt and developed their employability skills and attributes. Pegg et al., (2012) suggested that universities were responsible for the pedagogy for employment. This meant they should have been directing the ways in which teaching and learning took place regarding attributes, knowledge and skills to develop increased learning and career attainment. 

However as there was a lack of consistence, concerns were being expressed regarding the implementation, omissions and shortcomings, clarity of terminology and relevance of how universities were preparing their students for the world of work. (Daniels and Brooker 2014). The widening participation agenda also meant there were more graduates competing for jobs. (Gunn et al., 2010) 

For these skills to be embedded in the curriculum, staff needed to understand what was expected of them and why it was important. Many academics felt that they were now providers of skills not nurturers of knowledge and questioned why universities were marketing themselves as providers of graduates with the skills, understanding and personal attributes required by employers. (Daniels and Brooker 2014) Gunn et al., (2010) agreed with this as they identified that academics were facing “confusion, ambivalence and definitional ambiguity” as they felt the employers’ requirements were not always realistic and students were unable to see the importance of these skills and attributes. However, Pegg et al., (2012) made it very clear they felt that universities had a responsibility to the students to assist them in making the connections between their learning activities and how they translated into employability skills. Yet, Tymon (2013) identified that first and second year students did not make the connection between the activities. It was only in the third year, when the students started to actively look for work was the connection made. 

To address this issue, many universities developed employability awards in an effort to engage students and help them understand the skills employers wanted. Tibby (2012) believed the awards and what they meant confused employers and employers would prefer to employ students who had relevant work experience. BIS (2015) supported these ideas, as employers did not expect their skills requirements such as good communication skills and the ability to work as part of a team to change. Tymon (2013) established that students understood the importance of work experience as his research showed up to 90% of students felt “work experience was the best way to gain the skills they needed for work”. However, Tibby (2013) acknowledged that only 9% of small and medium businesses offered work experience to university students. Bourner and Millican (2011) identified that many employers valued volunteering as more valuable than work experience when students had been involved with more than one organisation and completed more than 50 hours. However, both Bourner and Millican (2011) and Tibby (2013) suggested that if volunteering was not part of the academic course, barriers such as lack of flexibility and lack of finances for students who were part-time, mature with caring responsibilities and or from lower socio-economic groups could put that group of students at a disadvantage. 

There is also an issue of what is a graduate skill or attribute. Tibby (2012) and Tymon (2013) both recognised that students lacked the understanding of the skills employers wanted. When asked employers rated communications skills as their number one requirement but students ranked this 16th. (Tymon 2013) Pegg et al., (2012) felt that every university needed to identify the needs of their local employers and examine the diversity of their students before deciding how to deliver their pedagogy. 

The Higher Education Academy (HEA) (2015) published a framework for HEI’s to guide universities through the process of embedding employability throughout degree courses. Embedding was seen as being more effective than having bolt-on modules. 

Figure 1: Embedding Employability Framework. (HEA 2015) 

This framework places embedding employability at the heart of the model. The next layer indicates that the ten strands are equally important and need each other to ensure the success of the model. The four stages inform and draw on the relevant needs, wants and priorities of stakeholders, industry, colleagues and employers. This is how the framework can be personalised to each institutions needs as suggested by Pegg et al., (2012). This framework could be the answer regarding the issue of academics ambivalence if they can develop a greater understanding of the role they can play in embedding employability. 

As Daniels and Brooker (2014) pointed out that while universities could try and produce students with the graduate skills and attributes employers believed they wanted, they could not guarantee successful outcomes and students had to take some responsibility in building their own sense of identity. 

Recommendations. 

It is suggested that people who undertake vocational course such as health and social care, nursing and social work are more likely to live within a 25 mile radius of their education provider (OECD, 2014) therefore, it is recommended that further, local research needs to be undertaken. A small-scale piece of qualitative research could benefit and inform a University regarding the perception local businesses has of the skills and attributes they could expect if they were to employ a graduate of a local university and how lecturers feel they are embedding those skills into the curriculum for students. 

Conclusion 

Somehow, all the different needs, wants and perspectives, need to be drawn together to enable universities to provide students with the skills and attributes needed and wanted by employers to ensure the UK is able to be competitive against other countries. 

This literature in context review, demonstrates that the three parties need to work considerably closer together to provide the economy with world-class graduates. Further qualitative research within the university and local business would inform a university as to the success of their efforts of producing graduates with the skills and attributes needed by local employers. 

Reference List 

Bourner, T. and Millican, J. (2011) Student-community engagement and graduate employability. Widening Participation and Lifelong Learning, 13(2), pp.68-85. 

Browne, J. (2010) An independent Review of Higher Education Funding & Student Finance [online]. [Accessed 20 February 2016]. Available at: < https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/422565/bis-10-1208-securing-sustainable-higher-education-browne-report.pdf> 

Daniels, J. and Brooker, J. (2014) Student identity development in higher education: implications for graduate attributes and work-readiness. Educational Research, 56(1), pp.65-76. 

Department for Business Innovation & Skills (2011) Higher Education Students at the Heart of the System [online]. [Accessed 22 February 2016]. Available at: < https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/31384/11-944-higher-education-students-at-heart-of-system.pdf> 

Department for Business, Innovation & Skills (2015) Understanding Employers’ Graduate Recruitment and Selection Practices: Main Report [online]. [Accessed 12 February 2016]. Available at: <https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/474251/BIS-15-464-employer-graduate-recruitment.pdf> 

Dowling, A. (2015) The Dowling Review of Business-University Research Collaborations [online]. [Accessed 21 February 2016]. Available at: < https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/440927/bis_15_352_The_dowling_review_of_business-university_rearch_collaborations_2.pdf> 

Education England (2016) The Dearing Report (1997) [online]. [Accessed 3 February 2016]. Available at: < http://www.educationengland.org.uk/documents/dearing1997/dearing1997.html> 

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  Abstract

Higher Education (HE) Students are increasing diverse, with larger numbers participating from none traditional backgrounds. Factors such as: finance, employment commitments, family and carer responsibilities, academic pressures and coping with student life, all impact on a student’s mental health. Higher Education Institutions (HEI) offer support services to students, for both moral and legislative reasons. This article explores from the academic literature, the factors that students face, and how HEI support students with mental health issues. The analysis uses a UK university to investigate how support is incorporated in practice. It further recommends a research project should be undertaken, into level 4 students, and their perceptions of MHI in students, and support services provided by HEI. From the finding of this research more effective ways of engagement with students can be considered. 

Key words: mental health, higher education, support, stigma 

 Introduction 

The Department of Health (2017) report on mental health issues (MHI) within the United Kingdom (UK), the ‘Five year Forward View for Mental Health’ (FYFVFMH) recommends an inclusive and joined up approach to tackle mental health, where everyone shares responsibility. The Adult Psychiatric Morbidity Survey (2014) found that 37 per cent of 16-74 year olds surveyed within England were accessing mental health treatment services with conditions such as anxiety or depression. The first year at University (level 4) is challenging, personal, financial, and academic issues can negatively impact on student’s mental health and contribute to drop out rates. High drop-out rates can impact on a University’s finances and leave students with debts and no qualification (Tobin, 2016). This article will discuss policies that influence and guide Higher Education Institutes (HEI) and how they support and assist their students. It will further research the factors that cause MHI in students. An anonymous University in England will be used as a case study. 

Legislative Issues 

There are two types of legislation that guides MHI in HEI, that which applies specifically to HEI concerning their responsibility to students with MHI, and that which guides policy for the whole of UK society. The Special Educational Needs and Disability Act (SENDA) (2001) extended the Disability Discrimination Act (DDA) (1995) to include education. Consequently, HEI have a legal responsibility to students with disabilities, including those with MHI. Students can seek legal redress if ‘reason adjustments’ are not made. Further they have a positive duty of care to promote equality for students and staff with disabilities (Royal College of Psychiatrists 2011). Wisker et al. (2008) suggests that SENDA (2001) has renewed interest in Mental Health (MH) and Higher Education (HE). Population wide (specifically England) policies, include the FYFVMH (2017) and the Preventing Suicide in England (PSE) (2017). Both are intended to provide cross government and multi-agency strategies to tackle MHI and suicide prevention. Consequently these overlap to create a joined up approach, FYFVMH e.g. requires all local authorities to have multi agency suicide prevention plans in place by 2017. However, PSE e.g. is tasked with reducing suicide rates in high risk groups such as young and middle aged men, and people with a history of self-harm. 

Epidemiology 

Establishing the size and nature of student MHI is a contentious issue, some research projects focus in-depth on a particular HEI and others in less depth, across many HEI e.g. Holt and Powell (2017) research from one HEI, found from 3663 respondents 1015 had emotional or MHI, 756 were female and 255 males. Most common medications students used were anti-depressants and anxiety medication. Fewer respondents sought help, than those who identified that they had MHI. Reasons that were given were stigma and a lack of information, debt was also an issue. Although this research project provided an insight into the nature and scope of the problem it was only one university and its findings may not, be transferable to other settings. 

However, by comparison a more extensive study by the American College Health Association (2011) had 90666 participate from 141 institutions found: 36.3% experienced sadness; 35.1% loneliness; 31.6% overwhelming anxiety; 24% hopelessness and 15.5% experienced depression that impaired functioning (American College Health Association, 2011). 

Some interventions in countries culturally similar to the UK, such as this research, can be used to inform practises. Conley et al. (2013) concluded from their research, that to reach a broad audience in HEI, interventions need to be systematic and integrated into the structure and organisation of (HEI) and support from staff, students and administrators is essential. To improve the success of interventions it is necessary to recognise that not all students are the same; they are not one homogenous group. This will be explored in more detail. 

Student Diversity 

A student’s suitableness for a course needs to be considered. Research into attrition rates of mental health students in Scotland found that older students were more able to cope, act more maturely, and be more self-aware with emotional challenges (Camber, 2010). Nolan and Smojkis (2003) recommend identifying maturity and self-awareness in potential recruits is important and suggests they should be screened and trained to determine whether they could be vulnerable to MHI. Further to this Ibrahim et al., (2013) suggests that, universities should introduce confidential screening for MHI and that support should be provided. This diagnosis at the beginning of courses, could aid prevention of student MHI. Although Cambers (2010) research identified age as a positive factor in course progression, there are other differences such as socio-economic status and stigma that need investigating. 

Socio-economic Status Issues 

Low socio-economic status is linked to depression; students with higher perceived control, more highly education mothers, and those from wealthier backgrounds were less likely to suffer from depression. Depression impacts on students learning, and their quality of life, and progression rates. More depression occurs in the final year: due to academic demands; rising debts; future unemployment considerations; and career choices. Schemes to widen participation need to include safeguard mechanisms to protect student’s mental health (Ibrahim et al., 2013). Alternatively, Baker et al. (2006) identified that education had included extensive social policy, it is charged with keeping people healthy, strengthening families, creating independent and confident individuals, and tackling exclusion. Yet university graduates are often debt ridden, and unable to secure well paid employment. Widening participation to include lows socio-economic statue students is immoral, if there not supported with their MHI, and therefore to unable to academically progress, and find employment. 

Stigma Issues 

Better progression rates can be achieved when students are encouraged to seek support. Stigma is a major barrier and should be tackled first, as it prevents student’s engagement with mental health support services. Often they feared discrimination effecting their studies and employment opportunities. They are often penalised and disempowered for missing standards, deadlines, and seek support from family and friends. Subsequently, students who did disclose often had better outcomes and the university offered them counselling, and disability support. The Student Union was often involved, securing extensions for assessments. There is often a ‘perception’ of discrimination rather than ‘actual’ discrimination (Martin, 2009) (Quin et al., 2009). One solution is clear and open guidelines regarding information when a declaration of MHI is made, students will have more confidence if they are aware how it is stored and used (Quin et al., 2009). 

By comparison Australian research found a demographic dimension to stigma, it was more prevalent in males, a younger age group, those born outside Australia, the less well educated, and those less likely to recognise depression. Therefore, mental health interventions need to target more these groups (Reavley et al., 2011). Stigma can also be inter-related to the issue of social anxiety. Russell and Topman (2012) suggest it is a persistent hidden disability that affects learning and wellbeing. Engagement in public speaking and group work can develop confidence which can tackle stigma. The supportive role and pedagogy of staff, is vital to achieve this and improve participation and attendance. There is general agreement within academic literature, that stigma is an important barrier that needs to be tackled to in improve students’ MHI outcomes, any intervention needs to recognise these differences within the student groups it seeks to support. Academic literature suggests that no two HEI have the same makeup of students. 

Changing Demographics 

More research is needed to establish the diversity of HE students, to make mental health services more efficient: as students are young, socially and culturally diverse, and increasing numbers are from groups with traditionally low rates of participation. International students face unique issues, their numbers have increased recently, they face additional challenges e.g. inadequate English, infrequent visits home, and not meeting their own and their family’s expectations. These epidemiological issues mean studies from 10-15 years ago, are not an accurate reflection of current students (RSP, 2011). Without a detailed picture of student diversity, what support they need, and services will never be able to deliver efficient tailored support they require. 

Further, questions need to be asked about the type and scope of research carried out. It is often small in scale, qualitative, content specific studies, where the participants have little power over policy and practise (Ennals et al., 2015). This can give a distorted view of the nature and size of the issues faced. Ibrahim et al (2013) suggests that there are few research studies into socio-economic status and its role in HE student outcomes. Little research has been carried out into the effectiveness of student counselling services e.g. Connell et al. (2008) research found an average of 70% of clients showed improvement. However, this was only for attendees, those who would not use the services, and those who failed to complete, were the most at risk, yet why clients failed to attend was unknown. To know why people do not attend services or complete is difficult to investigate as they are not there, yet to improve attendance this information is vital. Research into attendance and use of mental health services suggests that a lack of service awareness, accessibility of service, trust in services and service providers, cultural competence of services, racism, perceptions of self-reliance, socio-economic status and gender differences are all barriers to engagement with services (Worrell et al.:,2009). To investigate these barriers focus groups and in depth and semi-structured interviews could be carried out with service users who do attend, to establish the reasons why other students may not attend. According to Jacobsen (2012) using a select group of informants and these data collection methods, and using the approaches of Phenomenology, Grounded Theory and Ethnography, an understanding of theories and cultural perspectives of different groups can be established. From this research, interventions can be developed to tackle these barriers for both those who are not attending, and those who find barriers when they do attend. 

Professional Support Staff 

The role of staff in delivering these services is important. Administrative, academic and medical staffs, who range from NHS psychiatric, to HEI counsellors, deliver support services. In the UK 4% of students are seen by counsellors and Mental Health Advisors, who may refer students to psychiatric services (RSP, 2011).Whilst stakeholders work together, they do not do so in a universal manner, thus further investigation is required to understand this lack of coordination. It is important to be aware of the role of HE staff can play. They can identify students at risk, be sympathetic to build trust, be aware of problematic learning issues, and provide academic support. Tutors should be sensitive to an individuals’ learning style. However HE staff, need to be aware of boundaries, e.g. contact times and how they can assist their students, so that students do not become to dependant. Although developing basic counselling skills can be useful, it is also important to be able to signpost students to more specialist services when necessary (Wisker, 2008). Martin (2009) suggests staff need to develop knowledge and understanding of about MHI including signs and symptoms such as: poor health, poor hygiene, and tiredness, Quin et al. (2009) further suggests poor attendance was a sign of possible MHI and should be monitored to aid intervention. Policies need to be clearer within universities on how they intend to support students and staff at all levels. A clear attendance policy could be beneficial to students able to attend, and staff to monitor, yet discriminatory to those who are carers and unable to attend. Draconian policies can do more harm than good, being student focused is important to avoid this. Halpern (2007) supports this view point, and suggests a more effective policy is to target the most ‘at risk’ students in terms of their propensity to achieve. The attendance policy of institutions should make students aware of the benefits of attendance on attainment, and that it is not worthwhile for institutions enforce strict policies on attendance. 

Students Service Preferences 

How services are delivered determine their effectiveness. Often students want results rather than knowledge Tzotzoli et al. (2016) research into student’s service preferences found the majority wanted a technique to cope with their difficulties rather than understanding them, and preferred online support systems. Holt and Powell (2017) further identified the university website and email as the preferred method of receiving information about services and make appointments for mental health services. Yet most students had heard of these services through an induction or welcome week. This suggests that using mixed methods of delivering information is still important. Often if students are gathered in a HEI setting MHI messages can be delivered effectively. 

University Setting 

In fact, universities should be where health promotions using the ‘setting approach’ are carried out. Creating healthy, supportive, and sustainable learning, working, and living environments for students, staff and visitors should be a priority. Health should be at the university’s core business: its learning; research; and knowledge exchange, contributing to the health, wellbeing, and sustainability of the wider community (RSP, 2011) (Martin, 2009). HE as a setting is also important as the 18 – 25 age range is where signs of MHI are most likely to occur, and university life has stress factors (Wisker et al., 2008). However due to widening participation some students fall outside this age range according to the Higher Education Statistics Agency (2014) in 2012-13, 6.3% of UK domiciled entrants to HE were aged 25 to 29 years and 13.2% are over 30 years. 

Alternatively Quin et al. (2009) recommends a formal link between the NHS and HEI support services to improve student experiences. This has advantages of a more interconnected service for students and staff reducing communication barriers. However, this co-operation maybe difficult, due to a resource constrained environment, and no common definitions of mental health. Practitioners use different definitions, some refer to mental health: issues; illness; problems; difficulties; and effects, which then affect how information is analysed. Issues of transfer of confidential information between organisations could also be an issue. Despite these barriers NHS and HEI should seek ways to work together (RSP, 2011). Subsequently the majority of academic research supports the need for co-operation and co-ordination between services due to the increased efficiency of support services and better outcomes experienced by the students, e.g. a student who is stigmatised by MHI would only have to potentially disclose once in a joined up service, in a familiar and secure setting. 

An analysis of a UK university 

Using a UK based university as a case study, how support services seek to assist students with MHI in practise can be analysed further. To comply with SENDA (2001) procedures to tackling MHI are incorporated into several of this university policies, for example in its Equality and Diversity Policy, it concurs with the legal definition of disability, including mental impairment. Secondly also, this university has a specific policy giving advice to staff on how to deal with student critical incidents, mental health crisis’s and concerns. This gives guidance to staff for supporting students with MHI, a legal framework, procedures and emergency contact details. Its aim is to increase accessibility, retention and enabling all students to maximise their potential. This is an example of how national policy is incorporated into an individual HEI setting. This is also in accordance with Universities UK (2015) the representative organisation for the UK’s universities whose advice, recommends institutions need robust policies and procedures for supporting students and their mental health matters. 

The university has a Mental Health and Wellbeing Co-ordinator, their role includes signposting advice, help, and providing information to students and staff, raising awareness and liaising with specialist agencies and training staff. Guidance and advice is also provided for meeting criteria for the Disabled Students’ Allowances (DSA). This is evidence of the university meeting policy objectives in FYFVFMH (2017) to improve co-ordination. By comparison it also meets the SENDA (2001) requirement to positively promote equality. 

The university also provides counselling services for both staff and students and has link counsellors to aid communication between the different faculties and the service. Areas of focus are: student difficulties and appropriate referral; facilitate initiatives; and providing workshops for both students and staff. Counselling services are confidential with a policy for data storage, which conforms to the Data Protection Act (1998). For students and staff individual counselling is provided. On the main campus this is available throughout the year in office hours, two days a week. However, on the less populous campus, this is restricted to two days a week in term time only. It is an example of how constrained resources, are dealt with in practise. Workshops, self-help leaflets and computer aided programmes are also available. The evidence from the literature review supports the view that co-ordination is essential. The clearly defined Data Storage policy demonstrates to students the priority given to its importance. 

The university’s Student Enabling Centre also provides support for a range of student’s different needs and special learning requirements, 230 students who had disclosed a MHI were supported in 2014 – 2015 which was a 36% increase from the previous year. This is another example of a student focused support service where ease of access is prioritised. The increase in numbers is important, however no explanation was provided. This gap in knowledge requires further investigation to identify whether MHI are increasing, or more disclosure is happening. 

All these activities that support students are outlined in the University UK (2015) guidelines which sets out HE institutions responsibilities, recommending they should have an holistic approach including the wider student experience, from admission to graduation and beyond, including areas such as tuition, assessment, support and accommodation. The examples discussed previously in this article show how policy, procedures, and resources are allocated to both comply with legislation and are applied in practise. Further research into the experiences of both students and staff is required to establish the effectiveness of MHI services. 

Recommendations 

A small scale study is recommended with level 4 students and their perceptions of MHI in students, and support services available. Suggested inclusion criteria for the research would be level 4 Health Studies students, from a widening participation university. This would provide a diverse population, mainly from none traditional HE participating groups, in their first year of university, which many find a challenge to adapt to. A qualitative approach would be recommended, Jacobsen (2012, p.34) suggests a qualitative approach “seeks to understand how individuals and communities perceive and make sense of the world and their experiences”. The aim of this research would be to establish what these experiences are, and what are, the underlying factors that influence them. Semi structured focus groups would be undertaken to collect data from students and staff. Prompt questions would be asked, and the feedback would be voice recorded and transcribed to identify key themes. 

A quantitative approach would also be used allowing for wider student participation; this would allow from the sample population, inferences to be made about the whole population from the results of this smaller sample (Hickson, 2008). Data collection from students would consist of a questionnaire survey about student’s awareness of MHI and support services experiences. This would be applied to larger numbers, as there are more students than staff and the research focuses more on student’s perceptions. 

Data triangulation would then be used, as more than one method of data collection has been included. Methodological triangulation using a combining of quantitative and qualitative approaches would help improve validity (Robson, 2011). 

Conclusion 

MHI in HE is of increasing concern, from this literature review the following issues have been identified. Stigma must be tackled first before any effective intervention can be made. Policy and legislation is essential to ensure organisations and staffs have the necessary guidance to comply with. There needs to be further research into the nature and size of the problem based on establishing the demographics, and diversity of the students, for issues such as socio-economic status. Greater consistency is required into what mental health definitions are used, across all organisations supporting HE students. This needs to be both within individual institutions and the external organisations that offer specialist services. There needs to be more co-ordination between different agencies and support providers. HEI Staff need to be better trained, services need to be more student focused, and delivered with their preferences in mind. Universities as settings are ideal places to co-ordinate and deliver a broad ranging approach to promoting mental health, for both staff and students, and the wider community. 

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 Correspondence: Marc Groves Institute of Community and Society, University of Wolverhampton. 

Email. Marc.Groves2@wlv.ac.uk 

 Abstract 

Students with dyslexia often face challenges and barriers within Higher Education (HE). They may not be aware that they are dyslexic, they often feel stigmatised and therefore do not make a declaration, and further feel that it may negatively affect their career prospects. Policies and practices that are in place to support students and the adjustments that are required to be adhered to by HE institutions are investigated. Nursing students with dyslexia face the same barriers and challenges but also unique ones due to the specific demands of their role. The challenges, and support they receive are further discussed and recommendations are made. 

Key words: nursing students, dyslexia, support services, adjustments, barriers, stigma 

 Introduction 

This article will discuss the challenges faced by nursing students with dyslexia in Higher Education (HE). Policies and practice regarding assessment, diagnosis and reasonable adjustments that are should be adhered to by HE educational institutions, will be investigated. Further analysis of the support service and the student’s experiences of them will be considered. Nursing as a profession requires accuracy of data collection and use, especially for safeguarding patients for example prescribing medications, these critical challenges will be investigated using nursing students as a case study. 

What is dyslexia? 

Dyslexia dates back as far as 1872 where a German physician had a patient with acquired dyslexia, due to a brain injury. In 1896 an ophthalmologist, Dr Morgan introduced a different concept of ‘congenital word blindness’ which was developmental dyslexia, not ‘acquired’. It was first claimed in 1917 by Hinshelwood that dyslexia was hereditary as well as it being characterised as an acquisition of storage in the brain, (Gayan, 2001). Even though there have been significant advances in 

research, diagnosing and assessment, has improved over time which has aided policies and practice, yet there is no universal definition of what constitutes dyslexia. Further students with dyslexia face unique challenges, nursing students will be discussed to investigate these issues in more detail. 

Dyslexia is an often-misunderstood, confusing term. “The word dyslexia is made up of two different parts: dys meaning not or difficult, and lexia meaning words, reading, or language. So quite literally, dyslexia means difficulty with words” (Catts, Adlof, Hogan & Weismer, 2005). 

There are two types of dyslexia; developmental and acquired. Developmental is described as a failure in ‘normal’ development. While acquired dyslexia arises as a result of neurological damage, typically during an incident that has caused some form of brain trauma. People who suffer with acquired dyslexia tend to lose the ability to read and write, due to their injuries (Vinegard, 1992). 

There are many theories which have sought to define dyslexia. However depending on the researcher’s ontology the definition varies and there is no common agreement. Many of the researchers agree dyslexia is a type of learning disability, affecting specifically language and reading skills, attention deficits, or motor problems. More than 50 definitions can be found within academic literature (Ott, 1997), demonstrating the difficulty of defining dyslexia (Pavey, Meehan, & Waugh, 2010). The definitions exist dependent upon the different characteristics, behavioural, cognitive and biological levels (Reid, 2009). The British Psychological Society (BPS) (1999) includes predominantly behavioural characteristics of reading and spelling. Although, the British Dyslexia Association (BDA) (n.d) focuses there definition on single word levels, such as, phonological difficulties. Reid’s (2009) centres his definition on difficulties with memory, speed of processing, time management, co-ordination as well as automaticity and suggests visual and/or phonological processes may be involved. McLoughlin, Leather and Stringer (2002) emphasise working memory to be one of the key feature for adults with dyslexia. 

The term dyslexia is used amongst researchers, clinicians, specialist teachers and medical personnel. The BPS (1999) and the BDA (2012) use it for research purposes because they apply clear and measurable dimensions. Whereas McLoughlin et al. (2002) definition is most useful for working with adults. Reid’s (2009) definition is practitioner-oriented, aimed at raising awareness and informing intervention. The variation in definitions is due to, what the application is intended for. The wide variation in definition can make supporting people with dyslexia more challenging, eg communication between different support services, and their varying definitions. 

Dyslexia can be studied using two models; the medical and social model. The medical model suggests people are disabled by their impairments or differences. Whereas the social model suggests the disability is caused by the way society is organised rather than the person’s impairment or differences (Hughes and Paterson, 1997). For example society assumes that individuals have no disability, such as dyslexia, this then means that if it goes undiagnosed it can become a barrier to an individual’s learning and development. 

What Policies and Practice are in place? 

By using policies, procedures and practices, society can support individuals by providing a framework to guide support. Dyslexia as an impairment is included in the Equality Act (2010), which states; “You’re disabled under the Equality Act 2010 if you have a physical or mental impairment that has a ‘substantial’ and ‘long-term’ negative effect on your ability to do normal daily activities”. According to the BDA (2012) dyslexia is a hidden disability thought to affect around 10% of the population, however 4% are said to be severely affected, furthermore it is the most common of the Specific Learning Difficulties (SpLD). According to Pennington (1991) one in six adults has the reading skills equivalent to an 11 year old. Under the Equality Act (2010), reasonable adjustments, (social model) must be made by all employers and educational institutions, in order to include and not discriminate against any person with a disability. In a study carried out by Gibson and Leinster (2010) nursing students with dyslexia that were given extra time to complete an assessment, performed better than students that were not granted an adjustment. This is an example of an adjustment that can positively impact on students with dyslexia attainment. 

The British dyslexia policy on the early identification of specific learning difficulties (BDA, p.2, 2007) highlights the need for more to be done to ensure there is support for the learners, by enabling the resources to be more accessible for the students. “It will be ensuring that the early identification and support of children with SpLD is an issue which will be addressed by all of the education regulatory bodies in their inspection of education provision”. This statement takes the sole responsibility away from just the teachers and implies everyone who is involved with the decision, such as the government and education regulatory bodies, have a responsibility to address the process of diagnosis and support. This is inclusive and brings together different stakeholders. The BDA has campaigned for years, for awareness training to be part of all teachers training. It was put into place in 2007 that, specialist teachers need to have a level 7 qualifications and a practising certificate issued by an approved professional body in order to conduct assessments especially for Higher Education (HE) (Jamieson and Morgan, 2008). 

In practice according to Wray et al:.(2011) despite barriers, more students with SpLD including dyslexia, are entering the nursing profession. Screening in either the workplace or placement and in education, allows for the early identification of the condition. This needs to be linked to both learning and support strategies. By providing support and reasonable adjustments to students with dyslexia, Higher Educational institutions need to allow students to demonstrate their knowledge and skills that will help reduce none progression rates. For financial reasons, retaining all students is a key priority of education providers and employers. However Wray et al:. (2011) further suggests that screening more students has implications for resources within institutions (assessment and support costs) and can slow the system down, however these can be offset by the benefits of increasing progression rates and retaining revenue from students. In the long term students can be supported through a more inclusive curriculum and better trained staff to support students. 

The government policy for special educational needs and disability (SEND) 2010 to 2015 identified the need for more support to ensure students reach their full potential. They acknowledged students with SEND need the same rights and protection for further education (FE) as they have when they are less than 16 years old. Higher Education Institutions (HEIs) by law have to make reasonable adjustments to accommodate disabled people and their needs. More than responding to a student or member of staffs needs, they have to be proactive towards any new students with a disability who enrol on any of the courses they offer, and members of staff working within the institution. 

The Special Educational Needs and Disability Act (SENDA) (2001) also required HE institutions to make ‘reasonable adjustments’, which had a major impact on students, support services and academic staff (Fuller, Riddell, & Weedon, 2008). In practice, SENDA includes proactive duties, which requires learning, teaching and assessment practices to be made more inclusive in anticipation of student needs (Hurst, 2009). 

Many institutions offer help through their learning support services (Singleton et al. 1999, in Michail, 2010 ). Universities generally have a Student Enabling Centre (SEC) which offers help, advice and support for students. They should provide a document detailing the Dyslexia Assessment Policy. This document provides information about dyslexia and the guidelines the University is required to adhere to. For example the Quality Assurance Agency [QAA] for Higher Education and the Disability Discrimination Act [DDA] are included. 

The document also highlights the reasonable adjustments, that make it more equitable between those with the condition and those without, complying with educational standards that all students are measured by. All university employees are expected to adhere to this policy in order to provide inclusive practice. 

Howlin, Halligan and O’toole (2014) research into the experiences of student nurses found that the support they received was not uniformed and students do not always receive the accommodations they require. It is important that students with dyslexia have an equitable basis to learn as other students. By achieving this progression rates can be improved, staff that support student should be advised by regulatory organisations who can provide guidance to improve uniformity and consistency. The Nurses and Midwifery Council are one such organisation. Students and staff could also be further supported by an improvement in the relationship, communications, and completing demands between academia, clinical areas and the student. A Balance is needed between the interests of patient’s safety and a student’s right to disclose. 

Students with dyslexia require support and adjustments to be made to be able to overcome their disability and maximise their academic potential. Dyslexic students are capable of achieving the same academically as students that do not have dyslexia but face more challenges, such as reading tasks can take longer, sentence structure may be confused, erratic spelling and short-term memory problems (Farrar & Young 2007). These policies help to reduce discrimination by providing support and making reasonable adjustments. They are not intended to give students with dyslexia more of an advantage, than those without, but to give them a level playing field to develop their learning and achieve the same outcomes. 

How does dyslexia affect adults in Higher Education (HE)? 

The exact number of students in HE with dyslexia has not been identified because it will vary between every institution. However if 10% of the population have it then it is not unreasonable to assume 10% of all students in each academic in take would potentially be dyslexic (BDA, 2007). In medicine according to the British Medical Association (BMA) (2009) the percentage of students declaring with SpLD showed an increase from a 1.3% in 2003 to 1.7% in 2007. Conversely some courses have higher percentages, for example the Art and Design degree at a local HEI (n.d) has three times the national UK average meaning 30% of their students are identified as dyslexic, in just one year group. Research has shown many children and adults with dyslexia are diagnosed at a later stage of their life rather than when they were at school (Riddick, Farmer and Sterling, 1997). Riddick (2010) found after assessments, dyslexic students express a feeling of relief. The diagnosis of dyslexia has finally given them the answer to their problems. Research has shown adults who have been assessed later on in life for dyslexia, were resentful for having gone through life feeling unintelligent, they grieve the loss of opportunity, which has detracted from their future (Morgan and Klein, 2000). 

The fear of having a label of a disability, can be concerning. Declaration of SpLD for nursing students once they had qualified and had gone on to employment was difficult. There perceptions were that it would have a negative impact on their future careers (Morris and Turnbull, 2007). 

However having dyslexia can be a positive. Research into the attributes of students on nursing course suggests that students with dyslexia are more intuitive, innovative, creative and multidimensional thinkers and have greater oral recall which will allow then to perform better in clinical settings than non-dyslexic students. These students perform better in classical teaching situations (Sanberson-Mann and McCandless 2006). Students, who are aware that they have dyslexia, can better understand the difficulties that they had experienced in the past (Riddick et al. 1997). They also present different strengths, such as, creativity (West, 1997) and lateral thinking or visual perceptiveness (Loncraine, n.d.). Moreover it can help the person to gain access to resources to improve their educational experience via the Disabled Students Allowance (DSA). According to Morris and Turnbull (2006) nursing students with dyslexia face a range of difficulties that create stigma and therefore barriers to disclosing their condition and taking up support services. Factors include: co-worker attitudes; patient safety concerns; expectations of support; confidentiality issues; and potential discrimination. These barriers affect the students learning experience. Solutions include the need for work place based disability awareness training and more educational support services. Work place barriers are more prevalent than in education where they were more support, and therefore work placed self-disclosure is more difficult. 

The Department of Health (DoH) (2001) produced a strategic document, “Looking Beyond Labels”. This examined dyslexia as a disability in a health care setting. More generally, the SpLD Working Group (2005) set out tests to be used for identification purposes by educational psychologists and specialist teachers, which helped implement the regulations that came into effect in 2008. According, to Rice and Brooks (2004) when applying for Disabled Students Allowance (DSA) there is a lack of clarity and identified boundaries in dyslexia assessments for HE students. In order to be eligible for DSA, the students need to have a full dyslexia assessment by a psychologist or specialist teacher (Meehan, 2010). DSA make funds available to dyslexic students to purchase equipment, such as computers, dictaphones and/or any other devices that are useful for their studies, as well as access to 1:1 support by a specialist teacher. However the funding for the DSA is currently undergoing scrutiny and massive cuts, the National Union of Students (NUS) (n.d) suggests this will be detrimental to disabled students. It will reduce their opportunity to attend university as the resources will not be as readily available and put them at risk of not being able to gain a first or upper class second honours degree. Although, there have been clear boundaries identified between those who qualify and those who do not, once in receipt of a diagnosis, institution must adhere to the required reasonable adjustments, including; extra time in exams and additional tutorial support for coursework (Riddell & Weedon, 2006). 

Despite the improvements in dyslexia awareness, students still face difficulties. The BDA (2012) describe these challenges as still being unresolved. The Disability Discrimination Act (DDA) (1995) and other disability legislation has had an important influence on HEI and other support services which has increased the numbers of students identified as dyslexic entering HE. According to Weedon & Riddell (2006) the percentage of students diagnosed with dyslexia increased from 15% in 1994/5 to 49% in 2002/2003. Whereas, Fuller et al. (2005) suggests 32% of disabled Higher Education (HE) students were dyslexic. It is necessary to consider further, that the late identification of dyslexia has been partly due to lack of teachers’ training and knowledge and/or the lack of school resources (Michail, 2010). More research needs to be done to prevent students from not being assessed in mainstream education and further education (FE). 

According to Fuller, Riddell and Weedon (2005) disability policy varied between institutions, with one university having a good understanding of dyslexia and others questioning the boundaries between disability and factors arising from disadvantaged backgrounds. The co-existence of social disadvantage and dyslexia is clearly a complicating factor. Weedon and Riddell’s (2008) research found student’s levels of access to support and reasons for requesting it, also varied between universities and they suggest one reason for this variation is how students perceive dyslexia and their level of need. Michail (2010) study found some of the mature students noticed a vast difference since the days they were at school and they were impressed with the help and support that current younger students receive once they were diagnosed. This suggesting differences in learning history and previous experience of support will impact upon the students opinion. These discrepancies in support for example in nursing students were in factors such as, students not receiving accommodations. According to Howling et al (2014) better coordination is required between the different stake holder, such as academia, clinical areas and the student, in areas such as communication and interdependent demands. Their research also suggested that regulatory organisations, such as nursing and midwifery council (NMC) should provide guidance to those who support students with dyslexia and how they can make reasonable accommodation. 

University can be daunting for all students, especially students with dyslexia who on average face additional challenges. Due to the structure of courses, lectures may be given at speed (Rice & Brooks, 2004). Dyslexic students often find taking notes during lectures can be overwhelming, whilst trying to concentrate on writing something down and listening to the lecturer (Rice & Brooks, 2004). Further rapid reading and writing can fatigue the eyes and brain more than students without dyslexia. During revision periods, dyslexic students become distressed, highlighting reading as one of their main problems at university (Weedon & Riddell, 2008). Dyslexic students require more time to read a page than their peers, Riddick, Farmer and Sterling (1997) examine automaticity in dyslexic children and concluded if skills take around 100 hours to master, it would take a dyslexic child around 1000 hours (10 times as long) to reach the same level. According to Rice & Brooks (2004) students with dyslexia also find assessment and exam conditions stressful as they find the pressure of writing, working to deadlines, and reading carefully very tiring. Specific challenges are encountered by nursing students, there needs to be accommodation made between the rights of students to disclose and receive support and the rights of patients to be safeguarded (Howlin, Halligan and O’toole, 2014). For example, Morris and Turnbull 2006) found in their study that dyslexic students had problems with, clinical documentation, patient handover, information recall and drug calculation. However it could be argued that transparent systems, procedures and policies contribute to patient safeguarding as disclosure is more likely, subsequent support can be given and patient safety improved. 

Summary 

There are a wide variety of definitions that are used within different specialist areas, theories and models. How, the policies that are adhered to within educational establishments, are essential, to ensure all students (including students with a disability) are able to complete their education, to the best of their ability. More work is needed to be done to ensure children are identified at school and the process of support can begin. HE students have to deal with being assessed and getting a diagnosis of dyslexia, students then have to deal with labelling and the application of DSA. Whilst still potentially trying to overcome their earlier learning experiences and establishes how to access any available support and contend with day to day university expectations. More research needs to be done, to investigate, how dyslexia affects mature students’ and whether students are getting the relevant support within HE. 

However, with the appropriate support students have the ability to empower and enrich their lives through education. Dyslexic graduates can be assets for helping the economy grow. University life can be challenging for these students but with appropriate support they can overcome the barriers created by their dyslexia. However, this can only occur if: staff are trained and are made aware of the difficulties students with dyslexia face, staff and HE institutions must make reasonable adjustments, and teach in a more holistic and inclusive manner, and to include people who process information differently to their peers. A co-ordinated approach is required between all HE staff, students and specialist practitioners, to reduce the difficulties experienced, in order to support all students to reach their true potential. 

All these challenges that are faced by all students in HE and are more universal in there nature, the challenges faced by Nursing students demonstrate that specific groups of students face specific challenges such as discussed in this literature review. For example the need to prescribe accurately medications and keep accurate records as it is essential for patient safety. It is not that other careers do not require these skills; it is the fact that errors can have the severest on consequences for patients that creates an additional level of stigma and an incentive not to disclose. Professional bodies need to provide guidance to its members on how they should support Students with dyslexia. By creating a more transparent, incentive driven, and supportive environment these barriers can be tackled and a more positive outcome for all can be achieved. 

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Correspondence:

Rebecca Homer, Institute of Sport and Human Sciences, University of Wolverhampton 

Email: r.homer@wlv.ac.uk 

 Abstract

KUDOS (Knowledge, Understanding, Development, Opportunities and Standing) is the University of Wolverhampton’s professional development scheme which is accredited by the Higher Education Academy (HEA) for the recognition of professional academic practice. It is based on the dimensions and descriptors of UKPSF which was created by sector-wide leads and is backed by, the HEA, Guild HE, the Department for Employment and Learning, the Higher Education Funding Councils for England, Scotland and Wales, the National Union of Students and Universities UK. In order to gain recognition for practice via Fellowship of the HEA all the dimensions of the criteria must be met and this is achieved through a reflection on academic practice and a portfolio of evidence. This article is one such example of a submission that presents an illustration of a light hearted yet quintessentially honest account of academic practice. 

 Key words: KUDOS, Higher Education Academy, recognition of professional academic practice 

 1. Academic practice overview: 

Today, I’m Dean-David Holyoake. I have been teaching officially since the late 1990’s. I started teaching an MA in Solution Focused Brief Therapy at the University of Birmingham and as time progressed I accidentally found myself as the Course Director of its 7 modules until decommission in its 10th year. During this period I also developed, set up and organized the profitable Priory Awards in CAMHS (Child and Adolescent Mental Health Services) in association with University of England. Development of these awards involved budgeting, employment of specialized personal, commissioning of facilities and the usual recruitment of learning materials. After a number of promotions I was lucky enough to be employed as a specialist in CAMHS teaching on the under graduate nursing programs at the University of Wolverhampton. My career in higher education has not been plain sailing and I have written about my vulnerabilities in a series of research ethnographies (Holyoake 2012a, 2012b, 2012c). These writings relate to D3, D4 particularly D5 and D6 and of course the successful co-ordination of teams (D7) as I will go on to show. 

I have had a number of successes, recognitions and leadership roles. I achieved my first teaching qualification in 1992 as part of the English National Board’s Teaching and Assessing portfolio. In that same year I also completed my Student Assessor course at the Queen Elizabeth School of Nursing. Other teaching qualifications were to follow, but practice and peer recognition has come in many forms. I was voted on to the Royal College of Nursing Adolescent Steering Committee and also elected as a Member of the Steering Committee Royal College of Psychiatry (Quality Network for In-patient CAMHS). I was an active Associate of Royal College of Nursing Development Council for Nurse Education and a member of the National Association of Nurse Consultants in CAMHS (D3, D4). To date I have contributed to the development of the Diploma and Certificate programme at Change (Solution Focused Registered Organisation in Birmingham) (D1, D2, D6) and been a member of the Independent Healthcare Forum, Developer of CAMHS kartoons™ (D5), Priory Finalist (Innovative Prize) (D5), a British Army Veteran (D7) and Nominated for Cutting Edge Teaching Style (National Union of Students). In addition I have been Keynote speaker and collaborated with other educationalists at Conference, Dale & Holyoake (2009a, 2009b, 2009c), Thain & Holyoake, (2009a, 2009b, 2009c, 2009d, 2009e), Holyoake & Golding (2011, 2012), Conlon & Holyoake (2013). I have published over 100 articles related to clinical and education practice in peer reviewed journals and had 7 books published. I have Organised National CAMHS conference in partnership with APSA (The Association of Professionals in Services for Adolescents), De Montford University, Quality Network Inpatient CAMHS and for 8 years I was the Developer and Facilitator of Adolescentunit.com Online Social Network (A3, A4, K4). I have worked at the Healthcare Commission and Health Inspectorate Wales as a CAMHS Inspector, managed and developed 9 specialist adolescent units in the UK, contributed extensively to Nursing Standard Reader's Panel (see listed Refs), been a book reviewer, I’ve scrutinised and consulted with University of Helsinki and University of West England, been a Sub editor for ‘Mental Health Care’, taught on Doctorate programmes, supervised and examined doctorate students. I suspect there is more, but I really am embarrassed of my bragging, so now wish to move on to my reasoning to how my role and experiences meet the criteria set out in the KUDOS Senior Fellow criteria. 

2. Involvement in teaching and learning initiatives; 

I will try and focus on an appreciation of the Descriptors and their relevance to my ‘Teaching’ and ‘Learning’ initiatives. In my early days this amounted to attempting to use an overhead projector, remembering my chalk (no joke), using the right pen on new fandangle things called whiteboards and commanding a disinterested audience with my knowledge, authority, wisdom and wit (Holyoake, 1997c, 1998b). Yet, as we all know, teaching and learning have moved on fast encouraged into a new age by the twitching hands of technology. The age of simply exchanging information and rote learning have long since gone having been ruthlessly purged by a new era of blended learning, merged resourcing and facilitated protocol. As I have stood before large groups of over 100 and then facilitated small intimate gatherings of 10 or so my ‘confidence’ to adapt to the teaching needs of learners and my own growth issues has increased (see Holyoake (2013a, 2013b, 2013c), Conlon & Holyoake (2013). In turn, so has my trust to try new designs, learning activities (I’ll discuss these in more detail in the Case Studies) and re-think the relevancies of core knowledges (K1 through to K5) (Holyoake, 2008a). More specifically, I have developed subject material (K1) concerned with CAMHS blended learning initiatives for groups of practitioners from 9 in-patient units throughout the UK (Holyoake, 2012a). A series of 18 days (split into learning weekends) based at Frome in Somerset which had to be assessed and developed into classroom environments, play areas and quiet rooms (A1 - A4). In addition, I developed ‘patchwork assessments’ (K2 & K5, A2, A3), online sessions (K4) and the articulation and subsequent moderation (K6) with these groups. My work at MA level at the University of Birmingham made use of block teaching with a small team and many international students. The design of the courses were flexible and the progrmmes of study vibrant enough to meet the expectations of students who were self-funding and technically consumers (V1) and also important for my own self development (A5). 

When thinking about assessing initiatives I recognise that practice based professions such as nursing have a residing dichotomy between the good academic nurse who is practically useless and vice versa. Thus when considering A2 and A3 (Areas of Activity) K3, K4 and K5 (Core Knowledge), V2, V3 and V4 (Professional Values) my practice have been transformed by my new found confidence through a mixture of repetition, growing reputation, ‘knowing’ my subject as well as having the guts to embrace new technologies, environments, role plays, and the concept of the ‘technician’. The SMART programs advocated by Metcalf (2003) (Solutions for Motivation and Academic Resources in Teaching) being part of my emergence. This includes the idea of identifying the Goal and the Customer and ‘observing’ academic success (Holyoake, 2003: Hakesley-Brown, 2002). So apart from commissioning and developing learning environments I have engaged in various forms of digital learning including social networking (Thain & Holyoake 2009e), floor-work (e.g. the simple act of sitting on the floor and play (Holyoake, 1997d, 2013c), group activities such as framing time into segments to aid learning and designing activities and feedback to the wide range of grading I am responsible for. 

3. Educational and staff development activity; 

Gibbs (1988) asks us to position ourselves so I ask the question: How have my thoughts and feelings encouraged change in my performance and relationships with members of my team? How do I meet the expectations of the A5, V4, D3 and D7 KUDOS dimensions and descriptors through my action? To answers these I argue that when developing the Priory Awards in CAMHS I was responsible for the coordination of Key educators across at least 3 sites. This meant negotiating professional training, monitoring, mentoring and supervision for these individuals. Apart from the responsibilities I have related to placement training of nurse mentors I am reminded that via ‘educational audit’ of clinical areas, liaison and linking with clinical placements is an everyday occurrence with my current students and role responsibilities. In my past role at the University of Birmingham my D7 responsibilities came under the umbrella of coordinating the entire 7 modulated programme between a team of 3 and additional specialists in the field. This included the monitoring of quality, calendaring, room booking, supervision, additional training needs, interdepartmental liaison and a maintenance of a general feeling of wellbeing for the core and extended staff group. In this respect, my understanding of the organization processes in the variety of educational roles sits into V4 criteria and D3, D7. 

My reflection on staff development and ‘Professional Values’, has led me to other educational theorists including the early pioneering work of Allen (1976) and her use of peers to teach peers and the fact that my ideas about team teaching might not actually be that original. Yet, the appreciation of creating space and places for ‘dynamics’ to circulate and do their work not only point up the importance of diverse learning communities (V1), promoting opportunities (V2), using informed approaches (V3) and acknowledging the wider context (V4) of educational learning styles but what Yerxa (2003) terms the stability of learning style. The courses at Priory, Birmingham and the Doctorate studies at University of Wolverhampton have all required an understanding of professional values and staff development (many of my doctoral and Masters students are also colleagues and fellow practitioners). In addition, at Birmingham the courses catered for many people with visual impairments and international students who had to overcome language difficulties. To overcome some developmental issues we promoted participation via electronic means and operated inclusive opportunities for payment arrangements. In relation to the extending professional values via the design of activities and subject materials I have relied on developing much classroom material, pre-session reading, performance activities, ice breakers and the afore mentioned digital learning approaches. Similar to Loo (1997) and the learning strategies advocated by Hartley (1998) my reflection is that the thousands of commentaries on such learning style analysis enable me to rethink my application of the key dimensions and conclude that teaching, learning and assessing may be about knowledge but just as much about engaging with how students generally learn (K3), evaluating effectiveness (A3) (K5) and clinical governance / quality assurance (K6) the notion of the Onion Model (Curry, 1987) with its metaphor of peeling away layers of construct (specifically relevant to the pedagogic application of A1, A2, K1, K2, K3, V3 as well as allowing teams of educationalists to emerge D3, D7) bit by bit so that learners make staged progress is a common vision of learning styles. This has certainly been a useful insight during my workshop type interventions and the development of graduated programmes for the development of new staff who’s inexperience can sometimes get the better of them (I will discuss my involvement with this in more detail in the next section). Alternatively, the idea of ‘Fundamental Dimension’ similar to those posited in the KUDOS model is a common educational model which seems to sit well with my practice and linking with both educational colleagues through co-facilitation and practice based colleagues in healthcare settings. The work of Riding and Cheema (1991) also appeals because of the interactive and ‘adaptive’ sentiments similar to Kirton (1994) and Allinson and Hayes’s (1996) intuition analysis. What these types of models do for my reflection is offer me hope that I am not alone in the collaboration with my colleagues and my role as ‘technician’. 

4. Collaborating with others; 

According to Rayner and Riding (1997) there are facets of education which like those offered by Kirton (1994) give me a pallet of possibilities from which to achieve and consider the collaborative dimensions and those concerned with how I can maximize my managerial impact (I present two different case studies to help me expand on this). The work of Jarvis (2006), Garrison and Randy (2000) in particular emphasises how transformative notions of change come about not necessarily through the imparting of knowledge, but through the multiplex of expectations which I have tried to bring into my teaching and coordinating practice. So when thinking about Gibbs (1988) I reflect on how I have with the help of colleagues been involved in the purposeful development of clinical settings in class room and clinical skills areas. Developed role plays and real life scenarios as well as live supervision in the family therapy modules. I have mentored, supervised and assessed different multidisciplinary groups including pharmacists, dentists, health visitors, GP’s, medics, psychologists, psychotherapist as well as teachers and nurses. These groups have enabled me to consider the way I pace and match my activities, make sense of my core knowledge and stick to my professional values. My collaboration and supervision of more junior staff as well as my role as a module coordinator have enabled me to develop programmes which promote the following as a concern for the entire team: 

•  easy to digest soundbites 
•  memorable jargon 
•  assimilation into new realms 
•  connectivity between concepts 
•  fun and simple engagement (consumption of the entertainment industry). 
•  links between worth, added value and use beyond the session (this usually shows itself in terms of practice skills) (additional context can be seen in my ethnographic work: Holyoake, 2012, 2012a, 2012b, 2012c). 

As with my early thoughts, these points on my ability to negotiate, define and employ with a team (usually 3 to 5) measureable objectives for sessions and the delivery of modules per se. I will ask ‘what is it that you think I can teach (or do for) you?’ or ‘what needs to happen here for you to know it was worth getting out of bed and turning up?’ I always evaluate too, by asking ‘what has worked well?’ ‘What should the next group/colleague expect more off?’ Additional strategies for physical activities are well documented, but I have found that the work of Ginnis (2002) includes novel activities such as Forum Theatre, Hide and Seek, Hot seating, Information Hunts and Marketplace and enables me to be adaptive to the coordinating, managing and mentoring of others in a respectful and advisory role in the many modules I have run delivered over the past 20 years. 

5. Areas of research, scholarship and/or professional practice 

I have included an extensive reference list of research and scholarship to help aid my application. I also note that I am currently rated at about 16.2 on Research Gate and similar peer group social networks (I note the average is currently 3.2). Once again I apologies for this boasting. So rather than spend too long dwelling on these I will state that I am a fully committed social anthropologist of the post-modern variety and actively engage in conference, writing and publishing to that effect. In terms of my KUDOS I reflect that this has implication for the Dimensions and Descriptors in that contact, interaction and using writing as a vehicle not only enables me to maintain and demonstrate appropriate teaching practices it allows me to consider myself an independent academic who is engaging (D2 – teaching in situ, blended learning initiatives, patchwork assessments, digital feedback and additional work as Supportive Tutor for students with additional needs (V1)), integrated (D5 – clinical issue revisions, legislation and theoretical updates), continuing with professional development (D6 – additional coaching qualifications (I’m a first level Hockey Coach), Teaching qualifications PG Cert Ed 2002, interdisciplinary experiences in drama training, psychotherapy, play therapy and music) and able to manage, co-coordinate, mentor and relate to others (D7 – Research and publication in to my supervision of colleagues, management of teams and the successful co-ordination of social networks including adolescentunit.com), some of these claims are cited in the following publications: Holyoake (1997d; 1999, 1999a, 2000, 2001a, 2008a), Davis & Holyoake (2001), Holyoake & Reyner (2005). I will now introduce the first of 2 Case Studies in support of my application. 

Case Study 1: The Case of the Large Group (120 Learners) 

The aim of my Case Study reflection is to first show how I have had a significant impact upon the co-ordination, support, supervision, management and mentoring of others (whether individuals and/or teams), in relation to teaching, learning and assessment. Second, demonstrate my sustained effectiveness in my teaching and learning. Case Study 1 allows me to consider these in more detail because it forms part of my role coordinating a compulsory module within the Pre-Registration Nursing Degree in which we as a large team (15 Senior Lecturers across 3 sites) teach large groups of up to 300 learners per module intake. The module covers 4 themes: Psychology, Nursing, Interacting with patients and Communication. The size of the group can be overwhelming, disconnected, disinterested, sometimes unmanageable and occasionally intimidating. For the students there is sometimes an ethos of detachment and a desire to be entertained which shows itself in bouts of idle chit-chat and lateness. It seems that I am not alone in my assessment of these phenomena because exploration of large group behaviour stretching back over the years to the early work on testing as a motivating factor (Fitch et al, 1951), even financial incentives (Maier & Zerfw, 1964), to current issues to do with social networking (Vivek et al, 2009) and to issues of social identity (Ellemers et al, 2004). Yet principally the issues of the large group remain pretty steadfast for the team even if the teaching, learning and assessment criteria’s have altered from information giving to information connectivity. My observations of this case study as well as Case Study 2 are founded on ideas which are not the sole preserve of me, my colleagues or the learner. 

Case Study 1 is a reflection on 4 sessions involving the same team teaching first year nursing students from 4 branches (Mental Health, Adult, Midwifery, Learning Disabilities). As part of their common foundation these learners are expected to attend 12 2 hour long sessions on topics related to interpersonal skills, empathy, self-development and communication. For my team it means contributing to at least 2 of the sessions. The actual content is broad yet, in blunt terms quite straight forward. However, the coordination of these sessions is far from simple. The size and the afore mentioned dynamics create a sense of ‘needing to pull together’ within the team of 15 Senior Lecturers including myself my role has and continue to be one of ensuring that the module is planned for, pre-prepared, contingencies set in place, roles designated, timetables completed and equality and fairness demonstrated between all facilitators. As such, the coordination (as shown in my emergent Figure 1) has to be responsive to the differing phases that the team approach goes through. 

Principally, the management of Case Study 1 is about design and planning of activities which are pre-loaded. This means I have learnt over time that teams teaching and assessing large groups require a significant amount of structure, perceived order and routine (set break points and agreed timing), well established links between concepts, plenty of summaries and a certain amount of catch up space for new teachers and more junior staff. Being sensitive to their self-esteem is also an issue which I have found is best catered for by opting for a blended approach in terms of the material development (A1) and the actual teaching (A2). These in turn take into account the nature of the setting (A4) and due to the professional nature of the subject a continual professional learning (A5). In short, coordination of novice colleagues is best done when there are plenty of options for maneuver so they can excel in at least one thing to build their confidence, for example the delivery of the 30 minute workshop towards the end of the session or the question and answer period. To achieve this blend I traditionally promote a sense of togetherness in the team (end of session debriefs, support notes and electronic Emeets) and have always made the extra effort to be inclusive starting from first greetings to the agreement of objectives of the session. Designation of tasks and roles include for the planning of materials (A1), the engagement e.g. plan of who’s teaching what (A2), the environment (A4) to encompass an introductory and arrangement phase. So including the setting of objectives I will open proceedings I encourage colleagues to help me develop initiatives which reflect live cases, a reflection, or some sort of story to engage and raise the expectations that the topic is critical for student learning. I wish I could claim that I achieve this order to get them to a highpoint, but this is not always the case. 

Figure : Case Study 1 – Typical Layout and Co-Authored Learning Space 

The physical activities we use require a significant amount of preparation. The use of props is also favorite of mine which sometimes needs me to convince colleagues. In the past I have devised huge bingo cards, playing cards for ‘higher or lower’ strategies, treasure hunt clues, a wheel of fortune (not rigged!), gone to the dogs (a gameshow involving old dog racing footage), the traditional pub quiz, murder mystery using other members of staff on pre – recorded clues and videos. I note that when successfully implemented these type of activities in the large groups creates a buzz for the staff team. In additional to the preparation, the actual management, ordering and levels of sophistication to explain rules, direct movement and simply remembering ‘plans’ per se is a skill requiring the afore mentioned confidence. In my experience though we have found the whacky activities are usually met with a degree of excitement and anticipation which allow me to match and pace the environment (A4). I am not alone in this experience which seems to be born out in literature previously discussed on the big group pertaining to dimensions (V3 &V4). 

The Total Alignment (D7) 

As part of my co-ordination, support and supervision of colleagues (D7) (governing expectations in my role during the establishment of the Priory Awards, my role as Course Director on the MA in SFBT at University of Birmingham as well as my current Module Leader and Coordinator roles at University of Wolverhampton) the importance of an aligned and systemic approach to the Case Study 1 teaching, learning and assessment is about the ‘team around the Teacher’ as a concept is one which doesn’t simply occur because it is a good thing. In fact, there is a mountain of hidden work, administration and frustrating phone calls into offices in faraway building to faceless names including external examiners, assessors, course commissioners. Yet my idea of alignment is applicable with the key descriptors of the KUDOS, but requiring D3 and D7 mindsets. These simple maxims center on the belief that core values (commitment to knowledge, activities and professional values as well as successful coordination) not only provide quality learning, ensure credible and consistent standards, but also through the application of the 5 ‘areas of activity’ allow for a sustained and contribution to an enjoyable learner experience. These human approach core conditions align themselves as a spine through all dimensions of good learning and teaching and knowledges as something more connective and what Steinaker & Bell (1979) might term ‘synthetic’ and I’d argue pertain to successful co-ordination, support, supervision, management and mentoring skill sets, but the large group is one thing, what about the management of the intimate? 

Case study 2: The Intimate Coordination 

Case Study 2 concerns my management and coordination of small collectives of educators who facilitate therapy skills to groups of 12 learners for a long time frame (usually over a year). The coordination skills for a smaller team brings about different types of demands which I have attempted to formalize in the following figure. It shows how the staff support has to be more reflexive and less planned than the larger groups. It relates to more psychotherapeutic dynamics which can be related to particular issues ranging from early work on exchange theory (Salisbury, 1969) to Arrow et al’s (2000) work on the identification of system theory and the role of creativity in generating ideas (Paulus, 2000). These having obvious consideration for the KUDOS dimensions and the creating of scholarly space for teams working with more intimate groups. 

I have chosen Case Study 2 because unlike Case Study 1 the structure, techniques employed and therefore intended opportunities for learning, management and coordination are on the opposite end of a spectrum due to the small intimate nature of the group size. This obvious distinction immediately brings to the fore the fact that circumstances requires different ‘teaching skill sets’ which center less on information delivery and more on facilitation, trust building and a more intimate sense of responsibility between teacher and learner (this has implications for all of the teachers in the team). This usually seems to include special consideration of the assessment of learners in these smaller cases as I have made use of pertinent procedures usually related to observation, viva and examination. In the past I have developed patchwork assessments (A3). 

Knowledges 

In the 1956/57 FA cup final Aston Villa beat Manchester United 2 – 1, and less importantly Bloom’s Taxonomy was published (Bloom et al, 1956). Unlike Aston Villa, this taxonomy of learning continues to be a winner and the first of many which have enabled me to place a framework to the objectives I want teams to achieve in sessions. For the larger groups, such as analysed in Case Study 1, my intentions rarely rise above categories concerned with ‘Knowledge and Understanding’ as opposed to intellectual skills such as ‘Application’, ‘Analysis’, ‘Synthesis’ or ‘Evaluation’ which are the preserve of the smaller more intimate groups. This is an important distinction because any attempt to moving beyond explaining important information into realms of ensuring learning spaces solving, creating unique answers and making critical judgements requires more thoughtful coordination and support for team members. Taxonomic hierarchies such as Bloom (others I use include Steinaker & Bell, 1979; Benner, 1984) work with reference to KUDOS dimensions (K2, K3, K4, K5, K6 and D7). 

Figure: the Coordination Ideals of Case Study 2 

For example, in both Case Studies I may have wanted learners as well as teachers to walk out being fully functioning professional practitioners who I organize individually (in terms of quality assurance, technology, acknowledgement of learning levels, types and abilities and as such suitable methods for teaching), but recognise that conditions and staff abilities require strategies dependent on context. 

My exposure to Bloom and others has enabled my understanding of pedagogic ordering and coordination (D7). In both Case Studies. Any colleagues can access knowledge more readily than ever before. Personal issues to do with authority, reliability and implications which resonate with professional values (V1, V2, V3 and V4 and then K4, K5, A4) can show themselves in managing teams dealing with these small groups. The performance dynamic has become one about trust, believability, motivation, hope and a witnessing of the teachers engagement and subsequent management of the assessment marking (A3). As a team we no longer rely on a single hand in assignment to assess the ability of the learner to grasp concepts even if we do on one another to fill in the gaps of knowledge and confidence of the learner. As just noted this has resonance for all 5 ‘areas of activity’ dimensions as well as ‘core knowledgies’ because demonstrating comprehension is on a different taxonomy to making critical judgements. The management and coordination of the stress created by assessments reminds me of additional staffing issues I have encountered with the management of smaller groups. 

Coordinating Assessment 

The work of Maisch (2003) has influenced my thinking on assessment (A3). Introducing innovative assessment formats for the Priory Awards necessitated careful thought about criteria, course objectives, academic standards and procedures. The use of multi-voiced, multi-level assessment such as ‘Patchwork Text’ enabled a sub dividing of assessment against coherence, comprehension, justification, tentativeness and conceptual levels. The aim being about what Parker (2003) identifies as both method and the product of synthesis. As fancy as this may sound the idea of producing smaller pieces of work and justifying how they connect, making decisions as to the destination of key elements and achieving a sense of autonomy being just part of the challenge, because coordinating this between staff memebers can be a challenge. I am also reminded of the feedback I produce with my colleague John Thain on the Doctorate programme at the University of Wolverhampton, as well as the verbal feedback we as a team give during ‘live supervision’. The learners on these programmes are mostly mature professionals and academic to boot. This serves up a mixture of interpersonal issues for any marker who has to at least be perceived as ‘knowing their stuff’, having the ‘authority to make comment’ and the skills to encourage incentive, engagement and generally get the best out of busy people. The Intimate group provides different opportunities for managing the delivery of feedback and therefore coordinate the assessment needs for the team. I make special note of this in relation to D7, but note that I have made several conference workshops and speeches to this effect (please see if interested educational conference papers). 

Part 3 CPD review and plan 

I have 2 aims for this section. First, I want to sum up where I think I’m at by highlighting my achievements and recognizing success no matter how small. Second, I want to sketch out my projected 5 year plan with reference to ‘Professional Values’ (V1 – V4 Figure 7). 

Where Next? 

To date I have a number of achievements which have a bearing on my expected future journey. Some of these are represented in my publication list and previously noted contributions to my professional status. In this vain my future wants and desires are modest and include more of the same. I intend to continue publishing, developing my teaching activities, knowledge and professional values. 

Dissemination & National Profile: The Next 5 Years 

I would say that my academic writing has progressed and served me well. In terms of my own confidence building and dimensions (K6), (V3, V4) and of course (A5) (Sherwin et al (2014|). I have an urge to access, learn more about the World Wide Web. Now I know that I might be few years behind, but through my academic work to date I realise the world is not getting any younger, smaller or authentic. It might have been that in the past a general mistrust of cyber-realities were well founded among academics, but now, well I suspect that’s being challenged. I am finding myself increasingly drawn to the realms of cyber-space. In some of my own work with students here at the University of Wolverhampton (Holyoake & Searle, 2015). I have identified how the next twenty years will be dominated by a new type of information experience. In light of this I am losing faith in the authority of the Journal (I am currently asked to become Editor for at least one new Journal on a monthly basis) and I suspect Jean Baudrillard’s (1981) observation that “we live in a world where there is more and more information, and less and less meaning”, is resonating for me personally. But it offers up many exciting possibilities. My rationale for how it impacts on my practice is as follows: 

•  First, I intend to develop my ideas more publically, rendering them more immediate and therefore replicate the performance and dynamic inspirations I have reflected on here into the realms of Blog, Vlog and Website activities. I acknowledge that I think this requires levels of sophistication and consistency that I am currently unable to guarantee. I will liaise with better people than myself in regards to this. 
•  Second, I intend to adapt, adopt models and persona more akin with artists, performers and technicians rather than scientists. 
•  Third, I intend to consider self-publishing as a more viable route as opposed to the publishing models I have been trapped in during the past 25 years (7 published Books / 150 + articles and panels). I am hoping that this will benefit my colleagues and students with access to my work. 
• Fourth, my teaching is becoming more aligned and less composite with all the dimensions of my research. In short, more joined up and therefore analytic. 
• Fifth, I am to seize being a general Ramp Hawker (Philip, 1980, 1977, 1955) and make sure everything I do appeals and have value to my peer group, the people who will not simply walk by. 

Regarding a timeline, well, after all of these years I recognise that my aims generally go backwards and forwards, so I could be formal and put in a pretend one, but I suspect you’d know! 

Appendix 

Figure 8: Gibbs’ model of reflection (1988)  

References: 

Allen, V. L. (ED) (1976) Children as Teachers: Theory and Research on Tutoring, New York, Academic Press 

Allison, J. ; Hayes, C. (1996) The cognitive style index: A measure of intuition-analysis for organizational research. Journal of Management Studies, 33, p119 – 135. 

Arrow, H. ; McGrath, J. E. ; Berdahl, J. L. (2000) Small groups as complex systems: Formation, coordination, development, and adaptation, London, Sage Publications. 

Baudrillard, J. (1981) Simulacres et Simulation (Trans: Sheila Glaser), Paris, Éditions Galilée (French) & (English) University of Michigan Press. 

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley. 

Bloom, B. S.; Engelhart, M. D.; Furst, E. J.; Hill, W. H.; Krathwohl, D. R. (1956). Taxonomy of educational objectives: The classification of educational goals. Handbook I: Cognitive domain. New York: David McKay Company. 

Cassidy, S. (2004) Learning Styles: An overview of theories, models, and measures, Educational Psychology, Vol 24: No 4, p419-444 

Curry, L. (1987) Integrating concepts of cognitive or learning style: A review with attention to psychometric standards. Ottawa, ON, Canadian College of Health Service Executives. 

Ellemers, N. ; De Gilder, D. ; Haslam, S. A. (2004) Motivating Individuals and Groups at Work: A 

Social Identity Perspective on Leadership and Group Performance, Academy of Management Review 2004, Vol. 29, No. 3, p459–478. 

Fitch, M. L.; Drucker, A. J.; Norton Jr., J. A. (1951) Frequent testing as a motivating factor in large lecture classes, Journal of Educational Psychology, Vol 42(1), Jan 1951, p1- 20. 

Holyoake, D-D; Searle, K. (2015) Cyberchondria: emerging themes for children's nurses in the internet age. Nursing Child and Young People, Vol 27,(5):34-8 

Garrison, D. R. ; Archer, W. (2000) A Transactional Perspective on Teaching and Learning: A Framework for Adult and Higher Education, Advances in Learning and Instruction Series. Opinion Papers, Elsevier Science. 

Gibbs, G. (1988) Learning by Doing: A guide to teaching and learning methods. Further Education Unit, Oxford Brookes University, Oxford. 

Ginnis, P. (2002) The Teacher’s Toolkit: Raise Classroom Achievement with Strategies for Every Learner, Bristol, Crown House Publishing. 

Greenaway, R. (1988). Powerful Learning Experiences in Management Learning and Development [4]. 

Hartley, J. (1998) Learning and studying: A research perspective, London, Routledge. 

Jarvis, P. (Ed) (2006) The Theory and Practice of Teaching (2nd Edition), London, Routledge. 

Johns, C. and Graham, J. (1996) Using a Reflective Model of Nursing and Guided Reflection. Nursing Standard 11 (2) 34-38. 

Johns C (1995) Framing learning through reflection within Carper’s fundamental ways of knowing in nursing. Journal of Advanced Nursing. 22, 2, 226-234 

Kirton, M. J. (1994) Adaptors and innovators, London, Routledge. 

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 Correspondence:

Faculty of Education Health and Wellbeing,

University of Wolverhampton

D.Holyoake@wlv.ac.uk 

 Abstract:

Obesity, a pan-global disease has risks to health and significant contribution to morbidity and mortality. Its associated pathological abnormalities are important health hazards contributing to illnesses. An immediate cost effective primary prevention must reach out to the global community. In this article, I argue that exclusive breastfeeding with cellular, immunological, genetic, hormonal and bioactive components has potential to prevent obesity. The argument is strengthened by some evidence that in the absence of breastfeeding, and by the substitution of artificial formula in early life, fundamental cellular pathways that are best mediated by substances in breastmilk may be adversely affected and this can result in both obesity and in its associated diseases. The integration of the unique protection from infection without much inflammation obtained by breastfeeding, and its capacity for early genetic programming add to its protection in this area. The genetics within breastmilk and their influence to its constituents, if modulated, are opportunities for primary prevention. Additionally, if the genes through breastfeeding with beneficial epigenetic change to the nursling, are inherited, individuals, communities and generations can be protected. Both the social care worker and the scientist may do well to consider how, despite only modest statistical evidence of the role of breastfeeding in obesity protection, there is wealth of knowledge within its protective potentials. The areas highlighted in this article, if further explored, could make an impactful difference towards reducing the burden of today’s escalating health cost and social care all over the world. 

Key words: breastfeeding, obesity, health, primary, prevention 

 Introduction 

Global statistics of childhood overweight and obesity show increasing trends (Onis, Blossner and Borghi 2010). The World Health Organization (WHO) estimates 43 million overweight children under the age of 5 and by 2020 in excess of two thirds of global disease burden to be soon linked to obesity related problems (Onis, Blossner and Borghi 2010). Trends indicate a disturbing increase in the prevalence of overweight and obesity worldwide and its prevalence is projected to reach a ssignificant 9% or 60 million people in 2020 (Wang and Lim 2012). The global prevalence of childhood overweight and obesity increased from 4.2% in 1990 to 6.7% in 2010, a pattern projected to reach 9.1% estimated to be around 60 million, in 2020 (Onis , Blossner and Borghi 2010). In growing economies of the South East Asian region, Malaysia recorded a significant increase in obesity prevalence among adults, from 4.4 % in 1996 to 14 % in 2006. (Khor, 2012). In Vietnam, prevalence of overweight and obesity in adults increased considerably from 1992 to 2002. (Tuan, Tuong and Popkin 2007). Of note is the suggestion that Asians are more likely to develop central obesity which is adversely linked to many obesity- related comorbid states. (Thomas, Ho, Lam et al. 2004). Paediatric obesity has variable distribution in parts of the globe. In areas such as in Africa, the prevalence of childhood overweight and obesity in 2010 is estimated at 8.5% and predicted to reach 12.7% in 2020 (Onis , Blossner and Borghi 2010). A study reported the prevalence of overweight and obesity as 12.6% and 6.2% in junior school students and 11.5% and 4.3% in high school students, respectively (Ahmadi, Gharipour, Nouri et al 2014). The global impact of obesity and the effect it has on health resources is further appreciated when one notes that of the 43 million children overweight or obese referred to earlier, a large proportion were in developing countries (Wang and Lim 2012). Thus, the prevention of obesity is a crucial health and social issue and an effective international obesity- related health cost appraisal is needed (Tremmel, Gerdtham, Nilsson et al 2017). Health programmes must universally emphasise the early prevention of both short term effects of obesity to all but specifically in children because of the enduring impact to society and plan cost effective strategies to entirely overcome its long term health consequences. 

1. Multifactorial causes of obesity 

There are multifactorial causes of obesity (Jou, 2014; Sahoo et al 2015). Both endogenous and exogenous factors contribute (Jou 2014 ; Sahoo et al, 2015) (Figure 1) and psychosocial aspects of obesity (Beck 2016) can occur either as a part of obesity or as a result of it. Many causes overlap making distinction of mechanisms of obesity sometimes difficult. 

Figure 1: Multifactorial causes of obesity 

Simple obesity is mainly predisposed to by eating habits and lifestyle factors (Weker, 2006), risk factors for familial ‘clustering’ of obesity are the interaction of both genes and environment (Li, Lou, Du et al 2014) while hormonal obesity is a feature of specific endocrinopathies (Jou, 2014; Sahoo et al 2015; Lugo, Pina and Cordido 2012). A child with an obesity syndrome may also have a history of familial obesity. Syndromes are linked to obese phenotypes and in the majority of morbid obese cases there is involvement of a genetic mutation implicating the function of hypothalamic regions controlling food intake (O’Rahilly and Farooqi 2006). The genetic causes of inheritance patterns in monogeneic and polygeneic obesity (Hinney, Vogel and Hebebrand 2010) are well documented. The overarching importance of obesity is its link to potentially dangerous health conditions. In children as in adults, a spectrum of disorders is linked to obesity such as hypertension, dyslipidaemia, impaired glucose metabolism, nonalcoholic steatohepatitis, obstructive sleep apnea, orthopaedic complications and psychosocial problems (Jarolimova, Tagoni and Stern 2013). Paediatric hypertension is a predictor of adult hypertension, and this precedes cardiovascular mortality risk in adults (Raj 2012). Cardiovascular disease manifests as heart failure, acute coronary syndrome, and premature sudden death (Rosiek and Leksowski 2016). Of note is obesity-related left ventricular hypertrophy (LVH) and its dysfunction in children (Attar, Safdar, Ghoneim et al 2016). It merits mention that obesity is also a risk factor for the development and progression of cancer with poor prognosis in specific types of tumours (Hopkins, Goncalves and Cantley 2016). The aetiopathogeneses of the underlying influences predisposing to, a consequence of, or a complication due to obesity are not fully elucidated. However, certain fundamental mechanisms are suggested (Figure 2). A chronic low-grade inflammatory state accompanies obesity, pathologically explained by elevated systemic inflammatory markers in serum and inflammatory cell infiltration of tissues (Lee, Lee and Choue 2013). Inflammation is activated early in adipose tissue expansion and in chronic obesity with an overall tendency for the immune system towards proinflammatory responses (Bull and Plummer 2014; Houghteling and Walker 2015). Dyslipidaemias, muscle hypertrophy, hormonal abnormalities and deranged end organ responses to hormonal action are sometimes recognised in obesity and contribute to a variety of associated diseases (O’Rahilly and Farooqi 2006; Jarolimova, Tagoni and Stern 2013; Attar, Safdar, Ghoneim,et al 2016). ‘Dysgenesis’ or abnormalities of commensal gut microbial flora in the human gut is now known to impact an individual’s health (Dietert and Dietert 2012). As postulated by Dietert, R and Dietert, J (Dietert, Dietert 2012) failure to adequately incorporate commensal microbes in the neonatal period is a crucial component that potentially deters “holistic health”. The pathogenesis of many metabolic diseases including obesity has been related to the gut microbiota which, with the host, are involved in dynamic homeostatic mechanisms (Lee, Lee and Choue 2013; Bull and Plummer 2014; Houghteling and Walker 2015). Altered gut microbial composition together with predisposing factors, could cause or exacerbate the aetiopathogeneses of underlying obesity (Dietert and Dietert 2012). Additionally, the gut microbial milieu is also influenced by in utero events, postnatal contact and exposure. 

Figure 2 : Known and possible aetiopathogeneses of obesity-linked disorders and comorbid conditions. Can breastfeeding reduce health care costs and social care burden that result from at least some of these links ? 

2. The placental – amniotic fluid- maternal -foetal tetrad 

In utero the growing foetus is nourished both by the placenta and also by maternal, foetal and amniotic fluid factors (Mor and Cardenas 2010; Neu 2015). The placental – amniotic fluid- maternal–foetal symbiotic tetrad influences growth and maturation by hormonal, bioactive and immunological factors (Mor and Cardenas 2010; Neu 2015). It is noteworthy that constituents of the tetrad skew immunological factors uniquely to one of immune modulation (Neu 2015; Floris Kraft and Altosaar 2016) Microbial colonisation of the foetal gut occurs in utero by substances from the amniotic fluid (Neu 2015; Floris, Kraft and Altosaar 2016). The permeable foetal gut absorbs swallowed amniotic fluid and has nutritive and regulatory roles (Neu 2015; Floris, Kraft and Altosaar 2016). This modulates intestinal inflammation and affects bacterial colonization of the foetal gut and gut inflammatory responses, impacting the weight of the newborn (Mor and Cardenas 2010; Neu 2015; Floris, Kraft and Altosaar 2016). In pregnancy human placental lactogen (hPL) is secreted into maternal and foetal circulations, activating maternal production of insulin-like growth factor (IGF) further influencing foetal metabolism (Handwerger and Freemark 2000). In the foetus, receptor mediated action of hPL occurs with production of IGFs, insulin and lung maturational factors, vital for foetal survival (Handwerger and Freemark 2000). Protection from foetal infection is by placental trophoblasts with their anti-microbial peptides such as human beta defensins (Mor and Cardenas 2010), secretory leukocyte protease inhibitor (SLPI) (Mor and Cardenas 2010; King, Critchley and Kelly 2000;) and beta interferon (IFN-β) (Mor and Cardenas 2010) . 

From the moment of conception, throughout pregnancy and at birth, the mother and infant are involved in cellular signals, which are probably bidirectional (Floris, Kraft and Altosaar 2016). For these signal mediators to function physiologically, they are protected from biological degradation and although not yet fully elucidated, their signals control growth and development in the prenatal and postnatal phases (Floris, Kraft and Altosaar 2016). With potentials for diverse action, they are impacted by many extrinsic factors , such as maternal diet, mode of delivery, microbes in the maternal gut, and the type of milk feeds postnatally (Floris, Kraft and Altosaar 2016; Dunlop, Mulle, Ferranti et al 2015; Tremaroli and Backhed 2012 ; McGuire and McGuire 2015). 

3. Breastfeeding , obesity and associated conditions 

i. Breastfeeding transfers maternal genomic information , influences development and function of tissues in the nursling 

An infant is born with a set of genes, its expression and regulation determining many states of health and disease. The early postnatal period is crucial with environment and nutrition potentially influencing genetic expression. DNA methylation and imprinting, histone modification by acetylation and methylation and RNA associated silencing are epigenetic influences (Simmons 2008); these, with other postnatal experiences modify, alter or impact gene expression without alteration of the DNA sequence (Simmons 2008). At birth, fetal swallowing of maternal flora influences the infant’s gut milieu, directly and indirectly influencing growth and maturation of the gastrointestinal tract and other organ systems (Neu 2015). Postnatally, nutrition by the lactating mammary gland is an influential exposure both because it is continuous and repeated, and by the nature of its constituents (McGuire and McGuire 2015). Mammary stem cells can differentiate into adipocytes and epithelial cells (Zhu and Nelson 2013). The mammary gland consists of glands, ducts, connective tissue and adipose tissues. Adipose tissue principally makes up the volume of the breast consisting of adipocytes, fibroblasts and macrophages (Zhu and Nelson, 2013; Kajimura and Saito, 2014). Adipose tissue exists in two forms, and evidence suggests that both forms can undergo transdifferentiation (Kajimura and Saito, 2014). White adipose tissue (WAT) is for energy storage as triglycerides , brown adipose tissue (BAT) is responsible for thermogenesis via uncoupling protein-1 and its sympathetic innervation, predominantly a mechanism utilised by the newborn ( Kajimura and Saito, 2014). In adipose tissue, hyperplasia, a primarily irreversible process, denotes the increase in number of adipocytes and is determined from childhood to adolescence remaining constant during adulthood, in both lean and obese individuals (Spalding, Arner, Westermark et al 2008 et al); in an adult about 10% of fat cells are renewed annually (Spalding, Arner, Westermark et al 2008). Hypertrophy involves the accumulation of triglycerides which are able to take up, store, and release free fatty acids depending on systemic nutritional status, and are uniquely capable of tolerating high concentrations of lipids without lipotoxicity (Rutkowski, Stern and Scherer 2015). The mammary epithelial cell (MEC) embedded in the mammary fat pad , constitutes the functional unit of the mammary gland and together with adipose tissue influence its growth and milk production (Zhu and Nelson 2013 ).While the infant suckles at the nipple, ducts that link lobules, lobes and glands allow milk to flow through them. Breastmilk, the nutrition of the mammary gland, is a rich source of early stem cell progenitors and differentiated cells (Witkowska-Zimny and Kaminska-El-Hassan 2017). Milk microvesicles are formed from the apical parts of the MECs or from the milk fat globules (MFG) (Bourlieu and Michalski 2015), which during secretion into milk envelop their cell contents and contain abundant mammary cell ribonucleic acid (RNA) (Lemay, Ballard, Hughes et al 2013). The genes in breastmilk represent different cell populations and show great variation in expression (Lemay, Ballard, Hughes et al 2013). Although the activators of these events are not well defined, it is possible that both incorporation of maternal genomic information into tissues and control over how tissues of the nursling develop and function occur by breastfeeding (Irmak, Oztas and Oztas 2012). It is proposed that breastfeeding is capable of transfer of messenger RNAs (mRNAs) transcripts from mother to nursling (Irmak, Oztas and Oztas 2012). These are coding RNA molecules that transmit genetic information from maternal deoxyribonucleic acid (DNA) to the ribosome as a template for protein synthesis. It is also suggested that microvesicles containing mRNA transcripts possess reverse transcriptase activity and that they are transferred to cells of the nursling by endocytosis (Irmak, Oztas and Oztas 2012). mRNA, acted upon by reverse transcriptas, termed ‘retrotransposoons’, are integrated into the tissues of the nursling (Irmak , Oztas and Oztas 2012). 

Maternal genetic influence does not cease here. Micro RNAs (miRNAs), noncoding RNAs which can also affect genes are found in breastmilk mainly from synthesis in the MEC (Alsaweed, Lai, Hartmann, Geddes et al 2016; Gigli and Maizon 2013). There seems to be different pathways by which miRNAs are formed (Shabalina and Koonin 2008;Chong, Zhang, Cheloufi, et al 2010); one biosynthetic pathway requires two RNaseIII enzymes. Initial transcription is by RNA polymerase II generating primary miRNA (pri-miRNA), these are acted upon by the enzyme Drosha to form pre-miRNA (pre-MiRNA) which is then transported to the cytoplasm and is enzymatically cleaved by Dicer which is loaded onto an argonaute (Ago) protein which primarily forms the RNA-induced silencing complex (RISC) (Shabalina and Koonin 2008). 

An array of different miRNAs are synthesised in the MEC (Alsaweed, Lai, Hartmann et al 2016) with dynamic action. In the lactating mammary gland, the cell content is known to increase post-feeding (Alsaweed, Lai, Hartmann, et al 2016), suggesting that MECs synthesise miRNAs as the infant suckles from the breast, underscoring the importance of demand feeding for the nursling to obtain the full spectrum of miRNAs. In this context, there are a few issues to be considered. How far is the range of miRNAs that direct gene expression entering the milk feed responsive to infant suckling? Mother to infant communication seems to occur during breastfeeding – variables such as the health status of the lactating breast as well as of the “mother and infant dyad” are suggested (Hassiotou, Hepworth, Metzger et al 2013). Similarly, in the setting of this discussion, could an infant by the nature of suckling in hunger or in satiety, trigger or suppress the expression of genes for appetite impacting factors in breastmilk? Is it conceivable that the weight of an infant triggers cellular messages to modify synthesis of genes that produce pro-obesity proteins? Are maternal genes within the “intelligence” of breastmilk destined for some form of communication educating the infant’s course of “bio-geno-immuno-nutritive” (Kutty, 2016) pathways provided through her breastmilk? By post- transcriptional gene modification, in a myriad tissues of the breastfed, genetic information is assimilated into tissues (Melnik and Schmitz 2017); these potentially confer epigenetic modification to the expression of genes in the nursling (Melnik and Schmitz 2017). The unfolding of genetics in breastmilk seems fundamental to health, metabolism and disease (Dietert and Dietert 2012; Melnik and Schmitz 2017). 

ii Breastmilk proteins, the enteromammary axis and gut bacteria 

Unique proteins in breastmilk influence both the metabolism and weight of the nursling. These macronutrients consist of milk fat globule membrane (MFGM) proteins , caseins and whey (Lönnerdal, Erdmann, Thakkar et al 2017).The mother produces them despite her diet as milk macronutrient composition is not notably affected by fasting (Rakicioğlu Samur , Topçu et al 2006). Milk proteins are bioactive, biologically affecting tissues, some with features that optimise in vivo action, resisting digestion in the gastrointestinal tract for purposeful physiological functions (Lönnerdal, Erdmann, Thakkar et al 2017; Davidson and Lonnerdal 1987). The metabolism of the nursling is affected by the milk feeds and the microbes in the gut (Davidson, Lonnerdal 1987; Jost, Lacroix, Braegger, et al 2013). Tangibly breastfeeding establishes the maternal – to - infant bond via the enteromammary axis, linking the mother’s gut to her lactating mammary gland, influencing factors in the milk feed (Jost, Lacroix, Braegger et al 2013). Through this bond, many potential influences of the mother’s gut which are under novel stimuli, are factually and at present, hypothetically, directly or indirectly transmitted to her nursling (Obata and Pachnis 2016; Jost, Lacroix, Braegger, et al 2013). The immature neonatal immune system is thus under maternal influence and in some ways there is “immune education” because breastmilk stimulates useful gut bacteria such as Bifidobacterium, Clostridiales and Lactobacillus which positively influence homeostasis for optimal growth and metabolism (Jost, Lacroix, Braegger et al 2013). Different microbial patterns induced by artificial feeding will not provide the nature and extent of homeostasis or influence metabolism in the same manner, and this is supported by the suggestion that such microbial flora is potential nidus for abnormalities of metabolic maturation and homeostasis, predisposing to immediate and long term metabolic derangements (Riiser 2015; Jost, Lacroix, Braegger et al 2013). 

iii Breastmilk proteins , adiposity and organ effects- do they save a nation’s health resources in the long term ? 

Breastmilk is dynamic during phases of lactation and at different times within a feed with variation in its proteins, cells, fats and other constituents. Early in lactation, whey concentrations are high, compared to casein, comprising beta and kappa caseins (Lonnerdal 2013). The median whey-to-casein ratio, nearly 80:20 in colostrum falls to 60:40 by the second week (Lonnerdal 2013). Colostrum, the first ‘vaccination’ of a breastfed infant has immunoglobulins and other whey proteins for early protection, with α-lactalbumin having highest concentrations (Lonnerdal 2013). Other bioactive proteins are lactoferrin, lysozyme, secretory immunoglobulin A(sIgA), haptocorrin, lactoperoxidase, bile salt stimulated lipase and tumour growth factor- beta (Lonnerdal 2013). Breastmilk is a source of iron with high bioavailability and in term infants protects against iron deficiency anaemia, the commonest micronutrient deficiency worldwide (Qasem and Friel 2015); this deficiency impacting growth and development and predisposing to infections. Metabolic effects of lactoferrin, a bioprotein with immunological activity are evident by its ability to increase insulin sensitivity and lower blood sugar levels(Ono, Murakoshi, Suzuki et al 2015), with a possible beneficial role in decreasing visceral fat and the metabolic syndrome (Navarrete, Ortega, Bassols et al 2009 ) - in vivo actions are therapeutic approaches to explore in obesity linked conditions. 

Differences by feeding mode in the amount and content of proteins and their amino acids ingested at different periods of lactation and their influence on hormones and growth factors may explain varied growth patterns observed in the breastfed compared to the formula fed infant (Csap and Salamon 2009). Casein forms 30% of the total protein in breastmilk and 80% in cow’s milk. Caseins have a high content of proline, and form micelles of calcium and phosphorus (Csap and Salamon 2009). In breastmilk the content of glutamic acid is highest and methionine lowest, whilst, of the essential amino acids, leucine and lysine are the highest, followed by those of isoleucine, valine, threonine and histidine (Csap and Salamon 2009). Compared to the protein intake of breastfed infants which declines with age in tandem with requirements for protein during the early months of life for growth and development, the protein intake of formula fed infants is more or less static and tends to exceed metabolic requirements after the first 1-2 months of life (Ziegler 2006). Insulin synthesis and secretion are stimulated in infants fed formula with high levels of protein, as indicated by increased urinary C-peptide compared to breastfed infants (Luque, Monasterolo, Escribano et al 2015; Socha , Grote , Gruszfeld et al. 2011). The actions of insulin influenced by the variations in protein supply affect adipose tissue and other organs. (Dimitriadis, Mitrou, Lambadiari et al 2011). Insulin enhances active transport of amino acids into muscle and stimulates protein synthesis .It decreases lipolysis in adipose tissue, stimulating fatty acid and tricylglycerol synthesis , enhances uptake of triglycerides into adipose tissue and muscle and reduces fatty acid oxidation in muscle and liver (Dimitriadis, Mitrou, Lambadiari et al 2011). Insulin is primarily involved in metabolic activities but its growth factors, such as IGF, control growth and differentiation of many cells and tissues. There is possible “cross-talk between the various ligands and receptors of the IGF family” (Werner, Weinstein and Bentov 2008 ). Based on postnatal differences in growth and development of organs, target tissues are differently sensitive to actions of IGF-1 in infants (Luque, Monasterolo, Escribano and Ferré 2015; Dimitriadis, Mitrou, et al 2011; Werner, Weinstein, Bentov 2008). There are modulation and dynamic levels of these factors, their binding proteins and specific proteases in breastmilk with a decline of their levels over the course of lactation (Milsom, Blum and Gunn 2008). The insulin like growth factor-1 (IGF- 1) axis is possibly influenced differently by formula feeding compared to breastmilk, contributing to higher body weight in formula fed infants (Socha, Janas, Dobrzañska et al 2005). IGF influences local and systemic cell growth and differentiation by autocrine and paracrine signals of organs including the musculoskeletal and endocrine systems (Wang , Bikle and Chang 2013) . The early protein hypothesis denotes the protein- induced growth of organs as possibly due to IGF-1 (Luque , Monasterolo, Escribano et al 2015; Laron 2001). Reiterating the importance of physiological levels of IGF-1, its deficiency is associated with Laron Syndrome, such infants being short at birth (Laron 1999); with abnormalities involving the brain (Laron 1984), musculoskeletal system and heart (Brat, Ziv, Klinger et al 1997; Feinberg, Scheinowitz and Laron 2000). 

Amino acids of digested milk proteins are regulatory nutrients in breastmilk. In the absence of breastfeeding and with replacement by artificial feeding, quantitative or qualitative differences in the amino acids in cow milk- based infant formula is postulated to be a cause of obesity. (Melnik 2012). The mammalian target of rapamycin (mTOR), is recognised to be “a master regulator of cellular, developmental and metabolic processes”; (Jaina, Arauzc, Aggarwala et al 2014) and, nutrition, influencing growth and development, coordinates this link (Melnik 2012, Laplante and Sabatini 2012). mTOR controls the expression of miRNA (Laplante and Sabatini 2012). mTOR is assembled into two distinct complexes, mTORC1 and mTORC2 with suggestion that there may be a link between the two (Jaina, Arauzc, Aggarwala, et al 201). Nutrients can modulate signalling of miRNA and leucine, an essential amino acid and a precursor of fatty acid and cholesterol synthesis is found to activate mTORC1 (Jewell, Flores and Guan 2015). Additionally obesity related comorbidities that burden health and social support systems in the long term; these maybe partly explained by the suggestion that consumption of cow milk- based formula is not species specific, dissimilar in its leucine content from human breastmilk (Melnik, John and Schmitz 2013; Melnik and Schmitz 2017), as a result, it may be argued that uncontrolled stimulation of hormonal and cellular pathways results in abnormalities and disease(Jewell, Flores and Guan 2015 Melnik and Schmitz 2017) A nation’s health resources could be affected by these diseases with a dismal statistical impact- if indeed the higher quantity of leucine in infant formula signals mTORC1 differently than that of breastmilk, increasing adipogenesis and irreversible adipocyte hyperplasia ( Melnik, 2012; Melnik, John and Schmitz 2013; Melnik and Schmitz 2017) , predisposing to obesity and its associated conditions. mTORC1 signalling by leucine also increases blood flow and arterial pressure (Harlan, Guo, Morgan et al 2013) and mTOR activation has been linked to murine cardiac hypertrophy (Lollo, Batista, Moura et al 2013) 

The proteins in breastmilk also constitute the active components of the membrane proteins of the milk fat globule and include lactadherin, butyrophylin, xanthine oxidase, human milk mucins and membrane mucins on the fat globule (Lonnerdal 2013), with much potential for immune modulation (Zanabria, Tellez, Griffiths et al 2014). The milk fat globule (MFG) per se is rich in RNAs, and supplies energy as nutrients via triacylglycerol (TAG) (Zanabria, Tellez, Griffiths et al 2014). Its bioactive constituents influence the metabolism of lipids TAG has a role in determining microbiota of the gut that modulate immune responses (Zanabria, Tellez, Griffiths et al 2014). Specific micronutrients are protected and cholesterol absorption is lowered by MFG (Fernandez-Hernando, Suarez, Rayner et al 2011), rapidly clearing chylomicrons from plasma (Fernandez-Hernando, Suarez, Rayner et al 2011) miRNAs, functioning at the post-transcriptional level of gene synthesis regulate genes associated with lipid metabolism (Fernandez-Hernando, Suarez, Rayner, Moore 2011). miRNA precursors may influence cholesterol homeostasis, fatty acid oxidation, and lipogenesis (Rayner, Suarez, Davalos et al 2010). The abundance of miRNAs in breastmilk may reflect the extent and influence on growth and metabolism provided by the genetics of breastfeeding. 

At six months of age an infant who is exclusively breastfed must start complementary feeding. Undigested substances in infant weaning diets such as fibre are fermented in the colon to produce Short Chain Fatty Acids (SCFA); SCFAs are sources of energy requirements for the colonic epithelium (Schwiertz, Taras, Schäfer et al. 2010; Byrne, Chambers and Morrison 2015). Gut microbes via SCFAs may stimulate Glucagon-like Peptide -1 ( GLP-1) a neuropeptide from the transcription of the proglucagon gene, influencing satiety, gut transit times and insulin secretions (Byrne, Chambers and Morrison 2015 ). 

iii Breastmilk hormones and obesity 

Hormones in breastmilk play a role in metabolism and physiologically balance states of energy deficit with excesses (Savino, Ligiuori Fissore and Oggero 2009; Savino, Fissore, Liguori, Oggero 2009). Some hormones are inversely related to obese states while others more directly prevent obesity. During energy deficit, ghrelin in breastmilk, a peptide hormone and a stimulator of growth hormone secretion is released from the stomach and the mammary gland by signals from the arcuate nucleus for appetite stimulation (Savino, Liguori Fissore et al 2005). The active form of ghrelin increases during a lactational period and decreases over time (Savino, Liguori Fissore et al 2005). Formula fed infants, receive a higher amount of ghrelin, with greater feeding impetus compared to breastfed infants leading to increases in weight and growth rates (Savino, Petrucci, Lupica et al 2011). A correlation between ghrelin in breastmilk of obese and non obese infants suggests its regulatory effect acting together with other hormones (Savino, Petrucci, Lupica et al 2011; Savino, Liguori, Fissore et al 2009). Levels of satiety and food preferences exert early stimulus, influenced by the type of milk feeds (Brown and Lee 2012). Plausible basis for cultural and ethnic differences in cuisine prenatally is the recognition of taste and odours as the fetus swallows amniotic fluid flavoured by the mother’s diet (Mennella, Jagnow and Beauchamp 2001). Flavours of maternal diet through breastmilk continue to influence the breastfed infant (DeCosmi, Scaglioni and Agostoni 2017). This, complemented by the interplay of breastmilk hormones seem important in weight control. Excessive intake of food has a link to “polymorphisms in the fat mass and obesity-associated gene (FTO)” (Karra, O’Daly, Choudhury et al 2013) FTO may cause epigenetic change via a potential regulatory RNA modification, predisposing to human obesity (Karra, O’Daly, Choudhury et al 2013). 

Adinopectin is reactive to energy deficits, released from adipocytes in the fasting state, decreasing in obesity. Its effective levels in breastmilk favour its penetration of the intestinal barrier to modify infant metabolism (Khodabakhshi, Ghayour-Mobarhan, Rooki, et al 2015). In breastmilk adiponectin is inversely linked to infant weight and body mass index (BMI) , protecting against overweight and obesity in later life (Ballard and Morrow 2013). The adipokine, Nesfatin-1, in breastmilk with a role in obesity might be expressed by nigral dopaminergic neurons (Shen, Song, Du, Yong et al 2017). Hormones in breastmilk that inhibit appetite and increase energy disbursement by central action, such as leptin, derived from the adipocyte, as well as by interaction with CCK and pancreatic insulin intestinal peptide YY, impact weight control (Perry and Wang 2012). As in utero, postnatally, leptin in colostrum and breastmilk correlates with body mass index (BMI) in infants (Casabiell, Piñeiro, Tomé et al 1997). It acts through the Ob- receptor (s-Ob) and reduces food intake while increasing energy expenditure (Catli, Dunda and Dundar 2014; Savino, Liguori and Lupica, 2010). Either from maternal plasma or by active production in the MEC, (Bonnet, Delavaud, Laud et al 2002) leptin acts on specific neurons in the hypothalamus and upregulates anorectic α-melanocyte-stimulating hormone (α-MSH) and downregulates orexigenic neuropeptides (Zhou and Rui 2013). Leptin also has specific effects on T-lymphocytes such as enhancing proliferation of naive and memory T-cells, increasing interleukin-2 (IL-2) and interferon-gamma (IFN-gamma) (Riejos, Najib, Alvarez et al 2010; Ouchi, Parker, Jesse et al 2011); a single component in breastmilk having a number of useful functions. 

iv Adipose tissue inflammation, infections and breastmilk protection 

Integration of knowledge on the causes and pathogenesis of obesity and how the potentials by breastfeeding can counter mechanisms that cause obesity may clarify its role in prevention. 

A nutrition linked epigenetic mechanism that is inheritable has been proposed (Kaati, Bygren and Edvinsson 2002). It was earlier mentioned that chronic inflammation is an obesity linked aetiopathogenetic mechanism. Hypertrophy and hyperplasia of adipocytes occur during lipogenesis (Jung and Choi 2014; Ghigliotti, Barisione, Garibaldi et al 2014). Accumulation of triglyceride inside white adipocytes causes hypertrophy (Jung and Choi 2014; Ghigliotti, Barisione, Garibaldi et al 2014), an increase in the size of adipocytes. Adipocyte hypertrophy is not a limitless process hence when excessive, large hypertrophied adipocytes experience hypoxia and may not be able to perform the physiological functions associated with this tissue. (Rutkowski, Stern, Scherer 2015; Schwartz, Woods, Porte et al 2000). In obesity, adipose tissue is infiltrated by a large number of macrophages, and this is related to systemic inflammation and insulin resistance (Weisberg, Mc Cann and Desai 2003; Ouchi, Parker, Jesse et al 2011). Being an active endocrine organ, adipose tissue- derived adipokines have proinflammatory effects contributing to the complications of obesity. (Weisberg, Mc Cann, Desai, et al 2003). There is also interrelationship between adipose tissue and infections where pathogens maybe postulated to cause, exacerbate or modify immune responses in obesity. (Hedge and Dhurander,2013) Hence, responses in breastfeeding that shield from early and recurrent infections together with its predominant antiinflammatory action may be viewed as general antiobesity protection. 

In the acute protection against respiratory infections in early life, there is immunomodulation, with breast milk immunoglobulin G (IgG) significantly absorbed by the breastfeeding infant (Li, Liu, Jiang, et al 2017). It has been shown that high levels of IgG on the nasal mucosa are able to protect against respiratory syncytial virus (RSV) infections (Vissers, Ahout, de Jonge et al 2016). In cases of previous infections, memory cells produced in breastmilk potentially ameliorate infections; the absence of such immunological memory favours recurrent infections and chronic inflammation, heightening the proinflammatory scenario alluded to earlier, already present in obesity.

Immunological memory in breastmilk involves both arms of immunity and disease- causing microbes gain access to the body mainly through mucosal portals. In breastmilk, CD8+ T cells have intestinal and mucosal homing receptor and memory cells (Sabbaj, Ghosh, Edwards et al 2005). Its B cells , are switched memory cells primed to secrete antibodies(Tuaillon, Valea, Becquart et al 2009). To emphasise the role of breastmilk as an anti-inflammatory agent, breastfeeding from allergic mothers with intact B cell immunity, successfully protect offspring from allergic airway disease (Matson, Thral, Rafti et al 2009). At the cellular level, miRNAs have a role in immunity and may link inflammation, immunity and obesity (Ge, Brichard, Yi and Li 2014). 

If chronic inflammation is a pathogenetic mechanism of obesity, secretory immunoglobulin A also (sIgA) is deemed to have antiobesity function. In defence and protection against local and systemic infections without inflammation, sIgA , at mucosal sites block attachment of pathogens to epithelial cells ( Mantis, Rol and Corthésy 2011). As is already well established, in the airways, sIgA functions efficiently to shield mucosae from injury without inflammatory responses (Mantis Rol and Corthésy 2011), and, pertinent to this discussion in reducing the pathogenetic mechanisms in obesity . It directly reduces pathogen induced proinflammatory responses and prevents pathogens binding to intestinal cells for transepithelial transport which may otherwise stimulate systemic immune responses (Mantis and Rol and Corthésy 2011). Moreover, potent antiinflammatory effect by sIgA per se is its ability to interact with dendritic cells (DC) through the specific intercellular adhesion molecule (ICAM)-3 grabbing non-integrin receptor 1 (SIGNR1) (Monteiro 2014). Gut intestinal microbes are important again here- as part of the mucosa associated immune system (MALT), sIgA, influences gut intestinal microbiota by both Fab- dependent and Fab- independent mechanisms (Mantis Rol and Corthésy 2011), downregulating proinflammatory pathogens and allergen induced responses (Mantis Rol and Corthésy2011). Furthermore, microbial colonization itself can generate antibodies in the gut shaping composition of beneficial gut microbiota through “antibody-mediated immunoselection” (AMIS) (Kubinak and Round 2016). The absence of breastfeeding and replacement by artificial formula has been known to cause more diverse bacterial flora such as coliforms, C. difficile and Bacteroides fragilis. (Mueller, Bakacs, Combellick et al 2015) which can cause infections and diseases. Lipopolysaccharides, (LPS), the outer membrane constituent of coliforms regulate expression of cannabinoid receptors via the LPS receptor, triggering systemic sepsis (Csóka, Németh, Mukhopadhyay, et al 2009)- this could potentially enhance adipose tissue inflammation through infection, stimulating aetiopathogenetic mechanisms associated with obesity. 

iv Antioxidants in breastmilk and obesity 

The antioxidant enzymes in breastmilk namely superoxide dismutase (SOD), catalase and glutathione peroxidase (GSHPx) together with bioactive nutrients protect from oxidative stress. (Živković, Sunarić, Trutić, et al 2015). Obesity results in conditions that stress the endoplasmic reticulum (ER) by the unfolded- protein response (UPR) (Zhang and Kaufman 2008 ). ER stress and the UPR lead to obesity-induced inflammation, triggering activator proteins, kinases, acute-phase responses and reactive oxygen species (ROS) (Rains and Jain 2011). Chronic exposure to ROS affects glucose transporters, impairs insulin-stimulated glucose uptake (Marseglia, Manti, D’Angelo et al 2015) and may predispose to specific cancers (Wang, Li, Ye et al 2016). The enhanced antioxidant capacity of human milk compared to the reduced levels in commercial formula (Mehta and Petrova 2014) is a general advantage in breastmilk against many causes of oxidative stress. It is possible that the antioxidant capacity of breastmilk may be protective in obesity-induced inflammation in adipose tissue . 

Conclusion 

The impact of obesity on immediate and long term health is of great concern both for the individual as well as for the community. Primary prevention is mandatory because of the mechanical stressors of obesity and its important comorbidities. Breastmilk has potential action against obesity, because of its interactive constituents of “bio-geno-immuno- nutrition” (Kutty 2016), and can positively influence or counteract some aetiopathogenetic mechanisms. By epigenetics and by the inherent nature of its constituents, breastmilk can potentially alter the expression of diseases (Verduci, Banderali, Barberi et al 2014), including obesity. Although, with time there may be a weakening effect of the benefits of breastmilk (Horta and Victoria, WHO 2013) contributed to by the influence of other dietary and lifestyle factors, the impact by multifunctional miRNAs in breastmilk may be different. Through the capacity to change genetic expression, the influence of breastfeeding may be more enduring then presently surmised, endowing the lactating mammary gland with substantial potential for broad but important metabolic protection. Furthermore, if epigenetic expressions can be inherited (Kaati, Bygren and Edvinsson 2002) the epigenetic influence of genes through breastfeeding could endow natural feeding as a necessary vaccine that can be modulated in an individual and across communities and generations (Figure 3), the absence of which detrimental to overall health. 

Figure 3: The public health and social care impact of obesity protection by breastfeeding. 

In other words, in the absence of breastfeeding, miRNAs in formula feeding can increase the risk of “diseases of civilization” ( Melnik 2017) such as obesity , type 2 diabetes mellitus and so on (Melnik 2017) – these, if inherited, have a negative impact on the health burden of a population, but on the other hand, inheritance of potential protective action against these diseases by optimal physiological growth and function of organs by breastfeeding may be holistically viewed as a generational public health tool to reduce morbidity and mortality risk. Early prevention of adipose tissue hyperplasia and hypertrophy by breastfeeding may reduce the later difficulties encountered with weight control and the problems linked to overweight. 

When discussing more specific protection through breastmilk, a number of interventions to the breastfeeding mother may be possible (Alasil and Kutty 2015). Just as maternal immunisation can give focused protection to the nursling against specific infectious diseases, (Alasil and Kutty 2015) could targeted obesity- related modulation transmitted through breastmilk be feasible through intervention in high- risk families? 

This idea must clearly be further developed. Research on cellular mother- to- infant signal activators may take the lead in the therapeutics of obesity-comorbidity states. Milk industries could benefit from knowledge of the dynamic action of breastmilk proteins in bionutrition, immunology and genetics. 

The epigenetics of breastmilk nutrition enhanced by modulation must be considered advancements in health care. With more in- depth research in the areas highlighted in this article, exclusive breastfeeding could be priceless primary vaccination against obesity across the global community reducing health care cost and social care burden. 

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Correspondence: 

Faculty of Medicine and Defence Health 

National Defence University of Malaysia 

Kem Perdana Sungai Besi 

57000 Kuala Lumpur 

Malaysia 

e-mail: prameela.kutty@yahoo.com 

 Abstract 

Background: The rise in diabetes worldwide and its significance as a cause of disability and premature death has increased the interest of researchers in diabetes mellitus. There is a large volume of published studies describing the role of factors such as income, poor education, inadequate housing conditions and unemployment as key social determinants in the development and progression of type 2 diabetes (T2D). This study therefore set out to investigate the main socioeconomic predictors of T2D in England. 

Methods: Based on the available literature on the socioeconomic determinants of T2D, the variables, unemployment (long-term and short-term), overcrowding, income deprivation and no qualification were selected. Data on the socioeconomic determinants and prevalence of type 2 diabetes were retrieved online from the registry of the Office for National Statistics and the Health and Social Care Information Centre respectively. This was done specifically for the 64 randomly selected districts in England. Following preliminary analysis, multiple regression was conducted to ensure there was no violation of the assumptions of regression. 

Results: Correlation indicates a significant moderate positive correlation between the prevalence of T2D and each of the variables: long-term unemployment, no qualifications and income deprivation, but no significant relationship with overcrowding. Multiple linear regression analysis indicates that long-term unemployment and no qualification were significant predictors of T2D in England. 

Conclusions: The evidence from this study suggests that the prioritisation of resources, especially in periods of austerity and welfare reforms, to target these key predictors may achieve much in reducing the prevalence of T2D in England. Hence, it is recommended that a comprehensive data collection of these demographic characteristics are integrated into the existing process, and the collective effects of social, economic and biologic factors are investigated in future studies. 

Key words: Type 2 diabetes, education, unemployment, income deprivation and overcrowding 

 Introduction 

In recent years, the rise in diabetes worldwide and its significance as a cause of disability and premature death has increased the interest of researchers in diabetes mellitus. In 2010, more than 3.1 million people in England aged 16 years and above were diagnosed with diabetes (NICE, 2015). While this seems extreme, based on WHO criteria, out of every seven people in England, one is likely to have impaired glucose tolerance or impaired fasting glucose (NICE, 2015). One particular form, type 2 diabetes (T2D), may account for about 90% of diabetes globally, and is caused by a combination of genetic and environmental factors (Patel, Bhattachanya and Butte, 2010). Taken together, these current findings highlight the importance of this public health challenge. 

Diabetes is a type of disease that has an extensive impact on the finances of individuals and their families, and on the national healthcare budget and economies. The long-term consequences of diabetes are significant, especially with increasing age (Alonso-Moran, et al., 2014). An implication of this is the associated premature death, loss of production and need for informal care in individuals with T2D (NICE, 2015). According to Hill, Nielsen, and Fox (2013) structures in place to tackle the rising prevalence of type 2 diabetes are constrained in their ability to adequately take into account the influence of social determinants of health. Existing interventions are limited to addressing behavioural changes such as increasing physical activity and dietary modifications, and the management of the symptoms of diabetes as they arise. This is known to lead to temporary improvements in health outcomes (Walker et al., 2014). 

The present study does not deny that clinical interventions influence health; rather, it suggests that while advances in clinical interventions have improved health, they also have some limitations. A number of authors have examined these limitations. For instance, despite the creation of the Nation Health Service in 1948 and universal accessibility to health services in the UK, inequalities still exists in morbidity and mortality (Morris et al., 1988, in Braveman and Gottlieb, 2014, p. 20; Mackenbach et al., 1997; Mackenbach et al., 2008). As Walter et al. (2014) argue: “social determinants of health may provide a better understanding of why these lifestyle changes are not improving outcomes”. The existing accounts of socioeconomic determinants and type 2 diabetes are focused on the relationships between only one of the socioeconomic determinants and T2D without taking into account other influences (Adler and Stewart, 2010). For example, in a study which set out to determine the effect of educational level on the development of diabetes found that the prevalence of diabetes was inversely related to educational attainment (Medalie et al., 1974, in Connolly et al., 2000, p. 177). 

The lack of research quantifying the collective influence of the social determinants (income deprivation, unemployment, low education and overcrowding) on T2D precludes statements regarding whether these factors have a significant effect on the rising prevalence of T2D. Therefore, a study that establishes the collective relationship among the four aforementioned predictor variables on the prevalence of T2D in England will help in the development of population-based intervention programmes. It may also lead to a consideration of the impact of policies in these areas on the health of the population and any necessary reforms of social and economic structures that generate inequalities in health (Hill, Nielsen, and Fox, 2013). 

METHODS 

Data and methods 

Based on the available literature on the socioeconomic determinants of T2D, the variables, unemployment, overcrowding, income deprivation and no qualification were selected (Brown et al., 2003; Chaufaun and Weitz, 2009; Pilkington et al., 2010; Touma and Pannain, 2011). Data on the determinants of T2D for 64 randomly selected districts in England were obtained online from the registry of the Office for National Statistics census data (ONS) (2011). It collects information on the entire population through pre-addressed questionnaires distributed nationwide either by post or by hand. The confidence interval was 95%, and the sampling error was minimised using statistical techniques such as the ‘Coverage Assessment and Adjustment Process’ (CAA) to provide information about individuals and households missed or those counted more than once. Further details regarding the ONS census 2011 design have been published elsewhere (ONS, 2012). 

Prevalence of type 2 diabetes in England, was retrieved from a separate database, the Health and Social Care Information Centre (HSCIC) which has the responsibility for collecting data on the registrations, care processes, treatment targets and complication rates of diabetes in England and Wales (HSCIC, 2012). The HSCIC collects data from electronic patient records from general practices and secondary care outpatient data from the Clinical Commissioning Groups (CCG). The last-validated national diabetes audit, published in 2014 covering the years 2012-2013, was used in this study. 

Ethical Considerations 

The significance of ethical considerations in any study cannot be overemphasised. Thus, adhering to the professional standards of research is necessary and should be reviewed before carrying out the actual study (Polit and Beck, 2012). This research study has adhered to the ethical guidelines provided by the University of Wolverhampton. This study accessed confidential information about the health and socio-economic status of people and hence there was a need to ensure that it is kept private. However, the retrieval, compilation, coding and analysis of secondary data in the public domain raised few ethical questions as there was no interaction with the individual respondents. 

Study Variables 

The variables invested in this study are as follows: 

•  Prevalence of type 2 diabetes: This is the proportion of the population with T2D, registered at a primary or secondary health care centre in England. 
•  Income deprivation: This is the proportion of the population living in income-deprived households relating to low income (<60% of the national median average income) (Public Health England, 2016). 
•  Overcrowding: This is the proportion of the population residing in households with one or more rooms less than required. 
•  Long-term unemployment: “Average number of monthly claimants of Jobseeker's Allowance who have been claiming for more than 12 months, expressed as a rate per 1,000 of the working age population” (Public Health England, 2016). 
• Short-term unemployment rate: “Mean monthly number of persons who were claiming out of work benefit, divided by the population aged 16-64 and multiplied by 100, for less than 12 months” (Public Health England, 2016). 
• No qualifications: Percentage of the population with no formal qualifications. 

DATA ANALYSIS 

All data analysis in this study was carried out using SPSS version 20. First, descriptive data were generated for all variables. After that, preliminary investigations were carried out for all variables. To ensure the independent variables are not correlated to each other (there is no multicollinearity) but correlated to the dependent variable (linearity), a correlation matrix and scatterplot were conducted respectively. To ensure the residuals in the model and sampling distribution are normally distributed, a histogram and a probability-probability (p-p) plots were generated. Next, the assumption of homoscedasticity is met for generalisation of the results generated from a sample population. This is achieved through the generation of scatterplots among the variables. Finally, a multiple linear analysis was conducted to examine the collective influence of these variables simultaneously on T2D. 

RESULTS 

The assumption of multicollinearity was assessed with a correlation matrix of all the variables. A Pearson’s r data analysis reveals a strong correlation between short-term unemployment and income deprivation (r = 0.936, p = 0.000) and therefore are redundant. Hence, only one variable should be used in the final model (Field, 2013), see table 2 below. The correlation matrix conducted to explore the relationship between the independent and dependent variables can be seen in table 2 below. Significant results are in bold, identified as **where p <0.001. There was a significant moderate positive correlation between the prevalence of T2D and each of the variables: long-term unemployment, no qualifications and income deprivation. This indicates that as the levels of long-term unemployment, no qualifications and income deprivation increases in England, the prevalence of T2D also increases. The analysis however, did not show a significant relationship between the prevalence of T2D and overcrowding, hence it was excluded from the final regression model. 

Table 2: Correlation matrix between socioeconomic determinants and type 2 diabetes (significant results in bold, **p <0.001) 

To identify the significant socioeconomic determinants of T2D, a multiple regression analysis was conducted. The results were significant, F (3, 60) = 12.69, p = 0.000, R² = 0.388 suggesting that long-term unemployment, income deprivation and no qualification accounted for 38.8% of the variance in the prevalence of T2D in England. The other 61.2% of variance is explained by other factors not included in the regression model. The individual predictors were examined further. No qualification was a significant predictor of T2D, B = 0.061, p = 0.011 suggesting that for every percent increase in no qualification, the prevalence of T2D in England increased by approximately 0.061 percent, if all other independent variables are fixed. In addition, long-term unemployment rate was a significant predictor of T2D, B = 0.057, p = 0.010 suggesting as the long-term employment rate increase by one unit, the prevalence of T2D increased by 0.057 units. The results of the multiple linear regression are presented in table 3. 

Table 3: Results of regression analysis showing that long-term unemployment and no qualifications are significant predictors of type 2 diabetes in England 

Therefore, for every 1000 individuals experiencing long-term unemployment, an extra 0.057 percent T2D is expected if all other independent variables are fixed. However, income deprivation was not found to be a significant predictor of T2D in England. 

DISCUSSION 

This study was set out to identify the significant socioeconomic determinants of T2D in England. The realisation that socioeconomic factors predispose the population to the risk of diabetes means that solutions to social and economic problems can indirectly lower the prevalence of diabetes. This study has offered important insights into the socioeconomic determinants of T2D, particularly identifying the long-term unemployment rate, no qualification and income deprivation as being responsible for close to 40% of the rise in the prevalence of T2D. Furthermore, the identification of the long-term unemployment rate and no qualification as major predictors of T2D in England are of great importance to policy makers in the prioritisation of resources, especially in periods of austerity and welfare reforms, when there is a reduction in public spending by the government. 

Current interventions concerning T2D focus on symptoms and behavioural changes, such as diet and physical inactivity (Hwang and Shon, 2014). Arguably, the socioeconomic determinants of health are responsible for most of the behavioural changes. According to Marmot and Wilkinson (2006), the social indicators of health are considered the most significant predictors of health outcomes in the community. For instance, individuals with low levels of education and low income are more likely to consume unhealthy diets and are more physically inactive, with resultant T2D (Smith, 2007; Hill, Nielsen and Fox, 2013; Clark and Sharon, 2014). Hence, the responses to T2D should not solely depend on clinical interventions but also on improvements in quality of life. 

A conceptual framework shown in figure 1 below was developed to explain a suggested link between socioeconomic determinants of health to T2D. Within the model, it is suggested that increases in interventions and the establishment of policies to reduce income deprivation, long-term unemployment and no qualifications would impact upon the prevalence of T2D in England. The bidirectional arrows between the independent variables suggest their inter relatedness based on available literature. Whereas, the asterisks indicate a significant relationship. 

Figure 1: Pathway linking the socioeconomic determinants of health to T2D 

Furthermore, the prevalence of diabetes is graded on the basis of the social determinants. For example, ‘food insecurity’ leads to a two-fold risk of diabetes in comparison with the population that consumes a healthy diet (Currie et al. 2009). The grading of T2D on a social basis underscores the need for policymakers to provide practical responses to social problems. Laxity in implementing policies based on the social determinants of health is having a significant impact on efforts to combat the prevalence of T2D. Local and National governments should formulate and implement policies geared towards improving the social status of their people (Hill, Nielsen, and Fox 2013). In addition, it is important to ensure that any improvement in social status is complemented with behavioural change through health education to avoid being counterproductive. This can happen when people with improving social status resort to sedentary lifestyles that raise the risk of developing T2D. 

A policy pathway to reduce the rising prevalence of T2D in England should include ‘health in all policies’ (HiAP) and address long-term unemployment and no qualifications in the population. A collaborative approach of ‘health in all policies’ can have a great impact in lowering the prevalence of T2D and other non-communicable diseases (NCDs). A key aspect of HiAP is tackling the wider social determinants of health and health inequalities. Like most other European countries, the United Kingdom has adopted this strategy and given local authorities the responsibility for public health. Commenting on this development, Buck and Gregory (2013, p. 1) argue: 

“while this is a welcome move, there are as yet few resources to help local authority officers and teams identify ‘what works’ in improving public health and reducing health inequalities. How, then, can they decide which areas to prioritise, and through which interventions?” 

It is therefore important that a health impact assessment is carried out prior to developing any policy (Dannenberg et al., 2008). As noted by Kemm, Parry and Palmer, (2004) most human activity is influenced by health, consequently, most public and government decisions have a tendency to impact health either positively or negatively. Therefore, interventions to improve health may be channelled towards ‘non-health’ areas like education, agriculture and the economy, and this can be steered by Health Impact Assessment (HIA). 

Previous literature and the current study have shown that long-term unemployment is associated with unhealthy lifestyle behaviours. However, the relationship between employment and susceptibility to the risk factors of T2D is not straightforward. For example, it is arguable that the unemployed may engage in physical activities as they search for manual work and this may reduce their propensity to develop obesity. On the other hand, the low quality of life and stress related to unemployment may increase their susceptible to the risk factors of T2D (Filarski, 2014). Employment itself may not provide a complete solution as an increase in income may lead to a tendency for a lavish and sedentary lifestyle (Steckel, 2013). Work places should adopt health promotion activities, such as the provision of canteens with affordable healthy foods, free or subsidised gym membership, routine stress management courses and health education seminars. 

According to Koen, Klehe, and Van-Vianen (2013), the longer an individual stays unemployed, the more likely they are to lose job-skills and the motivation to work. Gradually, this may reduce the chances of gaining gainful employment. Therefore, there is a need for relevant government agencies to ensure that the unemployed can return to work as soon as possible. This can be achieved by establishing interventions that increase the employability of such individuals (Koen, Klehe, and Van-Vianen, 2013). A pilot study conducted in 2010 (Hillage et al., 2012) demonstrated the cost effectiveness of helping unemployed participants return to work. Following an assessment, case management techniques, such as confidence building, motivation and vocational rehabilitation, and clinical support, including cognitive behavioural therapy, were offered to unemployed individuals. About 72% of participants returned to work within 10 to 12 weeks. The current data provide insights that championing such initiatives on a wider scale will inevitably assist more people to become ‘fit for work’. 

An important intervention to help reduce the impact of income deprivation on the population is to encourage individuals to tend a garden. A study exploring the major benefits of gardens estimated that community gardeners saved between $75 and $380 in procuring food each season (Hlubik, et al., 1994, in Armstrong, 2000, p. 320). Also, gardening within income deprived areas gave greater access to fresh vegetables and nutritious food when compared to the high intake of unhealthy foods such as sweets and fizzy drinks that are seen in non-gardening families. One study by Alaimo et al. 2008 examined the trend in healthy eating and found that only 17.8% of non-gardeners consumed fruits and vegetables at least five times a day, while a higher proportion was noticed among gardeners, nearly a third. 

Furthermore, multiple studies have shown that gardeners have improved mental state, especially as the gardens can serve as areas for leisure activities and exercise (Armstrong, 2000; Rappe and Kwela, 2005). For instance, a study conducted by Penninx et al. (2001) suggests that there was a reduction in depressive symptoms with physical activity. Therefore, it is possible that the setting up of community garden initiative can provide healthy food and improve mental health through the favourable effect of nature on emotion and exercise, with a resultant decrease in the prevalence of T2D. Besides, it a low capital venture and cost-effective method of creating self-employment since 80% of the cost is in labour (Hlubik, et al., 1994, in Armstrong, 2000, p. 320). 

The level of literacy has a direct link to the prevalence of diabetes. Health should be emphasised in education-based policies to ensure that everyone knows the components of a healthy lifestyle (Nutbeam, 2008). People with no qualifications may lack the knowledge to make health decisions about the kind of lifestyle to lead. The solutions lie not only with policy formulators but also with the general public who should embrace the knowledge available and lead healthy lifestyles (Nutbeam, 2000). Schools give information about types of food, diseases and the importance of making healthy decisions. However, the acquisition of knowledge is not limited to schools, but it is influenced by the attitudes of individuals. It should start within families and the community prior to and during schools and college education (Thomas and Irwin, 2011). Responses to the issue of no qualification and its relationship to diabetes should be based on a broad framework that cuts across generations and institutions. 

A community literacy strategy is needed to improve literacy levels (Nutbeam, 2008; Thomas and Irwin, 2011). Community programmes should mainly focus on the adults who lack the necessary skills to comprehend health-based messages. As part of corporate social responsibility and community service, the schools in each community should organise literacy programmes with the local community. The schools should provide the human resources while the members of the community should organise the venue for this highly important initiative. The government in a bid to improve literacy levels should finance these community-based programmes for the common good of the nation. Importantly, the acquisition of the necessary literacy skills through community programmes should be followed by health-based programmes (Nutbeam, 2008). 

One primary limitation of the study is the non-availability of data on age, gender and ethnic groups with T2D resulted in such factors not being measured. Accurate information on these variables could be critical to link condition-specific interventions to susceptible population. Hence, it is recommended that a comprehensive data collection of these demographic characteristics are integrated into the existing process, and the collective effects of social, economic and biologic factors are investigated in future studies. A major source of uncertainty is the data used to calculate income deprivation during the initial data collection. According to Galobardes et al. (2006),”the personal income is a sensitive issue and people may be reluctant to provide such information”. An implication for this is the possibility that the income may either be exaggerated or understated. This could be a likely explanation of why income deprivation was not found to be a significant predictor of T2D. Hence, data and findings on income should be interpreted with caution. Additionally, the socioeconomic determinants examined in this study were continuous data, and thus relatively crude. In future investigations, it might be informative to include dichotomous measures of socioeconomic determinants that are essential for group comparisons. Also, future work is required to test opposite trends in the socioeconomic factors. For instance, if increasing income level has a positive effect on decreasing T2D. 

CONCLUSION 

In conclusion, using multiple regression analysis, this research has shown that long-term unemployment, income deprivation and no qualifications are significant determinants of type 2 diabetes, with unemployment and no qualifications being the strongest predictors in England. The increased prevalence of type 2 diabetes in districts with low employment and high rates of no qualifications is a particular problem because it can exacerbate health inequalities. Even though the National Health Service provides universal and accessible medical services, people living with diabetes also share some of the expense, such as prescription costs and lower productivity at work or limit academic completion, which in-turn can promote further unemployment. In order to reduce the burden of T2D on the individual and society at large, it is important to tackle ‘the cause of the causes’ which are the social determinants of health. 

The answer to the research question (what is/are the significant socioeconomic determinant(s) of type 2 diabetes in England?), was thought to include income deprivation, long-term unemployment, overcrowding and no qualifications. However, contrary to expectations, it is now possible to state that, no relationship was found from the present study between overcrowding and the rising prevalence of T2D in England. Furthermore, this study has identified long-term unemployment, income deprivation and no qualifications, as being responsible for close to 40% of the prevalence of T2D with unemployment and no qualifications being the strongest predictors. Overall, this findings strengthens the idea that the socioeconomic determinants are strong predictors of health and this corroborate the ideas of other researchers (Marmot and Wilkinson 2006; Hill, Nielsen, and Fox, 2013a), who suggested that the social indicators of health are considered the most significant predictors of health outcomes in the community. A possible explanation of this might be the chronic stress, psychological imbalance and low motivation that arise due to these determinants, thereby, increasing the risk of unhealthy behaviours. 

In general, interventions primarily target the obesogenic environment by reducing the availability of unhealthy food or environments, while making affordable healthy choices readily available. However, unhealthy choices are known to be influenced by the wider socioeconomic circumstances of the population. Therefore, interventions targeted at mitigating these public health issues may ultimately have a great impact on reducing the prevalence of T2D and other non-communicable diseases (NCDs) in England. The evidence from this study suggests that the prioritisation of resources to target these key predictors may achieve much in reducing the prevalence of T2D. By building upon the ‘health in all policies’, prioritising interventions to policies that ameliorate income instability, low academic attainment and employment crisis, with a resultant less stressful environment, could make individuals adopt healthy lifestyles such as healthier eating and more physical activity. 

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Correspondence: Dr Onuekwa Samuel Chizia 

University of Wolverhampton 

Faculty of Education Health and Wellbeing, 

University of Wolverhampton, United Kingdom. 

Email: samchizy@yahoo.com