Hungary for advanced nurse practice, a glimpse of naivety, and a placed booked for a longer life

Péc is a lovely city in the Southern part of Hungary. I have been before and was privileged to be able to spend some time there last week. I had been invited to present a paper at an international nursing conference organised by the University of Péc's. The focus of the conference was Advanced Nursing Practice. We had run such a programme in my old School for over 10 years and, I had invited my colleague Anabella, the programme director to present her experience. Unfortunately she was unable to make the trip due to other commitments. So I came, and I am very glad I did.

There was a real sense of energy about the conference, an energy that clearly underpinned a determination to develop and put in place the concept of advanced practice in taking the nursing profession forward. There were other international speakers there, from the US, Slovenia, and the Czech Republic. The International Council of Nurses was represented as was the Hungarian Secretary of State for Health. The presence of the latter was an unprecedented show of political will and support. The papers delivered on both days enthusiastically stated the professions' ambitions and assertively identified the issues and challenges that will need to be dealt with. The energy and enthusiasm was infectious and I am very confident that progress will be made.

Many of the issues appeared universal – a lack of funding; the difficulty in designing a curriculum that reflects the profession of nursing and its attributes whilst also educating and training in areas usually associated with medicine; who should teach the students; the poor image of nursing; and of course medical opposition to the proposed changes. In some ways, it was an event that very much reflected the discussion I'd been part of at a meeting in London last Monday. I attended the Nursing and Midwifery Council thought leaders group looking at the educational preparation for graduate nurses in 2025-30. The discussion was powerful and focused, well that was until colleagues from one of the big 5 consulting companies came to speak with us about the ongoing educational framework review.

Now I don't mind naivety in others, in fact sometimes I think it can be both cathartic and very productive. I wasn't convinced this was the case with these consultants. I think they were just naïve. Geraldine Walters, the recently appointed Director of Nursing and Midwifery Education, Standards and Policy at the NMC joined us and she at least appeared to have an open mind in terms of what the role of NMC might be in determining the future shape of nurses education in the UK.

Yesterday as I travelled the 200 km back to Budapest I was able to reflect on the differences and similarities of both these sets of discussions. There were many. Both nations are politically, economically and demographically challenged and current models of health care are unsustainable. Demand for health care exponentially outstrips our capacity to provide it. The shape and rapidity of change in health services almost out paces our ability to develop the skilled and knowledgeable workforce required to provide it. However, I was buoyed up to see that psychology, and the recognition of the importance of the interpersonal relationship were being foregrounded in both conversations.

This was something reinforced in my dipping into a book given to me as a gift by my new colleague Aniko. She has claims to citizenship in Serbia, Hungary and the US, and is currently working in Ohio improving the quality of care provided by medics and nurses. The book Complications, by Atual Gawande is written in the style of one of my favourite authors, the late and great Oliver Sacks, the Poet Laureate of Medicine. Amidst the technology of medical intervention, the despair of disease, both Gawande and Sacks successfully remind us of the importance of remembering the person who should be central to our work – the patient, and another human being. 

I have to confess, I have not read an actual book, as in something printed on paper for a number of years. Apparently 1 in 3 people in the UK rarely or never read for pleasure. But that is not what I am talking about. I meant that these days most of my reading happens on line, or through my Kindle (other readers are available). Not that how you read matters when gaining the benefits of reading. In a study published recently in the journal Social Science and Medicine, Avni Bavishi and colleagues claim that reading is not simply an indulgent pastime, but a form of life support. Their paper claims that people who regularly read books tend to be healthier, richer and better educated in general, all of which could contribute to a longer life (and there is no need to read the small print)! 

Removing the Gilded [Eli] Lily’s Mask with Sticky Fingers

Last Wednesday evening I found my hands covered in that kind of sticky substance that seems to get everywhere, clinging to skin, clothes and hair. I was packing the car at the time and checking a case of Christmas present wine when I noticed my hands were sticky. One of the bottles had leaked and black sticky gunge was the consequence. Whilst I was able to wash my hands and was soon on my way, it seems what I should have been more worried about was what I couldn't see on my hands. Professor Pieter Dorrestein, from the University of California, San Diego School of Medicine, reports that there are at least 1000 different microbes living on the averages persons skin.

In a study he published last week in the Proceedings of the National Academy of Sciences, he reported that we leave trace chemicals, molecules and microbes on every object we touch, and these can reveal much about us. Even washing hands thoroughly cannot hide the presence of these molecules. By analysing the molecules left on peoples mobile phones, the researchers could tell the likely gender of the person, whether they drink coffee, wear sunscreen, prefer beer over wine, like spicy foods and whether they are taking medication for depression. 

We know that worldwide, mental health problems account for £1.6 trillion worth of economic burden. That’s more than the combined costs of dealing with cardiovascular disease, chronic respiratory disease, cancer and diabetes's. We know that 1 in 4 of us will experience a mental health problem each year. We know that 1 in every 10 people will experience this as depression. We also know that the average age of onset for depression today, is 14 years compared to 45 in the 1960s.  What we don't know is what causes this mental health problem and what the best way might be of helping people through a depressive experience.

Indeed it's difficult to find a study that provides any degree of certainty. When I was becoming a mental health nurse (something I increasingly think of as a lifetimes work) I was taught that depression was caused by low levels of the brain chemical serotonin. Much treatment has thus been focused on prescribing antidepressants that correct this imbalance. However there have been many studies that show most of these drugs don't work. The most recent, published in the Lancet earlier this year, found that of the 14 leading antidepressant medications only Fluoxetine (Prozac) helped young people with depression more effectively than placebo pills. The rest were reported to have no effect on symptoms but could give rise to serious side effects (suicidality being one of these).

There is evidence that other factors could be responsible for depression in some people. Professor Carmine Pariente, from Kings College London published a study in July this year that focused on the use of biomarkers which can measure inflammation in the body. The study showed that those people with high levels of inflammatory markers also made up the group who are most likely not to respond to antidepressants. One outcome from this result is the possible conjecture that inflammation in the body, caused by the body’s immune system reacting to an infection and or stress may be responsible for an individual's depression in much the same way that our experiences and environment might.

In children and young people this is an important consideration and adds to what we already know. In the UK, there are 850,000 children aged 5 – 16 who have mental health problems, of which 80,000 have a diagnosis of severe depression. Dr Valarie Mondelli (also from Kings College London) has published a study that found that children who experienced high levels of infection or trauma in childhood may have compromised immune systems. They were found to have higher levels of brain inflammation and were more susceptible to developing depression as an adult.  Indeed, 50% of all lifetime cases of mental ill health (including depression) begin by the age of 14. 

I have long thought that medication as a way of treating mental health problems with young people is not the most effective response. The evidence appears to support my view. For me and many others, finding ways of building emotional resilience in our children and young people is the key to making a difference. There is a nothing new to be known in how we do this. For example, play and learning, particularly with others, is important in gaining a sense of self, self-worth and self in relation to others. Likewise, diet and exercise, physical as well as mental can help ensure physical and psychological development is balanced and sustained.

This is not rocket science! In my experience of being with and around children of all shapes, sizes and ages is that most either don't mind or really dislike getting their hands dirty. But most will really enjoy taking part in activities that might result in this state of being. Its up to us to make sure this happens, and occasionally be there, ready with the wet wipes.

We’re alright, but our shoes are covered in blood…

I woke up on Friday to the sad news that Leonard Cohen had died, aged 82 years old. Some said the album he released in October was his way of saying goodbye to the world. We will never know. I was fortunate to see him perform in Manchester a couple of years ago, and in my youth I once met him in a hotel bar in Kensington, London, not quite the Chelsea Hotel, but close. It was a powerful encounter.

For different reasons, the 2 days I spent last week at this year’s HAELO HOSTS were also about powerful encounters. Alongside Salford Royal Hospital NHS Foundation Trust, Salford City Council and Salford Clinical Commissioning Group, the University of Salford is a stakeholder partner in Haelo. Just 3 years old, Haelo is an innovation and improvement science centre with expertise in digital connectivity and building capability in improvement science. They work collaboratively to deliver large scale improvement programmes in health and social care. You can find out more about them here. 

The theme for this year's Haelo Hosts was 'Daring Greatly', a theme that was brought to life, sometimes very starkly, by the telling of people's stories. The first of which was Michael Woodford's. He was the former President and CEO of Olympus (the medical equipment and camera manufacturing company). In 2011 he uncovered the biggest corporate criminal fraud ever committed in Japan’s history. He was sacked and endured great stress and defamation of his character and reputation. It was an interesting story, vividly told, but a story for me that lost some of its gloss when I discovered that he had been awarded a reported £10 million pounds in compensation.

Other stories of daring greatly followed. There were a couple of really confident young people telling their tale of developing a youth manifesto in Salford as part of the work supported by the Reclaim organisation. Reclaim work with young people from pressurised communities. They were followed by a colleague from Virginia, in the US, who told of his work reducing gun crime in the City of Richmond (home of the world’s first electric street care system). Amazingly he managed to persuade the City officials to employ the gun toting criminals in developing the successful solution – daring greatly indeed.

Ian Jolley, former soldier who had served over 22 operational tours told of his journey through the horrors of Bosnia, the Gulf War, Northern Ireland, Kosovo and Iraq. His quietly spoken narrative of how he dealt (was dealing) with mental health problems caused by the trauma he witnessed was emotionally challenging as were the words of Fiona Murphy.She spoke of the work she has been engaged with in making end of life care an experience filled with humanity, respect and dignity. There were a lot of tissues being used.

There were some lighter moments. Jim Easton, CEO of Care UK, the largest independent health care provider in the UK summed up the first day with both pathos and humour. His organisation provides health care in many UK prisons. He recalled contacting his colleagues who had dealt with the recent organised stabbings at Pentonville Prison to ask how they were. He was told they were 'all alright' but as their 'shoes were covered in blood' could the company 'buy them new shoes'… …he also had a wonderfully humorous range of [true?] Mother-in-Law stories. And then there was the Haelo Film Festival. My colleague from the School of Arts and Media, Dr Kirsty Fairclough, joined me for the dinner and presented the prize on behalf of the University for the 'My Story' category.

However, the story that has stayed with me was one from Day 2, and it was the account of Martine Wright. On the 6th of July 2005, it was announced that London would host the 2012 Olympics. Martine went out to celebrate, and the next morning had an extra 10 mins in bed. Subsequently, the underground train she caught on the 7th of July was later than her normal train. She sat 3 feet away from a suicide bomber, who then detonated his bomb.  Martine was the last survivor to be freed from the carnage. She lost both her legs and almost 80% of her blood.  52 people lost their lives. Her story was initially heard in complete silence, but as she told of how she slowly overcame the changes and changes to her life, the hall filled with laughter. She not only went to the 2012 Olympics, but went there as a member of the British floor volleyball team. She married her boyfriend, and now has a son, she learnt to fly and ski, yes ski! And she hasn’t stopped - 'Daring Greatly' indeed - she took personal inspiration to a completely new level.

Returning to last Friday's news. A couple of nights before, my wonderful eldest daughter had asked what I wanted for Christmas. I said 'the complete box set of Leonard Cohen’s studio albums'. She texted me on Friday to say Amazon had come up with the goods, but she had just heard the sad news. Before she married her equally amazing husband, Stewart, and took his name, she was named Jennifer Warne. There was a different Jennifer Warnes, who was a lifelong friend and sometimes backing singer for Leonard Cohen in the 1970's. In the 1980s she released a critically acclaimed album 'Famous Blue Raincoat', in which she covered some of Cohen's best songs. This album was credited as being largely responsible for reintroducing Cohen's greatest work to the world again.

RIP Leonard, you were also a man who dared greatly!

I’m not an arsonist, I just have a burning obsession

Last night was Bonfire night. At my Bolton home, the 6 houses on my lane have a shared apple orchard that has a small wooded area running around it. For over 20 years that I can recall, we have made a clearing, built a bonfire, and got the children to make a Guy. Friends and families have gathered around for an evening of shared food, drink and good conversation. We occasionally have one or two fireworks, but mainly it’s about relaxing company, a good fire and a chance to catch up. And so it was last night, although I may have enjoyed a beer of two more than I should have. Whilst celebrating around the bonfire each year is probably not a ritual as such, for most of us it definitely has a ritualistic flavour.

Rituals serve a very functional purpose, which is why they are so often found in religious ceremonies. Ritual is both a mnemonic device and a trigger. As a mnemonic device rituals serve to mark an event as being important or significant. So while I sometimes struggle to remember what I was doing last month, I can clearly remember the last bonfire, a year ago, and bonfires before that. As a trigger, preparing the bonfire, and food, buying the drink and eventually lighting the fire sets the stage for what is about to happen.

Throughout our lives most of us will come into contact with rituals at different life stages - births, bar mitzvahs, coronations, graduations, marriages and funerals and so on. However, for some people ritual becomes a part of their everyday life. For example, those with a obsessive compulsive disorder (OCD). This is a common anxiety disorder. In fact about 1 in 50 people, males and females equally, will experience a OCD at some point in their lives. In the UK that is just over 1 million people. A number of familiar and famous people have lived with an OCD, including: David Beckham, Justin Timberlake, Cameron Diaz, Charles Darwin and Florence Nightingale.   

Donald Trump describes himself as being 'borderline OCD' (whatever that might mean) but apart from possibly being obsessive about becoming President of the US he does not have an OCD. He reportedly won’t shake hands with people, particularly teachers who he believes have '17,000 germs per square inch on their desks' but this is a phobia and not a sign of OCD.  OCD involves people experiencing distressing and/or frightening repetitive thoughts, which however irrational they may seem, keep coming into their mind. They do so despite whatever the person does to resist or ignore them. Compulsions are actions that people believe they must repeat to feel less anxious or in order to stop these obsessive thoughts.

Compulsions commonly include excessive checking, cleaning, counting, and other ritualised behaviours, which whilst sometimes providing temporary relief from anxiety often get repeated in order to 'get it right'. However, unlike the compulsive and obsessional behaviours associated with drug and alcohol use or gambling, or even those that run every day – all behaviours that are usually pleasurable - the signature of OCD is that the compulsive behaviour never gives pleasure, and the behaviours are always experienced as an unpleasant demand or a burden. 

OCD is a much misunderstood condition. It is the distortion of the familiar - (counting, checking, cleaning) - things most of us do, that can be the most difficult aspect of the disorder to understand. Most of us will have checked for the 10th time that our passport is in the inside pocket just as it was 5 minutes before. Such temporary states of compulsion and obsession are ameliorated once we are on the plane or whatever. For those living with OCD, the situation can be very different. 

However, these days there is a wide range of help and successful treatments available for those with an OCD. While mental health services continue to be under-funded and there can be problems in accessing care, these are generally peripheral elements in why people don't always seek help for their OCD. Often the reason for people not seeking help is that they don't want others to know they need help. So it can take a long time before people with an OCD seek support from mental health services. Some will go to great lengths to hide their ritualistic behaviour, and many will experience overwhelming shame because they are unable to stop such behaviours.

As with all mental health problems, and OCD is no different, the more we can talk about it, the sooner we can reduce the stigma surrounding the experience of mental health problems and the easier it will become to reach out and help people. And thankfully, we don't need to always light a bonfire to get people together and start talking...

...although bonfires are fun!