Monthly Archives: May 2009


Often in practice and in teaching, there are situations where the practitioner or tutor makes a judgement about someone else’s work. Sometimes the person has a strong feeling that the other has misjudged something, and sometimes, or maybe often, this other person’s decision is described as ‘inappropriate’.

Things that are inappropriate include jokes, touch, remarks, modes of dress, approaches to others, laughing at funerals. In the language of teenagers, ‘so cheeky!’ but in the language of mental health professionals, ‘inappropriate!’

The message, whether casual or serious, is that the person has transgressed – behaved against cultural or professional norms. Within that though, is an unspoken message, that the person calling ‘inappropriate!’ has the power to decide what’s ok, and what’s not ok, and what’s more, my way is, yours isn’t.

To me this is the exact opposite of how we should be approaching both nursing and teaching. This word has the power to exclude and disadvantage, put the other person on the wrong foot, put one person in a one-up position, the other one-down. Surely this word is the most inappropriate word for us to be using?

A funny joke?


A funny joke?


That’s the other problem with it. It doesn’t give much clue as to what was wrong. So when I say the word itself is inappropriate, you only have the barest idea of why I say so. Me saying it, and being a teacher, is that enough? Both values and evidence are implied, but if I don’t feel like explaining, it’s implicit, well, I don’t have to.  I don’t have to account for myself. Well I do and so does everybody else. This word is first of all, undemocratic, and secondly disempowering.

It doesn’t tell us anything, apart from the power differential. So if something is inappropriate, should the other person just guess why? Of course not! So if I was to go into class in a mini skirt and low cut top, there would be reasons that wouldn’t be a good idea. It would be distracting from the messages I would be trying to get across, and could undermine the mutually respectful relationship I would be hoping to establish in class. Perhaps I would also be modelling (I don’t mean this in any fashionable sense) a mode of dress that could lead to difficulties in a clinical area, where service users need clarity of boundaries. But I can imagine if I were to dress like that, I would hear that it was inappropriate. I might realise that I was in the wrong but would not have clear guidance on what was not ok about my behaviour, or how to put it right. So my second point is that inappropriate is lazy.  Teachers need to clarify things for students, likewise nurses for service users, it’s part of our accountability and duty to be there for others’ development. It’s what we’re paid for, and not to do so is fraudulent.

So values too are undermined by use of this word. (I’m getting sick of writing it now, and it’s also quite hard to spell.) By implying something is wrong, we are clearly calling on our value system. I shouldn’t wear revealing clothing in class – but who says, and why not? Well, it would make other people uncomfortable, distract them, and undermine my professional position and relationships. It wouldn’t be fair.

Breakfast on the commode anyone?

When I was a student nurse one of my ‘inappropriate’ decisions was to say (perhaps rather too angrily) to a nursing officer (nowadays a modern matron) that I was not ok about patients eating their breakfasts while sitting on the commode. The sister was very clear to me that this behaviour was inappropriate. Mine that is.

So here the word was used for discipline – in this profession you don’t step out of line, this is the hierarchy, this is your place. The act is not separated from the person, there is no option for inclusion, ‘what you did was not ok, but you are’. The cultural element implied means that the person feels that if you want to be one of us, you have to act just like us. There is not space for non-conformity, alternative opinions, discussion. To me this system is one of the most damaging aspects of nursing, the risk that we reinforce what’s ok and not ok in relation to a vague but strong idea of appropriateness which is culturally reinforced through generations, but because not explicit, is difficult to challenge.

I did learn from this, that if you want to change things in the NHS, it’s better to do it from the inside. At that moment I felt very much the outsider, frowned upon from all quarters. Yet really, the behaviour that was inappropriate here, people eating food on top of … well do you want to tell me I’m inappropriate if I write it? And of course inappropriate doesn’t even cover it – humiliation  injustice and dehumanization, this practice arose because of understaffing and all round under-resourcing. So not only does the word not deal with the issues, it colludes with the cover-up of what’s really wrong.

Equal voices and respect?

So, I’m asking you, my colleagues as teachers, nurses and nurses to be, let’s sack this word, it is harming us, and harming those we are planning to help. It’s disempowering, excluding, unjust, makes things unclear, and contributes to a negative nursing culture. Instead we need to take the long road. This will mean stopping to think about our values, norms and expectations, and whether we can justify these, and taking the trouble to account for ourselves. In the end our destination will be fairer, more equal and inclusive, a nursing culture where we can all challenge supportively and take opportunities to develop as ourselves as a person and a professional, and be there in the same way for other people, aiming for equal voices and respect.


Images from Flickr as follows

 ‘I’ Picture by Marron Glacé on Flickr

‘A funny Joke’ Tootdood

Drug addiction?

Flickr click image
Photo by taiyofj : Flickr click image

There have been many discussions on over reliance/ dependence on medication over the years. Personally, I do think that both public and professionals rely too much on pill popping. I certainly feel a degree of sympathy for GP’s who have a few minutes to decide on someone’s illness and treatment plan. The prescription of a drug is likely to work so this becomes a ‘default’ option (and my apologies to any GP’s reading this.  I am aware that this is very simplistic but it does illustrate a point that is true for all professionals. And patients…well, when I see a health professional I will admit to feeling comforted by popping a pill. After all, a pill means that my illness is treatable doesn’t it?


Click image)
Medicine (photo KB35 on Flickr : Click image)

But hang on. If this deeply held belief that pills cure illness is flawed, then what is even more flawed is the idea that medication even treats mental illness. Lets look at depression. Depression involves the lowered state of serotonin and so all anti-depressants work by increasing levels of this neurotransmitter through one means or another. But aren’t we missing the point? By increasing serotonin levels all we are doing is dealing with the symptoms of an illness, not the illness itself. Schizophrenia treatment is exactly the same but here it is reducing the elevated dopamine.

My point – we are not dealing with illness eradication, rather we focus exclusively on symptom suppression. But this is the nature of mental health problems. It would be foolish to think that a little tablet taken twice a day will be a panacea for all our ills – unfortunately though, this is exactly what people think.

Birmingham City University – Recovery forum


We are planning to start a Recovery Forum at Birmingham City University.  In January I contributed a post about the Hearing Voices module that had been running throughout the autumn term.  The course gave students an introduction to the work of Marius Romme and Sandra Escher, whose work has inspired the Hearing Voices Network.  There are now over 170 Hearing Voices groups in the UK. 


The Hearing Voices module encourages participants to begin using Romme and Escher’s Maastricht Interview Schedule with service users.  The Maastricht Interview Schedule is not a quick assessment tool, but rather a way of helping people to talk about voice-hearing.  We also discussed ways that people have found to cope with problematic voice-hearing; and we talked about group work led by voice-hearers themselves, that has been shown to be effective in offering support, hope and meaning to people.   


The underlying premise of this work is that voice-hearing itself is not a problem which needs to be eliminated.  Many voice-hearers consider their voices to be positive, or at least an acceptable part of their experience.  Romme and Escher’s work helps people to talk about their voice-hearing experience, to accept that the voices are real – and may have meaning based on life experiences.  This respect for the experience of the person is at the heart of the recovery movement.


The recovery process according to the Mental Health Foundation 

  • provides a holistic view of mental illness that focuses on the person, not just their symptoms
  • believes recovery from severe mental illness is possible
  • is a journey rather than a destination
  • does not necessarily mean getting back to where you were before
  • happens in ‘fits and starts’ and, like life, has many ups and downs
  • calls for optimism and commitment from all concerned
  • is profoundly influenced by people’s expectations and attitudes
  • requires a well organised system of support from family, friends or professionals
  • requires services to embrace new and innovative ways of working

The recovery movement has been gaining strength within and outside of mental health services.   Many people with the recovery movement are challenging the traditional language and power structures of psychiatry – and the recovery model is as much user-led and influenced by professionals. 


In order to support those who have attended the Hearing Voices module to continue to work collaboratively with voice-hearers, and according to the recovery model we are setting up a Recovery Forum at Birmingham City University.  We anticipate the first session to take place in July 2009.  There will be more details to follow.  Members of university and trust staff with an interest in this area are also warmly invited to attend. 


Holistic fantasies revealed

It would be foolish to say that nursing – indeed any health profession I know – offers true holistic health care. Sure, we talk the talk of being holistic. We say that we cater for all needs and care for the individual – a principle that is enshrined in the Code of Conduct. And yes, we have wonderful assessment tools that are designed and tested to identify the areas needing attention. We pride ourselves on how we cater for the idiosyncratic goals of the person being cared for.


But do we really offer holistic care?

Or do we hide behind a false veil of ‘professionalism’ and only deal with what we want to deal with rather than dealing with what the person wants?


Let me explain.


Holistic health care means caring for all health needs. What about sexual health? I, and every nurse I have spoken with, have never asked a patient about their sexual health needs. What a minefield that would be! Imagine the legal problems I would face if I asked a female (or a male for that matter) if she had any sexual needs that she would like me to address whilst she was on the ward. Would my plea of holistic health care be enough to satisfy a judge that I am not a perverted sexual predator? Unlikely. Would the NMC jump to my defence as I have upheld the Code?


And please, don’t make me laugh by saying that we at least cater for religious needs. It strikes me that if you are not Christian or Muslim then the health services either cannot or do not want to help you with your religious needs. But even these two religions only have a token gesture made to them. The problem here is that it would take effort to organise and money to pay to allow people to practise their religion – two commodities that are in precious short supply in the health care system.


Of course, we have iatrogenic conditions and nosocomial infections – it is particularly worrying that professional caused conditions and hospital acquired infections are so common that we have words dedicated to them. So do we even offer physical health care?


Holistic health care is an ideal that we should (and do) strive for. But lets be realistic – it ain’t here yet.