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World Mental Health Day: How to make positive changes to your wellbeing

Nicky Lambert, an expert on mental health, reveals how people can take several simple steps to improve their personal self-care

It is World Mental Health Day on Tuesday 10 October. This year’s theme – set by the World Foundation of Mental Health – has been called ‘mental health is a universal human right’.  

It is a day that reminds all of us to make positive changes to increase our wellbeing and to raise awareness of mental health issues more broadly.

Pressures related to the ongoing fallout from the pandemic and cost of living crisis continue to impact mental health.

According to the World Health Organization (2020) more than 264 million people experience depression globally and it is the leading cause of disability. In addition to rising numbers of people with mental health problems, there are ongoing staffing and funding shortages and despite nurses’ best efforts mental health service provision can be limited, with long wait times.

Whilst there have been significant strides forward in public understanding of mental wellbeing, the stigma around many mental health conditions remains and can form a barrier to people seeking support and reaching out to help others. It’s important that we are all aware of the indicators of when we need help and that we know how best to support our own psychological wellbeing.

Raising awareness

Signs that professional help may be needed include:

  • Feeling constantly overwhelmed and unable to cope or see a way forward.
  • Significant personality changes or an increase in agitation, anger, anxiety or other mood changes.
  • Withdrawal or isolation from others, poor self-care.
  • Talking and thinking a lot about suicide or feeling you can’t go on
  • Or uncharacteristic engagement in risk-seeking behaviour

If you or someone you know needs help – which can range from a supportive conversation and counselling through to more formal care, please tell someone. There are university systems (Counselling and Mental Health – CMH) that are designed to help and offer guidance on emotional wellbeing and mental health. Please come forward when you first notice something amiss and don’t wait for a crisis before reaching out.

Promoting self-care

There are some misconceptions about self-care that we should address before looking at ways to support wellbeing. It is not indulgent or a luxury to look after our mental health – in the same ways that we have to be mindful of our physical health the same is true of our emotional and psychological wellbeing. Also, there is no right way to do it. Everyone is individual in their needs and what they find nurturing, however there are aspects of our lives that can offer us prompts to action:

Mental aspects of self-care – Set realistic goals and priorities and learn to say no without feeling guilty – boundaries help you place your energy where it is most needed.

Physical aspects of self-care – Move more! Just 30 minutes of walking every day can help boost your mood and improve your health. If it’s raining find somewhere you can be free to be by yourself and dance like no one is watching to your three favourite songs!

Environmental aspects of self-care – Spend some time outdoors every day, develop an awareness of nature, grow something at home – it can be anything from a house plant or herbs to liven up a meal.

Spiritual aspects of self-care – Reassess your purpose in life, think about what makes you happy and try to align yourself better to your goals. It may take time to make changes (if they are needed), but it is important to live a life that is meaningful to you and to identify things that you are feel grateful for.

Recreational aspects of self-care – Being creative takes many forms, perhaps you are a great cook, or you love making music or gardening. We can forget to play sometimes and remembering to prioritise times when we experience joy and the calm focus of being in a state of ‘flow’ is essential to our wellbeing.

Social aspects of self-care – Many bonds linking us have been placed under strain over the last few years. Even if you are at a distance from the people you care about, a regular zoom call with old friends or sharing a WhatsApp group with family or a local community keeps us stay connected.

About the author

Nicky Lambert

Nicky is an Associate Professor at Middlesex University, she is registered as a Specialist Practitioner (NMC) and is a Senior Teaching Fellow (SFHEA). She is also a co-director of the Centre for Coproduction in Mental Health and Social Care. Nicky has worked across a range of mental health services both in the UK and internationally supporting staff and practice development in acute and mental health trusts, councils, businesses, charities, HEE and the CQC. She is active in supporting mental health and wellbeing with the RCN and Unite. She is an editorial board member for Mental Health Nursing, and on the education and policy committees of MHNAUK. Nicky engages with local trusts and with the RCPsych to support sexual safety in mental health services. She is also a Trustee for The Bridge a charity supporting women to make positive choices, and encouraging improvements to fitness, health & well-being.

Twitter: @niadla

Health & wellbeing Social commentary

Life is digital by default – what’s the impact on young people’s mental health?

An online webinar brought together leading clinical and academic experts to discuss the impact in the rise of technology on the mental health of children and young people. This event, which was chaired by Middlesex University Criminologist Dr Elena Martellozzo, was organised by the UK Council for Internet Safety Evidence Group (UKCIS) and supported by the UKRI Mental Health Network (eNurture) and the Department for Culture, Media and Sport (DCMS).

 “The last decade has seen a startling level of technological innovation,” said Professor Sonia Livingstone OBE, eNurture Network Deputy Director.

 “We’ve moved, I’d suggest, from seeing technology as a valued addition to our lives, to seeing technology as its vital infrastructure and as COVID-19 has made that really clear now, for young people especially, life is digital by default.”

As technology becomes a crucial part of our everyday, what is the impact on the mental health of children and young people? The COVID-19 pandemic and subsequent lockdowns have seen children and young people off school for large periods and spending even more time online, either learning, playing or socialising.

“Being online can be a hugely positive experience for adults, children and young people, however it is also presents a risk of harm and there is growing concern about the relationship between technology and the mental health of children and young people,” explained Rachel Bishop, the Deputy Director of Online Harms Policy at DCMS.

“The pandemic has brought this into sharp focus with children’s screen time averaging nine hours per day during lockdown which is nearly double the average prior to COVID-19 (according to the Pandemic Parenting Report).

A study by Ofcom has found that children were lacking structure and routine, and were instead spending a large amount of time online often unsupervised. While screen based online platforms can support learning, social networks and reduce feelings of loneliness, they can also impact mood, self-esteem and body image as a result of extended or prolonged time engaged with screens.”

Image of a small child light up by a blue screen in bed with parents who are in the dark

Mental health crisis among young people

Dr Bernadka Dubicka, Chair of Faculty of Child and Adolescent Psychiatry, Royal College of Psychiatrists presented some insightful data on the mental health crisis among young people in the United Kingdom. She argues that this is rising significantly alongside the growing reliance on technology.

In 2020, one in six children aged five to 16 were identified as having a probable mental disorder increasing from one in nine (10.8%) in 2017, according to The Mental Health of Children and Young People in England 2020 report. The increase was evident in boys and girls. The rate has risen in boys aged 5 to 16 from 11.4% in 2017 to 16.7% in July 2020 and in girls from 10.3% to 15.2% over the same time period.

Negative impact of social media

The Good Childhood report, 2020 concluded that among 24 countries reviewed UK adolescence between 10 and 15 years are doing least well. The NHS Digital Prevalence Survey, 2018 of children aged 11 to 19 showed those with disorders were much more impacted by social media.

For example nearly 42% with mental health disorders compared to 25% without compared themselves to others; 27.2% with disorders compared to nearly 14% without admitted that likes, shares and people’s comments affected their mood; 66.6% with disorders compared to 52.8% without spent more time than they meant to online.

Children and young people with mental health problems are often turning for help because of content on social media.

Victoria Hornby, CEO of Mental Health Innovations which runs the 24-7 crisis helpline Shout, said suicide deaths of celebrities “spark anxiety among young people” so they share support services. “Within 15 minutes of the death of Caroline Flack we were beginning to see a significant increase in volume on our platform,” she argued.

The National Suicide Study in children and young people also found teenagers in particular were “more profoundly affected” by suicide related internet use.

Too much screen time can damage development

The negative impact of too much screen time on young people’s development has also been well documented.  The review paper the Online Brain, How the Internet maybe changing your cognition concluded “excessive Internet use impairs brain and verbal development”, “mass acceptable/rejection/social comparisons affects self-esteem” and “media multi-tasking affects attention and memory”.

The World Health Organisation recommends limiting screen time for children aged one to four to one hour per day, stating the “potential benefit of reducing sedentary screen time outweighs the possible harms/costs & may increase health equity”.

This may seem extreme but technological use starts at a very early age. A third of patients referred to NHS England’s National Centre for Gaming Disorders started gaming aged six years or younger, according to its founder Dr Henrietta Bowden-Jones, OBE. She said many of the patients were “very thin or obese”, with “poor eating habits, self-care and little exercise”, and suffered from loss self-esteem, social anxiety, low mood, poor regulation of boredom and attachment issues, with gaming providing “escapism, connection, communication and acceptance, achievement”.

“Half of the children turned violent, sometimes very violent when things were taken away which stopped them from gaming, in some families the police were called 20 or 30 times. I had underestimated the terrible impact on families,” said Dr Bowden-Jones.

What happens next?

What can be done to tackle the detrimental effect of too much screen time and technology on the mental health and wellbeing and children and their families?

Rachel Bishop of DCMS said its plans for online harms legislation will ensure companies are more “responsible for people’s safety online, especially children” alongside the Government will publish its response shortly to the white paper – the Adult Online Hate, Harassment and Abuse assessment – with legislation following next year, which will be accompanied by non-legislative initiatives including a media literacy strategy and safety by design framework.

To the question  If there was one thing that you would change about the digital world, what would that be? posed by Dr Graham Richard, Psychiatrist & Clinical Director, Good Thinking, Dr Dubicka answered:

“Global togetherness on technology, regulation, safety and responsibility from the tech companies, as we have seen for climate change.”

Research and guidance is essential

Victoria Hornby also provided an insightful response: “We need to have much clearer signposting of safe sources for help. We have young people who regularly contact us saying ‘I did an online quiz to see if I have depression or an eating disorder’ and the random searching with completely unfiltered content can be damaging for children.”

Literacy on the impact of technology on mental health is crucial. “The digital world will not go away and it’s only when we get guidance and knowledge which helps parents, professionals and young people directly, that we will advance this whole debate,” commented Professor Gordon Harold, Professor of the Psychology of Education and Mental Health at the University of Cambridge and eNurture Director.

Further research into the impact of technology on mental health is also essential. The Nurture Network (eNurture) is a UKRI funded programme, which supported this event and has seven associated networks, is funding start up research projects and practical interventions designed to examine how the digital world is changing and its impact on young people.

The academic and clinical experts all agree that there must be an onus on technological companies as well to address concerns about the impact of their technology on young people’s mental health.

Dr Mark Griffiths, the Director of the International Gaming Unit at Nottingham Trent University, said structural characteristic such as the ‘Like’ button on social media or the event frequency in gambling, are really important in determining whether someone will have a problem.  

“If you’ve got a product and you know a small minority of your clientele are going to have a problem with it, you have to take responsibility,” argued Dr Griffiths.

“The great thing about technology, is we can actually harness that technology to help treat those people who unfortunately do suffer from problematic or addictive behaviours.”

Written by Paul Harper, Middlesex University Press Officer, and Elena Martellozzo, Middlesex University Criminologist.

Arts Coronavirus and COVID-19 Health & wellbeing

Exploring the impact of dance

Michela Vecchi, an Associate Professor of Economics at MDX, is leading a team of researchers to explore the potential effects of dance on wellbeing and on our professional life across cultures.

Benefits of exercise

The benefits of physical exercise on mental and physical health have been known since the ancient Greek and Roman times; often summarised by the motto ‘mens sana in corpore sano’, meaning “a healthy mind in a healthy body”.

Recent research across different disciplines is providing increasing evidence to suggest the presence of important connections between body and mind. In particular, keeping active and exercising is not only good for our physical health but has also important consequences on our mental health.

Michela dancing in her kitchen

Dance can boost wellbeing

Although any form of physical exercise has beneficial effects, dance gives an additional boost to our brain functions and our wellbeing.

Current studies, carried out by scholars across a diverse range of fields including psychology and neuroscience, are showing the effectiveness of dance in improving cognitive functions and wellbeing among a wide range of individuals and particularly those affected by dementia. Dance blends the positive effect of music, which stimulates the reward centre of the brain, with the motor, sensor and coordination regions of the brain. Dance involves memory, emotions and creativity, hence the secret of its success, is its complexity.

In recent years, various organisations, such as Dance Well and Aesop, have been organising dance sessions for elderly people and those suffering from Parkinson’s. These initiatives are growing and increasingly involving individuals of all ages and disadvantaged groups among society, such as refugees. Dance promotes connections among people and contributes to build a sense of community and inclusivity.  

Can dance improve our performance at work?

Economists have always recognised the positive relationship between cognitive skills and productivity and, more recently, wellbeing is often listed among the factors that can promote performance. Therefore, dance at work could improve our working life, the quality of our work and promote creativity and productivity. These are important assumptions that require new evidence.

The outbreak of COVID-19 has profoundly changed our working life. Those of us who are not key workers have spent significantly more time at home than before. Adjusting to the “new normal” often involves a new working routine, with keeping fit at home and maintaining our wellbeing becoming more important than ever.  The dance world has also had to quickly adjust to the changing environment and move to online delivery of classes on a much larger scale than in the past.

Be part of the research

In our study, my team and I explore the effects of dance on wellbeing and productivity during these challenging times. To this end, we are calling on amateur dancers who practice in their free time at home, novices, semi-professionals and professional dancers alike to complete our survey.

You can also complete the survey in another language other than English.

Michela stretches on her kitchen island with ballet point shoes

Blog written by Dr Michela Vecchi and Dr Patrick Elf

Coronavirus and COVID-19 Health & wellbeing

#MentalHealth Awareness Week

Nicky Lambert, Associate Professor in the Department of Mental Health and Social Work at Middlesex, encourages focusing on our mental wellbeing and looks at the mental health of current NHS staff.

We are in the middle of #MentalHealthAwarenessWeek  and this is an excellent time to think about this year’s theme:  #KindnessMatters. The focus for the campaign was originally going to be sleep, but in this socially distanced world, which has shown how precarious things can be, kindness could not be more important.

Graffiti of nurse wearing a mask and making her hands form a heart in front of her

This crisis has brought out the best in many of us. Communities have come together to help each other and friends and families are taking time to connect and noticing how much they miss each other. A sudden shock can make us reevaluate our choices, but the shock of this pandemic is passing.

Being anxious gets tiring, we get used to it and it gets boring. We notice that the summer we had expected is passing us by; the anticipation of sports, holidays, graduations are all gone now. We are at the stage when old habits reassert themselves, people get grumpy and complain and tempers can fray.

This is when the importance of practising kindness kicks in – it’s not something that comes naturally to everyone, all the time. It takes intention, and it takes well, practice! 

Practice good mental health wellbeing

As a mental health nurse of twenty years standing, I’d like to make a plea that you take some time out this week to consider your mental health in the same way that you monitor your physical wellbeing. Many of us have noticed that we are less physically active because of lockdown, not eating or sleeping well because of our worries and we are starting to take steps to readjust.

During this # MentalHealthAwarenessWeek please take some time to think how you support your mental wellbeing as well and purposefully do something every day to be kind to yourself and the people round you.

Mental health of NHS front line staff

This is a concerning time for everyone. For the 1.4 million NHS staff, it’s not only worrying, but it’s also a confusing and sometimes frightening experience. On one hand the public are literally applauding their efforts and there is praise for staff working in challenging situations and putting the wellbeing of others before their own. However longstanding issues of poor pay and staff shortages have been compounded by dangerous working conditions due to a lack of Personal Protective Equipment (PPE) particularly in the early days of this crisis.

Not only are staff dying as a result of caring for people with COVID-19, those deaths are falling disproportionately on the BAME community who make up a significant part of London’s heath staff.  Those who are unable to be with their colleagues on the front lines of practice because of their own health status or carers responsibilities can feel guilty. Those who find themselves described as ‘heroes’ and ‘angels’ sometimes struggle to process their negative feelings. It can be hard to be open about feeling despair or fear when you are expected to be superhuman. It may also lead to ‘moral injury’ (the psychological impact of bearing seeing things or having to make decisions that violate one’s everyday moral expectations).

What support is being offered?

 A mental health hotline has been launched for NHS staff to receive support and advice (tellingly it’s staffed by volunteers). However staff in Mental Health and Social work and Nursing departments at Middlesex University are also rising to this challenge. 

We are working with The Pan London Practice Learning Group and others to develop resources for the capital’s nursing students as they take up an extended placement to help staff our health services.

A request from a local trust led to a joint project between MDX nursing staff and My Care Academy who developed free online resources to support staff who needed to learn new skills to offer care after death for patients suspected or confirmed COVID-19.

For the International Year of the Nurse and Midwife, we were to host the prestigious International Mental Health Nursing Research Conference. Obviously a conference is not possible this year but our Centre for Coproduction in Mental Health and Social Care have helped develop a solution in the shape of an innovative collaboration between @Unite_MHNA @WeMHNurses and @MHNRconf. By using a range of social media channels, the Centre will bring a range of mental health speakers to new listeners, connect up colleagues and celebrate the work of mental health staff at this challenging time.

What next

The last few years have discouraged us all from making predictions, but our staff and academics will continue to be flexible in the support of our students and to ensure they have access to the best quality online learning.

We will use our expertise to be responsive to the needs of front line services and help to build and sustain the health and social care communities that we all rely on in these challenging times.


Dance, cognition and ageing

Dr Michela Vecchi, our Associate Professor of Economics, and dancer, discusses the physical and, more importantly, mental improvements dancing can bring.

In recent years, we have seen an increasing interest in dance; Strictly Come Dancing has become an all-time favourite Saturday night show, the provision of ballet type fitness classes has risen dramatically, and the Royal Academy of Dance, usually associated with young girls and boys training for their grades, is now offering classes to women over the age of 55 under the appealing name of Silver Swans.

The main reason behind this new dance-exercise rage? Dance not only exercises the body but also does wonders to your mind.

Physical exercise, dance and health

The benefits of physical exercise on mental and physical health have been known since the ancient Greek and Roman times, as summarised by the motto ‘mens sana in corpore sano’. Contemporary studies carried out by psychologists, neuroscientists and physiologists agree that being active and engaging in a variety of physical activities promotes not only physical health and wellbeing, but also cognition. Cognition includes those mental processes that assist us in everyday life, like learning, remembering, speaking, moving and interacting with others. These abilities decline with age and, in the most severe cases, this decline leads to degenerative conditions like dementia, Alzheimer and Parkinson’s Disease.

Although physical exercise is good, recent studies are increasingly showing that dance has additional benefits compared to a wide range of physical activities, particularly in reversing the signs of aging in the brain. There is fast growing evidence on the role of dance in preventing cognitive decline in older individuals affected by Parkinson’s Disease and dementia. Improvements in balance, reduced motor impairment, and general improvements in the quality of life, have been recorded in several studies.   

Professor of Economics Rafi Eldor, from the University of Tel Aviv, provides a personal and inspiring account of his experience with Parkinson’s disease and of how dancing has helped him coping with the condition. After his diagnosis and with no prior dance experience, he decided to fight the disease by challenging his body and “becoming a dancer rather than a PD patient”, and the results have been amazing.

The benefits of dance have not only been recorded in individuals affected by dementia but also in healthy elderly individuals. Studies comparing the effects of dance to other forms of physical exercise, such as cycling, Nordic walking, and aerobics show that dance induces additional improvements in memory, learning and balance. The benefits of dance have not only been assessed in relation to other physical exercise practices. A major study conducted by the Albert Einstein College of Medicine in New York City shows that the improvement in cognitive abilities related to dance is higher compared to other cognitive activities such as reading, writing or doing crossword puzzles. The study concludes that the only physical activity to offer protection against dementia is frequent dancing.   

Why is dance so effective?

It is still not clear why dance is so effective in improving cognition, but the advantages are likely to be rooted in the stimulation of different brain functions, which are necessary to learn new steps and routines, to move in time with the music, to balance and express emotions. It is well known that the brain is stimulated when learning something new and in dance this stimulation comes from different types of activities. Going back to the popular TV show, it is easy to see that ballroom dancing requires contestants to learn new styles and techniques and adapt them to the movements of the partner and to different types of music. Dancing is not just a form of entertainment, and the benefits of this complex set of actions should not be underestimated.

Why wait for old age?

Although scientific work has primarily focused on elderly individuals, you do not have to wait for old age to start dancing. On average, cognitive abilities start to decline in the mid-thirties as part of the natural ageing process. This does not limit our everyday life and  forgetting a wedding anniversary may not trigger a major family crisis; however, it is a signal that our brain is slowing down.

The dance-exercise rage has led to the provision of several types of classes for adults that can easily fit around busy work and family schedules. It has also contributed to overcoming the stigma attached to dance, particularly regarding age, class, race, gender, level of physical activity and appearance.

Dance is not only for the young with slim and supple bodies, but it is an alternative way to exercise, open to all ages and levels of abilities. Why not give it a try?


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Health & wellbeing Social commentary

Supporting Parents in the Digital Age

Today’s parents are facing many new challenges and safeguarding issues once their children become active online. Dr Jacqueline Harding has launched an online TV channel specifically for parents who are concerned about protecting their children online.

There’s little doubt that many parents are feeling overwhelmed about how to support their children in the digital age as confirmed by my own recent small scale study in 2018 and other larger studies (Livingstone, 2018).

In an attempt to meet parents’ needs using a familiar format and one that parents often feel is more accessible, Tomorrowschildtv was built as a pilot online channel for parents of children from birth to 18 years, with over 40 films designed to help and support parents in the digital age led by a former BBC presenter with parents, experts and children debating specific issues. It was filmed at Middlesex University by students and is launching 29th November 2019.

In agreement with Livingstone’s (2018) observations of the lack of support for parents, my study revealed anxiety right across all age ranges. Indeed, Ofcom’s study (2017) revealed a similar picture where more than three quarters of parents of 5-15 year olds have sought information about how to manage online risks.

Addressing Parents’ Concerns

In answer to questions about identification of specific help/advice regarding media that a parent might seek out regarding these matters, answers typically fell into the following four broad categories: safety; behaviour; time restrictions and educational opportunities.

Several parents expressed similar concerns and the need for sources of help around behaviour and media with most parents admitting to feeling like a ‘bad parent’ or wishing not to appear negligent (this was a reason for seeking help). Parents commented on the lack of advice available about suitable lengths of time for their children to spend on a particular media device:

“I need to know how much screen time is too much?”

Although overwhelmingly, parents were primarily concerned about online safety regardless of age, parents of younger children tended to speak of their fear increasing as their child matures. Typically, parents reported feeling anxious:

“Desperate, yes, I’d say I was desperate for help.”

“They are so quick… they minimize the screen…I need support from someone who knows about these things.”

“I won’t allow a phone until secondary school – it’s too worrying – although there is less about stranger danger nowadays it’s more fear about online.”

“I heard about a child in the media…they were bullied online and committed suicide… it’s so worrying.”

“I worry about YouTube videos with inappropriate content still coming up even with parental controls.”

“I’m worried about my child (six years old) and her use of apps to insult people.”

“Access to porn had such a bad impact on my child – it caused him to act up at a later age.” (child now 13)

“I caught my child being the abuser online – I was shocked…”

The study found agreement with Livingstone’s (2018:11) enquiry into where parents might turn for advice about digital media where answers differed according to the age of the child. Parents of younger children were more confident of where to search for help and spoke of seeking help on Google, Mumsnet, CBeebies, Facebook mums’ groups, forums, and from peers. Others suggested that the responsibility shifts to the child as they mature: “My own children will get advice when they are older at primary school.”

Parents of children in the 6-12 year age range spoke of going to the school and asking for help. This also correlated with Ofcom’s (2017) study, where 61% of parents seek help or advice from their child’s school. In the study a number of other parents felt unable to seek help from their own parents) as:

“They wouldn’t know what to do… all this stuff happened after their time,”

and continued by trying to offer suggestions such as: “Kids YouTube might help… maybe; or a neighbour?”

Parents of 12-18 year olds were the most puzzled and felt unable to think of where to begin to access help, and three parents with children ranging between 13 and 17 years, were openly bewildered about where to access help.

Feeling helpless

Ofcom’s recent study (2017: 209) found that ‘one in six parents of 12-15 year olds feel they don’t know enough to help their child manage online risks’. One parent stated: “I guess I feel pretty helpless.”

In response to questions around a dedicated online TV channel for parents providing support – the responses were overwhelmingly positive. Some participants were even anxious to ensure that other parents would know about the resource by suggesting that it must be discoverable. The majority of responses to the suggestion of an online video-based platform tended to suggest the level of anxiety that parents were experiencing:

“I’m desperate for help”

“Online TV great…so it’s available on my phone.”

“Definitely yes.”

In light of Livingstone’s (2018) comments: ‘parents have woefully few sources of support and advice when they have digital questions and dilemmas,’ the parents’ responses in our study were unsurprising.

Health & wellbeing

Researching survivor experiences of trauma

Mia Scally, Professor Joanna R Adler & Dr Miranda A H Horvath explore the risks facing researchers working with survivors of trauma, and what can be done preserve the researcher’s emotional safety.

‘Self-care is foundational to our power, our resilience, our creativity, our health and our collective impact. Just as a fire needs breathing space between the logs to burn, we need spaciousness in our days to be impactful and sustainable’Norma Wong

Research with survivors of any traumatic event or series of events can be an incredibly powerful experience. ‘Bearing witness’ to a survivor’s experience should not be undertaken without full consideration of the potential costs and challenges that might arise for both the survivor and the researcher, and the benefits of undertaking such research should be clear and justifiable.  This includes prioritising the emotional safety of the researcher as part of the design of a project and as a prerequisite for ethical approval, as highlighted by the World Health Organisation.

This blog post seeks to explore how a researcher might be affected by research with survivors and how this can be mitigated.

The research project

As part of my doctoral studies (supervised by Dr. Miranda A H Horvath and Prof. Joanna R Adler), I am investigating women’s experiences of child custody in the context of intimate partner violence and abuse (IPVA). This exploratory research will build on knowledge within England and Wales, where literature on this topic is limited. This mixed-methods research project combines secondary research (qualitative analysis of online posts) with both qualitative (interviews with survivors) and quantitative methods (a survey for professionals*) to form three interconnected studies. Study one was completed in 2017 and involved thematic analysis of 68 online public accounts and associated comments threads detailing female survivors’ experiences of the child custody process where IPVA has been present. Study two involves in-depth interviews with survivors of IPVA.

The interviews have been completed and this posting is being written as a reflection whilst embarking upon the analysis process. The interviews were recorded and transcribed verbatim, resulting in repeated exposure to the content of each interview. Although fewer in number than the 68 online accounts, engaging with women’s narratives first-hand and immersion in their accounts entails more emotional labour.  The interviews included descriptions of violence, deeply personal accounts from women experiencing distress and trauma, and suggestions of poor or limited professional responses that have resulted in feelings of frustration and anger (mostly for the survivors but also for me). ‘Bearing witness’ to these women’s lived experiences and their repercussions involved a great deal of personal navigation and active management.

This is not uncommon and other researchers have discussed various forms of emotional labour throughout trauma-related research. They argue that emotions are part of being human and that qualitative research requires you to view things from the perspective of the participant. Emotional labour in such research can include feeling and showing emotions (e.g. as part of post interview reflection, or during an interview itself), suppressing emotions (particularly in academia, rigour and emotion may be perceived as incompatible), and navigating these emotions as part of the research process (e.g. considering one’s own relationships in a different light).

I found myself experiencing each of these elements: feeling emotionally exhausted by the interviews, then subsequently by the transcription; avoiding writing in my reflective journal because I wanted to suppress these emotions; and finally, reflecting on how my world view might have changed as a result of what I now know. Some of these reactions can be explained as vicarious or secondary trauma and can result from one-off or repeated exposure to survivor trauma. Vicarious trauma (in this context) is defined as a reaction to or an alteration of the inner world of the researcher because of empathising with the survivor and their traumatic experiences (e.g. someone researching child abuse might become more protective of their own child). Secondary trauma can also result from such research and is characterised by a symptomatic response similar to post-traumatic stress disorder. This can include taking on the trauma of the survivor, avoiding the research that is the source of the secondary trauma, and experiencing symptoms such as sleep disturbance or hyperarousal.

Research has explored the impact of working in the field of violence against women on practitioners and clinicians. Vicarious trauma experienced by researchers is less well understood although, there has more recently been acknowledgement that ‘the role of a researcher is different from that of a clinician or counselor and potentially more traumatizing because of an inability to “help” the victim’ (p96). I found this particularly difficult to balance (partly as a result of my previous experiences in supporting survivors of violence and abuse) and I spent time reflecting on my role in this research and what I could do to ensure the women being interviewed were supported. Offering participants a debrief sheet that listed support services was helpful here (and also an ethical requirement). I also chose to send participants a copy of their transcripts prior to commencing analysis. Participants were able to add to these in a different colour so that they could continue their story beyond the time limitations of the interview. This came from one of the women in the study. The participant was frustrated because she had to leave but wanted to finish telling her story. I equally didn’t want to silence her story so this is the solution we arrived at together. Another survivor mentioned how helpful the interview experience had been for her and how much she gained from sharing her story with me. That was powerful and helped me in return because I saw that the research was able to give back. It was able to ‘help’albeit in a different way than that of a clinician or a counsellor.

Protecting the researcher

Through counselling, close supervision and a reflective journal I was able to identify and work through the emotions raised by this project. I am much more able to recognise the impact of research and I ensure that I practice appropriate self-care when this is necessary. I make sure to undertake only one interview or transcription per day for example, and I take the time to read non-academic books so as to recuperate. Some work has been undertaken to help identify what other researchers have found helpful to militate against some of the impact of research with challenging topics and this is briefly summarised below.

Preparation – knowing what to expect from the topic and preparing for the project is seen as key. Planning debrief sessions, regular meetings with the research team, reading around the topic, and considering the risks to researcher wellbeing are all vital. Risk assessments are usually conducted as part an ethics process and emotional wellbeing should be considered as part of this. In addition, when preparing for data collection, it is important to take into account how to schedule the interviews and allow time for reading, processing and engaging with the material generated. The consensus is that too much exposure to challenging content in one day can be overwhelming. Try to ensure that you only undertake one interview in a day and plan your day so that you have minimal work or research related activities for the rest of it. This also applies to transcription of interviews and taking breaks when reading data is particularly important in research in these domains. Participants in previous research also found that limiting exposure to challenging topics in the way of media/books/TV was helpful.

Formal and informal support – Having a range of sources of support is viewed as beneficial by researchers. Clinical supervision, regular meetings with research supervisors, ongoing counselling (don’t wait until you realise you need this to organise it), and debriefing sessions with colleagues are all cited as helpful forms of formal support. Informal support may include discussions with family and friends, colleagues or team members. Making time to process the impact of researching sensitive topics and having open discussions about this is important.  If you are a Middlesex University student undertaking research that explores sensitive or distressing topics, please see the Wellbeing team website to see what support the Counselling & Mental Health service can offer you. If you are a member of staff, you can access the employee assistance programme – Optum.

Know how to support survivors – Coles et al. (2014) highlight this for two reasons: it is important to understand the boundaries of your role as a researcher – you are not typically a counsellor and are unlikely to be able to make professional onward referrals. However, you can signpost sources of support and this may itself provide peace of mind for the researcher. Such signposting can be as simple as developing a debrief sheet for participants with sources of support – required for ethical approval to research with human participants and vital to minimise harm to survivors – and sharing the contact details or location of local support services.

Understand your limitations – Being clear with your supervisors and yourself about whether and how you are coping with challenging content is vital. This can require reflection and may be an ongoing process. Knowing when to stop a task that is causing you harm is important. Evidence around whether having experienced the topic you are researching places you at increased risk of vicarious or secondary trauma is mixed, however keeping a reflective journal can be helpful here. Try to spend ten minutes whenever you can, writing about your experience of doing research and the current task. Take some time to explore how you are feeling about the process, analysis or findings. This serves not only to safeguard your mental wellbeing but also to enable you to develop as a researcher. In qualitative research, reflecting on what you bring to the research is part of the process.

Self-care – Take some time to do something fun or relaxing and schedule this in. Going for a walk in the woods, spending an hour at the gym, reading a book, taking a long bath or going out for a nice meal – this will be different for everyone. For some helpful resources, see this Self-Care Starter Kit developed by the School of Social Work, University of Buffalo.

Research that matters – For some, knowing that the research will make a difference can help them cope with the content. Are you going to publish from the research? Is it going to help develop or evaluate interventions? Will it contribute to the literature or help develop policy? Keeping this in mind may help.

I keep a reflective journal, attend regular supervision, have ongoing counselling and like to watch far too much reality television – what works for you?

*If you are a professional involved in the child custody process and would like to contribute to this important research, please consider taking part in or sharing the following survey exploring beliefs and practice when it comes to custody decisions.

Acknowledgements: Thank you to Naomi Graham for kindly taking the time to read, comment on and reduce the word count of the first draft of this blog post (some would say this is the hardest part!)

Health & wellbeing

NMC Fitness to Practice: a radical change?

Roger Kline Middlesex UniversityIn this post Roger Kline, Research Fellow at Middlesex University Business School, examines a new consultation document from the Nursing and Midwifery Council, which includes long-overdue changes to the NMC’s Fitness to Practice processes.

On March 28th 2018 the Nursing and Midwifery Council agreed a public consultation document on Fitness to Practise that states there is a pressing need for further change to fitness to practise for the following reasons:

  • A growing body of evidence suggests that an unintended consequence of regulators’ current fitness to practise model is a culture of blame and denial. That runs contrary to the values of openness and learning that are central to a patient safety culture.
  • We know from our own research that black and minority ethnic nurses and midwives are more likely to be referred to us by employers. That disproportionality creates a perception of unfairness which, again, runs contrary to patient safety,” Paper NMC /18/33.

Step forward anyone who would have imagined this five years ago.

The regulators of UK healthcare professionals have been heavily criticised (including by me) in recent years. Those criticisms have included failing to get the balance right between blame and learning; an inability to hold employers and senior managers to account whilst drawing individual registrants into long and damaging processes which are not obviously in the interests of patients but are damaging to staff; not supporting whistleblowers who are referred to the NMC as punishment; not sufficiently taking account of the context (such as staffing shortages, or bullying) in which fitness to practice is questioned;  and failing to respond to patterns of the disproportionate referrals of black and ethnic minority registrants without questioning why patterns exist.

In some senses, the regulators have mirrored the failings of employers who themselves have too often focussed on individual blame rather than systemic failings, on individual lapses rather than the context which made shortcomings in practice likely. The pattern of disproportionate referrals of BME staff to regulators reflect the pattern of disproportionate disciplinary action against BME staff in the NHS.

Why a new strategy?

So what has led to this change?

Firstly, there is a growing understanding within healthcare that learning from mistakes and poor performance is rather more productive than finding scapegoats for what went wrong. Fifteen years ago An organisation with a memory emphasised the importance of understanding systemic shortcomings rather than individual errors. More recently the thinking of patient safety advocates such as Sidney Dekker and the relentless work of the Clinical Human Factors Group has been influential.

Secondly, is a growing understanding that how staff are treated is intimately linked to the care and safety provided to patients. Staff engagement, respect and compassion are good for staff and patient care and safety whilst bullying and discrimination are not just morally offensive but are unacceptable because they waste talent, damage staff health, increase turnover and absenteeism, and are linked to poorer and less safe care. In particular, strong correlation has been established between the treatment of Black and Ethnic Minority staff (one third of doctors and one fifth of nurses and midwives) and the treatment of (all) patients. This understanding has led to the NHS Workforce Race Equality Standard, and a strategy for leadership development that explicitly links this evidence to healthcare improvement.

Thirdly there is now an awareness that the previous (unevidenced) dominant HR paradigm of primarily relying on policies, procedures and training to enable individual staff to challenge bullying, discrimination or unfair treatment was unlikely to ever succeed.  Instead, the best employers are now emphasising the employer’s responsibility to proactively intervene, prevent (not just respond to) unfair treatment and to try to ensure staff are treated fairly.

Parallels with disciplinary action

There are important overlaps between these themes which can decisively help in reducing levels of bullying, tackling discrimination and reducing the scale of unnecessary disciplinary action in the NHS, and in particular the disproportionate impact of such action on BME staff.  Early evidence from a number of NHS trusts suggests, for example, that inserting some form of accountability prior to any disciplinary investigation being started would help shift the focus from blaming individuals to considering system failures that are the predominant causes of errors. Together with applying the science of “human factors” which focusses on system shortcomings not just individual failings might allow healthcare employers to follow the expectation of the courts that they stop their “knee jerk” use of disciplinary suspensions.

It is much more likely that BME staff will enter the disciplinary process, and research suggests a prime reason for this is the failure of managers, at the point at which when errors or poor performance occur, to have the same informal and honest conversations with BME staff that they should normally expect to have with white staff. A small but growing number of NHS Trusts have demonstrated that radical reductions in the levels of disciplinary action, and not only for BME staff, can be achieved in ways which also prompt learning, not blame.

The nursing regulator sees the light too

I know from discussions with the NMC that their new strategy is in part a response to these developments. It is also a response to research commissioned by the NMC in which Elizabeth West and colleagues confirmed the nature and scale of disproportionate referrals of BME staff from employers, but interestingly not from members of the public.

The paper approved by the NMC Council on March 28th rightly states that:

“We consider that effective and proportionate fitness to practise means putting patient safety first, and that an open, transparent and learning culture will best achieve this. We are not alone in thinking that a culture of blame and punishment is likely to encourage, cover-up, fear and disengagement.”

It goes on to explain that:

“To achieve these aims, we need to take a consistent and proportionate approach to fitness to practise. We also need to be fully transparent and accountable… We will need to deal with concerns when they are serious enough that we need to take regulatory action to ensure patient safety, or because they cannot be managed locally… In these types of cases we should take into account the context in which patient safety incidents occur and also enable registrants to remediate concerns at the earliest opportunity. Then we should only hold hearings where there are real areas of dispute to be resolved.”

New strategic principles

The proposed strategy sets out its two “desired regulatory outcomes” as:

  • “A professional culture that values equality, diversity and inclusion and prioritises openness and learning in the interests of patient safety.”
  • “Being fit to practise means that a registrant has the skills, knowledge, health and character to do their job safely and effectively.”

The consultation document sets out a number of (welcome) strategic principles which include:

  • “Fitness to practise is about managing the risk that a registrant poses to patients or members of the public in the future. It isn’t about punishing people for past events.”
  • “We will take account of the context in which the registrant was practising when deciding whether there is a risk to patient safety that requires us to take regulatory action.”
  • “We may not need to take regulatory action for a clinical mistake, even where there has been serious harm to a patient or service-user, if there is no longer a risk to patient safety and the registrant has been open about what went wrong and can demonstrate that they have learned from it.”

The paper argues there will always be instances where disciplinary action by employers and regulatory action by the NMC is appropriate:

  • “We will always take regulatory action when there is a risk to patient safety which is not being effectively managed by an employer.”
  • “Deliberately covering up when things go wrong seriously undermines patient safety and damages public trust in the professions. A registrant who does so should be removed from the register.”
  • “We will only take regulatory action to uphold public confidence if the regulatory concern is so serious that otherwise the public would be discouraged from using the services of registrants.”
  • “Some regulatory concerns, particularly if they raise fundamental concerns about the registrant’s professionalism, can’t be remedied and require removal from the register.”

A change of culture

The paper calls for “a professional culture that values equality, diversity and inclusion and prioritises openness and learning in the interests of patient safety” and explains that:

“When looking at harm, we need to differentiate carefully between accidental errors or failures in the system, and deliberate or reckless behaviour and those who conceal patient safety concerns… Maintaining public confidence in the professions doesn’t mean that we need to punish people when something goes wrong. Making a registrant go through a lengthy fitness to practise process just to punish them would be counterproductive, given that a blame culture undermines patient safety.”

The paper continues:

“Research also tells us that our current fitness to practise processes don’t contribute to a healthcare culture that values diversity, equality and inclusion. There is an overrepresentation of registrants from outside the EU and from black and minority ethnic (BME) backgrounds in fitness to practise proceedings, driven by disproportionate referrals from employers.”

This is not just an issue for nursing and midwifery registrants. The paper notes that:

“This is a concern in other parts of the regulatory sector. General Medical Council research found that BME and non-UK doctors are overrepresented in investigations, (General Medical Council: ‘The state of medical education and practice in the UK 2015’  (pp. 58- 83) ) while five years of General Dental Council hearings data reviewed by the British Dental Journal in 2009 showed that dentists trained outside the UK made up 42% of registrants charged (Singh et al ‘A five-year review of cases appearing before the General Dental Council’s Professional Conduct Committee’ British Dental Journal vol 206 no. 4 Feb 28 2009).

The PSA too

At its Board meeting the week previously the Professional Standards Authority (the regulator of professional regulators) finally moved in a similar direction by including a new draft Standard 3 on diversity, for consultation, which adds a new requirement that:

“The regulator understands the diversity of the registrant population and its service users and ensures that its processes do not impose inappropriate barriers or otherwise disadvantage people with protected characteristics”.


This changed paradigm for the regulation of nurses and midwives is very welcome. However, setting out the new strategy is one thing, applying it may be another. To do so successfully will inevitably mean the NMC will need to:

  • Query why some employers have much higher levels of referrals than others and what the implications for a learning culture are
  • Ask some employers why BME nurses and midwives are being disproportionately referred. NMC investigation panels and staff will need to rethink how every referral is handled
  • Insist on greater diversity on panels and amongst senior staff at the NMC
  • Query employment practices within some employers which discriminate against some BME registrants (deliberately or otherwise)
  • As the strategy itself explains this will involve the NMC “holding full hearings only in exceptional circumstances”
  • Acknowledge the evidence that referrals can seriously damage the health of nurses and midwives most of whom are cleared eventually of any breach of the NMC Code.

There are elements of the report which need scrutiny, notably regarding transparency in those hearings that do still take place. But, in my view, this welcome consultation document signals that the NMC is now serious about adopting an evidenced approach which draws on human factors and the evidence of discrimination. At a time of immense pressures on front line staff and their managers it has never been needed more. The real test now is whether this change of direction in policy can be effectively translated into improved practice. For that to happen will requiring not only holding the NMC to account, but the leadership of nursing and midwifery throughout this land. Read it and decide for yourself.

Read the full consultation document ‘Ensuring patient safety, enabling professionalism’ on the NMC’s website

Roger Kline is Research Fellow at Middlesex University Business School. He was previously joint director of the NHS Workforce Race Equality Standard implementation team. He was co-author with Michael Preston Shoot of Professional Accountability in Social Care and Health: Challenging unacceptable practice and its management (Sage. 2012)

Health & wellbeing

Researching the wellbeing of students

Professor Antonia Bifulco, Dr Stephen Nunn, Dr Ruth Spence, Deborah Rodriguez and Dr Lisa Kagan of the Centre for Abuse and Trauma Studies at Middlesex University have been using a novel online approach called CLEAR to investigate the mental health and wellbeing of degree students. Here Dr Lisa Kagan gives an overview of the research and its findings so far.

We wanted to understand more about student life events. Our ESRC-funded research project ‘Stress online’, led by Professor Antonia Bifulco, involved designing and testing an online platform called CLEAR (Computerised Life Events Assessment Record).  CLEAR is based on and mimics a widely used interview of life events. The reason for going online rather than using the traditional interview is that it is more private and less time consuming but more personal and detailed than a questionnaire.

CLEAR looks at many different life events which fall under the broad categories of lifestyle, health and relationships. Examples of a life event could be things that are milestones like starting university and graduating, to having your computer hacked, relationship break up, illness etc. Unlike conventional life events questionnaires which would give a generic score for a particular life event, CLEAR helps the participants to think about the surrounding context of the event. The participant is then asked to give a rating of how negative and how positive the event was on a scale of 1-5.  Personalised feedback is provided upon completion about their individual life events and psychological wellbeing.

What did we want to look at?

We also added in a variety of questionnaires looking at depression, wellbeing and health and had access to student’s grades. A final questionnaire we used measures something called attachment style, which looks at how we relate to others – either in a secure, trusting manner or in a more insecure way such as fearing rejection. We know from previous research that having an underlying insecure attachment and then experiencing a severe life event is related to depression. We wanted to see if our new measure would also show this. Over the past year we asked students as well as a previously depressed group and a control group take part in our study to see what CLEAR can tell us about this.

University students - Photo by NEC Corporation of America (Creative Commons 2.0)
Photo by NEC Corporation of America (Creative Commons 2.0)

Who took part?

Altogether 328 participants completed CLEAR, including 126 Middlesex students. Most were first year psychology students and the vast majority were female. Not surprisingly, almost a third of all student events in the last year were related to education.  Work, health and partner events were also common ones, and along with education events, were more likely to be ones that were rated as very negative. The average number of life events was 2 per student with the highest being 8!

What did we find?

What was interesting was that 35% of students reported feeling depressed at some point over the past year which was much higher than the midlife control group (8%). They also reported lower feelings of general wellbeing and unlike the midlife samples, positive events did not seem to make any difference to feelings of wellbeing. Consistent with our previous studies, students who filled out CLEAR who had an insecure attachment style and a very negative life event were more likely to experience feelings of depression.

With regards to student grades, those who achieved higher grades were less likely to have experienced feelings of depression, were more secure in their attachment and had not experienced traumatic events over the past year. Contrary to what we might have expected, experiencing general negative life events did not have an impact on grades.

What next?

Of particular interest and cause for concern is the general psychological wellbeing of students and how they can be supported in this time of life. Although most of the student sample were female first year psychology students, these levels of depression are consistent with media reports. We are hoping in the future that CLEAR will identify students who may be at risk for depression and other mental health issues due to ongoing life events. They can then be signposted to the appropriate services and receive the support they need.  We also hope it will help people have a better understanding of their stress and its impact on their health through the personalised feedback at the end.

We know anecdotally that some participants felt that the measure helped them to think about their experiences over the past year and how they dealt with them. We are still collecting data as part of a further study looking at student wellbeing. If you are a student interested in having a go at CLEAR please email us at and we will give you a personal login.