Brighton Journal of Research in Health Sciences

Supporting Research in the School of Health Sciences


Message from Professor Ann Moore

apm21On behalf of the Centre for Health Research it is a pleasure to have been invited to write a small piece for the inaugural issue for our new journal. This is a very welcome development for the new School of Health Sciences and I would like to thank all the members of the editorial team for all their hard work and commitment in putting the first issue of this journal together. I wish the journal well for all its future developments. Writing about and reporting regularly on research and scholarly activities is an important component of all academic members of staff routine activity. Sometimes early on in your career this can be a challenging concept and your confidence may be lacking in terms of your ability to write and to publish in an academic journal. The Journal has been set up by the editors to nurture and support members of staff and students who wish to write for an academic journal. It is anticipated that the editors’ and reviewers’ comments on your work will help to strengthen your manuscript. Through this you will learn more about how to craft research and scholarly papers that sit within your field of practice.The Journal will also give all staff the opportunity to publish their research news and thereby share research activities across the school. The journal is therefore a very welcome development in this new school and I look forward to seeing this development over
the coming years.
Professor Ann Moore
Director of the Centre for Health Research
University of Brighton


Hundreds of recommendations adopted by the Department of Health, but have we seen it all before? The Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: a socio-historical context


Following a Public Inquiry led by Robert Francis into the reasons why poor care at the Mid Staffordshire NHS Foundation Trust was not challenged by a wide range of National Health Service (NHS) regulatory bodies between 2005 and 2009, the Department of Health (DoH) has committed to the implementation of more than 200 recommendations for change in both primary and secondary care. Planned developments range from increasing the powers of government-sponsored health and social care regulator the Care Quality Commission, to promoting cultural change throughout the NHS (DoH, 2014). The stated aim of these changes is to protect patients from unacceptable and unsafe care in the future (Francis, 2013; DoH, 2014).

This review was written as background for research on ways in which the recommendations of the Francis Report may relate to the education of healthcare professionals. Its objective is to to identify the key themes underlying the 290 recommendations of the Francis Report, and to consider these themes in the context of recent NHS policy for England. Archived documents are used to trace the course of policy developments, from the New Labour reforms of the early noughties, through to the coalition governement’s Health and Social Care Act 2012, and the publication of the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry in 2013.

The relevance of key DoH policies to events occuring at the Mid Staffordshire NHS Trust will be explored, and reasons examined for the widely expressed view (Moore, 2013) that, in the current political climate, there is a serious risk that the recommendations of Francis will be implemented only where they coincide with pre-existing DoH policies.

Preliminary search of the literature relating to the Francis Report and the education of healthcare professionals

A preliminary search of the literature identified no published research relating to ways in which the Francis recommendations may be applied, either to the education and continuing professional development (CPD) of healthcare professionals in general, or of podiatrists in particular. The University of Brighton online library catalogue was searched using the terms: “Francis Report”; “Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry”; “Francis Report education”; “Francis Report podiatry”; “Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry education”; and “Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry podiatry”. A summary of search strategy, search terms and number of results returned is presented in Table 1.

Table 1. Preliminary search of the literature relating to the Francis Report and the education of healthcare
professionals: search strategy, search terms and number of results returned



The Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: a socio-historical context

The process of mapping recent NHS policy developments as a context for the recommendations of the Francis Report (Francis, 2013) began with Not the Francis Report: a National Voices Report on How to Ensure Safety & Quality (National Voices, 2012). (See also, Discussion, below.)
21 key documents were reviewed: five government-commissioned reports; six White Papers; four Acts of Parliament; five reports not commissioned by the government, and two pieces of comment and analysis. A classification of the literature reviewed is presented in Results, Table 2 (below).

Mechanism for review of archive material

Data extracted from each document

  • Title
  • Author
  • Author background
  • Date
  • Publisher
  • Summary

Data analysis is descriptive


A classification of the literature reviewed is presented in Table 2.

Table 2. Classification of the literature reviewed



Underpinning the 290 recommendations of his Report, Robert Francis identifies six core themes: culture; compassionate care; leadership; standards; information; and openness, transparency & candour (DoH, 2014, p.9).

With the purpose of developing these themes, the initial government response to the Francis Report (DoH, 2013) included the commissioning of a number of further reports, including one from Professor Don Berwick (National Advisory Group on the Safety of Patients in England, 2013) asking for ways to make “zero harm a reality in our NHS”. A summary of Berwick’s recommendations (see Figure 3, below) can be read as a summary of the themes underpinning the recommendations of the Francis Report.

Figure 3.Key themes underpinning the recommendations of the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (aka the Francis Report)
(Francis, 2013; National Advisory Group on the Safety of Patients in England, 2013)


Concepts of “patient-centred” care and “putting patients first”
As reflected in its title, Hard truths: the journey to putting patients first, the DoH response to the Francis Report places the allied concepts of “patient-centred” care and “putting patients first” at the centre of its stated ambitions for NHS change (DoH, 2014). “Patient-centred” care is characterised as the experience of being treated as a “person rather than a number” (DoH, 2014, p.38), while the related concept of “putting patients first” is defined as “placing the quality of patient care, especially patient safety, above all other aims” (National Advisory Group on the Safety of Patients in England, 2013, p.36). Both these ideas can be seen to reflect Minister for Health, Lord Ara Darzi’s 2008 definition of high-quality care, as care that is “clinically effective,  safe and  personal” (DoH, 2008, p.8).

Cultural change through lifelong learning
The key strategy proposed by Francis, both for the delivery of patient-centred care and also for the implementation of his recommendations generally, is the promotion of cultural change throughout the healthcare system (Francis, 2013) (see also Figure 1, below). Francis (2013) and many others, including the DoH (2014), the King’s Fund (2012), and the National Advisory Group on the Safety of Patients in England (2013), identify the professional training and CPD of clinicians and health service managers as a key tool for the achievement of this cultural change.

But what does it all add up to?
In Not the Francis Report: a National Voices Report on How to Ensure Safety & Quality (2012), Don Redding, director of the coalition of health and social care charities, National Voices, argues that there was no need for a report from Francis and his team, that “ample evidence and consensus already exists” (p.2) to support reforms that will improve the quality and safety of health and social care. Redding (2012) argues that the themes identified by both Berwick and Francis (above) are not new. He suggests, instead, that attempts to address these themes form a thread that weaves its way through the history of NHS policy. Exploring this idea, these themes will be traced through three recent NHS White Papers (3.3.1 to 3.3.3, below) and compared against the recommendations of the Francis Report (2013).

The NHS Plan: a plan for investment, a plan for reform (DoH, 2000)

In July 2000, Tony Blair’s Labour government published the NHS Plan: a plan for investment, a plan for reform. This White Paper is built on earlier ground-breaking policy documents including A first class service: quality in the new NHS (DoH, 1998) and Clinical governance: its origins and foundations (Nicholls, Cullen, O’Neill, & Halligan, 2000). Like Francis (2013) and others (DoH, 2014, National Advisory Group on the Safety of Patients in England, 2013), the authors of both these documents emphasise the need for system-wide cultural change that includes reflective learning, staff development and patient-centred care based on partnership between patients and professionals.

Through the first half of the noughties, one notable and generally well-reviewed strategy for the achievement of the desired cultural change was the delivery, to 40,000 NHS staff, of a three-day management skills course known as Leading an Empowered Organisation, or LEO (Jones, 2005).

Setting out plans for a “reformed and patient-centred NHS”, the NHS Plan: a plan for investment, a plan for reform became law as the Health and Social Care Act, 2001. A key policy strategy included the establishment of Primary Care Trusts (PCTs), designed to improve the integration of health and social care by commissioning both of these services together. Major investment in clinical staff aimed to reduce long waiting times for treatment and to abolish the ‘postcode lottery’ in standards of care (DoH, 2008).

Staffing levels
It is noted that, as at the turn of the century, NHS staffing levels remain a contentious issue today, with a policy of inadequate staffing identified as a significant contributory factor to failures in care at Stafford Hospital (Francis, 2013).

As recommended by Francis, all NHS Trusts are now required to publish monthly, ward-by-ward nursing and midwifery staff numbers (DoH, 2014). In addition, the National Institute for Care Excellence (NICE) has published guidelines for staffing levels in adult inpatient wards in England (NICE, 2014). In contrast to the generous financial provisions of the 2001 Health and Social Care Act however, present-day requirements for major financial savings (DoH, 2011) make it unclear how far these staffing guidelines are likely to be implemented in practice.

The development of NHS Foundation Trusts
With direct relevance to the events at Stafford Hospital between 2005 and 2009, under the Health and Social Care Act 2001 high-performing NHS Hospital Trusts were granted ‘Foundation Trust’ status and a degree of independence from DoH control (DoH, 2005). The aim of Foundation Trust status is identified as allowing health service managers freedom from centralised decision making, thereby increasing patient choice through the delivery of health services that are responsive to local needs (DoH, 2005).

Despite the disastrous standards of care reported by Robert Francis within the Mid Staffordshire NHS Foundation Trust (Francis, 2010), the Health and Socal Care Act 2012 states that all NHS Hospital Trusts should aim to become NHS Foundation Trusts by April 2014.

Under the Health and Social Care Act 2012 and in line with the recommendations of the Francis Report, the DoH has recently increased the powers of the independent regulator of Foundation Trusts, Monitor (DoH, 2012; DoH, 2014). This development is opposed by influential commentators including Don Redding (National Voices, 2012), and Dr Hamish Meldrum (British Medical Journal, 2011), who believe that while regulatory bodies such as Monitor and the Care Quality Commission need to work better together, increasing their regulatory powers is likely to have a negative effect on patient care.

High quality care for all: NHS next stage review final report (DoH, 2008)

Aiming to reflect the views of 60,000 NHS staff and patients, and led by surgeon and Minister for Health, Lord Ara Darzi, this document presents the Labour government’s 10-year plan for the NHS.

Building on the Health and Social Care Act 2001, the key policy aim of this White Paper is identified as improving the quality of NHS healthcare, with ‘quality’ defined as care that is clinically effective, personal and safe. As in the Health and Social Care Act, 2001, this definition of high-quality care echoes the concepts of “patient-centred” care and “putting the patient first” that are identified by Robert Francis (2013) as the foundation stone of his recommendations for change.

Evidence-based practice
Building on documents such as Cullen, O’Neill & Halligan’s Clinical governance: its origins and foundations (2000), Darzi’s 10-year plan identifies the continued development of NICE guidelines and NHS Evidence as an important strategy for the delivery of high-quality care through evidence-based clincal practice. This is a strategy that continues to play an important role in the delivery of NHS healthcare, with Equality and excellence: liberating the NHS (DoH 2010) promising a “relentless focus on clinical outcomes” p.4.

Valuing NHS staff
Like Francis, Darzi identifies staff wellbeing and CPD as key to the delivery of high-quality care. Pledges on these issues are laid down in the first NHS Consitution, developed as part of this White Paper (DoH, 2008, p.77). Strategies for enhancing staff wellbeing include investment in preceptorships and apprenticeships, and a commitment to ensuring opportunities for CPD. By specifically rejecting the setting of any further national targets, Darzi acknowledges, and aims to reduce, the heavy administrative burden on clinical staff.

This commitment to reducing target setting is reiterated both in Equality and excellence: liberating the NHS (DoH 2010) and in the DoH response to the Francis Report (2014). In addition, like Darzi, the DoH (2014) identifies CPD as a key area for development within the health service. Based on strong recommendations from both Francis (2013) and the National Advisory Group on the Safety of Patients in England (2013), The DoH (2014) states that “Education and training should be a running theme throughout a healthcare practitioner’s career” (DoH, 2014, p.93). Developing this theme the government response to Francis continues that, as supportive management that facilitates staff engagement is shown to deliver better patient outcomes (King’s Fund, 2012), it must be “implemented with the rigour of a new drug” (DoH, 2014, p.91). To date, these ideas are yet to be translated into significant policy. A summary of proposed or actual changes to healthcare education legislation in response to the recommendations of the Francis Report is presented in Table 3.

Table 3. Summary of proposed or actual changes to healthcare education legislation in response to the recommendations of the Francis Report


Empowering clinicians and increasing patient choice

With the aim of empowering clinical staff to “set the direction of the services they deliver” (DoH, 2008, p.64), Darzi’s 2008 White Paper gave high-performing GP practices the freedom to offer previously hospital-based services, such as diagnostic imaging, in a primary care setting. Expanding on this theme, GPs were enpowered to buy services not only from the NHS, but also from the private and charity sectors, so that all patients referred for hospital treatment were now able to choose from several NHS and private sector providers (British Medical Association, 2013). Under the Health and Social Care Act 2010 this idea has been developed further, to become the controversial Any Qualified Provider scheme, whereby services are delivered by any qualified private provider on a payment-by-patient basis (DoH, 2010).

Equality and excellence: liberating the NHS (DoH, 2010)

Published only two years after Darzi’s 10-year plan, Equality and excellence: liberating the NHS sets out the new coalition government’s vision for the NHS.

Like Darzi’s 10-year plan, the stated aims of this White Paper include putting patients first and improving healthcare outcomes, with the expansion of patient choice identified as a key strategy for the achievement of these goals. A more controversial proposition is the idea that increased competition, in the form of the Any Qualified Provider scheme, will bring about improvements in the performance of healthcare providers. Key policies include abolishing the PCTs established by the New Labour government in 2001,  and delegating their health-care-commissioning role to GPs overseen by an independent NHS Commissioning Board. In contrast to earlier policies designed to facilitate closer integration of health and social care services (DoH, 2001), social care is to be commissioned separately, by the Local Authority.

The policies of this White Paper were formally opposed by many professional bodies, including the British Medical Association, the Royal College of General Practitioners, the Royal College of Nursing and the Allied Health Professions Federation (Rogers, 2012). Two issues identified as key causes for concern are, firstly, that the fast pace of policy change poses an excessive risk to patient safety; and secondly, that by forcing GP commisioners to offer NHS contracts to private providers, the AQP scheme risks destabiising local health economies and making collaberative work in multi-disciplinary teams more difficult.
In a demonstration of misalignment between stated DoH aims and likely results of DoH policy, Hard Truths: the journey to putting patients first (DoH, 2014) makes frequent reference to the importance of supporting NHS staff to work effectively in multi-disciplinary teams, a well-evidenced strategy for the delivery of safer, more effective healthcare. Clinicians, including Dr Peter Carter of the Royal College of Nursing, and Dr Hamish Meldrum of the British Medical Association, argue that by fragmenting integrated care pathways, the AQP scheme will make services less efficient and put patient safety at risk (British Medical Journal, 2011). in March 2012, Equality and excellence: liberating the NHS was passed into law as the Health and Social Care Act, 2012.

Echoing the concerns of the professional bodies, Francis comments that insufficient risk assessment appears to have been undertaken by the DoH with regard to the implementation of system-wide change (2013 p.63). He goes on to note his impression that clinician advisors to the DoH are not at the heart of policy making on a number of issues, including the Foundation Trust agenda. He concludes that this lack of clinician involvement in policy making is likely to have negative implications for patient safety throughout the NHS.


Aiming to consider The Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry in a socio-historical context, this review begins by identifying the key message of the Francis Report as an urgent need for widespread cultural change throughout the NHS. The overarching goal of this cultural change is to ensure that patients are protected from inadequate and unsafe care such as that provided at Stafford Hospital between 2005 and 2009.

Comparing the key themes underlying the recommendations of the Francis Report with the policy aims and strategies of three recent DoH White Papers, the hypothesis is supported that the themes identified by Francis are not new, but rather form a thread that weaves its way through recent NHS policy. A number of recurring themes are identified, including the key role of CPD in the delivery of high-quality healthcare, the need for partnership between patients and clinicians, and policy maker ambitions to increase patient choice.

Reflecting the concerns expressed by many professional bodies, Francis highlights the risk that, by demanding rapid organisational change (DoH, 2010) allied to tight financial control (DoH, 2011) , current DoH policies may compromise the ability of the NHS to deliver the identified goal of safe, patient-centred care. Healthcare commentators argue that, against the current poliitical background, many of the recommendations of the Francis Report may be more wishful thinking than a practical blueprint for change (Moore, 2013).

Nancy Jones, Podiatrist and Dr. Christopher Morriss-Roberts, Senior Lecturer, School of Health Sciences


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Francis, R. (2010). Robert Francis Inquiry Report into Mid-Staffordshire NHS Foundation Trust. London: HMSO. Retrieved 1 December 2013 from www.

Francis, R. (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, Executive Summary London: HMSO. Retrieved 1 December 2013 from

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Jones, K. (2005). Leading an Empowered Organisation (LEO): does it work? British Journal of Community Nursing. 10(2), 92-96.

The King’s Fund. (2012). Report from The King’s Fund Leadership Review: leadership and engagement for improvement in the NHS. Downloaded 15 January 2014 from

Moore, A. Mixed reviews for Francis’s epic. The Health Service Journal 2013; 123: 20-23.

National Advisory Group on the Safety of Patients in England. (2013). A promise to learn, a commitment to act: improving the safety of patients in England. London: HMSO. Retrieved 1 December 2013 from

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National Institute for Health and Clinical Excellence. (2014). Safe staffing for nursing in adult inpatient wards in acute hospitals. Staffing guideline 1.

National Voices (2012). Not the Francis Report: a National Voices report on how to ensure safety & quality. Retrieved 15 January 2014 from

Royal College of Nursing. (2013). Mid Staffordshire NHS Foundation Trust public inquiry report, response of the Royal College of Nursing. London: Royal College of Nursing. Retrieved 1 December 2013 from


Thoughts from the ground looking upwards

10976404-enfermedad-del-cerebro-humano-y-el-rompecabezas-de-inteligencia-con-un-laberinto-azul-brillante-y-elI love to write. I even wrote a book once. Of course I never allowed anyone to read it and it has long since been packed away, abandoned in a box somewhere in the loft. This, however, is a short and heartfelt piece I’d very much like to share with you. My name is Deborah and I’m about to start my PhD full time here at Brighton. I say about to start, in fact I’ve been planning starting this for the last year and for a quiet and rather shy person this has been some seriously scary stuff. I’m not talking about the academic side, with two degrees, a Masters and eleven years of teaching experience, that side doesn’t worry me. It was the whole concept of moving out of my comfort zone that left me literally quaking in my boots.

To put this into perspective, I’ve performed and supervised minor research projects before and it’s a process my methodical and problem solving brain really enjoys, but a PhD? Over the years since my first degree in 1989 people have often asked me when I was going to start my PhD and my answer was always the same, ‘never’, which is strange in itself since my personal mantra has long been ‘never say never’. Exactly! Where’s the logic in that and why would I feel the need to always say never even though the thought had crossed my mind many times? Why had I always dismissed it?

It all started almost a year to the day in July last year when I told my departmental head I was interested in performing some research and starting a PhD. Other people weren’t surprised at my decision but to me it was an absolutely enormous and almost unthinkable step that seemingly came out of nowhere on the spur of the moment. After all those years of saying never I jumped from ‘I’d like to do some research’ to a full blown PhD in about two minutes flat. So you’re probably thinking what is your problem here, why is it such a big deal? Well in one single word, ‘confidence’, or I could stretch it to two and say ‘self belief’, both are inextricably entwined and lead to the same agonising fear of taking that bold step out of the shadows and into the spot light. The same fear that made me give up my ballet as a child, prevented me from persevering with my book or showcasing my photography skills. After much soul searching I realised my routine stock PhD answer of ‘never’, was in truth the answer to a completely different unasked question: ‘Are you brave enough to do a PhD?’ Therein lay the real issue. I was scared stiff.

Over the years as a part time member of the academic staff I never really had much contact with the Clinical Research Centre (CRC) team even during my time as a Senior Lecturer and Clinical Manager. Although the concept of evidence based practice was very real and thoroughly embraced, ‘proper’ researchers were something that existed somewhere else. My work was highly clinical and student/patient based and I spent most of my time at the Leaf Hospital, I saw the career researchers as aloof and elitist, I saw myself as belonging to a different academic world and quite simply of no possible interest to them. They spoke a level of research language I didn’t understand or feel included in, symbolically they are housed on the top floor, even finding the right door and climbing those steep narrow staircases to reach the CRC was tricky, like a psychological maze. I use the term maze, rather than labarynth because to my apprehensive mind just physically finding them hidden away up in the roof seemed designed to make me take wrong turns, to put me off and get lost just as a maze is designed to do, rather than facilitate exploration like a labarynth. Maybe I’m just particularly sensitive but I know I’m not the only one who faces these fears and insecurities when in comes to moving out of our usual professional comfort zone.

What I’ve realised is that this was all in my head. I saw the PhD process as so much more than simply a large piece of heavily assessed academic work, I created my own barriers. I saw it as a process for laying myself bare to public criticism, of risking being seen as inadequate. I was worried about setbacks and failures and I realised it was this negative mental block that had been holding me back all these years, not just from my PhD, but from so many other things. I was scared of starting at the bottom again, of being ignorant and unsure, of getting it wrong and looking daft, of not understanding the language and process. Ultimately I was so used to being good at what I currently do that I was scared of having these new fledgling researcher abilities judged in what I perceived as a harsh and critical environment, one where I wasn’t sure I belonged or indeed was even wanted.

I have to say I hang my head in shame at these ignorant admissions.

One year on the CRC could not have been more supportive or helpful. Far from being elitist and aloof, once I physically found the right staircase and door the rooms were airy and light, I was made to feel included and valued, offered coffee, a quiet space to work if I needed it and abundant support and advice that has led me to feel that not only can I do this, but I that I will do this well.

With their support and advice I’ve come a long way even though I’ve not officially started yet, I know where I’m going, have formed my supervisory team and with their collective experience and help I’ve been shaping and forming my research questions and proposal ready to hit the ground running in October. Their support and the informal mentoring from my work colleagues and the research network has changed my whole outlook on the challenges ahead and I’m genuinely full of excitement about starting my PhD in October. Despite being the new girl I’ve been made to feel like an integral part of the research community, even though I’ve not even really began and I can’t thank them enough.

If I had to pick a moment when it all started to change for me it was when I took a deep breath last October and plunged headlong into attending the advertised research meetings, presentations and workshops, (work schedule allowing) and with each event my confidence, self belief and sense of belonging began to grow. I realised I was not alone in this and yes I would make mistakes, but that I’d put them right and yes I would have to stand up and defend my research from harsh and maybe unjust criticism, but with the right support and training it would be good research and both it and myself would stand up to that test and become stronger for it. I may still be on the ground looking upwards, but the climb doesn’t seem anywhere near so steep now that I know the research team are there to support and guide me on the path to being an early career researcher.

I’ll leave you with one final thought. As teachers we are constantly evaluating not just the content and application of our educational work but also the outcome. We all have well proven strategies to assess whether the pedagogic approach we have chosen for our students was effective, but how many of us really ever sit down and deeply assess our own development? I did, it was scary, I shook the box and this short piece of writing is part of the result. How do I know I’ve made a difference to my development? I know because one year ago I would never have submitted this for publication.

Deborah Whitham, Clinical Educator, Leaf Hospital, University of Brighton


Inaugural Conference of British Autoethnography Keynote. Autoethnography: threat and promise


A very warm welcome to all of you to this, the Inaugural Conference of British Autoethnography and the launch of the book Contemporary British Autoethnography (Short, Turner & Grant 2013). Before I start the keynote proper, I’ll tell you something of the history behind this conference. Three or four years ago Dr Nigel Short and I had a few conversations that acknowledged the significance of the North American luminaries of autoethnography, whose work contributed much to our learning the methodology and craft. At the same time, we recognised that it would be good to produce a British book to showcase the work that was being done on this side of the Atlantic. So in 2011, Nigel, Dr Lydia Turner and I met, rather opportunistically, on the Falmer site of the University of Brighton and had our first book planning meeting.

A little later, we started to meet with a few other people from our university who, like us, were already involved in the approach, including Drs Jess Moriarty and Mike Hayler, and we called our group ‘Altogether for Autoethnography’. We used this group in a critically supportive way  to help us with our respective works in progress. Two good and important things happened: with regard to the book, after having no luck with a couple of publishing houses, Mike Hayler managed to facilitate a contract with Sense Publishers in Rotterdam in Professor Ivor Goodson’s Studies in Professional Life and Work series. The second thing was that Professor Avril Loveless from our Education Research Centre gave us the support of her school in hosting this conference. As editors, Nigel, Lydia and I sought out and secured the contributors for the book, all distinguished British autoethnographers.

Okay, I’ll start off with a story about a  scenario that in my experience highlights a fairly typical and important issue, central to the uptake of autoethnography as a respectable and legitimate methodology.  Imagine a gathering of interested academics working in qualitative inquiry at a UK university somewhere in recent times. I’ve been invited along to contribute to a discussion about autoethnography and am one of the few people present who has published in the approach. It’s a small gathering but an international one and, in addition to us autoethnographers, there are a several academics working in narrative inquiry and qualitative research more generally and a small number of postgraduate students who are considering using autoethnography in their doctorate and who seem simultaneously attracted to and fearful of the approach.

At an early point in the meeting, one of the doctoral students raises a predictable and understandable concern. She doesn’t express it quite as succinctly as this, but essentially it’s about how to use autoethnography without transgressing the implicit and explicit rules of the academy around what constitutes proper qualitative research and proper qualitative researcher decorum. Put more simply, she asks ‘how am I supposed to break the organisational rules around what I should write about, and how I should write it, without getting into trouble?’

Her words reflect an ever-present risk for new and seasoned autoethnographers in the context of the universities many of them work in. We live in times characterised by what Sparkes (2013) and others refer to as ‘methodological fundamentalism; times in which a narrow, conservative view of what constitutes scientific inquiry has insinuated itself into academic life, privileging positivist research agendas and shaping their taken-for-granted superiority as gold standard in the operating assumptions of the academy.

We also live in times  where neoliberal, new public management and audit, performance and target-driven academic cultures hold sway (Grant 2014a),  which function in the shaping of the subjectivities of academics with regard to what is valorised in the name of ‘excellence’ and ‘quality’; times where sober rationality is coded safe, proper and synonymous with tacitly accepted high standards for conducting qualitative research. And many of those affiliated to mainstream, what Mazzie and Jackson (2009) label ‘conventional’, qualitative inquiry join in this game in policing these standards. The net result is that embodied, highly reflexive, performed emotionality is often disparaged, reviled, coded dangerous and seriously transgressive, or ignored as meaningless.

Apart from the political, managerial and ideological assemblages contributing to contemporary forms of scientism shaping experiences, assumptions and behaviour in British universities, there are also more longstanding implicit rules about the management of emotion at play. These operate both in academic disciplines and the structuring of relationships in universities as bureaucratic organisations. In the early 1990s and later, the work of Stephen Fineman (1993, 2003), the organisational emotion scholar, suggested that the absence of what he described as ‘zones of expressive tolerance’ for the expression of emotion will always be to the detriment of bureaucracies. The dark side of organisations will out, somehow, despite the best rational efforts of organisational actors, so overly-rational organisations always have an emotionally transgressive underbelly.

Around the same time, in a groundbreaking text in the history of autoethnography, entitled Investigating Subjectivity, Ellis and Flaherty (1992) pointed out the wonderful irony in what was, up until then, a sociology of emotions pitched almost exclusively at a rational level. The message of these authors was let’s do the sociology of emotions emotionally, and, given the crises of representation and authority in the social and human sciences in the 1970s and 1980s, let’s not be afraid to embrace subjectivism while we’re at it. The explicit charge was to give researcher-participants centre-stage status more in qualitative research projects.

It’s difficult to ignore the great contribution of subjectivism for the social and human sciences. Witness the number of inter-related ‘turns’ in recent decades: the critically reflexive turn (eg Pillow 2003), the poststructural turn (eg Jackson and Mazzei 2009, 2012); the affective turn (Clough and Halley 2007); the narrative  turn (see Grant, Biley & Leigh-Phippard 2012). Despite this, subjectivism is constantly pathologised in various ways in many quarters in higher education and, ironically, in many quarters of qualitative research teaching and practice. A friend of mine who’s having a hard time at her university about this very issue recently suggested that charges of solipsistic ‘self-obsession’ often levelled against autoethnography and autoethnographers should be reframed as ‘generous researcher self-representational practices’.

I don’t recall hearing conventional qualitative inquiry taken to task for being ‘other-obsessed’. But, in terms of its colonialism,  I believe that this would be a reasonable charge. Much conventional qualitative inquiry seems to myself and others to be a form of voyeurism or scopophilia – a kind of qualitative porn, with researchers, and readers by implicit invitation, safely on the outside looking in, and always seeing the reassuringly familiar – which evokes a comfortable feeling of expectations being met; a form of cultural tourism that demands only safe and distanced recognition and empathy. This positions participants forever as ‘other’, with minimal or no disruption to existing socio-cultural structures, structures of power and politics, and with no passionate call to change the world (Grant 2014b; Jackson and Mazzei 2009, 2012). But of course such colonialism is effaced, obscured, denied, or disavowed in mainstream work that lacks criticality.

I frequently see examples of the above year on year in the, mostly, health-related qualitative work that I peer review for journals and research committees and in papers presented at conferences. What is notably absent in much of this work is any developed sense of critical reflexivity; any sense of what Wright Mills (1959, 2000) described over 50 years ago  as ‘the sociological imagination’: evidence of researchers’ reflexive awareness of the relationship between them and the socio-cultural and historical spaces they occupy. So, of course, important issues around power and politics are  absent from many of those texts, as are standpoint positions, and, of course, passion.

At micro, meso and macro levels, the organisations in which some of these studies take place are often treated as neutral, benign, bricks and mortar backdrops to practice, rather than socially constructed phenomena riven with tensions, contradictions and, often, plain nastiness. These organisations are left seriously under-critiqued and under theorised, or just not theorised at all.  At worst, this results in naïve realist texts which are parochial, insular and theoretically deficient.

In contrast, I guess there’s a fair number of people working within autoethnography who wear their hearts on their sleeves. For many of us, it’s not enough just to write it, or talk about our topics. We are condemned to live them – at least as much as we can, sometimes because we function as standpoint or movement scholars for our research areas, rather than, to borrow a term from Frank Furedi  (2004), simply educational technocrats. For some real and virtual audiences, this can be endearing, engaging and connecting, while for others it can confirm what a bad, unruly, dangerous, undisciplined and unscholarly lot we are, lacking distance, balance and objectivity.

But autoethnography is, according to Carolyn Ellis, meant to be unruly. It seems to me that one sure-fire way of doing autoethnography without troubling too much or breaking some of the rules of the academy game is to produce safe, anodyne, sanitised un-challenging work. I’ve read  some published papers over the last few years that purport to be autoethnographic, where culture and power structures are ‘stroked’ rather than interrogated and critiqued, or not really discussed at all. When I read them, I picture – perhaps unfairly –  the writers of these tales as nice, coherent, clean living folk caught up in some 1950s post-war consensus time warp, who  always find love, and triumph over adversity well before pyjamas, cocoa and a sensible bed-time, and confirm what a lovely and safe place the world (their world) is if you just stick to the rules, in a fair and balanced way.

At my most un-charitable, I also picture a composite metaphor to represent this kind of, to my mind pseudo-autoethnographer: how about someone who’s part Cliff Richard, with large chunks of Barbara Cartland thrown in for good measure? Producing the autoethnographic equivalent of  some distant unpopular cousin of Rock music, with all the sweaty, sexy and exciting bits removed, and the rock of course; combined with fanciful, sugar-coated romantic fiction – stories about relationships and life devoid of all the credibility, complexity, messiness and tragedy of human existence, in short with all the life removed. Fortunately, neither the book launched here today as part of this conference, nor its workshops, contain such contributions. (Apologies to Cliff Richard and Barbara Cartland fans here today, by the way).

Kitrina Douglas and David Carless (2013, 103) recently described autoethnography in terms of its ‘…past, present and future history… as a continual “coming out” – over and again – for each new student, colleague, editor, and conference delegate we encounter.’ Perhaps suggestive of Denzin and Lincoln’s (1994) moments in qualitative research more generally, Kitrina and David argue that the ‘Moments of autoethnography’s history are …. Happening simultaneously and repeatedly (in different contexts for different people) … the future of this always contested, often marginal methodology hangs in the balance, as autoethnography… seems to be always and at once a threat and a promise.’

So, while realist and literal tales share methodological space with experimental, performance and postructural work, it’s hard to seriously interrogate culture without threatening its operating assumptions. But, in terms of social justice, these threats are aimed hopefully at shaping a better world. Where there are threats to established cultures there are also boundaries. And, at the risk of over-stretching military metaphors, where there are boundaries there are border guards who police them. However, thankfully, there is also the promise of irritating insurgents, 5th columnists, quislings, resistance workers. Autoethnography threatens the stability of normative methodological practices and promises a steady stream, or perhaps torrent, of robust challenges. It also does this in relation to both its own assumptions and scholarly parameters, when these become parochial and  insular, and to those of qualitative research more generally. Hopefully all of this will be confirmed in the workshops today and is well-represented in the book.

At this point, for the benefit of delegates here who might be new to the approach, I’ll provide one possible summary of what autoethnography’s about, drawing from our book (Grant, Short & Turner 2013). Autoethnography is described as a contemporary qualitative methodology that demands unusually rigorous, multilayered levels of researcher reflexivity given that the researcher and the researched are often the same person, with the exception of pragmatic mixed methodological designs, permutations such as analytic autoethnography and what Ellis (2013) has recently described as collaborative witness or relational autoethnography.

As it strives towards the experimental, the approach demands the pursuit of creative writing practices that locate it as much in the humanities as in the social and human sciences. Autoethnography owes its existence to, among other phenomena, the narrative turn  in those disciplines and continues to be governed by critical tensions in the  philosophy of science underpinning qualitative research more generally, including in the ongoing postmodern and poststructural critiques of liberal-humanist and realist, literal representational practices of conventional qualitative research (Grant 2014b; Jackson and Mazzei 2009)

So autoethnographies that appeal to readers to believe in a coherent, reliable narrator, who assumes centre stage in a story that faithfully transmits the lived experiences of her or his identity, which progresses from a beginning to an end, co-exist with poststuctural autoethnographies that play with notions of the de-centred, disconnected, incoherent, time- and shape-shifting, constantly emerging subject. To labour a point here, autoethnographies having an implicit investment  in ‘the liberal humanist subject that is an individual person or self’ (Jackson and Mazzei 2012, 10) share genre space with autoethnographies acknowledging the historical constitution of subjectivity and the ‘entangled production of agency’ (where agency is constantly performed, enacted, emergent, contingent, rather than constituting an essential quality that someone possesses).

Tensions within the approach are also played out at the level of related assumptions about culture, culture being central to the autoethnographic agenda. In recent years, Carolyn Ellis (2004), one of the doyens of the approach, described autoethnography as research, writing, and method that connects the autobiographical and personal to the cultural. By ‘culture’ she meant the meaning construction woven in human and material contexts as people go about and through their lives.

It seems to me that this definition can lend itself to the idea of culture as a kind of folksy form of liberal social participation, where no one group is better or worse than any other, where no group stands out as particularly privileged or disadvantaged, and where people are endlessly, uncomplainingly and uncomplicatedly assimilated – woven into the quilt of life. Or at least with complaints about life that can be documented in such a way that does little to explicitly contest the pre-determined shape, texture, pattern, purpose and function of the quilt. Reflecting hegemonic cultural practices, the smooth operation and management of social, political and ideological structures remain minimally challenged or disturbed. This is arguably played out in the politics of those autoethnographic representational practices that tend more towards mainstream, conventional qualitative inquiry.

In contrast, and without wishing to suggest an overly simplistic binary between conventional and more edgy autoethnographies – we operate from and share a broad church – those autoethnographers who embrace a more critical and poststructural edge to their work might regard such representational practice as anathema to trenchant and reflexive cultural interrogation. Textual practices which expose oppressive, deadening and creativity-stifling sociocultural agendas and experiences are key in challenging cultural hegemony. To this end, autoethnographers may adopt the role of cultural trickster in employing fictional and satirical devices to highlight cultural contradictions (Grant 2013).

I believe that cultural trickster or, to use a more sober term, cultural conscience agent autoethnographers perform a valuable service in exposing the dark side, the black holes, the lacunae of cultures – the parts people are perhaps aware of in their peripheral consciousness, but, by tacitly held common consent, don’t usually talk about and don’t want to talk about. Such exposure amounts to speaking the unspoken and unspeakable and refusing cultural invisibility Short (2013).

The cultures that contribute to our subjectivities form part of taken for granted dominant discourses. From a critical theoretical perspective, dominant discourses – big stories or master narratives – discipline and routinize life and  behaviour to the extent that the margin of human unpredictability, or margin of freedom, increasingly narrows (Grant and Leigh-Phippard 2014). From postmodern and poststructural critical standpoints, Calhoun and Karaganis (2001, 194) argue that ‘…criticism and theory are best used to increase the size of this margin, breaking the grip – if in only occasional ways – of predictable  action and habit’.

I think that ‘breaking the grip’ is a nice metaphorical device to guide the purpose of the kind of autoethnography that  some of write and read.  We want to continue  to develop our sustained, small contribution to breaking the grip of  insidious, potentially or actually harmful, discursively grounded cultural and representational practices, as these often escape critical academic, professional and public gaze.

Speaking the usually unspeakable,  and breaking the grip, goes with a reflexive concern over the use of language, where the assumption of language as a neutral vehicle for reporting research is explicitly rejected. Those with aspirations towards autoethnography should take writing and representational practices very seriously indeed and regard writing as a craft they need to work at, just as if they were practising a musical instrument in order to improve and gain mastery over it. So research is not written up. Instead, knowledge is created through writing: draft after draft after draft after draft…..

Representational practices include a concern for representational  ethical concerns, as voiced eloquently by Lydia Turner and Andrew Sparkes in our book. Compared with other research approaches which follow a tick-box approach to ethics, autoethnography throws up myriad ethical complexities. Taking writing, representational and ethical practices seriously also implies a concern about literary style. Poetic forms, the explicit deployment of metaphor, messy texts, experimental writing and the disruption of linear time  are just a few of the devices and tropes that characterise contemporary autoethnographic work.

By breaking the grip, speaking the unspeakable, experimenting with form, structure and content, and constantly pushing back the representational boundaries, autoethnographers increase cultural tolerance for the expression of emotion: for what can be said about this area of cultural life, this organisation, this institution, this discipline, this group of people. In this context, autoethnographic studies function as acts of resistance to challenge cultural operating assumptions and are well represented in the book. Doing all of this puts the embodied, visceral person into writing, which Jess Moriarty describes  in her chapter as putting the blood back into what would otherwise be Halal texts.

In summary, autoethnography reinforces the importance of storytelling and personal narrative in the human and social sciences. Accepting that in an important sense readers are ventriloquists, shaping what autoethnographies say for them, autoethnographic storytelling helps them not only learn about the personal lives of autoethnographers – lived experience if you’re a traditionalist or liberal humanist, witness accounts maybe if you’re a postructuralist – but also about the social and cultural worlds in which we are all situated in myriad and diverse ways. It  gives people – autoethnographers and their audiences – the cultural and symbolic capital and narrative equipment to shape and re-story their lives. This underscores the narrative ethical dimension of the approach: as morality tales, autoethnographies arguably provide resources to help people both interrogate and challenge aspects of their worlds and themselves in them, and work towards re-shaping these worlds in the interests of social justice.

For those reasons, autoethnography significantly contributes to the history, practice, witnessing and interpretation of living. This and the strong focus on writing, representational practices, cultural critique and reflexivity, makes the approach important for emerging and experienced narrative scholars, and for those interested in oral and life history, biography and autobiography methods, for researchers, scholars and students across the humanities, social sciences, communication, education, social work and health, and for qualitative researchers generally. Conventional qualitative researchers would do well to consider using autoethnographic strands in their work, to add another, rich dimension to it.

And what of its future? Its future’s in its present. You can sing and use music as the basis for  autoethnography, something that David Carless and Kitrina Douglas are involved in; you can express it through paintings, photographs; through innovation at the level of method, methodology and theory. For example David and Kitrina utilise and value personal stories in the book; Jess Moriarty writes autoethnodrama; Nigel Short and Mike Hayler build on the metaphor of the journey to construct their work; Ken Gale and Jonathan Wyatt develop the theory and practice of assemblage autoethnography; David Gilbourne and Phillip Marshall use fiction to glimpse the essence of self; Brett Smith and myself focus on the culture of the academy, respectively storying artificial persons and deploying satire; Andrew Sparkes writes meta-autoethnography and Lydia Turner reflexively explores relational ethics.

You can also take autoethnography in a different relational direction, in the form of what Ellis (2013) recently described as ‘collaborative witnessing’. This is something that Helen Leigh-Phippard, Nigel Short, Laetitia Zeeman and myself have been involved in for some years now. I’ll tell you about some of our work at this point, starting with its context.

The language used in mental health interventions traps people in stories. These stories may misrepresent them, socially disadvantage them, disempower them, discriminate against and stigmatise them (Thornicroft 2006; Grant, Biley & Leigh-Phippard 2012).

From a narrative ethical perspective, great care should be taken over how people are represented. However, some communities may claim an exclusive right to define and portray individuals in particular ways, with unfortunate consequences. These include policy, professional and empirical mental health representations of people that are reductionist, doing immense disservice to  emotional and contextual lives.

This highlights the issue of language as a site of the struggle over representation and meaning. People create myriad meanings about themselves and others through engaging with each other in everyday life practices. The ways in which we can be abusively or humanely represented, or can represent ourselves in texts, can never be exhausted, as language and nuanced meaning are infinite and ever-shifting dialogic and cultural resources (Holquist 2002). This facilitates the constant emergence of different communities of textual meaning making (Frank 1995; Richardson 1997), implicating the relevance of both narrative ethics for representational practices (Adams  2008) and re-storying to reflexively resist normative constructions of identity (Grant and Zeeman 2012; Grant and Leigh-Phippard 2014; Grant, Leigh-Phippard & Short in review).

In contrast to representational plurality and differentiation, it is notable that a reductionist trend in the representation of human suffering in the mainstream mental health literature seems to go constantly unchallenged, generally speaking. With a handful of exceptions, including my own and Nigel Short’s work and my work with Nigel and Helen Leigh-Phippard (eg Chase-Grey and Grant 2005; Grant et al. 2008; Short 2005), readers would be hard put to spot a real, fleshed-out, life-contextualised person in much of the mainstream British policy-informed mental health literature. Instead, individuals with problems in living are usually described as sanitized bundles of diagnostic labels, symptoms, emotions, cognitions, behaviours or treatment outcomes.

In this context, I believe that the work I’m currently involved with Helen and Nigel positions it within a social justice agenda. The overall research project is entitled The Book, The Stories, The people. It proceeded from a text that we published in 2011 called Our Encounters with Madness (Grant, Biley & Walker 2011). After textual analysis of the book and interviews with contributors about the experiences associated with writing their chapters, we used creative non-fiction short stories in a relational autoethnographic design as collaborative witness accounts of our experiences of institutional psychiatry. These stories were decentred to the extent that we all have what might be described as hybrid emerging identities: so we’re scholars-mental health academics-survivors-mental health practitioners… We strive to avoid writing from one privileged, or transcendent, identity position.

This has resulted in autoethnographic book chapters (Grant 2013; Grant and Leigh-Phippard 2014), and autoethnographic and practice development papers (Grant 2013; Grant and Leigh-Phippard 2014; Grant, Biley & Leigh-Phippard 2012; Grant, Leigh-Phippard & Short in review; Grant et al. 2012; Taylor, Leigh-Phippard & Grant 2014). In this work, we role-modelled narrative restorying (Grant and Zeeman 2012)  to liberate ourselves from the narrative entrapment of institutional psychiatry, from stories told about us and others which are disabling, pathologizing and discriminatory, and constructed in the name of mental health ‘care’ and ‘treatment’; for us, mental health survival is a social justice issue.

I hope our work functions as exemplars of autoethnography in exposing oppressive cultures and cultural contradictions, which enable writers to re-story themselves into betters futures, both individually and as part of liberating storied communities. Thus is the hegemony of biomedical reductionism and institutional psychiatry challenged, highlighting the therapeutic and political possiblities of autoethnography.

Readers can use those stories in lots of ways: for those in recovery and survival, for example, to use as exemplars, not to copy directly, but as a possibility focus to orientate and use selectively as narrative templates and resources for their own life restorying (Grant, Leigh-Phippard & Short in review).

Turning from our work, present and future developments in autoethnography can also include pushing the colonial-busting poststructural manifesto of Alecia Jackson and Lisa Mazzei (2009, 2012), to include more respect paid to the unconscious, the unspoken – voicing the in-between, dreams and silences, shifting the focus away from conventional literal representational practices (Grant 2014b).

Qualitative research, including autoethnography,  grounded in the sufficiency of the literal voice neglects important inter-related issues. Briefly, these include the historical, contextual and discursive circumstances involved in the production and performance of voice; the positioning of subjects within structures of power; and the ambiguity and contradictions within  and between individuals and their lives.  All of this makes assumptions of coherent voice and similarity between research participants problematic (Grant 2014b).

Voice cannot be considered an innocent and straightforward way to account for a ‘self’. Power, subjectivity and desire shape the ways in which individuals speak of their present and their lives overall. Further, consciousness can never be fully present to itself through language (Jackson and Mazzei 2009, 2012). The light of human meaning is always refracted  through the dark glass of language and language is always unstable. Any expectation of indisputable meaning is confounded by  words forever constituted by myriad significatory traces of other words.

If it is accepted that there can therefore never be a clear unambiguous statement of anything, then all stories have the status of simply being one story in place of another (Mazzei 2009). Written and spoken voice is forever condemned to insufficiency: As MacLure (2009, 100) argues, ‘Neither can deliver the fullness and immediacy that fuels the dream of presence’.

On these grounds, the act of writing participant and researcher voice from a poststructural qualitative research perspective constitutes the performance of provisional ‘truth’. There is nothing before or behind language use and such performance is about speaking and writing oneself and others into existence within relations of power. Following Deleuze, Davies (2009) argues that an individual, rather than being a self-conscious ‘I’, is a location where thoughts may emerge. The act of writing opens the writer to becoming what is not yet known and what can never be contained in words, as Jonathan Wyatt and Ken Gale admirably demonstrate in the book. Writing should therefore aspire to the constitution of other, different, ways of knowing and seeing, rather than to the constant rehearsal of the familiar (Davies 2009; Richardson & St Pierre 2005).

Autoethnographic theatre is already happening through, for example, the work of David Gilbourne, David Llewellyn, Phil Marshall and Jess Moriarty. I’d like to see more organisational reflexive performance – autoethnodramas of academe – to build on the counter-discursive challenging of the neoliberal, new public management agenda. This would complement the work of Andrew Sparkes, Brett Smith, myself and others with, I hope, lots of satire included. Some aspects of our universities desperately need lampooning.
Overall, I’d like to see more of us refusing to separate our personal histories from our academic histories; more of us writing back against the grain of the taken for granted and helping others to do so too, in storying a future marked by compassion, solidarity, communion, change, justice and hope.

I hope you all enjoy and profit from the day.

Alec Grant, PhD, Reader in Narrative Mental Health, School of Health Sciences


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Therapeutic Photography


There is accumulated evidence that art through many mediums has an intrinsic value in modern healthcare provision (Staricoff 2004). McNiff (1981) endorses the position that all art forms are valid and a variety of creative expression that stimulates all the senses is therapeutically beneficial. Warren (2007) argues that such meaningful avenues of expression build resilience, support recovery and are unlimited in therapeutic value. He argues that individuals can be empowered through the creative process in the creation of an image, word, sound or movement which gives an individual affirmation to the ontologically secure position that ‘I exist. I have meaning’.

Photography provides vast opportunities within mental health care for therapeutic interventions (Bach 2001; Glover-Graf and Miller 2006; Smith and Grant 2014; Weiser 2014 accessed 1 June 2014). Throughout this essay I will explore the value of photography as a public art form and its benefits within mental health care. I will draw evidence from both literature, personal experience and practice, in using photography as a therapeutic tool.

Photography as public art

Photos are everywhere; with the digitalisation of the 21st Century there has been a change in in the accessibility of photography. Previous to the appearance of modern technology, photography was a highly technical medium that was not accessible to all. Nowadays advances in technology mean that photography is much more widely accessible; rather than requiring expensive equipment and a darkroom, taking pictures only requires a disposable camera or mobile phone. The tradition of family photo albums has largely been replaced through social network sites and cyber storage, and the rise in accessibility of the Internet means that visual images captured through photography can be shared with wider audiences (PhotoVoice accessed 1 June 2014).

Photography in healthcare

The use of photography in healthcare can be dated back to the work of Dr Hugh Diamond who used photography with psychiatric patients in the mid-nineteenth century, and by the mid-twentieth century ‘phototherapy’ was used for both physical and psychological health care (Wheeler 2012). The works of Jo Spence (Fig.1), further strengthened the impact of photography as a therapeutic intervention. Her controversial works in the 1980s used photography as a medium to explore and make sense of her own experience in healthcare whilst undergoing cancer treatment (Dennett and Spence accessed 1 June 2014).

NaishImg1Figure 1. Jo Spence and Terry Dennett, The Picture of Health? 1982-86

The formal use of ‘Phototherapy’, which aims to improve people’s social and empathic sensitivity, requires some minimal training (Smith and Grant 2014; Weiser 1999; Weiser accessed June 2014). However the use of less specific therapeutic interventions in healthcare using photography requires no formalised training. The benefits of photography within healthcare are extensive due to the variety of processes involved, such as taking and processing photos, looking at old personal photos and exploring photographic images taken by others. The ensuing therapeutic advantages include providing support for individuals to: explore self identity, better understand and explore the social context behind images, aid memory, use as a tool to communicate and creatively express emotions through creativity (Bach 2001; Fryrear 1980; Glover-Graf and Miller 2006; Weiser accessed 1 June 2014; Wheeler 2012).

The use of photography as a therapeutic tool within mental health care holds particular value in the exploration of self and self-identity. A significant factor amongst high proportions of individuals who have experienced mental health issues is a ‘negative self–image’ is (Glover-Graf and Miller 2006). The use of photography in exploring self-image can support an individual to develop self-knowledge and create a positive self-image, which in turn impacts on confidence and self-esteem (Weiser 2014 at). In addition, using photography to explore self-identity induces conversations that allow an individual to control how they tell their story and validates their own experience (Bach 2001, PhotoVoice accessed 1 June 2014).

Photography can provide a transformative narrative to enable people experiencing mental distress to engage in dialogue and explore meanings and their significance (PhotoVoice accessed 1 June 2014) – to, in short enable people to make sense of their worlds (Martin 1999). Furthermore, photography can provide a medium to communicate and express what cannot be verbalised. For people who are experiencing mental distress this can be of particular value. This is particularly well demonstrated through John Keedy’s (2012, accessed 1 June 2014) ‘it’s hardly noticeable’ exhibition (Fig.2). Keedy uses photography to express experiences of, in his terms, ‘unspecified general anxiety’. His images provide an insight into this experience.

naish-img2Figure 2.  John Keedy ‘It’s Hardly Noticeable’ VIII, 2012

My use of photography in the Allsorts youth project

I have used photography in my own life as a therapeutic intervention in a number of settings and have observed the benefits of photography in others. For the past nine years I have worked both on a voluntary and employed basis at Allsorts youth project, based in Brighton. Allsorts supports young people aged 13 to 26 who identify as lesbian, gay, bisexual, transgender or unsure of their sexuality or gender orientation (LGBTU). Although identifying as LGBTU is not a mental health issue, people who do so are at greater risk and are more likely to experience mental health issues due to discrimination in the context of a long history of LGBTU oppression within social structures (Mental Health Foundation accessed 2 June 2014; NHS choice accessed 1 June 2014).

Allsorts, places great importance on the use of art in its mental health and well-being programmes, through media such as music, creative writing and visual arts. Photography has been used extensively within Allsorts to affirm identity, build confidence, raise self-esteem, and challenge social constructs and normative notions such as heteronormativity cisgender bias. In addition to the individual therapeutic benefits of using photography as an art form, the images produced are very often published and used in campaigns to raise awareness of the LGBTU issues in the wider community. This adds a further dimension to the therapeutic benefit of photography for the young people involved, in the way that it helps them build on their confidence and self-esteem.

Identity is a key issue for LGBTU young people who attend Allsorts as this often conflicts with heteronormative and cisgendered biased social structures, causing oppression and isolation (Butler 1993; Mayberry 2013). Inevitably, an LGBTU identity can become the focus of a person’s identification. The social power of heterosexual cisgenderd identity is normalised, and LGBTB people are ‘othered’ through social discourses, for example ‘the gay doctor’ (Beasley 2005). In order to support young people to recognise that they do not have to be solely defined by their sexual orientation or gender identity, Allsorts worked collaboratively with Star Peers to produce a photo campaign that recognised that LGBTU people were defined by more than their sexuality or gender (Fig 3, accessed 1 June 2014). The project used self-portraits and words with the phrase ‘I am…’ that defined individuals in terms other than that of their LGBT status.

naish-img3Figure 3. Allsorts & StarPeers ‘I am…’ 2013

Whilst working with young people and taking photos of their portraits using words to define themselves, I noticed that they initially struggled to find phrases or words that were separate from their LGBTU identity. This offered opportunities for open dialogue with young people around their identity and what it meant to them.

Further, this was the basis of a further project using photography, to explore with young people what Brighton meant to them. During the ‘what Brighton means to me’ (photos unpublished) project, I supported young people in creating photos that told a story about their relationship with Brighton as their home. Throughout this project I observed the multifaceted benefits of photography as an art form. The process of taking the photos provided young people with an opportunity to support and encourage each other, strengthening their relationships. Whereas other art forms such as drawing or painting can initially be quite daunting for people who feel they have no creative ability, photography essentially simply requires capturing images. Them realising that they were able to create images through the use of cameras this boosted the confidence of the young people involved in creative expression. Furthermore the opportunity to explore Brighton rather than staying at the youth centre created a fun and enjoyable experience and the dialogue of telling their story initiated a vast range of conversational subjects. For some, Brighton meant excitement, community and home. For others, Brighton was place of safety and sanctuary in its diversity and acceptance of the LGBT community. Through sharing their experiencesof the images they created, the young people were able to add context to their identity and those experiences.
A significant photography project produced by Allsorts was ‘HumanBeing:BeingHuman’, (Allsorts 2014, accessed 1 June 2014) in which young Transgender people used photography with autoethnographical text to tell their own stories, in an exploration of self-identity. Whilst I was not directly involved in the production of this project it did serve as a tool to have a meaningful discussion with a young person through exploration of the photos.

During one of Allsorts drop-in sessions I was looking through HumanBeing:BeingHuman’ ‘with a transgendered female, Emma aged 19 (pseudonym used to protect confidentiality). Emma commented on one of the ‘non-recognisable self-portraits’, saying that she wished she could be ‘non-recognisable’. I asked Emma to expand on this, which gave her opportunity to tell her story. Emma has only recently joined Allsorts and had not disclosed her gender identity anyone outside of the facility. While Allsorts provided her with a safe space in which she could wear makeup, be known as ‘Emma’ and referred to with the pronoun ‘she’, outside of Allsorts Emma is known by her birth name and referred to as male.

We had a long discussion exploring Emma’s two conflicting identities. This discussion in itself was therapeutic for her, as she had not had the opportunity to discuss this before. In addition Emma said that HumanBeing:BeingHuman gave her hope, insight into the fact that she is not alone and a determination to pursue her identified gender as a female. This experience highlighted to me the importance of sharing stories and experiences in order to support individuals in the wider community. Photography provides a medium through which oppressed minority groups such as LGBTU communities become visible:

Without the visual identity we have no community, no support network, no movement. Making ourselves visible is a continual process.
(Joan Biren 1983, Cited in Muholi 2010, 5)

Photography, heteronormativity and me

I personally enjoy photography; I find the process of capturing an image that creates meaning for me and induces an emotion or meaning for others therapeutic. I realised the significance of my own therapeutic relationship with photography through creating visual images for a photo essay earlier this year. Identifying as a lesbian and having active involvement in challenging heteronormative concepts in the last decade, I chose to write my essay on challenging stigma within mental healthcare through the experience of the LGBT community. It wasn’t until I created the photo ‘Bottled Up’ (fig.4) (Naish 2014) that I realised I had not been able to express the impact that hetronormative discourses within society had had and continues to have on me as an individual. Until that moment the notion that my sexual orientation had been oppressed, was a metaphorical concept that had no validity other than what was ‘felt’ by me. In producing the image it created a ‘concrete’ visual expression, which I have not been able to verbalise previously.

naish-img4Figure 4. Jaime Naish ‘Bottled up’ 2014

My use of photography in nursing placements

My experience in using photography is predominantly related to my work with LGBTU young people. However I have also used photography in my nursing placements, including while working in the community mental health team when my mentor and I were supporting a 52-year-old man, John (pseudonym to protect confidentiality) who had a diagnosis of generalized anxiety disorder. One of John’s coping strategies wass to visualise places where he felt safe and secure if he becomes anxious in public. However recently he had been finding it difficult to retain such an image in his mind. We discussed both what the causes of this may be and the value of a number of different techniques to support his visualization, one of which was to use photographs of images that invoked feelings of safety, to support his visualization.
When I next saw John he reported that he had had an experience of becoming anxious whilst out shopping. He had used visualisation and mindfulness as a coping strategy to get himself home, although he still found it difficult to manage his anxiety. However he did remember the suggestion of looking at photographs and picked up an old family holiday album. John was surprised to realise he had spent an hour looking through photos, enjoying and laughing at memories of him and his brothers having fun on the beach. This served as a valuable distraction tool for him. Furthermore he showed me a photo of himself and his brothers as children on the beach, which he had saved onto his phone, and said ‘this is my favorite photo – it takes me to a place where I have no worries’.


Photography provides vast opportunities within mental health care for therapeutic interventions. Its overall significance should be understood is in the context of how using the arts generally can benefit healthcare, since Other media such as literature, movement and dance, music and myriad other art forms also have significant value in both the mental and physical Healthcare arena. In nursing there is the opportunity to utilise art to add another, counterbalancing dimension to the dominant medical model. Photography is a relatively cheap and simple to use medium in which health care users can explore self-identity, and express emotions through visual creativity.

Jaime Naish, Mental Health Nursing BSc (Hons) student


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An investigation into the use of humour among Paramedics as a factor in coping with stress and an element affecting resilience against burnout. A Literature Review


The word ‘Humour’ originates from the Latin for ‘fluid’ (Buxman 2008). Historically it was believed that the body contained four ‘humours’ (Blood, Phlegm, Yellow Bile and Black Bile), which governed a person’s health (Scott 2007). Today, though humour is considered ‘the quality of being funny’ (Collins English Dictionary 2011) there is no universally accepted definition (Buxman 2008; Moran 1990). Humour has a multidimensional value in healthcare (Beck 1997, 346); to help calm patients (Beck 1997), as a stress coping strategy (Mildenhall 2012), educational tool (Baid and Lambert 2010), and for group cohesion (Watson 2011).
The question of what affect different types of humour and different humour styles might have upon stress coping strategies is a significant one (Dyck and Holtzman 2013); especially for healthcare (Moran and Massam 1997). The aim of this literature review is therefore to analyse what is currently known in this area, highlighting aspects relevant to paramedic practice and possibilities for future research.


In order to achieve the aim of the study a systemic literature review was conducted. Initial searches of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, NHS Evidence, PubMed, ScienceDirect and Google Scholar databases using the keywords: burnout’ AND ‘paramedic’ OR ’emergency medical personnel’ OR ‘EMT’ OR ‘prehospital’ OR ‘pre-hospital‘, ‘resilience’ AND ‘paramedic’ OR ’emergency medical personnel’ OR ‘EMT’ OR ‘prehospital’ OR ‘pre-hospital‘, ‘humour’/ ‘humor’ AND ‘paramedic’ OR ’emergency medical personnel’ OR ‘EMT’ OR ‘prehospital’ OR ‘pre-hospital‘. The Boolean operators AND and OR were incorporated to combine search terms and focus results in the relevant area under consideration (Hart 2005). American/English spelling adaptations were included to locate all relevant literature (Moule and Goodman 2009). Searches yielded a significant number of studies but not all were available in full text. Those giving only abstracts were examined to see if they had noteworthy relevance; where found to, alternative avenues were investigated to acquire the full text. Some were obtained through online libraries via Google Scholar. Others, unavailable without payment, were excluded from the review. In order to conclude to the most suitable and narrow results the following inclusion and exclusion criteria were used:

  • Primary research: written by the person who developed the theory or conducted the original research (Polit and Beck 2006)
  • Published in English
  • Peer reviewed: research examined for bias or inappropriate subjectivity by the researcher’s peers or colleagues (Holloway and Wheeler 2010)
  • Free to Access

Due to the relative infancy of research into burnout (Felton 1998) and the older study of humour use (McCreadie and Wiggins 2008) no year of publication boundaries were set; resulting in the discovery of research which significantly informed this review. Additionally, worldwide parameters were allowed to investigate whether use of humour might uncover research with cultural factors relevant to the diversity of healthcare workers in Britain. Though people from ethnic minorities made up only 2% of ambulance staff in 2005 (National Guidance Research Forum 2005) it could be argued that paramedics engage with many healthcare workers in and out of the NHS as part of their work, making this consideration initially relevant. However, as only a limited number of studies, of minimal relevance were uncovered this review concentrates on first world research.

Secondary sources ‘can provide rich data’ (Munhall 2007, 382), however, they are only used where primary research was unobtainable and then limited to discussion areas or additional reference support. This is because secondary sources are one author’s commentary upon another author’s primary research, which can raise concerns over interpretation or bias (Macnee and McCabe 2008).

The Journal of Paramedic Practice was manually searched (due to online inaccessibility) with one article uncovered, aiding discussion elements.
Data saturation ‘indicates that everything of importance to the agenda of a research project will emerge in the data and concepts obtained’ (Holloway and Wheeler 2010, 146). This point was considered reached after repeated searches revealed the same articles closest to the research question.

Qualitative research studies the meaning people give to phenomena (Parahoo 2006), whereas quantitative research investigates ‘phenomena lending itself to precise measurement’ (Polit and Beck 2010, 565). The framework of Lobiondo-Wood and Haber (2002) (appendix 2) for critiquing qualitative and quantitative research was used to critique the three main studies considered central to the research question. Additional research was identified using a snowballing technique – where references in one study lead to locating works by other authors (Polit and Beck 2010).


Review of the research uncovered three main themes:

  1. Burnout: a condition experienced by paramedics
  2. Humour: a factor in stress relief and resilience
  3. Humour use by paramedics

Burnout: a condition experienced by paramedics

Originally used to describe the cessation of a jet engine, Felton (1998) additionally notes that in the 1970’s burnout was first applied to humans by psychologist Herbert Freudenberger. Freudenberger studied how healthcare personnel he worked with changed from being passionate about their job to becoming distant and apathetic; describing themselves as ‘burnt out’ (Ruysschaert 2009). Building on Freudenberger’s work, Maslach and Jackson (1981) published their research into the measurement of burnout, which became seminal for subsequent studies.
Burnout produces a combination of emotional exhaustion, de-personalisation, and reduced personal accomplishment (Maslach and Jackson 1981) being most frequently found among ‘human services professionals, particularly in healthcare’ (Felton 1998, 237). Chase (2014, 1) proposes that ‘no one burns out who wasn’t on fire to begin with’, suggesting burnout is peculiar to people with high expectations of themselves. Maslach and Leiter (2005) agree, proposing that idealists, perfectionists and those with a strong sense of purpose are most at risk. When ideals of relieving suffering, and expressing compassion, are thwarted by time or circumstance a sense of failure and inadequacy can lead to chronic stress and burnout (Chase 2014). The effect of burnout may include physical and emotional exhaustion, increased levels of anger, headache, insomnia, chronic hypertension, gastrointestinal complaints, immune dysfunction, infertility, sleep disorders (Felton 1998; Sophianopoulos, Williams & Archer 2012) as well as higher rates of alcoholism, drug abuse, increased smoking and caffeine intake and coronary heart disease (Frank and Ovens 2002).

Nirel et al (2008) identifies lack of administrative support, long hours, poor work / life balance, and poor salaries as causes of burnout in paramedics particularly. Sophianopoulos, Williams & Archer (2012) add shift work to this list. The impact of burnout upon paramedic’s families is also noted by Regehr (2005), significantly affecting the quality of interpersonal relationships. Increased levels of depression were noted by Griner (2013), with increased percentages of suicidal ideation acknowledged by Sterud et al (2008).

Much literature on burnout makes mention of Maslach and Jackson (1981), Griner (2013) noting burnout is usually measured in healthcare workers using Maslach’s Burnout Inventory (MBI) developed from this research. MBI is a self administered questionnaire which notes a range of responses to an individual’s feelings about their work (Kashka, Korczak & Broich 2011).

‘The Measurement of Experienced Burnout’ by Maslach and Jackson (1981) was first presented in the peer reviewed Journal of Occupational Behaviour, published by Wiley since 1980 ( The authors acknowledge use of qualitative data drawn from other researchers, citing: Freudenberger (1974; 1975), Ryan (1971) and Wills (1978), as well as previous personal research (Maslach 1976), and collaborative work with Pines (1977), however no reference is made to any literature review being conducted. This is possibly due to the infancy of research into burnout at the time (Felton 1998) or that some researchers prefer a brief overview rather than comprehensive literature review to set their study in context (Polit and Beck 2004). Additionally, ethical considerations are not mentioned, though it is unlikely researchers would neglect the basic principles of safeguarding participant’s rights and ensuring their safety (Parahoo 2006). Furthermore, footnotes acknowledge the study was supported by a Bio-Medical Sciences grant, which is awarded only after submission of an application showing all research considerations have been covered (Polit and Beck 2004). Two sample groups were drawn from a range of human services occupations across America including: Physicians, Police, Psychiatrists, Nurses, Social Workers and Counselors. Qualitative data was gathered through semi-structured interviews – presenting a set of questions allowing for individual responses but leading to similar data from participants (Holloway and Wheeler 2010), and quantitative data through questionnaires – a means of collecting specific, measurable data (Holloway and Wheeler 2010). How participants were recruited is not recorded. An initial 47 item questionnaire concerning ‘feelings and attitudes about work’ was compiled with each statement rated on two dimensions: Frequency and Intensity. An answer range of 1-7 gave options between ‘never’, to ‘every day’. This questionnaire was initially administered to 605 people – being a large enough group to be representative of the whole 1025 member sample (Polit and Beck 2010).

Four factors were discovered from the data and titled: ‘Emotional Exhaustion, ‘De-personalisation‘, ‘Personal Accomplishment’ and ‘Involvement’. The fourth factor, though appearing consistently in the data was rejected as a subscale due to its eigenvalue ‘being inconsistent with reliability’ (Maslach and Jackson 1981, 104).

Since publication MBI has been tested by numerous researchers; Schaufeli and Enzmann (1998), cited by Glasberg, Eriksson & Norberg (2007) suggest 90% of empirical studies into burnout now use MBI, giving credence to its dependability. MBI has also been used in organisational settings other than healthcare, including a telecommunications company, pension company and insurance company (Gonzalez-Roma et al 2006) increasing confidence in the transferability of MJ findings.

MJ found that results due to age varied, with younger people scoring higher risk of burnout than older – this is potentially significant when compared to McAlister and McKinnon (2009) who found similar factors in their study of student and qualified paramedics in Australia. The suggestion of Gayton and Lovell (2012) that healthcare workers with longer service owe their resilience to an element of natural selection is also interesting to note in light of this. Married workers were found to have lower risk of burnout than single or divorced workers – possibly equated to the beneficial factor of greater social support noted by Gustafsson et al (2010) and Dyrbye et al (2010).

MJ conclude with the desire that MBI may lead to greater understanding of burnout, ‘influencing future job training, recruitment and design to alleviate the problem’ (Maslach and Jackson 1981, 112); its widespread adoption by researchers (as mentioned above) suggests some accomplishment of this.

Stress is a significant issue within the NHS with an estimated 30% of all staff sickness absence related to it (NHS Employers 2012). Paramedics are particularly susceptible to levels of stress that can lead to burnout (Regehr and Millar 2007) and like other human service workers they use diverse strategies to cope with it (Hawkins 2008). The following chapter examines one strategy, humour use, which has a particular relationship to the emergency services (Charman 2013).

Humour: a factor in stress relief and resilience

Defined as ‘the ability to rebound from adversity and overcome difficult circumstances in life’ (McAlister and McKinnon 2009, 372), resilience is identified by researchers as key in the avoidance of burnout (Gayton and Lovell 2012).
Resilience consists of different factors including level of social support and personality (Grafton, Gillespie & Henderson 2010). However, of all factors highlighted in the development of resilience, the use of ‘humour’ stands out as a common theme (Essex and Benz-Scott 2008; Felton 1998; Grafton, Gillespie & Henderson 2010; Griner 2013; Ruysschaert 2009; Strumpfer 2003).

A ‘complex phenomenon, incorporating cognitive, emotional, behavioural, physiological and social aspects’ (McCreadie and Wiggins 2009, 1079), studies have lead to three basic theories of humour types:

The Incongruity Theory: developed by Kant (1724-1804) notes the ‘punch line’ is different from that expected, – humour being derived from this mismatch (McCreadie and Wiggins 2008).

The Superiority Theory: developed by Plato (427-347) and Hobbes (1588-1679) suggests we laugh at the failings of others to feel better about ourselves (Feagai 2011).

The Relief Theory: developed by Freud (1856-1939) suggesting humour releases suppressed emotions (Hawkins 2008).

Though examples of all three can be found in resilience strategies, Freud’s theory is perhaps more significant as it aims to relieve anxiety and transform negative feelings (Buxman 2008). In ‘The Joke and its Relation to the Unconscious’ (Freud 2002), Freud suggests humour provides an acceptable form for raising taboo subjects, additionally offering a means for ridiculing and dis-empowering people’s fears. The idea of weakening a threat or fear through ridicule is one also attested to by Downe (1999) and Obrdlik (1942); McGhee (2013) suggesting this is due to the increased sense of control humour brings to stressful situations. Henman (2001) corroborates, having found humour fundamental to resilience amongst American prisoners of war in Vietnam and survivors of concentration camps. The significance of this is not lost when considering the stresses of emergency care.

Kuiper (2012), and Dean and Major (2008) found humour helped medical personnel distance themselves from stressful situations; Chinery (2007, 1) calling humour a ‘buffer’ against stress.

Several researchers note claims over the positive health effects of humour (McCreadie and Wiggins 2008) including: reduction of anxiety, increased pain tolerance, improved respiration (Buxman 2008), lowering of blood pressure (McCreadie and Wiggins 2008) and release of endorphins (Fabry 2011; Feagai 2011). However, the most cited case is that of Norman Cousins whose recovery from Ankylosing Spondylitis is often claimed due to humour use (Moran and Massam 1997).

In Anatomy of an Illness, Cousins states: ‘ten minutes of belly laughter had an anaesthetic effect giving me two hours of pain-free sleep.’ (Cousins 1979, 15) Rowe and Regehr (2010), and Mahony (2000) are not alone in challenging Cousins’ claims after subsequent research left them unproven.

On claims of stress reduction Moran and Massam (1997) cite Martin and Lefcourt (1983) who suggest sense of humour does not lead to decreased stress but rather that humorous people generate more humour to cope with stress. To the claim that humour increases pain tolerance, Weisenburg, Tepper & Swartzwald (1995) discovered humour had only a distracting effect, with similar results produced in sample participants watching horror films as humorous films (Weisenburg, Tepper & Swartzwald 1995, 210).

Mahony (2000) found no empirical support confirming laughter triggers endorphin release and suggests watching fish is as effective as humour at lowering blood pressure (Mahony 2000, 2). Mahony’s conclusion: ‘Humour trait is more beneficial than humour state’ (Mahony 2000, 2).

Research into humour use identifies four distinct humour styles revealing how people communicate with others, cope with stress, and build resilience (Dyck and Holtzman 2013): Affiliative Style: strengthening interpersonal relationships whilst maintaining positive self-esteem (Olson et al 2005), Self-Enhancing Style: Having a humorous outlook on life, boosting self-esteem and buffering against stress (Olson et al 2005), Aggressive Style: ‘put down’ humour / sarcasm and ridicule – often having a negative effect on interpersonal relationships (Kuiper 2012), Self-Defeating Style: being excessively critical or ridiculing of one’s self in an attempt to enhance relationships (Kuiper 2012).

For building resilience and coping with stress, affiliative and self enhancing humour are considered positive, whereas aggressive and self-defeating styles are considered negative (Hawkins 2008).

As well as acknowledging humour styles have positive and negative effects, Dyck and Holtzman (DH) questioned whether social support and gender might be factors which further influence the effect of these styles on well-being. Their quantitative method gathered a sample of 826 students, 65.3% Female, 74.3% Caucasian; with 88.7% between age 18-22. Participants were recruited through the psychology research pool at two Canadian universities. A ‘convenience sample’ – those most easily available (Polit and Beck 2010; Holloway and Wheeler 2010), this sample could be accused of bias (Polit and Beck 2004) as they were drawn from students interested in psychology research and therefore not truly representative of all university students. Data was gathered using online questionnaires, results being subjected to bivariate analysis – a means of quantitatively analysing two variables to determine the relationship between them (Babbie 2009). Analysis revealed:

Affiliative Humour was:

  • The highest average score
  • associated with lower levels of depressive symptoms
  • associated with higher levels of life satisfaction
  • associated with higher levels of perceived social support

Self-Enhancing Humour was:

  • associated with lower levels of depressive symptoms
  • associated with higher levels of life satisfaction
  • associated with higher levels of perceived social support.

Aggressive Humour was:

  • significantly higher in males than females
  • not significantly associated with depressive symptoms, life satisfaction or levels of perceived social support.

Self-Defeating Humour was:

  • The lowest average score
  • associated with greater depressive symptoms
  • associated with lower life satisfaction
  • associated with lower levels of perceived social support.

DH suggest that affiliative and self-enhancing humour styles could be interpreted as more socially attractive and therefore act to increase a person’s social support, whereas aggressive and self-defeating styles could produce the opposite. However, they note a potential alternative explanation might be that social support has a controlling influence on humour styles and their affect on well-being. High social support might enhance the use of positive styles, and diminish the effect of negative styles; whilst lower social support may have the opposite effect.

The application of this study to the paramedic setting is interesting in that it suggests social support; gender and humour styles all have an effect on well-being and potential resilience levels. The Ambulance Service has been a traditionally ‘male’ dominated environment (Sterud et al 2008, Bennett et al 2004) with potential for steering humour towards aggressive styles, (possibly less beneficial for female staff). Levels of social support within the Ambulance Service have also been identified as significant in the area of burnout and resilience (Van de Ploeg and Kleber 2003). In the following chapter the issue of humour use by ambulance staff will be examined to consider its effect upon resilience to burnout.

Humour use by Paramedics

Rebuffing the idea that humour in healthcare is unprofessional, Dean and Major (2008) champion its value in aiding communication, managing emotion, team building and burnout avoidance. Furthermore, within emergency healthcare research a common theme is the use of ‘gallows humour’ (GH) for stress relief (Alexander and Klein 2001; Bennett 2003; Rosenberg 1991).
GH is often used at times of tragedy or death (Bennett 2003, 1259). Freud (2002) notes its use by individuals, but Obrdlik (1942), in a study of the Nazi invasion of Czechoslovakia, was one of the first to document its use by whole societies. Its use by groups in stressful work environments has since been acknowledged (Moran and Massam 1997).

Amongst many paramedics, GH is considered ‘the biggest coping mechanism we have’ (Villeneuve 2005, 8). Diminishing negative feelings by re-framing a horrific situation GH offers a defense in overpowering situations (Van-Wormer and Boes 1997); whilst ‘maintaining sanity under insane circumstances’ (Kuhlman 1988; cited in: Rowe and Regehr 2010, 449). Several researchers noted how paramedics use humour to develop their social support (Mildenhall 2012) and build group cohesion (Rowe and Regehr 2010).

A seminal, qualitative study into humour use by paramedics is Rosenberg (1991) ‘A qualitative investigation of the use of humor by emergency personnel as a strategy for coping with stress’, which compares humour use by experienced and student paramedics, noting the development and adaptation of humour through exposure to clinical experience and exploring how changes in humour use may be ‘an adaptive method for coping with stress’ (Rosenberg 1991, 197).

Longitudinal research – ‘examining changes in a group over time’ (Burns and Grove 2001, 251), was incorporated in studies of 10 (ultimately 9) student paramedics from a convenience sample of 37. Known as the ‘pre/post trained group’, they were firstly interviewed before training, and then interviewed again after training.

A second group of 10 ‘experienced’ paramedics with 1-7 years experience were additionally recruited and interviewed once only. Their results, compared with the first group, provided cross sectional data for the study. Cross sectional research gives data from ‘more than one group of subjects at various stages of development, simultaneously’ (Burns and Grove 2001, 252).

Though participant numbers were small, data saturation – where no new data is uncovered (Polit and Beck 2010) was highly probable as the groups were representative of the ‘student’ and ‘experienced’ populations. Data was gathered using a structured interview – ‘the same questions, in same order, with same response options’, (Polit and Beck 2004, 349), but with open ended questions – ‘giving freedom to respond in narrative fashion’ (Polit and Beck 2004, 349). Inductive analysis – taking specific facts to form general theory (Macnee and McCabe 2008), ‘without the restraints imposed by structured methodologies’ (Thomas 2003, 2), was employed to make maximum use of the data; enabling recurrent themes to be categorized and counted.

Charman (2013); Mildenhall (2012); and Rowe and Regehr (2010) acknowledge the same with regard to humour building group cohesion, teamwork and social support.

Context of EMS humour: The ‘experienced’ paramedics stated that ‘they could not share the humour they used at work with family or friends’ (Rosenberg 1991, 199). Bennett (2003) suggests that because humour exists within a certain culture, what is funny to some will not be to others. Those ‘outside’ the group (including family and friends) may be repelled by GH because they ‘cannot fully comprehend the reason for its origin’ (Rowe and Regehr 2010, 456).

Goffman (1959) presents the concept of regions of acceptable behaviour within society. Applied to humour use in healthcare, this proposes that emergency workers have ‘Frontstage’, ‘Backstage’ and ‘Offstage’ environments which moderate their behaviour (Williams 2013a). As part of the unwritten rule of GH use, it is only acceptable in the ‘Backstage’ environment of either the crew room or at an incident scene where no non-emergency personnel are present (Williams 2013a; Watson 2011; Mildenhall 2012). GH is never appropriate in the ‘Frontstage’ environment where patient relatives look to paramedics for support (McCarroll et al 1993), and is strongly discouraged in the ‘Offstage’ environment – at home or off duty when paramedics are with relatives and friends, as they are ’outside’ the circle for understanding the nature or origin of the humour (Rosenberg 1991).

Purpose of Humour use: All participants, except three from the pre/post group, stated they used humour as a coping strategy; with the entire experienced group rating it higher in importance as a strategy than any of the pre/post group. The students emphasised the tension relieving aspect of humour use after a bad day which is also acknowledged by Moran (1990), who considers humour more associated with reducing stress after an event rather than during (Moran 1990, 368). In contrast, the experienced group strongly emphasised the cognitive and emotional refocusing power of humour; as noted by Buxman (2008), Freud (2002) and Kotthoff (2006). Rosenberg therefore suggests humour use becomes a deepening or maturing stress defense for paramedics.


This review identified three main themes: ‘Burnout: a condition experienced by paramedics’, ‘Humour: a factor in stress relief and resilience’, and ‘Paramedic use of humour’.
Chronic stress can lead to the three elements of burnout: emotional exhaustion, de-personalisation and diminished sense of accomplishment (Maslach and Jackson 1981). In healthcare this manifests as deterioration in the quality of care, high job turnover, absenteeism and increased health issues for those affected (Maslach and Jackson 1981). As paramedics are among those with the highest risk of burnout (Regehr and Millar 2007), this carries implications both individually and organisationally.

Implications for Paramedics
Maslach and Leiter (2005) and Chase (2014) suggest that a contributing factor in burnout of healthcare workers is the imbalance between the care they desire to give and the care they are able to give. For paramedics, shift work, pressure to meet targets, abuses of the service by some people, and poor work/life balance are elements which affect this (Mildenhall 2012; Nirel et al 2008; Regehr and Millar 2007; Sophianopoulos, Williams & Archer 2012).

Maslach and Leiter (2005) suggest that giving time to stress relieving pursuits such as sporting activities, hobbies and social relationships, enable individuals to defuse the stresses of work which lead to burnout. However, a consequence of shift work is that partners and friends may be at work themselves when paramedics are off duty, with repercussions for social relationships (Harrington 2001). In contrast, Sophianopoulos, Williams & Archer (2012) suggest that families of shift-workers often adapt to their situation, becoming more resilient. Further research in this area might reveal factors contributing to positive social adaptation, of benefit to paramedics.

Access to information on their patient’s outcome is a source of stress for some paramedics (Regehr and Millar 2007); the lack of such information leading to concerns over personal competency (Witmore 2013). Access to patient information is governed by the Data Protection Act (1998) making confidentiality a legal requirement in NHS employment contracts (Department of Health 2003). Legislation allowing paramedics access to information on their patient’s outcome would help reduce incident related stress and encourage reflection (Bishop 2013), potentially improving staff well-being and patient care (Okougha 2013).

Organizational implications
The Health and Safety at Work Act (1974) requires employers to do everything reasonably practicable to protect the health, safety and well-being of their employees, including minimising the risk of stress related illness. As an employer, ambulance Trusts are subject to this legislation. Occupational health departments aim to provide employees access to counseling services, post incident de-briefing opportunities and peer lead support groups (NHS Employers 2012). Additionally, the Boorman Review (Department of Health 2009) recommended the establishment of staff stress management initiatives to further address well-being issues.

The reluctance of paramedics to disclose the full stresses of their work to those in ‘off-stage’ environments means they rely on ‘backstage’ environments (crew-rooms) for relieving the pressure (Williams 2013a). With the introduction of ‘Make Ready’ (SECAmb 2010) where vehicles are re-stocked by contractors rather than crews; and the increased deployment of crews to stand by points, ‘backstage’ time could be significantly reduced. Though possibly beneficial for productivity this removes a potential stress relief outlet for paramedics (Mildenhall 2012). Research into the impact of these initiatives, as well as into ways ambulance services might be proactive in initiating positive approaches to staff at risk of burnout could contribute to a reduction in the strain placed upon services due to absenteeism.

Humour: a factor in stress relief and resilience
The potential of humour as a positive element within healthcare is acknowledged by numerous researchers (Dyck and Holtzman 2013; Rosenberg 1991; Scott 2007; Shepherd and Wild 2014; Watson 2011).

Of the three main Humour Theories (Incongruity; Superiority; Relief), Freud’s ‘Relief Theory’ has the strongest association to humour use by paramedics, suggesting humour can bring a culturally acceptable means of releasing suppressed emotion, dis-empowering a potential threat and re-framing unpleasant experiences into more emotionally and cognitively manageable ones (Buxman 2008; Downe 1999; Henman 2001; McGhee 2013). Mahony (2000, 2) considers ‘humour trait more beneficial than humour state’, a view given weight by studies into humour styles, whereby ‘affiliative’ and ‘self-enhancing’ styles have been found to have a positive influence upon resilience to stress and burnout; whereas ‘aggressive’ and ‘self-defeating’ styles can have a negative effect (Dyck and Holtzman 2013; Stieger et al 2011).

Implications for individuals and organizations
Dyck and Holtzman note how ‘aggressive’ humour styles are more common amongst men; whilst Mahony (2003); and Williams (2012), acknowledge that ambulance services are traditionally male dominated. Citing the Office of National Statistics, Williams (2012) highlights that in 2010 there were ‘approximately 13,000 male paramedics in the UK whilst the number of female paramedics was too small for a reliable estimate’ (Williams 2012, 370). However, figures for registered UK paramedics in November 2013 indicate 7667 female paramedics compared to 12451 male (HCPC 2013). These figures still reveal a predominantly male profession.

Though ‘aggressive humour style’ might not significantly affect male resilience levels, as Dyck and Holtzman (2013) hypothesise, the higher percentage of male paramedics may mean a dominant aggressive humour style exists culturally. As numbers of female paramedics rise the humour culture they encounter may, therefore, have implications for their resilience levels.

Humour use by Paramedics
Whilst humour use for calming patients and relieving stress has been noted, of particular interest is paramedic’s use of ‘gallows humour’ (GH).

Gallows Humour
Helping to re-frame stressful situations, making them more emotionally manageable (Van-Wormer and Bows 1996), GH is most often used in times of tragedy, oppression or death (Bennett 2003; Freud 2002; Moran and Massam 1997; Obrdlik 1942). Its use today being particularly prolific among emergency services personnel (Charman 2013; Mildenhall 2012; Watson 2011).

Rowe and Regehr (2010) point out that GH often appears in general society after a major disaster, suggesting GH offers a means of putting tragedy into perspective. The fact that GH use is prevalent among paramedics (who potentially encounter more traumatic situations than those employed outside emergency, medical or armed forces careers) is therefore understandable (Chase 2014).

Implications for Paramedics
The question of how humour use, particularly GH, relates to professionalism is an obvious one. The Health and Care Professions Council: Standards of conduct, performance and ethics (2012) highlights the expectation that registrants will deal respectfully towards service users, showing integrity, and the highest standards of personal conduct, whilst avoiding any action that would bring their profession into disrepute (HCPC 2012, 3). The potential for inappropriate humour use to breach these standards is strong. However, Rosenberg (1991); Rowe and Regehr (2010); and Williams (2012) indicate that tight boundaries for cultural humour use exist within ambulance services, where GH particularly is considered taboo outside specific environments, or with those outside the accepted group.

The concept of ‘Frontstage’, ‘Backstage’ and ‘Offstage’ environments (defined by whether any non-emergency personnel are present), has been suggested by Goffman (1959); Rosenberg (1991); Watson (2011) and Williams (2012). For paramedics, the ‘backstage’ environment, such as the station crew-room or ambulance vehicle cab, is considered the only one where GH is sanctioned. This self regulated cultural code of conduct would seem to act as a strong deterrent to breaches of professionalism, though cannot guarantee against them. The potential for GH between paramedics to be overheard by non-emergency personnel at the scene of a traumatic event is reasonably high and paramedics should be vigilant in guarding against it.

Implications for the future progression of the Paramedic profession
Literature considered in this review suggests the presence of a humour culture within the Ambulance Service that new recruits are socialised into (Rosenberg 1991). Furthermore, Essex and Benz-Scott (2008); McAlister and McKinnon (2009); Rosenberg (1991) and Villeneuve (2005), observe that recognition of the value of humour use as a coping strategy increases with clinical experience and years of service.

The role of socialisation in conforming new members of a group into cultural norms is a recognised phenomenon (Giddens and Sutton 2013). However, the question of whether socialisation into all aspects of ambulance humour culture is helpful or desirable within the modern Ambulance Service is potentially controversial. The benefits of appropriate humour use for relieving stress are attested to by many and not considered unprofessional (Dean and Major 2008). However, the more negative elements of humour culture such as overly aggressive humour styles and ‘put down’ humour, which Berk (2009) suggests is strongly associated with medical professions, may be unhelpful to some staff as the profession progresses.

Conclusion and Recommendations

This literature review has investigated the use of humour by paramedics as a factor in coping with stress and an element affecting resilience against burnout. Paramedic practice can be acutely stressful at times (Halpern et al 2012) though lower levels of chronic stress also exist within the role (Mildenhall 2012). The combination of this stress can lead to the emotional exhaustion, de-personalisation and loss of personal accomplishment that characterises burnout (Maslach and Jackson 1981).
Humour use has been identified as a factor in resilience and as a coping strategy against burnout among paramedics (Rosenberg 1991), being used as a distancing and re-framing technique in challenging situations and for fostering socialisation and group cohesion (Charman 2013). Its role in the development of student paramedics is also significant (Dean and Major 2008; Rosenberg 1991).

  • Recommendations for future research and practice as a result of this review include:
  • Investigating the effect of increases in female clinical staff numbers on the humour culture and staff resilience levels within the Ambulance Service.
  • Examining the impact of initiatives such as ‘Make Ready’ and reduced time at base stations upon paramedic’s resilience to burnout.
  • Exploring the socialisation process of student and newly registered paramedics into the Ambulance Service; the role humour plays in this and its effect on the development of group culture.

Chris Storey Paramedic Practice BSc (Hons) student


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Arts and Health: Creative Writing as a Reflective Method in Healthcare


In this essay I shall explore how creative writing can aid practitioners in the formation of therapeutic nursing relationships. I will first discuss some of the benefits and barriers to the establishment of the therapeutic relationship in nursing. I then turn to the potential of the use of the arts within health care, to establish reflective and self-aware practitioners. Following this, working towards closure of the essay, I turn to the value of reflective practice, including the benefits of creative writing to aid my awareness of self, particularly within the nursing role. In this context, I focus on my creative attempt, a fairy tale entitled The Girl and the Well, which can be found as an appendix to this essay, below the reference list.

Therapeutic relationships in nursing: benefits and barriers

All nurses must build partnerships and therapeutic relationships through safe, effective and non-discriminatory communication. They must take account of individual differences, capabilities and needs. (NMC 2010) To develop and inform our knowledge of patient health needs, nurses must build up a strong rapport with those in their care. They must establish a ‘therapeutic relationship’ (NMC 2010) in which patients feel able to express their needs, beliefs, social/cultural contexts and any pre-existing health knowledge. Good communication is essential in the negotiation of the therapeutic nurse and patient relationship. It has the potential to not only affect the actual care delivered but also how the patient perceives it. As Jootun and McGhee (2011, 41) state: ‘Poor communication can compromise care, which can lead to undue anxiety and frustration on the part of the patient’.

However, effective communication is a complex skill and can, particularly within nursing practice, prove problematic. Communication, as Balzer Riley states, ‘involves the reciprocal process in which messages are sent and received between two or more people’ (cited in Bach and Grant 2011, 11). These messages and delivered both consciously and subconsciously via body language, verbal discourse, eye contact, etc.

The communication process can become further distorted by the interpretation of these messages, which will inevitably be translated through individual schemas (Niven 1995). Schemas referred to an internal storage system informed by facts, experiences, beliefs and views, which we compare and contrast all new and incoming information to (Niven 1995). Processing this information allows us to make sense of our surroundings, to shape our social perception. However, the sense derived is not necessarily a universally accepted perception, as Niven and Robinson explain: ‘each individual’s different observations has been influenced by his or her background. The scene is constant, but the observations are different’ (1994, 40).

This highlights the fluidity of perceptions and their potential to become unconsciously prejudiced. In turn, this can lead to the individual selectively recalling information that can lead to the formation of what Oliver (1993) refers to as negativity bias. Individual prejudices and/or biases can form barriers to communication and therefore the successful formation of a therapeutic nursing relationship. Acknowledging that these barriers may be unconsciously constructed, how then do we as nurses overcome them and create ‘the right conditions for the development of mutual trust’? (Niven and Robinon 1994, 45).

The arts in health care

The nursing theorist Peplau (1952) proposed that is through the exploration of one’s ‘self’ that nurses may start to over come the barriers to therapeutic patient relationships. Peplau (1952, 12) argued that ‘Self insight operates as an essential tool and as a check in all nurse-patient relationships that are meant to be therapeutic’. This is a belief that remains popular in the twenty-first century and is supported by Freshwater (2002, 6): ‘Knowing and recognising self through self-awareness and self-consciousness … can be seen to be fundamental to the development of caring alliance which is to be therapeutic’. Wagner (2002, 121), further argues that the notion of self-awareness is fundamental to our understanding of what caring is:

Implicitly threaded throughout definitions of caring is the need to develop a sense of self, a sense of knowing ones beliefs and values, intention to help, moral commitment to be present, ability to respond competently to another’s need, and willingness to entre therapeutic relationships that encourage human connectedness.

So, how then does the nurse become more self-aware? Wagner (2002, 128) suggests ‘art therapy’ as a possible means, explaining that through the creative process one can unearth the ‘expressions of the unconscious psyche’. The use of artistic methods of expression in health is also promoted by Staricoff (2004, 24), who declared that the ‘relationship between the arts, particularly literature and medicine, stimulates insights into shared human experiences and individual difference, and increases the language and thoughts of the practitioner’.

Staricoff argues for the importance of literary works, which contemplate issues of illness and death, as a valuable resource for practitioners to aid reflection on clinical practice. Wagner (2002) extends on this argument in his assertion that, while the benefits of studying established artists’ work are clear, healthcare practitioners should personally participate in the creative process in order to develop greater awareness of self and personal knowing. However, the creative process and the encouraged confrontation of personal experience is not always an appealing or easy task particularly to those who have been encouraged to focus on the science of nursing and not its art.

The value of reflection

Reflection on and in practice is a process, which has long been encouraged in nursing and nursing education (NMC 2010). As a students nurse I have been encouraged to reflect on my experiences of nursing practice with placement mentors. Indeed, it is an NMC competency, which they have assessed my ability to engage in.

However, not until a recent meeting with my mentor did I fully appreciate the importance of self-refection and the impact it might have on my practice. During this meeting my mentor asked me to reflect on any personal barriers I might have which would prevent me from delivering care. My initial inclination was to reply in the negative; after all I came to nursing with the simple desire to care. However, I wanted to give her enquiry the reflection and attention it deserved and so I took my time to consider my personal values and beliefs.

This led to a consideration of how I have come to hold my personal values and beliefs, my experiences of life so far. In doing so, a somewhat contentious personal memory was re-surfaced, one that I was not aware still had to power to bother me. As with most unwanted/painful memories my initial response was to push it aware, ignore it and hope it goes away. However, through it surfacing I realised this memory/experiences was most likely the sort of potential issue my mentor wanted me to be aware of.

This was clearly an issue, that should I be reminded of it during practice, consciously or subconsciously, could effect my delivery of care. My unwanted memory was from my childhood experiences of living with a parent suffering from alcoholism. Alcohol addiction remains a predominant issue it the UK with ‘1.2 million alcohol-related hospital admissions in England in the year 2011/12, a 135% increase since 2002/03 (Alcohol Concern, 2014) It is inevitable that in my role as a student nurse (and a future registered nurse) I will be delivering care to patients effected by alcohol abuse. This is an issue I needed to reflect on more deeply on to ensure it did not ever bias my care.

I decided to use creative writing as a therapeutic technique to explore this issue. To gain a better understanding of my self in the hope that an increased self-awareness would deconstruct any barriers I may construct to in the attempted formation of therapeutic relationships with my patients. Creative narratives offer the writer permission to explore their own story (Grant et al. 2011) and thus use the art of storytelling therapeutically. Slater (2005,4) similarly argues that creative writing is therapeutic as ‘your own fears and short-comings will find expression in the process… the stories you generate will at once reveal to you your mind while offering up chances to change it.

However, while the reflective output from my creative endeavors promised to be beneficial to my future nursing practice, I found myself daunted by this personal and emotional task and sought some creative distance from it. I found my distance in the simplistic and symbolic style of the fairy tale. In the security of the traditional fairy tale third person narrative I reflected on my experiences of my mothers descent into alcohol addiction when I was a child. This narrative choice was not only elected to maintain fidelity to my genre’s structure but also for the theoretical therapeutic distance it provides. By writing in the third person, in a fantasy world of undefined time and place, using symbols and metaphors to represent emotionally painful issues and events, one can externalize one’s feelings and thoughts without having to explicitly confront them directly. I found this technique worked as a sort of mediator between my realistic memories and the feelings that arise from them. It is the symbolic nature of fairy tales, which have made them a useful and respected therapeutic device in the emotional treatment of children and adults (Brun et al. 1993).

In reflecting on my piece The Girl and the Well, I became aware of its somewhat typical representation of Freud’s theory of separation anxiety. This was expressed well by Bettelheim (1976, 145), who stated: ‘no greater threat in life than that we will be deserted, left all alone. Psychoanalysis has named this – man’s greatest fear – separation anxiety; and the younger we are, the more excruciating is our anxiety when we feel deserted’.

In acknowledging this Freudian interpretation I was able to accept and reflect and on potential feelings of anger at the neglect of myself as a child. In representing my mother I incorporated the formulaic fairy tale element of ‘splitting’ (Warner 1995, 212), a conscious writing strategy that divides the mother figure into two different characters, the ‘good’ mother and the ‘bad’ mother. The severing of the mother figure into these morally polarized beings allows me as the writer to ‘preserve an internal all-good mother when the real mother in not all-good … [and] permits anger at the bad mother’ (Warner 1995, 212). This strategy allowed me to really reflect on my more complex and conflicting feelings about my mother, a process that I found surprisingly cathartic.

Although I found creative writing for self-reflection an overall positive experience, it was a long process. I didn’t just write the entirety of my story in one sitting and feel suddenly healed and enlightened. It took time. It was a reflective period in which I felt completed to read and not just write. I remembered, sought out and re-read Sharon Olds (1987) poem ‘After 37 Years My Mother Apologizes for My Childhood’, which I feel aided my reflection and helped construct the image of my mother in the my tale. At this stage I feel ready to let my fairy tale go, it has served its purpose and provided ‘testimony’ (Grant 2011, 2) to my lived experiences.


I feel that my attempt at utilizing creative writing to explore my self, and therefore become a more self-aware caregiver, was successful. A nurse’s beliefs can be, as Ersser (2002, 56) argues, be ‘communicated to the patient with or without intention’, which highlights just how important it is for nurses to be self-aware in practice. Although I would never knowingly behave in a prejudiced way towards my patients, I feel this deeper reflection has made me more aware of a pre-existing potential issue, which I have had the proactive opportunity to work on. It has also made me more appreciative of the personal narratives patients have and that are always being constructed. As, Slater (2005, 11) argues, ‘Everyone, absolutely everyone had a tale to tell. And everyone, absolutely everyone will have to revise it, only to revise it again’. I believe the learning process has allowed me the freedom to really develop myself independently as a reflective writer and nursing practitioner, a progression I’m not sure I would have been able to succeed to in a more formally structured module.

Charlotte Pendlington, BSc (Hons) Nursing (Mental Health) student


Alcohol Concern. 2014. Campaign: Statistics on Alcohol [website] [ accessed 20 May 2014]

Bach, S. and A. Grant. 2011. Communication & Interpersonal Skills for Nurses. 2nd ed. Exeter: Learning Matters.

Bettelheim, B. 1976. The Uses of Enchantment: The Meaning and Importance of Fairy Tales. London: Thames and Hudson.

Brun, B., E. W. Pedersen and M. Runberg. 1993. Symbols of the Soul: Therapy and Guidance Through Fairy Tales. London: Jessica Kingsley Publishers Ltd.

Ersser, S.J. 2002. The presentation of the nurse: a neglected dimension of the therapeutic nurse-patient interaction? In: Nursing as Therapy. 2nd ed. edited by McMahon, R and A. Pearson. Cheltenham: Nelson Thornes Ltd.

Freshwater, D. 2002. The Therapeutic Use of Self in Nursing. [Online] London: Sage Publications. Available from: [Accessed 15 May 2014].

Grant, A., F. Bailey and H. Walker. 2011. Our encounters with madness. Ross-on-Wye: PCSS Books.

Grant, A. 2011. Introduction: Learning for narrative accounts of the experience of mental health challenges. In: Our encounters with madness, edited by Grant, A., F. Bailey and H. Walker. Ross-on-Wye: PCSS Books.

Jootun, D. and G. McGhee. 2011. Effective communication with people who have dementia. Nursing Standard. 25(25): 40-46.

Niven, N. 1995. Health Psychology: An Introduction for Nurses and Other Health Care Professionals. 2nd ed. Edinburgh: Churchill Livingstone: 25-42.

Niven. N and J. Robinson. 1994. The Psychology of Nursing Care. Leicester: BPS Books: 39-64.

Nursing and Midwifery Council. 2010. The code: Standards of conduct, performance and ethics for nurses and midwives. [Online] London: Nursing and Midwifery Council. Available from: [Accessed 20 May 2014].

Olds, S. 1987. The Gold Cell. New York: Knopf.

Oliver, R. W. 1993. Psychology & Health Care. London: Billlière Tindall: 159-176.

Peplau, H. E. 1952. Interpersonal Relations in Nursing. New York: Putnam.

Slater, L. 2005. Blue Beyond Blue: Extraordinary Tales for Ordinary Dilemmas. London: W. W. Norton & Company Ltd.

Staricoff, R.L. 2004. Arts in Health: a review of the medical literature. London: Arts Council England.

Wagner, A.L. 2002. Nursing Students Development in Caring Self Through Creative Reflective Practice. In: Therapeutic Nursing: Improving Nursing Care Through Self-Awareness and Reflection, edited by D. Freshwater. London: SAGE Publications Ltd.

Warner, M. 1995. From the Beast to the Blonde: On Fairy Tales and Their Tellers. London: Vintage.

The Girl and the Well

girl&woodOnce upon a time, there was a little girl who lived in the heart of a dark forest. Her name was Little Rose and once upon a time she had been happy. Little Rose had grown up in the comfort of a cosy cottage with her young and beautiful mother whom she loved dearly. Although she considered herself content, Little Rose’s mother was a curious woman with a longing to travel and know all there was to know about the world. One day, tiresome of their modest cottage, Little Rose’s mother announced that she was to journey alone into the forest in search of new and exciting delights to return home with. “Oh Mother,” sobbed Little Rose “please do not go! Or, if you must, take me with you. I won’t be any trouble.” Unaltered by her child’s pleas Little Rose’s mother kissed her daughter on the cheek, made her promise not to leave the cottage, and set out upon her expedition alone.

All alone Little Rose sat by the cottage window and awaited her mother’s return. Years past and yet Little Rose kept her little nose pressed against the pane of glass, willing her mother to walk through the clearing to their cottage; to return home. One day, to her great joy, Little Rose did see her mother emerge from out of the trees and towards their little cottage. “Oh Mother, you have returned to me! You are home. How I have missed you,” shrieked Little Rose as she ran to embrace her mother. However, as she got closer she froze and gasped. The woman in front of her, although with a likeness to her mother, was old and haggard. “You are not my Mother! My Mother is beautiful with a sweet face and fare skin. Your skin is sallow, your mouth is mean, your eyes are red. Oh where is my Mother? What have you done to her?” cried Little Rose. Irritated by the child’s wails, the changed mother pushed her daughter aside with a rough dirty hand, entered the cottage and closed the door behind her.

Left outside, on the other side of the door, Little Rose fell to the ground and sobbed. After a time, when she felt herself more steady, she picked herself up and crept to the window. Carefully peering through, she looked in horror at the sight which presented itself before her. There on the bed was her mother, she was not asleep but awake, breathing smoke, drinking a blood red potion and cackling a strange broken laugh. Her head was swaying an unnatural sway as she began to cough, sending forth hideous flecks of red and yellow slime from clenched cracked black teeth. “This monster is not Mother,” whispered Little Rose as she backed away from the door of her once happy home. “I shall find Mother and together we shall rid our home of this false creature,” vowed Little Rose.

All alone Little Rose set out for the first time into the woods in search of the loving mother she remembered. The woods were dark and unwelcoming and as Little Rose tried to make her way through the masses of unruly branches her hair and clothes were seized and shredded by sharp thorns. As night approached, and the little light that shone through the trees died, the woods became alive with the sound of wild and angry animals shrieking, hissing and growling their warning to those unfortunate enough to cross their path. Hungry and cold, Little Rose persisted on her desperate journey, wandering in circles and calling out for her lost loving mother. “Oh Mother, shall we ever find each other?” As she sobbed these words a worn old owl flew down and perched upon a branch close to where Little Rose lay. “Do not cry Rose, I can tell you where your mother is,” softy hooted the owl. “Where? Please tell me at once! I beg you!” implored Little Rose. Suddenly with a wide sweep of his wings the owl took flight and glided off in and out of the trees, “follow me,” he hooted as he disappeared into a mass of vines and leaves.

Pushing her way through the dense brier Little Rose came to a dry barren patch of earth upon which stood a rickety stone well. The owl perched itself upon the edge of the well hooting “here you are Rose, just as you asked.” Bewildered and overwhelmed with disappointment Rose began to yell “how could you? How could you be so cruel? My mother is not here! Oh, I am all alone and I will never see her again.” As her cries became whimpers the owl flew down and placed itself next to Little Rose sighing softly “you are not alone Rose, and you are not a little girl anymore, see how you have grown.” Rose looked down at her self and gasped, it was true she was no longer a child, indeed she was now a grown woman.

“Once upon a time,” continued the owl “a young woman entered these woods thirsty for adventure and exotic treasures, dissatisfied with the riches her life already held, she let her blind and selfish greed guide her on her journey and it led her to this very well. This is the ‘well of temptation’ and only those willing to forsake their souls to it may drink from it.” Rose slowly stepped toward the well and begrudgingly peered into its depths, “the blood red potion,” she exclaimed “oh mother, was I not enough for you?” The owl stared hard at Rose, “what do you wish to do now my dear? Perhaps you too would like to partake from the well? Or perhaps your heart yearns to return home?”, questioned the owl. Rose glanced again at the well, the thick red liquid was rich and velvety, its aroma strong and enticing. “I am so thirsty” murmured Rose, “maybe I should have just a little … I have no home now … even if I do wish to return there.”

She lowered the old pail into the well and once it was full carefully drew it back towards herself, she lifted it towards her lips and was about to take her first sip when she froze in horror. There staring back at her, reflected in the alluring liquid, was the haggard sallow face which had possessed her mother. “No” she cried, “No, this is not what I want! I want to go home! I want to go home!” As she declared her last words Rose threw the pail back into the well and ran as fast as she could out of the barren land and through the woods. She passed vines and brambles shouting to them “I want to go home!” and as she did they parted, clearing her way. She ran into the darkest part of the woods and shouted at the hidden sky “I want to go home!” and suddenly the trees swayed their branches aside letting the newly risen sun shine through. “I want to go home!” she yelled once again and as she did she ran out of the trees into a clearing leading to a lovely little cottage. Rose stopped in front of the cottage. Suddenly the cottage door flew open and out ran a beautiful little girl calling “Mother! Oh Mother you have returned! You have come back to your Little Rose!” Rose took the little girl in her arms, kissed her on the cheek and softly whispered “yes my little one, Mother is here, Mother is home.” Hand in hand they walked together back into the cottage where they lived together happily ever after.



The 15th Annual Mental Health Conference – 9th April 2014

The beautiful thing about learning is that no one can take it away from you (BB King)

The 15th Annual Mental Health Conference was marked by one of the first truly sunny days of the year and the feeling of warmth that this gave was carried into the conference itself. In the canteen, as everyone filled up on coffee, it was a delight to see quite a few of the usual suspects and a smattering of new faces
The proceedings started with a brief introduction from Sharon Davies who announced that the conference has now acquired charity status. This should help with raising funds, ensuring that it runs annually and is free to all who attend. As Sharon said, there are those who would not attend regularly if there were a cost attached, so this was important and positive news.
The Marion Beeforth memorial lecture this year was given jointly by Sara Meddings, Diana Byrne and Hazel Lambe. They have all been involved in setting up a pilot project to establish Recovery Colleges in the Sussex area. The two initial projects were in Brighton & Hove and Hastings and it looks like they have both been a great success. Recovery Colleges are a pioneering way of helping people with a mental health diagnosis (or their carers) to cope with their illness, to take charge of their own recovery process and to live a freer and more fulfilling life. Having been established in various parts of the country, Sara and the team are now planning to open colleges in various parts of Sussex.
Sara told us that the principles behind the college are that they bring together people with lived experience and clinical training and that the expertise of both these groups is acknowledged and given equal status. The colleges offer a range of courses to teach people coping strategies and applicants can choose from prospectuses courses that will suit them best and then, at the end of the course, they receive a certificate celebrating their success.
One of the great things about these colleges is that they ‘recycle’. Students can, if they wish, become teachers, thus bringing their own skills to the mix. Diana talked us through how this worked and how valuing it is to be able to bring one’s own experiences to the table to help others.
Finally we heard from Hazel who had graduated as a student from the Recovery College. She told us how rewarding she had found the process, how she felt that she had ‘re-engaged’ her brain and how she was now training to be one of the Peer Support Workers.
It was a truly inspiring presentation of an initiative that looks as though it may fill a huge gap for many people who have experience of mental illness. One of the overwhelming impressions was that the Recovery College provided some thing that had been missing for many people – hope.
After the presentation the conference divided into group work sessions that, on returning, fed back their thoughts on the Recovery College initiative. Feedback was, unsurprisingly, overwhelmingly positive. It really felt like the sunshine had followed us into the conference and stayed there.

Steve Smith Mental Health Nursing BSc(Hons) student


Trapeze: An Autoethography


The lights were so bright. So bright she could be a star. Stella Star, a Brighton burlesque dancer. She was so important and the people surrounding her were a higgle piggle of famous people or random relatives. The ultimate ending of it all was that Prince Andrew was going to collect her in his helicopter, free her from the Irish Police Station she was detained in, and take her to her star.

Six months later she was wading in the Thames, after ending up in a crack house in Lambeth, shiny sports car and art in the garage, stereo screwed to the walls, swanky apartment on the top floor. She only knew it was a crack house because her friend was a drug and alcohol worker; she’d never been in one before!

I write ‘she’, as the woman in the paragraphs above doesn’t feel like me. People ask if I remember my hallucinations and I do generally, once the booze had ebbed away. The crack den story, when I found a shotgun, and ended up in the Thames was a definite turning point. Not my usual New Years Eve that’s for sure. Not that I have ever been much of a wallflower, this turn of events was an all time low, even for me. My friends, frantic, had reported me missing. My 3 year old daughter was with her father for a few days. I didn’t have a clue what I was doing.

Before the crack den event, I had been psychotic two times in three years. This time I got some actual help and I actually listened. I had an amazing trainee social worker, who was on placement in mental health. He came every week for an hour, for two months. He listened to my worries and fears, of which there were many at the time and soothed me with the advice that things will feel different given time. It did. It does. He also advised I take up a sport. A hard sport. One which pushes you. A close friend also advised I gave up drinking. My standard coping mechanism of old. I had never learnt how to deal with life’s blows without it. Every time something bad happened I turned to it and when I was feeling high this was a very bad combination. It still puzzles me that this was never mentioned by any health professionals I came into contact with. It also puzzled me that, previously every time, I had an assessment my life history was taken. I never felt that this information was ever put to a therapeutic use. Time and time again I delved deep into the depths of my murky, tumultuous past, dredging up horrors, disappointments, trauma. As far as I can remember these were never used to help me forge a new path for my future. Each time I felt my utterances were a complete waste of time and why hadn’t someone documented it the first time so I didn’t have to keep repeating myself!

However, this time I did listen, for the first time. I began to accept there had been something wrong. My daughter was starting school and this freed up week days. I started to run, got addicted to that for a while. I ran by the sea. I became hypnotised by the changing scenery by the waters edge. How every time it was different, how many birds I saw, how many things I could ruminate about, in time to the gentle plodding of my feet hitting the concrete. Then the circus came to town.

The tag line for the show was ‘the circus you’ll want to run away with!’ I went to the show, only going out with close friends at the time, due to the shame my last bout of mania had brought upon me. My friend and I decided there and then that we would do this; we would become aerialists. A festival girl at heart, I’d always longed to be part of a show, on the stage, a performer. Puberty and a messed up childhood got in the way of those dreams. As a young girl I had longed to be in the Kids from Fame. Longed with a passionate young girl’s heart! As soon as I finished my A levels, I bought a £50 ticket to Glastonbury Festival, hitched a ride in a pink Fiat Panda and got lost in the mayhem of that world. I went back year upon year in various different guises, but always wondered how I could be a performer. I never believed in myself enough to be able to do it as an adult.

My first classes were a dream come true. The teacher was experienced and kind. I had my friend in tow too, my little security blanket. My daughter safely deposited at school, I would drop her off then don my leg warmers for my trapeze class once a week. I felt liberated. I felt like I was coming alive for the first time since perhaps puberty. I was discovering my body again, and also my mind. This time, the third round of recovery from mania, I was ready. I had more to lose. With the booze safely tucked up and away in the naughty corner, I could see more clearly I think. This last time I had pushed the boundaries way too far. I had a daughter now and she had to come first. Social services had become involved in our lives and it scared me that if I didn’t find a way back to wellness I might lose her. The threat felt very real. I had to find a way to make it work without medication. Trapeze was my way.

After a time I started to train very regularly. I soon met several local aerialists who trained around the city. I loved it. Not only was I becoming very, very strong, I was doing something exciting, bold and daring. I have never been a member of a gym, the idea itself sends me to sleep, but trapeze, well that’s more like it. I love its hardcore nature. The danger aspect. The fact you have to become very fit. I love the calloused hands you get, the bruises, the odd face plants (literally falling on my face). The skills I have learnt from the several teachers I have had, and from sharing my experiences with a lovely group of people has rewarded my mental health immensely.

I set up a children’s circus skills group, funded by the Scarman Trust, and we met weekly. I trained four times a week. I perform a little, work teaching at festivals and at an international aerial convention in Edinburgh. I worked hard. The training gave me hope. It built up a new version of myself, one in which I was proud. It was the closest I had come to fulfilling my dreams in my entire adult life. I have to concentrate. I have to be present in my body and mind. I get to express all those tumultuous whirling emotions in movement and a display of my strength. I spend a lot of time choosing the right music tracks, fitting my dance in. The enforced music searching, is therapy in itself. It took a long time to be able to play around with all the moves I had learnt. I learnt to dance up in the air, throw shapes, like on land. I feel like I can fly there.

There is all the rush and danger that I felt in my mania, but in a safe, methodical, creative outlet. When I work on a performance, I have to marry up a lot of different creative mediums: performance art, circus skills, music and I need to be brave. All the time I was training as an aerialist, my social situation didn’t change. I was still a single parent; I still had a very, very low income. I still suffered stigma and abuse on a regular basis, even from my close friends. I still lived in a small community that judged me as a mental health patient. Trapeze made me rise above it. Literally. That combined with the alcohol abstinence changed my life. I have found new friends. I discovered a route to a better, more stable me without medication, or contact with mental health services. I was still the woman coping with a life which had seen not only herself abused, but also her daughter. The pain of my reality was a lot to bear; my imagination leaking out was my escape. It needed to be contained but in a creative way. The thought of not being able to get out of bed, to do all the busy things a single mother has to do in a day to keep afloat, kept me off medication. I wanted to be healthy, not on route to a shortened, deadened life, where I had no way of navigating through my difficulties. I have always thought if the roots of a problem aren’t tackled, then the symptoms, psychologically will remain. Medication was just not an option. Besides, I was 33, I might want more children, and all the medication looked too toxic for that.

I began to think that I could share this gift I had been given. I kept meeting women who had had a troubled mental health history, but had discovered the healing properties of aerial circus. It might sound evangelical, but circus demands so much dedication and rewards you so utterly, so you want to sing it’s praises from the roof tops. More and more signs were pointing to me training to be a professional within mental health. I applied to be a mental health nurse. It was not an easy decision. Ever since I started I have been desperately trying to tailor it to my own interests and wonderings about the world. Whilst on the course I visited a project in London, a mental health trapeze project. It blew my mind and I swore I would replicate the amazingness of the London project in Brighton. I met people there who oozed happiness and pride. They all stated how much they enjoyed it, how proud they were of themselves, how fit they felt. All the participants were very vocal about how they had benefited from the trapeze experience and how it was transforming their lives. This is better than psychiatric drugs, I thought . This is something that I believe in, that I care about. Something I respected.

It validated my own experiences and was a way for people to work in a therapeutic, creative, possibly medication-free way. I applied to Southdown Housing, who now run Brighton and Hove’s day recovery services, for funding. The Women’s Only Mental Health Trapeze Project starts on June 4th 2014, with funding for an initial 6 weeks. I arranged it to be in the day time, so mothers can attend, and have ensured there is a creche space for their children also. I am so happy, as I truly believe this works for people.

My own experiences of trapeze and my journey to better mental health were my inspiration for the project and now my next challenge is how to bring my unique standpoint of ‘service user’ or ‘survivor’ and connect with my professional status as a mental health nurse. I am a very creative person, and hopefully my continuing work within creative performing arts will aid my transition into the profession of nursing. I am certain it will help. I hope my new venture with trapeze and mental health will inspire others and bring hope that a different future is possible for them, away from the constraints of the standard mental health system. ‘I would never have chosen to be taught this way but I like the changes in me. I guess I had to go to the edge to get there’ (Hobler Kahane 1995, 83).

Theoretical and methodological background

Writing this piece for me has been positive for my mental health in many of the ways that Taylor and her colleagues outline in their work on recovery writing and narrative restorying (Taylor, Leigh-Phippard & Grant 2014). Their idea that this process might challenge ‘social justice issues of disempowerment, isolation and diminished sense of self worth’ (Grant, Biley & Walker 2011; Grant, Biley & Leigh-Phippard 2012; Grant et al. 2012; Taylor, Leigh-Phippard & Grant 2014; Costa et al. 2012) resonates deeply for me. The act of writing about my mental health history in relation to art has made me consider things differently and the actual documenting of it has made me see my history in a slightly different light, a more positive one. This contrasts with the fact that as a person who had been given a psychiatric diagnosis I had for several years felt defined by this. As a student nurse I have used the technique of story telling and poetry on a psychiatric intensive care unit to great effect. I hope to use it as much as possible in the future.

My life story, which includes episodes of psychosis and hospitalization has been re-written as a positive one (Grant and Zeeman 2012). It is a hopeful story, not just for myself but others who may still be awash in the murky depths of their minds. Work such as Our Encounters with Madness (Grant, Biley & Walker 2011) and Our Encounters with Self Harm (Baker, Biley & Shaw 2014) are inspirational books which will hopefully help direct the world to a kinder place in regard to those, like myself, have suffered from mental distress.

Amy Barlow Mental Health Nursing BSc(Hons) student


Baker, C., F. Biley and C. Shaw (eds). 2013. Our Encounters with Self-Harm. Ross-on-Wye: PCCS Books.

Costa, L., J. Voronka, D. Landry, J. Reid, B. McFarlane, D. Reville and K. Church. 2012. Recovering our stories: a small act of resistance. Studies in Social Justice. 6(1) 85-101.

Grant, A., F. Biley and H. Walker (eds). 2011. Our Encounters with Madness. Ross-on-Wye: PCCS Books.

Grant, A., F.C. Biley and H. Leigh-Phippard. 2012. The Book, the stories, the people: an ongoing dialogic narrative inquiry study combining a practice development project. Part 1: the research context. Journal of Psychiatric and Mental Health Nursing. 19: 844-851.

Grant, A., F. Biley, H. Walker and H. Leigh-Phippard. 2012. The Book, the Stories, the People: An ongoing dialogic narrative inquiry study combining a practice development project. Part 2: The practice development context. Journal of Psychiatric and Mental Health Nursing. 19: 950-957.

Grant, A. and L. Zeeman. 2012. Whose Story Is It? An Autoethnography Concerning Narrative Identity. The Qualitative Report. 17(72) 1-12.

Hobler Kahane, D. 1995. No Less a Woman: Femininity, Sexuality and Breast Cancer. 2nd edition. California: Hunter House.

Taylor, S., H. Leigh-Phippard and A. Grant A. 2014. Writing for Recovery: A practice development project for mental health service users, carers and survivors. IJPD (International Journal of Practice Development). 14(1) 1-13.

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