Realistic evaluation of a pilot programme offering mindful compassion training to nurses

Realistic evaluation of a pilot programme offering mindful compassion training to nurses Author: Gavin Cullen, student number 51016337 Date of submission: 30 th April 2014 A dissertation in partial fulfilment of the requirements for the degree of MSc in Studies in Mindfulness at the School of Education, University of Aberdeen. 1

Disclaimer I declare that this dissertation has been composed by myself, that it has not been accepted in any previous application for a degree, that the work of which it is a record has been done by myself, and that all quotations have been distinguished appropriately and the source of information specifically acknowledged. Signature: Name: Date: Word count: 17, 612 words. Gavin Cullen 28.4.14 2

Abstract This dissertation describes a pilot programme offering mindful compassion training to nurses (MCTN) in the author s workplace, a National Health Service Child and Adolescent Mental Health Service. Compassion is putatively fundamental to nursing s professional identity and yet there have been media and formal inquiry reports of healthcare and nursing service provision failures. Consequently nurses are effectively being ordered to be more compassionate in policy and regulatory frameworks. Further, those expectations persist in already challenging contexts, given nursing s role in helping alleviate human suffering, and a backdrop of health service reform, financial pressure and increased patient rights and complaints. Simultaneously, mindfulness and compassion meditation training has been trialled showing promising health improvement results, including enhanced capacities for self-kindness and compassion towards others. The project s aims were to ascertain if MCTN would be useful to nurse colleagues in the latter respects personally and professionally. Further, a realistic evaluation approach, using mixed quantitative and qualitative methodologies, was used to identify relevant contextual issues and capture the realities of compassion in nursing. Project limitations included the subjectivity and complexity of the research approach. Nonetheless, MCTN appeared to be helpful to colleagues in real terms. Further, the findings tentatively suggested that while nurses are motivated to be compassionate they can develop fears of compassion due to adverse experiences in already stressful working environments. Supportive mechanisms like MCTN can help address this significant area and broaden nurses understanding and experience of compassion. Further research, however, is both required and recommended for more definitive understanding. Keywords: mindfulness, compassion, training, nursing, realistic evaluation. 3

Acknowledgements I would like to express my gratitude firstly to Dr Graeme Nixon s for his patient guidance. I would also like to thank all the staff at Aberdeen University who have also been involved in this course, especially: Dr David McMurtry, Edith Montague, Sarah Cornelius and Linda Craig. I owe the same debt of thanks to the MSc meditation instructors, who are, to a person, wonderful. They are: Heather Regan-Addis, Choden, Rob Nairn, Annick Nevejan and Fay Adams. The peer group of students on this course were every bit as inspiring in their enthusiasm, kindness and diversity. My thanks also goes out to all of them. The project described in this dissertation would not have been possible without the openminded support of workplace colleagues, including line managers and participants. Particular thanks goes to: Jane, Lorna, Tim, Val and Callum. The participants need to remain anonymous, but I thank you all, and hope that I have reflected your experiences accurately. Finally, I would like to thank Sarah, Ruth and Naomi for their love and support. This dissertation is dedicated to all of the above people, to CAMHS colleagues, and to anyone needing the support of a mental health service. May you all be safe, happy and well. 4

List of tables, figures and models Tables Table 1: Basic demographic information for cohorts one and two p. 36 Table 2: Summary of the author s compassion in nursing themes presented in participant interviews p. 40 Table 3: Mean pre- and post-mindful Compassion Training for Nurses (MCTN) selfcompassion scores p. 44 Table 4: Comparison of mean post-mctn Self-Compassion Scale sub-scale findings p.44 Table 5: Mean pre- and post-mctn Social Desirability Scale-17 (SDS-17) scores p.46 Table 6: Comparison of mean pre-mctn Fears of Compassion Scales (FCS) scores p.47 Table 7: Comparison of mean post-mctn FCS scores p.48 Table 8: MCTN project interviewees p.49 Figures Figure 1: Summary of MCTN project steps p.42 5

Models Model 1: Context-mechanism-outcome (CMO) model 1 p.63 Model 2: CMO model 2 p.64 6

Key abbreviations used CAMHS Child and Adolescent Mental Health Service(s) CF CFT CIN CMOc ESC EL FCS HB IPU LCCP MBCT MCTN MBSR MDT MHN NHS NHS ISD NICE NMC RCT RE SCN SCS Compassion Fatigue Compassion-Focused Therapy Compassion in Nursing Context-mechanism- outcome configuration(s) Essential Shared Capabilities Emotional Labour Fears of Compassion Scales (NHS) Health Board Inpatient unit The Leadership in Compassionate Care Programme Mindfulness-Based Cognitive Therapy Mindful Compassion Training for Nurses Mindfulness-Based Stress Reduction Multi-Disciplinary Team Mental Health Nursing National Health Service(s) National Health Service(s) Information Services Division The National Institute for health and Clinical Excellence Nursing and Midwifery Council Randomised Controlled Trial Realistic Evaluation Senior Charge Nurse Self-Compassion Scale 7

SDS-17 VBP Social Desirability Scale-17 Values-Based Practice 8

Contents Acknowledgements... 4 List of tables, figures and models... 5 Key abbreviations used... 7 Additional research data note... 11 1. Introduction... 12 1.1 The project focus and key concepts... 12 1.2 The specific research context... 16 2. Literature review, research question and project aims... 18 2.1 Overview... 18 2.2 National policy and professional expectations of nurses... 19 2.3 Nursing initiatives to support compassionate care... 22 2.4 Nursing and healthcare staff education trials... 24 2.5 Mindfulness in occupational settings... 25 2.6 Compassion meditation training in healthcare... 27 2.7 The research question and project aims... 29 3. Research approach and methodology... 30 3.1 Overview... 30 3.2 The author s worldview and the realistic evaluation approach... 30 3.3 MCTN programme outline... 34 3.4 Participant recruitment and demographic information... 34 3.5 Self-report outcome measures and analysis... 36 3.6 Interview format and analysis methods... 38 3.7 The researcher s field notes... 40 3.8 Ethical considerations... 41 3.9 Summary of the MCTN project steps... 41 4. Presentation of project findings... 43 9

4.1 Overview... 43 4.2 Outcome measure data... 43 4.3 Interview data... 48 4.4 Summary of MCTN project findings... 60 5. Discussion... 62 5.1 Overview... 62 5.2 Project findings and RE... 62 5.4 Project findings and meditation training research and theory... 67 6. Implications and recommendations... 70 6.1 Overview... 70 6.2 Implications and recommendations for the project setting... 70 6.3 Sharing project findings... 71 6.4 Implications for the author... 71 7. Reflections and conclusions... 73 7.1 Overview... 73 7.2 Project limitations... 73 7.3 Summary of project findings and recommendations... 74 8. References... 75 9. Appendices... 98 9.1 The nursing posts and NHS Agenda for Change pay bandings applicable to project participants... 98 9.2 Mindful compassion training for nurses (MCTN) group programme themes... 99 9.3 Participant Information Sheet... 101 9.4 Consent forms... 107 9.5: Sample baseline demographic information question sheet (for cohort 1) and supplementary demographic information for cohorts one and two... 110 9.6: Interview schedules (revised)... 117 9.7 The researcher s field notes... 126 10

9.8 Sample interview transcript... 170 Additional research data note The author has also submitted additional research materials in a CD-R disc as follows: Baseline demographic information question sheets Interview transcripts Excel spreadsheets summarising outcome measure data Sample session plans and hand-outs for the Mindful Compassion Training Programme for Nurses NHS research authorisation forms in a pdf format. 11

1. Introduction 1.1 The project focus and key concepts The research project discussed in this dissertation explores the use of mindfulness and compassion meditation training and its application to one of the most essential issues affecting the author s professional context: compassion in nursing (CIN). The author s project was the culmination of his participation in Aberdeen University s Studies in Mindfulness MSc programme. This combined academic study with experiential secular mindfulness and compassion meditation training. As such, it was the first British course to offer participants training in both mindfulness and compassion techniques, descriptions of which can be found in the MSc programme training manuals (Gilbert and Choden, 2013; Nairn et al., 2010a and b; Nairn et al., 2011a and b; and Nixon et al., 2011). All participants were asked to develop and maintain daily personal mindfulness and compassion practice with a view to delivering training to others in their professional contexts in the programme s final year (McMurtry, 2014). There are no universally agreed definitions for mindfulness and compassion (Goetz et al., 2010; and Keng et al., 2011). There were, however, helpful working descriptions of the terms encountered during the Mindfulness MSc. Firstly, mindfulness was taught as a process involving developing awareness of presentmoment experience through practising meditation techniques (Nairn et al., 2010a). This included aspiring to be aware of one s thoughts, emotions and physiological sensations as they arose with kindness and acceptance. Further, by engaging with present-moment experience in this way, mindfulness practice was linked to practitioners developing or maintaining self-compassion (Nairn et al., 2010a and b). This was partly because they would almost inevitably encounter initially uncomfortable psychological or physiological aspects of themselves during meditation practice, alongside aspects they were more comfortable with. Theoretically, by learning to accept the full panoply of experience with kindness, selfcompassionate mindful awareness could develop, enhancing psychological and physiological health in the process (Nairn et al., 2011a and b). 12

MSc compassion definitions reflected the Dalai Lama s (2001) notion that it involves a genuine and heartfelt desire to alleviate other people s suffering. It therefore incorporates a fundamental recognition of suffering, which can arise from sympathy and empathy, but which ultimately transcends both those qualities in order to take action to do something to relieve that suffering (Cole-King and Gilbert, 2011). In other words, compassion involves an awareness of and engagement with suffering, and a concomitant capacity to intervene to reduce it. The justification for the MSc focusing on meditation training includes promising mainstream healthcare research suggests that health benefits can arise from practising mindfulness and compassion techniques (see, for instance, Jazaieri et al., 2012; and MacBeth and Gumley, 2012). Those benefits include reduced depression and anxiety, and the aforementioned improved physical health, psychological resilience and well-being (Davidson et al., 2003; Khoury et al., 2013; and Neff and Germer, 2013). Two of the main mindfulness-based interventions are Kabat-Zinn s (2004) mindfulness-based stress reduction (MBSR) and Segal et al. s (2013) mindfulness-based cognitive therapy (MBCT), which is based on the former approach. Both programmes are considered to be able to enhance mindfulness practitioners self-compassion and kindness towards others, even though compassion is not taught directly in them (Segal et al., 2013). Further, enhanced selfcompassion is proposed as a key mechanism which facilitates the health improvements in mindfulness practitioners (MacBeth and Gumley, 2012). More recently programmes have been trialled which have a mindfulness foundation before progressing to explicit compassion practice These include Gilbert s (2010a and b) compassion-focused therapy (CFT); Neff and Germer s (2012) self-compassion programme; and Jazaieri et al. s cultivating compassion training (2012). Nurses professional code of conduct, produced and upheld by its governing body the Nursing and Midwifery Council (NMC) (2008), charges the profession with a duty of kindness. Moreover, compassionate care is proposed as the central tenet and raison d etre for nursing by leading nurse commentators (Chambers and Ryder, 2012; and Smith, 2012). The 13

rationale behind this is that nursing is a profession in continuous contact with human suffering; it s remit to care for people who are unwell, often experiencing psychological and/ or physical distress, and for whom full recovery may not be possible (Barker and Buchanan- Barker, 2005; and Simpson, 2009). Ongoing, lifelong health problems, disability and even death may be the prognosis for some patients (see, for example, Royal College of Psychiatrists, 2014). It is little wonder that people who choose to enter the profession are often assumed to be compassionate (Smith, 2012). Mental health nursing (MHN) focuses on patient s responses to the specific circumstances of their psychological problems and places great emphasis on developing and maintaining close, trusting therapeutic relationships with patients (Barker, 2009). Nurse theorists believe that those relationships must be founded on nurses compassionate understanding of patients individual and interpersonal difficulties, and good communication, emotional awareness, insight and empathy skills to benefit patients (Stickley and Freshwater, 2008). Further, while patients are unwell they can be at their most vulnerable, but generally do not get to choose the nurses they are expected to trust (Dinc and Gastmans, 2013). Simultaneously, patients need nurses to retain a sense of hope for recovery, whether the latter is full or partial (Spandler and Stickley, 2011). Compassion, whether or not it is assumed or expected in nursing, also appears to be crucial. Unfortunately, nursing s caring reputation has come into question following recent media and formal inquiry reports into poor standards of care in the National Health Service (NHS). For example the Mid-Staffordshire NHS Foundation Trust Public Inquiry Reports (2013a, b, and c) noted shocking lapses in providing even so-called basic care, such as ensuring patients received adequate hydration. Media reports suggested that an estimated 400 to 1,200 people could have died in just over three years in that Trust as a consequence of poor care standards (Owens and Meikle, 2013). 14

The shockwaves of that scandal could understandably affect healthcare policy and provision for some time. One current consequence is the criticism nurse education has received following the recent advent of degree-level registered nurse training. The British Government, for instance, has questioned whether emphasising higher academic attainment for the profession comes at the expense of nurses learning to provide fundamental care (Chambers and Ryder, 2012; and Smith, 2012). The Report of the Willis Commission (2012), sponsored by one of the main nursing unions, the Royal College of Nursing, has subsequently defended nurse education. Instead, The Report apportions blame to the NHS and its supposed failure to accommodate increasingly better qualified trained nurses. The current NMC (2010a) standards for nurse training, for instance, include care, compassion and communication as the first of five essential skills clusters (op. cit., p.103). Nonetheless, the NMC is reviewing how trained nurses maintain their professional registration, and demonstrate compassionate care as part of that process, in light of recent healthcare provision failings (NMC, 2013). Given the putative centrality of compassion to nursing and the promise of mindfulness-based interventions and emerging compassion training programmes, the author created a hybrid mindful compassion training course for nurses (MCTN). This comprised of mindfulness and compassion meditation techniques taught on the MSc and also featuring in MBSR, MBCT and CFT programmes. Further details describing MCTN are given in Chapter 3.3 and Appendix 9.2. MCTN s main purpose was to ascertain if its programme was helpful to nurses in developing or maintaining compassion. The also author wanted to give voice to nurses experiences of professional practice, especially given the heightened pressure on them to demonstrate compassion, and to pay attention to the context in which that occurs. To address these aims, the author adopted a realistic evaluation (RE) stance for the project, which is explored further in Chapters 2, 3, 4, 5 and 7. Given the complex nature of the subject matter, the project also employed mixed quantitative and qualitative methods (Creswell, 2014). Given the project aims, however, emphasis was placed on the latter. 15

The dissertation structure which follows begins with specific contextual information regarding the project setting in Chapter 1.2. Chapter 2 then considers the literature related to CIN and states the project research question and project aims. Research methodology is described in Chapter 3, and project findings are presented in Chapter 4. Chapter 5 compares project findings to pre-existing evidence and research theory, while Chapter 6 summarises project implications and proffers consequent recommendations for the project setting and the author. Chapter 7 concludes the dissertation with reflections on project limitations and further research. 1.2 The specific research context The project setting is a Scottish NHS Child and Adolescent Mental Health Service (CAMHS), which will not be named in order to maintain appropriate ethical boundaries. Scotland s fourteen NHS Health Board areas all operate CAMHS. CAMHS employ multidisciplinary workforces whose largest professional groups comprise nurses, followed by psychologists, psychiatrists, occupational therapists and social workers to work with patients up to age 18 (NHS Information Services Division, 2014a) (NHS ISD). Three CAMHS also have adolescent inpatient units, where patients are cared for over twenty-four hour periods. This project features nurses from one such service. Between them the three IPU s have 48 beds, are routinely full, have average lengths of stay ranging from one to several months, and provide a national service (Scottish Government, 2012). As statutory mental health services, CAMHS adhere to the Mental Health Care and Treatment (Scotland) Act (2003) principle that treatment should be provided in the least restrictive setting for patients. Accordingly, therefore, only patients with the highest needs are admitted to IPU s. Government policy (Scottish Executive, 2005), emphasising community care as the preferred option for young people, further reinforces the last resort nature of IPU admission. Simultaneously, however, there is arguably insufficient CAMHS IPU provision for the whole population (O Herlihy et al. 2001). Consequently, for the author, CAMHS IPU s always feel under pressure, even if only the minority of CAMHS patients are admitted to them. 16

10 % of people aged eighteen and under are estimated to be experiencing mental health problems at any one time (Mental Health Foundation, 2014a). In Scotland, this amounts to approximately 103, 800 young people and there are about 2,000 new referrals to all CAMHS each month (NHS ISD, 2014b). Most of those people will receive short-term treatment in weekly outpatient clinics. The CAMHS referred to in this project operates day and intensive treatment services which work in partnership with the IPU and have community outreach functions. Together with the IPU they support patients who have anorexia and life-threateningly low body weights; patients experiencing psychosis, such as hearing voices or feeling paranoid; patients who are aggressive; and patients whose self-harm is dangerous or who are suicidal. Although CAMHS regularly works with suicidal patients, completed suicides of patients receiving treatment are, in the author s experience, rare. A year before this project, however, an inpatient killed himself. The author mentions this here because the impact of his death was referred to by project participants and relates to project themes. To preserve the patient s confidentiality, however, no significant details of his suicide will be given. Nurses in the project setting IPU provide continuous patient care via day and night shifts. Those nurses are staff nurses, who have completed nurse training and are registered with the NMC, and non-registered nursing assistants. IPU staff nurses and nursing assistants are led by a junior and senior charge nurse (SCN). In the day and intensive treatment services the nursing teams comprise staff nurses, nursing assistants, community psychiatric nurses and senior charge nurses. All project nurses, as NHS staff, are also assigned different pay bandings according to their job descriptions, with higher band numbers representing increased responsibilities within the organisation (NHS Scotland, 2014). Appendix 9.1 lists the main nursing posts and bandings applicable to project participants. 17

2. Literature review, research question and project aims 2.1 Overview This chapter considers literature related to CIN, beginning with national policy perspectives, before outlining how compassion is conceived within the profession. Next, specific approaches to developing CIN are examined and contrasted with what some commentators believe is the reality of nursing practice, and why the aforementioned approaches may miss crucial aspects of that reality. The review then considers educational efforts used in nursing and healthcare to change staff attitudes and maintain professional values. Following that, examples of mindfulness and compassion meditation training in healthcare and nursing to date are considered, alongside concomitant challenges in providing those interventions. The chapter also builds a case for the MCTN project by exploring the context in which CIN is expected to flourish as well as considering the evidence based related to it (Pawson and Tilley, 1997). The author drew on course reading material and wider sources accrued for previous assignments to conduct this literature review. Various online resources were also accessed to pursue project themes. Those included Aberdeen University s PRIMO facility; the Cochrane Library; the National Institute for Clinical Excellence (NICE) archives; NHS National Education for Scotland resources; the Mental Health Practice journal and associated Royal College of Nursing (RCN) publications; the Mindfulness Springerlink journal; the Mindfulness Research Guide; and Google Scholar. This was not straightforward. For instance, by changing the search terms from compassion (in) nursing to compassion in mental health nursing, the number of items found progressively and significantly reduced. Further, the author found only rare references to training nurses in compassion, and no literature regarding training nurses using compassion meditation techniques. Moreover, to pursue a realistic evaluation (RE) approach to the project, the author followed Pawson s (2013) advice regarding literature reviews. Essentially, RE analyses evidence for the quality of its reasoning and utility in theory-building rather than just attending to data quality. In doing so, RE questions a traditional research hierarchy of best-to-worst quality evidence, in which quantitative studies, where participants have been randomly assigned to the intervention being examined or a control group for comparison, are taken as the gold- 18

standard for other methodologies to follow (Burns and Groves, 2010). Further rationale for Pawson and Tilley s (1997) stance is that: participants do not live in laboratories during or after research programmes; there is always be something else to learn about a topic; and contextual understanding is central to successfully transferring an intervention to different settings. The author therefore sought a range of evidence, encompassing policy and nurse training frameworks, quantitative meta-analyses, qualitative studies, and informed opinion based on theory and research. The research question and project aims are presented immediately following the literature review. 2.2 National policy and professional expectations of nurses The Scottish Government (2010) describe an expectation that healthcare workers, including nurses, carry out their work in a compassionate way as a central aspect of its national healthcare quality strategy. Unsurprisingly, given its findings, the Mid-Staffordshire NHS Foundation Trust Public Inquiry Reports (2013a, b, and c) recommended that the NHS establish shared values fundamentally based on compassion. The Scottish Government and NHS Scotland (2013) responded by surveying NHS healthcare workers and asking them to describe their values for practice. 10, 000 NHS healthcare workers replied, effectively pledging to deliver compassionate care. All Scottish NHS Boards are now required to sign up to and demonstrate how that pledge is being delivered. This seems positive; when asked, NHS staff described compassionate intentions. This concurs with research that nurses are still motivated to enter the profession primarily from a desire to care for others rather than to experience academic fulfilment or enjoy relatively stable employment, as some commentators feared would happen following the recent advent of degree-level nurse training (Smith, 2012; and Traynor, 2013). Further, Scottish mental health nurse education has emphasised values-based practice (VBP) for approximately a decade, by training nurses in the 10 Essential Shared Capabilities framework (Hope, 2004; 19

and NHS Education for Scotland, 2012). The latter includes themes such as learning to work in partnership with patients and respecting equality and diversity. In turn, VBP is associated with the recovery approach to mental health practice, an individualised approach to empowering patients to own and achieve recovery from mental health problems themselves, whether that is in the context of ongoing difficulties or full recovery from symptoms (Scottish Recovery Network, 2014). In the author s experience the 10 Essential Shared Capabilities (10 ESC s) provide useful pointers for maintaining caring nurse-patient interactions, and there is narrative evidence that patients value a recovery approach when it is implemented, and can feel dissatisfied when it is absent (Scottish Recovery Network, 2009). However, little objective evidence exists regarding the impact of the 10 ESC s and there is no guidance in policies explaining how VBP promotes compassion. Further, VBP and compassionate care are being linked to requirements that nurses prove their kindness in practice. For instance, in England a compassion index is being trialled to rate practising nurses, by counting behaviours such as smiling warmly towards patients (Department of Health, 2008). Meanwhile in Scotland emphasis is placed on delivering safe, effective and person-centred care, preferably with concrete evidence supporting each of those facets (NHS Education for Scotland, 2014). For example, healthcare staff are to gather regular patient and carer feedback about services using a listen, learn, act (NHS Education for Scotland, 2013, p ii) structure to inform service delivery. To the author, it is reasonable that public services are held accountable to the Government and the public. However, existing policy frameworks seem to reduce compassion to externally measurable behaviours, with few clues offered regarding how to sustain it. Indeed, the emphasis remains on action, as if compassion only functions as an outside-in process. While of course CIN demands activity, this stance contrasts with MSc meditation training, which emphasises an inside-out foundation and perspective. CIN is perhaps inextricably linked with task performance, and arguably so since Florence Nightingale s era in the 19 th Century. Rafferty (2011), for instance, describes Nightingale as 20

an embodiment of compassion-in-action and Nightingale s (2000) own writing details the activities she considered relevant to good nursing, such as an emphasis on orderly, clean hospital environments to reduce infection risks. Bradshaw (2011) and Traynor (2013) also propose that Nightingale s example was followed in her era by nurses training to build the right moral character, by maintaining: cleanliness, neatness, obedience, sobriety, truthfulness, honesty, punctuality, trustworthiness, quickness and orderliness (Bradshaw, 2011, p. 4). Bostridge (2008) suggests that Nightingale s legacy and leadership style was recently reviewed and perceived by some nursing commentators to have been too authoritarian. Rafferty (2011), however, urges today s nurses to use Nightingale s example as a credo for compassion (op. cit. p.3), a notion that the NMC seems to follow. For example, today s student nurses must be deemed by university and practice-based assessors to possess good health and good character (NMC, 2010b, p. 8) in order to be registered to practice nursing. Actions which are later deemed to contradict those attributes could lead to formal investigations and even professional disbarment (NMC, 2010c). Aspiring to compassion-in-action and maintaining good character, especially given the practical and ethical need to maintain public trust, seem reasonable to the author too. However, the working context for nursing has changed significantly and perhaps these ideals on their own are insufficient: modern healthcare services are under pressure to meet targets, such as reducing patient waiting times; make efficiency, often monetary, savings; and modernise or re-design, for example by integrating with social care services (Klein, 2013; and Scottish Government, 2011). And these pressures arise in a background of increased patient s rights; increased prevalence of complaints and litigation; inquiries into poor care; and the privatisation of aspects of healthcare services (Klein, 2013 and Smith, 2012). The net effect, for some theorists, is increased competitive striving within healthcare, with hospitals, nurses and other professions having to compete to meet targets and even maintain employment (Ballatt and Campling, 2011; Pollock, 2005; and Royal College of Nursing, 2011) As Gilbert (2010) proposes, the human brain s capacity for compassion, encompassing both self-kindness and concern for others, can and must respond to the pressure of such threats 21

using its fight, flight or freeze stress management responses. Unsurprisingly, research suggests that nurses can struggle to retain their original enthusiasm beyond two years of practice, and a recent online survey of twenty different employment sectors found that nurses had the second lowest sense of professional pride (Maben et al., 2007; and Randstad UK Care, 2013). Another problem, to the author, is the sometimes limited way compassion is referred to by nurse research. For instance, the terms empathy and compassion can be used interchangeably in nursing and healthcare literature (von Dietze and Orb, 2000). In contrast in Gilbert s (2010) multifaceted model of compassion, empathy, the ability to perceive and feel things from another person s perspective, is only one out of several compassionate attributes. The latter include: the motivation to care; sensitivity to the suffering of others; sympathy; the capacity to bear difficult feelings; and being non-judgemental. 2.3 Nursing initiatives to support compassionate care In nursing theory, there is also a divide between proponents of compassion as an affective process, arising from experiencing sympathy and empathy, while other theorists, perhaps aligning themselves with the traditional nursing views noted earlier, portray compassion as a moral stance guiding behaviour (Goetz et al., 2010 and Smith et al., 2010). The latter approach was adopted in a recent Scottish initiative to enhance CIN, the Leadership in Compassionate Care Programme (LCCP). The LCCP arose partly due to increased public dissatisfaction particularly with care of the elderly services (Edinburgh Napier University and NHS Lothian, 2012). Dewar et al. (2011), for example, describe a project in which the researchers negotiated agreement with nurses on how compassion could be demonstrated on a care of the elderly ward, observed nurses in practice, including noting existing good practice examples, and produced a bank of positive-care statements and images to enhance nurse-patient interactions. To the author, Dewar et al. s (2011) approach is helpful, because it involved positive engagement with nurses and efforts to improve care standards, potentially benefitting patients and meeting organisational targets. However, their paper does not describe staff or patient demographics; specific ward details or significant contextual information; or quantitative 22

methodology. Further, the author has not found any follow-up paper for this project. Pawson and Tilley (1997) argue that in order to replicate a project s success it is crucial to understand the context in which it occurred and the mechanisms by which it did so. For them, interventions work because participants make choices within them, and those choices are reflected in causal mechanisms. Although Dewar et al. s (2011) findings imply certain mechanisms, such as supportive researcher-nurse relationships, these are not significantly elaborated on. More importantly for the author, the question about how CIN might be sustained over time is not addressed. Smith (2012) proposes that CIN is intimately connected with the potential emotional costs (op. cit., p. 23) of nurses caring for patients, and that initiatives like the LCCP do not take enough account of those costs. Smith (2012) is referring here to the concept of emotional labour (Mann, 2004, p. 208). The latter term is hypothesised as applying to workers who are paid to contain and manage their own emotional experiences in order to do their job including putting their own feelings aside for the time-being and in relation to the professional image they are asked to present to the world (Theodosius, 2008). In turn, emotional labour (EL) has been linked to empathy in nursing theory. As noted in Chapter 1.1, empathy is hypothesised as being central to establishing effective nurse-patient relationships. Simultaneously, however, some research associates empathy with a range of increasingly negative outcomes for nurses, beginning with the momentary experience of being in touch with patient distress, to experiencing longer-term stress, and potentially a compassion fatigue (Coetze and Klopper, 2010 and Sabo, 2006). Although there are varying descriptions of compassion fatigue in associated literature, it has also been hypothetically linked with job dissatisfaction, physical and mental health problems and even an indifference to patients suffering (Mann, 2004). Organisational provision of clinical supervision can theoretically help nurses maintain compassionate care and prevent compassion fatigue (CF) (Butterworth et al., 2008). Supervision involves individuals or groups of nurses reflecting on clinical practice in supportive ways either with more experienced mentors or with peers (Butterworth et al., 2008; and Hawkins and Shohet, 2012). Supervision is, however, also linked with maintaining the care standards associated with healthcare service objectives and can thus be perceived as being a management strategy to control employee behaviour (Davis and Burke, 2012; and 23

Hawkins and Shohet, 2012). Further, the opportunity to engage with clinical supervision is at the mercy of the prevailing organisational culture (Butterworth et al., 2008; and Gonge and Buus, 2010). To the author, clinical supervision is currently being given less priority than previously, and it is usually held once every two months in practice. Consequently there are questions regarding what nurses do between supervision sessions. Potentially, nurses require the means to help them contain patients and their own feelings, and sustain moment-tomoment and longer-term, consistent compassion in sometimes challenging nurse-patient interactions (Bruce et al., 2010; and Shapiro and Carlson, 2009). 2.4 Nursing and healthcare staff education trials The other mechanism in nursing typically used to change attitudes and enhance compassion is nurse education, which theoretically also dates back to the Nightingale era, when the process of educating nurses and of nurses educating patients and others to manage ill-health emerged (Bastable and Alt, 2013). Given such a lengthy tradition, it is perhaps unsurprising that educative approaches are often considered key to influence nursing practice. Research projects attempting to reduce the stigmatising attitudes of healthcare staff illustrate this theme. Stigma theory suggests that people with mental health problems experience social discrimination due to false, often fear-based stereotypes others in society maintain regarding their divergence from so-called normality (Campbell et al., 2013; and Pilgrim, 2009). Reported potential consequences of stigmatisation include social isolation, reduced employment opportunities and poorer physical healthcare (Mental Health Foundation, 2014b). For the author the following honest studies reflect the uncomfortable notion that healthcare professionals can reinforce stigma too, and demonstrate the mixed results educative approaches can have in changing attitudes. First, Patterson et al. (2007), report on the successful use of educational interventions to reduce a mixed group of mental health and physical healthcare nurses negative attitudes towards self-harming behaviour. An intervention group of 69 nurses attended twelve university study sessions, which they were to reflect on during clinical practice between sessions. Compared to a control group, which instead attended a generic university research module, those receiving the interventions maintained improved attitudes for an eighteenmonth period. The authors credit the project s success partly to participants being able to 24

relate programme content to their real professional experiences and thus synthesise the two elements (Freshwater, 2008). This is a recognised adult learning theory stance (see, for instance, Kolb, 1983), and the findings are positive. However, the study was non-randomised, implying participants chose to attend the intervention or control group and the outcome measures used were self-report questionnaires. Participants may therefore have been influenced by the motivation to present themselves as exemplifying the right professional values (Fleming, 2012). Further, given the complexity and controversy of self-harm as a subject matter, and perhaps in order to help understand why participants made their respective choices, a mixed methods approach may have been more appropriate (Creswell and Piano-Clark, 2011; and Pawson and Tilley, 1997). More recently, Friedrich et al. s (2013) anti-stigma trial, involving over 1,400 medical students combined information sharing, lectures, patient narratives and role-plays, but failed to sustain initially promising results at a six-month follow-up. Interestingly, one of the researchers conclusions was that perhaps this was a consequence of participants experiencing distressing events while they were on placement. This is a theme relevant to the project setting the author explores in Chapters 3.6, 4.3 and 5. Ross and Goldner s (2009) literature review contributes further understanding to this challenging area. In it, they summarise 28 research papers which effectively place nurses into two categories. First, there are nurses who stigmatise patients or even mental health nurses and services, for example due to fear of patients supposedly unpredictable, bizarre or violent behaviour. Secondly, there are nurses who are stigmatised themselves either because they work in mental health services or because they themselves experience mental health problems. This concurs with Happell and Gaskin s (2013) finding that MHN, due to the aforementioned stigma, is the least attractive career pathway to student nurses from the four nursing branches: child and adult nursing, which focus on physical healthcare, learning disability nursing and MHN. 2.5 Mindfulness in occupational settings In the meantime, organisations and groups as diverse as Google (Tan, 2012), the American Marines (Stanley et al., 2011), sports psychologists (Hathaway and Eiring, 2011) and 25

business leaders (see, for instance, Beard, 2014; and Carroll, 2008) express interest in using mindfulness techniques to: improve creativity and resilience, task performance, emotional awareness, emotion regulation, communication and leadership skills, and reduce stress and sickness absence. In nursing, Cohen-Katz et al. (2005a and b) trialled two MBSR groups for a total of 25 nurses to reduce occupational stress. Their project was successful in the short-term and popular with participants, but its benefits were not maintained, an outcome the authors ascribe to hospital management failing to support MBSR training longer-term. More recently, Shapiro and Carlson (2009) concluded from various research projects involving nursing, medical and psychology students that mindfulness practice decreased anxiety and depression in those groups, even during high pressure periods such as sitting final exams. Dobkin and Hutchison (2013) also reviewed literature regarding the use of mindfulness in medical and dental schools world-wide and noted its presence in fourteen such establishments, again mainly for stress management purposes. Focusing on the latter area seems logical given reports of high stress levels in healthcare professionals, associations between stress and depression, and increased pressure on healthcare resource management (Ballatt and Campling, 2011; Klein, 2013; and Shapiro and Carlson, 2009). Arguably, however, the broader opportunities mindfulness training presents clinicians could be missed. Germer (2013), for instance, advocates mental health professionals develop mindful awareness to inform therapeutic relationships between mental health professionals and patients. There is a reasonable basis to this proposition. Carr (2009), for example, advocates that a good therapeutic alliance is the most significant variable a clinician can attend to. Within that very human dynamic, self-awareness, empathy, compassionate presence and a sense of shared humanity are considered its cornerstones (Stickley and Freshwater, 2002; and Williams and Stickley, 2010). Further, when asked, patients can often identify if staff are truly engaged in the present moment with them or are distracted, experiencing stress or distant (see, for instance, Brady et al., 2011). What patients seem to want are staff who are available to them as an accepting presence (Barker and Buchanan-Barker, 2005). 26

However, as Chapter 2.3 indicated, establishing helpful nurse-patient relationships can be challenging. Hypothetically those relationships require nurses to be safe containers for feelings too difficult for patients to manage in the here-and-now, which, in turn, requires nurses to accept and contain their own feelings too (Briggs, 2008; and Gairdner, 2002). For the author, mindfulness practice is a good theoretical fit with such aims. MBCT trials, for example, have demonstrated some efficacy in enhancing participants interpersonal relationships, with researchers correlating practitioners increased self-acceptance and selfcompassion with increased kindness towards others (Segal et al., 2013). Disappointingly for the author he found few healthcare studies focusing extensively on the potential of mindfulness training to enhance therapeutic relationships. Beddoe and Murphy (2004) piloted MBSR with 16 student nurses partly to see if it would enhance empathy in them towards patients. Project results were promising, but the main inevitable focus here was stress management. More recently, Brady et al. (2011) ran a fourweek MBSR course for an adult psychiatric inpatient unit MDT, most of whom were nurses. Notably, patients in this study reported that staff were more present for them during the project, when there were also fewer incidents of patients being aggressive. Finally, the author found one paper describing MBCT for mental health professionals. Ruths et al. s (2012) 27 pilot programme participants were mainly psychologists, who reported increases in psychological well-being and reductions in feeling anxious following the training. Unfortunately, no nurses participated and the impact of MBCT on therapeutic relationships was not explored. Further, the research team hypothesised that the main reason for participants volunteering for the programme was to enable them to deliver it themselves in the future. 2.6 Compassion meditation training in healthcare The author is not aware of MBSR or MBCT trials specifically focusing on enhancing compassion in nurses. Further, as referred to in Chapter 1.1, MBSR and MBCT exponents believe practitioners learn compassion from the implicit example the mindfulness instructor presents (Segal et al., 2013). CFT, however, is founded on the theory that explicit compassion training using it s mainly visualisation exercises confers considerable potential benefits to practitioners. (Gilbert, 2010 b; and Neff and Germer, 2012). Further, the latter techniques are intended to help people counter negative thoughts and feelings by learning to generate kinder 27

alternatives, and by engaging in CFT exercises practitioners can theoretically access the brain and body s capacities for self-soothing and contentment (Gilbert 2010b). In contrast, mindfulness practice, although often structured, for example by being mindful of one s breathing, is open to present-moment experiences generally, in order to facilitate enhanced self-acceptance. Gilbert and Tirch (2009) argue that some people, for example those who have experienced trauma or who are highly self-critical, could feel exposed to their perceived failings in such openness, and thus need the focus and guided, kindnessenhancing practices CFT offers. Compassion meditation training is, however, anecdotally renowned for being challenging (Gilbert and Choden, 2013). The very invitation to such training can be perceived as insulting to invitees, as if the training was being offered because they lack a fundamental human capability (Armstrong, 2011). Moreover, the training itself can stir up strong, sometimes conflicting feelings in participants (Gilbert et al., 2011; Nixon et al., 2011). For example, a typical compassion practice might ask participants to generate loving, kind feelings towards other people. Memories, experiences or perceptions of those people and participants relationship with them could then trigger positive, negative or mixed emotions (Gilbert and Choden, 2013). For the author, despite such challenges, including explicit compassion training on this project seemed essential, given the equally frank pressure on nurses to demonstrate kindness, as referred to in Chapters 1.1 and 2.2. Simultaneously, however, the author intended to follow Gilbert and Choden s (2013) advice and establish mindfulness practice as a foundation to his programme before progressing to potentially trickier compassion exercises. Further, to the author, the context within which compassion is expected to flourish in nursing is challenging. As a profession nursing is caught between the conflicting demands of professional regulation, academia, politics and economic uncertainty (Smith, 2012). It is immersed in human suffering. In MHN, there may not even be the relief of clear explanations for or agreements regarding how to treat health problems. Depression or psychosis, for example, cannot be seen on x-rays, and to some practitioners, including the author, there will always be a degree of diagnostic uncertainty in mental health practice (see, for instance, Farmer, 2010). There is also increasing conflict between, for instance, psychology and 28

psychiatry surrounding explanatory models and interventions for mental health problems (see, for example, Bentall, 2009; and British Psychological Society, 2011). 2.7 The research question and project aims Given the context for CIN described in this chapter, the author aspired to provide colleagues with training that would benefit their well-being, facilitate greater understanding of their working context and allow their views to be heard regarding this crucial professional issue. The project s central focus, therefore, was to answer the question: was MCTN useful to nurses in real terms? In order to explore that question there were two key project aims: 1. To identify individual, social, professional and organisational contextual factors which influence MCTN outcomes, and 2. To identify key enablers and inhibitors for participants in those four domains. 29

3. Research approach and methodology 3.1 Overview This chapter describes key theoretical assumptions under-pinning the realistic evaluation (RE) and mixed methods approach the author adopted to address project aims. Specific research methodologies employed are also summarised, including: participant recruitment and demographic information gathering strategies, and data collection and analysis methods. The chapter also considers how ethical issues were addressed and methodological adaptations the author made to accommodate the real life circumstances of the research setting and his deepening understanding of RE. The chapter closes with a diagram summarising project steps. 3.2 The author s worldview and the realistic evaluation approach Creswell (2014) defines a worldview as: a general philosophical orientation to the world and the nature of research that a researcher brings to a study (op. cit., p. 6). Although research design theory commonly links methodology to the central focus of a study, as expressed in research questions, Creswell and Piano Clark (2011) also contend that the researcher s worldview, which can be based on beliefs they hold arising from their professional background and previous research experience, plays a crucial role in this. Researchers should therefore be explicit about their worldview and how this influenced their methodological choices, so that others may follow and evaluate their work more comprehensively, and thus also lending their research greater validity (Creswell, 2014) The author s worldview incorporates the hypothesis that researchers do not need to be impartial observers of study subjects (Bentz and Shapiro, 1998). Research here is taken to be an honest, human endeavour, involving active participants, who choose to engage in research programmes or not, and with whom researchers have dynamic relationships (Bentz and Shapiro, 1998; and Pawson and Tilley, 1997). Further, as RE theory infers, neither the researcher nor study participants operate in closed laboratory conditions, but instead exist in open, dynamic, inter-acting and complex social systems, including those related to professional, social and personal domains (Pawson and Tilley, 1997; and Sayer, 2000). Given that the MCTN project was to take place in a setting where the author is a line manager to 30

some participants, these aspects of the RE approach were pragmatic as well as being part of his research philosophy. The author also contends that there is a compassion agenda implicit in national policies and regulatory frameworks applicable to nursing. In this agenda nurses are effectively being ordered to be compassionate, but, for the author, are not being given adequate means to achieve this. The author was therefore interested in a research approach which did not just demonstrate if MCTN worked or not but also provided the means for nurses views to be heard. To him, such empowerment could be achieved by drawing on critical realist research principles (Maxwell and Mittapalli, 2010; and Nairn, 2012). Critical realism endeavours to address oppressive societal forces and thereby reduce human suffering, and RE is considered to be a practical adaptation of that theory by its exponents (Bentz and Shapiro, 1998; Bhaskar, 1978; and Wand et al, 2011). Simultaneously RE encompasses an evaluation approach. The latter is commonly used in healthcare research to evaluate services or new interventions (Robson, 2010). Although RE is a specific framework developed by Pawson and Tilley (1997) it shares the pragmatism of the broader evaluation paradigm by being open to using any research methodologies which are appropriate to a programme s aims. This includes the possibility of combining quantitative and qualitative data methods. By incorporating critical realist thinking, RE also endeavours to influence political or organisational contexts by attempting to understand, if not address, the inter-relationship of social structures and human agency (Pawson and Tilley, 1997). It thus seemed to be a good fit for the author s own CIN agenda. RE also appears to be congruent with key theories which have influenced the development of mindfulness and compassion meditation training programmes. For instance, Gilbert and Choden (2013) note that although their mindful compassion training approach invites individuals to train in their methods, they: also want to make a strong point here about interconnectedness and our relationship to other minds and the societies we co-create (op. cit., p 15). Further, most mindfulness and compassion meditation programmes consist of experiential group training, a curriculum at least partially influenced and co-created by participant needs, and instructors role-modelling qualities such as kindness in order to have an impact on the individual and wider society (see, for example, McCown et al, 2010). 31

The social impact of mindfulness and compassion training has thus far been limited to theoretical aspirations in the literature, perhaps because their related research fields are relatively new and therefore still focused on demonstrating that the training works for given individuals. Accordingly, much of that research effort has been put into quantitative studies, including randomised controlled trials (RCT s) (Edwards et al., 2014). In RCT s, participants are randomly assigned to either the intervention being tested or a control group, which in healthcare involves the ubiquitous treatment-as-usual (Burns and Grove, 2010). Large-scale, multi-site RCT s are prized for the objectivity their proponents claim is achieved via randomisation and attempting to control for as many research variables, such as gender or age, as possible to find definitive proof of the intervention s efficacy (Kendall, 2003). In healthcare, such studies dominate the existing research hierarchy and practice guidelines (see, for example, NHS Education for Scotland and the Scottish Government, 2011). RCT s, however, result in numerical outcomes, albeit often in accessible and therefore persuasive before and after comparison scores (Burns and Grove, 2010). Indeed there are calls for future mindfulness training research to extend its quantitative evidence base by including economic impact studies (Edwards et al., 2014). For example, MBCT for depression could be compared to the costs of providing longer-term, standard treatments, including anti-depressant medication (Edwards et al., 2014). However, for some commentators, complex research questions, interventions and/ or settings require qualitative or combined quantitative and qualitative, i.e. mixed methods, approaches (Creswell and Piano-Clark, 2011; and Medical Research Council, 2008). Further, RE argues that it is not enough to demonstrate the effectiveness of an intervention; one also needs to understand the underlying mechanisms which facilitate effectiveness, mechanisms which may be contextspecific (Pawson, 2013). The author chose a mixed methods approach within Pawson and Tilley s (1997) RE framework hoping that both those aims could be met. Creswell and Piano-Clerk (2011) further suggest that in mixed methods studies researchers should clarify the relative emphasis they place on the quantitative and qualitative aspects of their approach. In the author s case, quantitative data was sought via self-report questionnaires to provide a snapshot of MCTN s relative efficacy and inform aspects of the qualitative aspects of the study. The latter centred on semi-structured interviews. These 32

methods are described further below in 3.5 and 3.6 respectively. Greater significance was assigned to the interview data, given the author s wish to give nurse colleagues a voice within the safety and anonymity of the project boundaries. A third strand of data was collected during the project in field notes kept by the author. Those notes, outlined further in Chapter 3.7, were used to collect contextual descriptions of the project setting to inform the interview process and cross-reference outcome measure and interview findings. The author thus also hoped to triangulate data between those three research methods (Simons and Lathlean, 2010; and Watson et al., 2010). To the author, the approach outlined above also coheres well with RE s understanding of what constitutes truth. RE draws on Bhaskar s (1978) and Popper s (1992) notions that: science grows with the cumulation of explanation, rather than on the bedrock of observational facts (Pawson, 2013, p. 9). The purpose of a study is therefore to contribute to cumulative understanding and the knowledge discovered in any one study can only ever be partial; there is always something else to be learned (McEvoy and Richards, 2006). For the author this is congruent with his personal meditation practice experience. Further, it is related to Pawson and Tilley s (1997) view that researchers and project sponsors should pay attention to contexts if they want to transfer interventions to different settings. Arguably, the latter concept has not received significant attention in healthcare, mindfulness or compassion meditation research to date. Indeed in current mental health practice emphasis has been given to developing manualised interventions that can theoretically be used anywhere with the same impact (Carr, 2009; and Wilson, 1996). This approach implies that people need the same things from treatment programmes, in the same order, and make the same choices within them. In contrast, RE suggests that participants choices can be contextspecific and implies that interventions evolve continually (Pawson and Tilley, 1997). Theoretically this occurs when researchers pick up the threads of previous projects, weave in new, possibly divergent ideas and leave further threads for the next research team (Pawson, 2013). The author would value such a process, given the significance of CIN to him and the new possibilities this project suggests. 33

3.3 MCTN programme outline MCTN was a hybrid programme devised by the author to help nurses establish a foundation in mindfulness practice and to then emphasise compassion meditation training. It was based on the following sources: MSc course mindfulness and compassion training (Nairn et al., 2010a and b; and Nixon et al, 2011); Gilbert s (2010b) CFT; and Gilbert and Choden s (2013) mindful compassion approach. MCTN comprised of eight weekly group sessions. Those were one and a half hours long, facilitated by the author, and included information sharing and instruction, experiential guided practice, group discussion and home practice advice. Hand-outs summarising key points and guided audio recordings of all practices were made by the author and provided to participants. These elements are typical of such programmes. For example, an eight-week programme is both a tradition in MBSR and an aspect of maintaining fidelity (McCown et al., 2010, p. xv) to its evidence base.. An outline of the programme themes can be found in Appendix 9.2. 3.4 Participant recruitment and demographic information The author sought and obtained recruits for three cohorts: Cohort one: ten nurses who wanted to participate in MCTN; Cohort two: a comparison group of ten nurses who did not want to or could not participate in MCTN; and Cohort three: two line managers of nurses in cohorts one and two. A third line manager participated in cohort one. Recruitment to the project was via purposeful sampling; nurses with an interest in CIN were sought (Creswell and Piano-Clark, 2011). Further, permission was obtained to run the MCTN groups during working hours for colleagues from the CAMHS teams described earlier, the inpatient unit (IPU) and day and intensive treatment teams. Consequently there would be fewer nurses available to provide a service during group times. In order to maintain as normal 34

and safe a service provision as possible, it was also important for the author to involve nursing line managers in helping decide which nurses could be in cohort one. Recruitment to cohort one therefore involved two layers of commitment: the author sought interested nurses who then needed to seek their line manager s approval too. Recruitment took five months and was completed the week before the first MCTN session in April 2013. In December 2012, the author presented the project and its aims to each CAMHS multi-disciplinary team involved, ensuring that as many nurses as possible were present, and followed up with an e-mail enclosing the participant information sheet shown in Appendix 9.3. The author later returned to each team base to speak with colleagues face-to-face to ascertain interest and leave consent forms (see Appendix 9.4) for prospective candidates to consider. In March 2013 the author met each project recruit individually to review and sign consent forms, gather demographic information (see Appendix 9.5 and table 1 below) and facilitate completion of the pre-training outcome measures. In total, 22 nurses were recruited to the project, constituting approximately half of the nursing group who worked in the IPU, day and intensive treatment teams. There were no inclusion criteria beyond participants being CAMHS nurses and there were no exclusion criteria. All CAMHS nurses understand spoken and written English. Sample variation was obtained in respect of age and gender, by recruiting both registered and non-registered nurses, and by participants holding different ranks within nursing. This is evident from table 1 overleaf regarding cohorts one and two. Cohort three s details have been withheld from this table to preserve their anonymity. 35

Table 1: basic demographic information for cohorts one and two Cohort one Cohort two Combined Number of 10 10 20 participants Age range 26-53 31-51 26-53 Females: 8:2 5:5 13:7 males Trained: 8:2 9:1 17:3 untrained nurses Range of 4-25 1-11 1-25 years of service Adult mental 8 nurses 6 nurses 14 nurses health service experience Experience of nursing in a psychiatric IPU 100% 100% 100% Additionally, 75 % of all participants stated they had previous meditation experience, however this was limited and no participants engaged in recent or ongoing meditation practice and for cohort one the MCTN techniques were largely new to them. Further baseline demographic information is given in Appendix 9.5. 3.5 Self-report outcome measures and analysis Quantitative data was collected from all participants using three self-report questionnaires in the month before the MCTN group sessions and in the month following them to test the programme s efficacy, compare the cohorts and inform participant interviews. This constituted a four month-period. Data was again collected from cohort three as part of this 36

process however their outcome measure findings were not included in analysis to maintain their confidentiality. The outcome measures administered were as follows: a) Neff s (2003) Self-Compassion Scale (SCS). The SCS is widely used in mindfulness and other research trials, including nursing, and has shown good reliability and validity internationally. (Heffernan et al., 2010; Jazaieri et al., 2012; and MacBeth and Gumley, 2012). It is a 26-item questionnaire examining self-compassion in three pairs of sub-scales: self-kindness versus self-judgement; a sense of shared humanity versus feeling isolated; and mindfulness versus over-identification with thoughts and emotions (Neff and Germer, 2013). The author believed it would be valid in this project because it centres on what people do in difficult times, and nursing, is, in his view, a high pressure and intermittently distressing role. The questionnaire uses a five point Likert-type scale ranging from one (things respondents almost never do under pressure) to five (things respondents almost always do). Scores can be calculated for each of the six dimensions listed above and to provide an overall self-compassion rating. b) Stober s (2001) Social Desirability Scale. One disadvantage of self-report questionnaires is the hypothesised tendency some people have to present themselves in a positive light, sometimes referred to as social desirability bias (Fleming, 2012; and van de Mortel, 2008). The SDS-17 is designed to test the extent to which that tendency might be present, by asking respondents to answer true or false to statements such as I sometimes litter. It has been found to be a sensitive, reliable and valid measure for eighteen to eighty year-olds (Stober, 2001). The questionnaire s use was suggested by Jazaieri et al. (2012); during their compassion meditation trial with members of the general public, they had wondered if some participants had volunteered in order to make themselves appear more socially desirable. c) Gilbert et al. s (2010) Fears of Compassion Scales (FCS). This comprises three subscales respectively examining fear of compassion for others, from others and selfcompassion. Items are rated on a Likert scale from zero (statements respondents do not agree with at all) to four (statements respondents agree with completely), and all 37

three types of compassion can be totalled. Higher scores indicate greater fears. For the author, the FCS advantage was their focus on a three-way flow between selfcompassion and giving and receiving compassion advocated in the theory MCTN borrows from Gilbert and Choden (2013). Moreover, no other studies known to the author have asked nurses to explore their relationship with all three aspects of compassion. The FCS have also demonstrated good validity, including amongst therapists working in the mental health field (Gilbert et al., 2010). Outcome measure analysis for this project was deliberately straightforward, given the emphasis on qualitative findings and the small sample sizes, which were unlikely to yield statistically significant results (Burns and Grove, 2010). Further, the purposes of quantitative data collection were to help identify if MCTN worked for cohort one participants and to identify significant trends in either cohort to help inform the interview process described in Chapter 3.6. The author therefore kept a record of pre- and post-intervention outcome measure scores for each individual participant; calculated mean score totals within each cohort; and compared the pre- and post-intervention mean score totals for cohort one and two. A summary of those findings is presented in Chapter 4.2. 3.6 Interview format and analysis methods The author originally proposed conducting individual interviews using a standard semistructured format, asking questions such as: has MCTN changed your perception of compassion in nursing? Closer reading of the RE approach, using Wand et al. s (2011) mental health service study example, however, revealed that such a format would be insufficient to meet the project s aims. RE projects require researchers to develop theories about the project context and hypothesised mechanisms central to an intervention s relative success or failure (Wand et al., 2011). Those theories can then be tested in interviews, where a teacher-student dynamic replaces typical researcher-interviewee question-and-answer dialogue and the participant s role is to illuminate, refine or refute the researcher s propositions (Pawson, 2013). 38

The author, having sought and obtained his project supervisor s advice and agreement to do so, therefore wrote a summary of his CIN theories he proposed were relevant to colleagues, and incorporated presentation of those ideas into the interview schedule. Table 2 overleaf provides a summary of those theories and a revised interview schedule is shown in Appendix 9.6. Ten interviews were conducted, involving four participants from each of cohorts one and two and both nurse managers in cohort three. The format consisted of talking through outcome measure scores as a warm-up to settle interviewees into the process; presentation of the author s CIN themes; and, if there was time left or if a subject had not already been covered, reviewing concrete questions from the interview schedule. Interviewees were selected on a pragmatic basis, i.e. according to which participants were on duty and available at that time. Interviews lasted up to an hour, were audio recorded and later transcribed by the author. They were then thematically analysed by hand coding and in relation to the author s CIN theories (Creswell, 2014). 39

Table 2: summary of the author s CIN theories presented in participant interviews Nurses attitudes to compassion are closely linked to their clinical experience, for example violence in the IPU, self-harm or even suicide- so nurses might be fearful of being compassionate, believing that it could open them to exploitation or harm, or feel sad when they have been close to patients whose actions are then hurtful. Nurses are used to keeping busy, so the idea of stopping and sitting still to just be, or to hang out in meditation practice doing nothing seems really strange, perhaps challenging and might even make nurses feel guilty, even if sometimes it is also enjoyable to relax. Further, keeping busy could be a way of some nurses defending themselves against how they feel in response to the disturbing aspects of clinical practice. The NHS, hospital management and even your SCN all expect nurses to be keeping busy too! Nurses attitudes towards expressing feelings and looking after themselves psychologically in other ways, e.g. via personal or social behaviours such as exercise or going to the pub for a drink, are key to how they might engage with mindful compassion training. The above also overlaps with a theme of how nurses relate to self-kindness; there seem to be a range of attitudes in CAMHS nurses, from those who almost seem to be automatically kind to themselves to those who struggle with it and give themselves a hard time, and also a number of nurses who have really stopped to think about what self-kindness means during this project. Previous experience of mindfulness or compassion meditation is also important, in that, for example, nurses might be more cautious about engaging with it if they had not encountered it before. 3.7 The researcher s field notes As indicated in Chapter 3.2, the author kept field notes during the project. Those were used to plan and reflect on MCTN group sessions and the project generally; reflect on the impact of facilitating MCTN on the author s own professional and mindfulness practice; and to note significant contextual themes and events in the project setting. The notes served a participant observation function by helping to refine aspects of the author s CIN theories and in triangulating outcome measure and interview data findings (Watson et al., 2010). 40

A copy of the field notes can be found in Appendix 9.7. 3.8 Ethical considerations Formal NHS ethics committee approval was not required for this project because it involved staff and not patients (NHS Research Ethics Service, 2010). Authorisation was, nonetheless, required from the local NHS research and development department and senior service managers. Two ethical concerns were anticipated for the project. First, taking nurses away from their normal duties could have caused colleagues or patients anxiety during group times. This was managed by holding the groups during a staff handover period, between two shifts, when the most staff would be available. No problems were noted or reported in this regard. Second, techniques taught in MCTN could have caused participants distress. This was managed by the author normalising meditation practice experiences, and by discussion and peer support within the group. Again, no significant problems were observed or reported. During the project the main ethical issue which arose was how to prevent identification of the project setting, specific participants or patients. To ensure anonymity, the author firstly submitted draft interview transcripts, field notes and dissertation chapters to his academic supervisor to verify appropriate boundaries were being maintained. Secondly, some information was omitted or changed. This included deciding not to name the specific CAMHS concerned; omitting details regarding a patient suicide; changing some field notes to make events more generic; excluding outcome measure data for cohort three; and redacting some names, statements and contact details even in the appendices. The author also assigned random pseudonyms to participants and other people referred to in the project. 3.9 Summary of the MCTN project steps A summary of project steps is provided in Figure 1 overleaf: 41

Literature and previous MSc Mindfulness Study modules reviewed September to November 2012 Tentative permission obtained from senior nurse manager and charge nurse peers, and field notes commenced November to December 2012 Proposal submitted to Aberdeen University, local senior NHS managers and the research and development department December 2012 to January 2013 Participants recruited, demographic information collected and pre-intervention outcome measures administered January 2013 to March 2013 Literature reviewed again and pre-intervention outcome measure data analysed March to April 2013 Interview schedule revised to incorporate author's CIN themes April 2013 MCTN group sessions held April and May 2013 Post-intervention outcome measure data gathered and analysed June to August 2013 Post-intervention interviews held, transcribed and analysed August 2013 to January 2014 Literature review updated February 2014 Figure 1: Summary of MCTN project steps Project written up for MSc dissertation January 2014 to April 2014 42

4. Presentation of project findings 4.1 Overview This chapter the researcher presents key data findings in relation to the MCTN project aims. Chapter 4.2 summarises quantitative project outcomes and Chapter 4.3 discusses interview themes which relate to participants perceptions of individual, social, organisational and professional contextual issues regarding CIN in the project setting. Those themes also imply ways in which sustaining compassion is enabled or inhibited for nurse colleagues. The chapter closes with a summary of project data findings in Chapter 4.4 4.2 Outcome measure data Self-Compassion Scale (SCS) results Neff s (2001) scoring advice is that overall self-compassion ratings of: 1.0-2.4 indicate low self-compassion levels; 2.4-3.5 are moderate ; and 3.5 and over are high. Possessing moderate to high levels of self-compassion has been correlated with better psychological health, emotional resilience and quicker recovery from health problems in related research (Neff, 2011; and Neff and Germer, 2013). Overall, therefore, comparison of initial and follow-up overall self-compassion scores gathered in this project suggests that both cohorts participants already possessed healthy levels of self-compassion and that MCTN was additionally helpful for cohort one nurses. As table three overleaf shows, the mean self-compassion score for cohort one rose from 3.07 to 3.4, an increase of 9.9 %, while cohort two s score remained the same at 3.11. 43

3.5 3.4 3.3 Table 3: Mean pre and post-mctn 'self-compassion' scores 3.4 3.2 3.1 3 3.07 3.11 3.11 2.9 Cohort 1 Cohort 2 Pre-MCTN Post-MCTN The extent of the apparent similarity between cohorts one and two at follow-up can be seen in table four which captures the mean scores for each of the six SCS sub-scales. There do not appear to be major differences in the positive sub-scales for self-kindness, sense of common humanity or mindfulness. Instead, bigger differences are reported two of the negative subscales of self-judgement and over-identification with negative thoughts and feelings, with cohort one scoring lower in each of these areas: 4 Table 4: Comparison of mean post-mctn SCS sub-scale findings 3.5 3 2.5 3.1 2.96 3.4 3.45 3.25 3.22 3.26 2.72 2.47 2.57 2.62 2.94 2 1.5 1 0.5 0 Self-kindness Common humanity Mindfulness Self-judgement Sense of Isolation Over-identification Cohort 1 Cohort 2 44

The author hopes, of course, that the project SCS scores do reflect both cohorts psychological health. These findings also replicate outcomes from other studies involving healthcare clinicians, in which mean overall self-compassion scores fall within the moderate range. Shapiro et al. (2005), for instance, trialled MBSR with multi-disciplinary general hospital staff cohorts. Here, the MBSR group had a mean self-compassion rating of 3.35 at follow-up, compared to the control group s 3.34. In later study, Shapiro et al. (2007), compared two groups of counselling and psychology students, one of which received MBSR training. The latter group s mean score rose from 3.01 to 3.49 during the project, compared to the control group s slight fall from 3.23 to 3.20. Finally Heffernan et al. s (2010) international study examined undergraduate and registered nurses psychological capacities and reported mean scores ranging from 2.92 to 3.49 in four cohorts of hundreds of respondents from three countries. Social Desirability Scale (SDS-17) results High scores on measures such as the SDS-17 theoretically inform researchers that participants have inflated the positive or minimised the negative aspects of how they represent themselves in self-report questionnaires (Fleming, 2012). Given that the author intended to conduct a simple quantitative data analysis and the SDS-17 is scored out of 16, an item in the original questionnaire having been removed later by Stober (2001), he considered any score greater than 8 as high. In this project, therefore, as table 5 overleaf shows, there was no overall concern regarding a social desirability bias affecting outcome measure results, as both cohorts mean SDS-17 scores initially and at follow-up were below 8: 45

8 7 6 5 4 3 2 1 0 Table 5: Mean pre and post-mctn SDS-17 scores 7.1 6.7 5.9 5.4 Cohort 1 Cohort 2 Pre-MCTN Post-MCTN There were two participants in cohort one and one in cohort two, however, who had SDS-17 scores over 8 at follow-up. Of those three, the cohort two participant had a self-compassion rating lower than their cohort mean and higher FCS scores. In their case, a high SDS-17 score does not seem to have accurately predicted a social desirability bias in their questionnaire responses. The cohort one participants with high SDS-17 scores both had SCS results above the cohort mean, however one of those nurse s FCS results were higher than the cohort average initially and on one of the FCS sub-scales at follow-up. For the remaining cohort one participant their FCS results were lower initially and at follow-up. Taking social desirability bias theory at face value, therefore, perhaps this latter participant s results were influenced in the way suggested in the literature. However, the nurse concerned also criticised the SDS-17 statements for trying catch them out as a morally bad person in front of a line manager (the researcher). Other participants shared a similar concern, albeit one expressed jokingly, and wondered if answering questions honestly might lead to investigations into their conduct after the project. Those participants did not score highly for a social desirability bias, however the author nonetheless felt that it may have been mildly unfair to put colleagues in such a position given their normal respective roles. Simultaneously the author does not believe the quantitative findings were invalid as a consequence of this dilemma. Their purpose was to provide general impressions of the 46

MCTN programme and inform the development of project theories regarding CIN. In that respect, the outcome measures were effective from the researcher s perspective, especially the FCS. Moreover, the author believes that cohort one s responses to the MCTN programme were genuine and the outcome measures facilitated a degree of participant reflection regarding compassion. The latter impressions can be gleaned from examples in the field notes (Appendix 9.7); the discussion of interview themes in section 4.3 below; and the interview transcripts (see, for instance, the sample transcript in Appendix 9.8). Fears of Compassion Scales (FCS) results The higher a person s scores on the FCS the greater their reported fears of compassion will be (Gilbert et al., 2010). In this project the main finding was that cohort one s mean scores on all three scales reduced significantly within the cohort and compared to cohort two, as tables 6 and 7 demonstrate. In cohort one, mean fears of expressing compassion for others fell by 23.03 % within the cohort and were 33.12 % less than cohort two s mean results at follow-up; fears of responding to compassion from others fell by 27.89 % within the cohort and were 51.93% less than cohort two s at follow-up; and fears of expressing kindness and compassion towards yourself fell by 41.53% within the cohort and were 52.42 % less than cohort two s at follow-up. 18 16 14 12 10 8 6 4 2 0 Table 6: Comparison of pre-mctn FCS scores 16.2 13.9 12.8 11.8 12.3 10.4 For others From others For the self Cohort 1 Cohort 2 47

18 16 14 12 10 8 6 4 2 0 Table 7: Comparison of post-mctn FCS scores 16 15.6 14.5 10.7 7.5 6.9 For others From others For the self Cohort 1 Cohort 2 For the author, the FCS results bridged the qualitative and quantitative aspects of this project. Although the reductions in fears of compassion scores for cohort one were encouraging, cohort two s scores were slightly worse over the same time period. This was both troubling and intriguing to the author. He wondered, for example, how colleagues could have arrived at such a potentially challenging place and what might happen if no support or intervention was available to help colleagues sustain CIN. Those conjectures then assisted the development of project theories discussed with participants in interviews. 4.3 Interview data The interview data below reflects the process described in Chapter 3.6 and therefore represents the refinement of the researcher s theories regarding CIN in the project setting. Disagreement with those theories offered by participants are summarised where this occurred. The author has grouped participant responses under theme headings derived from the RE structure applied to the interviews and subsequent thematic analysis. Also, as mentioned in Chapter 3.8, the author has used pseudonyms for interviewees, shown below: 48

Table 8: MTCN project interviewees A Pseudonym A Anne Cohort One Nursing role Community Psychiatric Nurse (CPN) Karen One Table nine: MTCN project Nursing interviewees Assistant Norma Name One Cohort CPN Nursing role Anne Veronica One One Community Psychiatric Nurse (CPN) Charge Nurse Karen Andrew One Two Nursing Assistant CPN Norma Louise One Two CPN CPN Veronica Rachel One Two Charge Nurse Staff Nurse Andrew Susan Two Two CPN Staff Nurse Louise Jemma Two Three CPN Charge Nurse Rachel Colin Two Three Staff Nurse Charge Nurse Susan Two Staff Nurse A sample Jemma interview transcript Three is provided in Appendix Charge 9.8. Nurse Theme: Colin CIN is important to Three nurses themselves Charge Nurse The author felt it was important to give colleagues opportunities to respond to the expectations placed on nursing that they must be compassionate, and there was a consensus that compassion is crucial. As Colin succinctly stated: I don t think you could do the job without it. There was also, however, concern that not all nurses live up to the compassionate ideal. As Louise remarked: I do wonder if it s a culture within nurses in general, some of them aren t compassionate at all. Interviewees also identified traditional organisational mechanisms which could sustain CIN, including individual or group clinical supervision and critical incident de-briefs. Cohort one nurses also felt that either further meditation practice alone or a combination of that and traditional support could be helpful. Anne summarised the latter view as follows: 49

I do sometimes think you do need to voice maybe if something s difficult, you know, you need a safe space in order to get through that and for people to be kind to you and help you get through that, but I also think you need the mindfulness on top of that in order to do all the other stuff you need to do by yourself. Simultaneously, however, there were significant factors potentially adversely affecting CIN. A perceived lack of time was a strong theme, for instance, linked to organisational objectives given, from nurses perspectives, more priority than staff support. Colin, for example, assessed the current NHS culture as being focused on having to meet targets. For him: The good bits of the job are when you sit down and when you have time to think about what sort of care are we giving this young person and their family.and being thoughtful about it, but that s not as much as the time we spend thinking: have I done the hand hygiene audits? Indeed, one interviewee described her view of NHS priorities in the following graphic terms: I just know from my friends who are child health nurses that they don t get any support there s no time to think, like if a kid dies you re expected to come back from the mortuary and continue your shift and there s no supervision, no debriefs. Despite agreement with CIN being important, colleagues also expressed concern that although nurses were generally good at being compassionate towards others, there was a lack of self-kindness in nurse colleagues; in Rachel s words: we do lack being able to look after ourselves a wee bit. The hypothetical value of enhancing self-compassion in nurses is explored later in this chapter. First, however, the author turns to the notion that compassionate care in nursing is both as an expectation placed on nurses and a quality they aspire to, in the context of sometimes distressing events. 50

Theme: CIN is linked with nurses clinical experience There was unanimous participant support for linking adverse incidents involving patients with nurses developing fears of compassion. For Jemma, an IPU charge nurse, those fears were a: natural reaction to working somewhere like the IPU. Susan, who had also worked there prior to transferring to day services, remarked that: compassion probably changed from the beginning til the end (of working in the IPU), and your tolerance was low. There was also agreement about the impact of a patient s suicide on compassion. Anna stated: If you re talking about the suicide, of course that affected everybody and how you managed things, and how you lost confidence in what you were doing. Karen stated that: there was a lot of guilt around and Veronica, the other IPU charge nurse, commented: it wouldn t surprise me that, that people s level of self-compassion would ve, their comfortableness with it would have decreased, and their level of self-blame and guilt gone up. Self-harm and patient aggression occur regularly in the project setting and contribute to instilling fears of being compassionate. Norma, for instance, stated that nurses: become more guarded as we become more experienced because how we learn to show our compassion you don t want to be seen as vulnerable or weak or easily manipulated. Meanwhile Anna added a social dimension to this theme when she remarked: it s difficult being compassionate towards people you know have been violent towards people you work with. And for Louise, reflection on these aspects of her role led her to conclude: 51

if you stop and think about it too much, then you might not come back. Despite those comments, participants also felt it was crucial to continue being compassionate towards others and to be seen to be compassionate. For the author, this was demonstrated by initial confusion during the interviews with some colleagues who had thought that when he was describing their FCS scores he was alluding to them lacking compassion. Anne, Norma and Louise all questioned the author regarding this, with Norma stating her case vividly: thought I was gonna get sacked for lack of compassion!...that s something I d like you to understand, that having a fear of compassion doesn t mean you don t do it do you think I m walking around not giving a shit? Such was the strength of feeling regarding this misunderstanding the author incorporated a more explicit explanation of the distinction between being and fearing compassion in remaining interviews. In addition to linking fear of compassion to distressing clinical experiences, the author had wondered if distressing professional experiences sometimes led nurses to over-compensate for a patient s difficulties, for example by giving particular patients more leeway than others. Here, there was only mild agreement with the author s theory; most interviewees who commented on this specific topic instead felt there was a need to maintain robust professional boundaries with or even a distance from patients. Andrew, for example stated: I m there as a nurse, but I m not a relative to this person, so I m also trying to gauge the compassion I m giving so I don t become too close. For the author, Andrew s statement also implies a fear of compassion and a need some nurses have for self-protection. Theory: nursing involves more doing than being, and nurses equate being compassionate with being busy Rachel described a pressure to be busy and to be seen to be busy: 52

there s certainly a kind of a feeling of if you re not seen to be active or doing something physical therefore you re not doing anything beneficial for people. She also stated that there was organisational pressure to: be the most effective you can be, and interviewees perceived the organisation, the profession and peers continually monitoring nursing care standards. Andrew, for instance, felt he should: make sure that you ve done all that you can, not, not even for how it feels for yourself, but if ever there was an inquiry into a situation I need to feel sure that I ve done everything I could, I ve followed all the procedures and everything not just for them (the patients) but to protect yourself as well. For some participants the pressure to be active coincided with personal drives to be busy. Louise, for example, described herself as: a striving perfectionist and wondered: if you sat down and did nothing, one how it would look, and two, there s, well, in my head, there s always something to be done. Further, being busy also served a protective function for some nurses by preventing them from dwelling on distressing work experiences or their own psychological issues. Rachel, for instance, remarked that during periods when nurses needed to physically restrain patients to manage aggressive behaviour there was almost an excitement and sense of it being: very difficult to settle down afterwards, while Louise stated that she: would have guilt about stopping being busy. Simultaneously CAMHS was attempting to reduce activity for activity s sake by nurses. These were being instigated by the IPU charge nurses and were challenging because, in Jemma s words: there s lots of, inverted commas, being busy in the office, when we re actually trying to create more of an ethos of being with the young people, but that s really hard work, trying to encourage that, and we probably don t manage it very well. The extent to which Jemma was being tough on herself and her colleagues could perhaps be judged partly by the fact that her work phone was called constantly during the interview and the latter was cut short due to work pressures. 53

Anticipating the challenges faced by nurses, the author also discussed how participants managed their feelings. Theory: nurses engage in their own individual and social ways to manage their feelings Participants engaged in a range of coping mechanisms, in Colin s words: as their way of letting off steam. Such mechanisms, again to quote Colin, included: exercise, walking the dog, or, for Susan: probably just taking time out by myself and speaking to people. In Andrew s case, having a young family was central to how he looked after himself. He would: talk to my wife, get out, do stuff with my kids, go-kartin. The author had already gathered data about how nurses managed their feelings in collecting participants baseline demographic information. Between the latter (see Appendix 9.5) and the interview findings, the author concluded that nurse colleagues maintained a diverse, healthy range of ways of managing feelings, adapted to lifestyles, personalities and interests. The author also found some differences between participants related to the one shared social activity the interviews touched on: going to the pub. In Anne s words this happened: when you have a rubbish day. Andrew described the process as: a release valve, and while all participants recognised and had previously participated in the phenomenon, some no longer did so or had become ambivalent about it. This seems to have been due to recognition that the process could maintain stress as well as help some people let off steam. Karen, for instance, remarked that on a nurses night out she feels: surrounded by the same conversations. Andrew felt similarly, but also then wondered how workplace stress could ultimately be managed: is there anything you could actually do to get rid of that in this job? I dunno if there is there s always something round the corner in this job, you never know what s round the corner. Susan added that stress in the IPU especially was inevitable. She perceived colleagues there as: run ragged they re miserable. 54

The author agrees with participants view that going to the pub as a means of releasing tension is a double-edged sword. Further, although his colleagues described useful personal coping strategies and were, according to the SCS data, generally psychologically resilient, the author nonetheless wondered if there was adequate support in total available to them, including organisational mechanisms, to help them cope with stress and sustain compassion. Given that all the project participants work in teams on shift systems, the author also proposes that individual and social dynamics could impact on professional and organisational issues and vice versa. It is therefore reasonable to consider identifying ways of helping nurses manage their feelings and sustain compassion in their roles which could potentially impact on all four areas. This was the rationale for piloting MCTN and this chapter now considers participants perceptions of that programme. In doing so, more emphasis will be placed on cohort one nurses views. Theme: MCTN could benefit nurses in managing their feelings and in sustaining CIN A key project goal was to harness a sense of camaraderie and safeness in the MCTN group by making the sessions closed and for nurses only. The group was also held in the quietest part of the CAMHS building, furthest away from clinical areas. Further, the author aspired to facilitate the group in the manner suggested by his mindfulness teacher training. This included proceeding at the group s pace in understanding the materials and exercises offered to participants; allowing for group discussions; and demonstrating mindful awareness by paying careful and kind attention to participants and engaging with them in an open, honest and accepting way (McCown et al., 2010). The author believes the above aims were largely met and that overall the group sessions were positive experiences for participants. Anne, for example, stated that: it helped that it was just nurses, it felt a bit more relaxed and comfortable, because we were all roughly the same level. For Karen, the group was: really comfortable a nice space. Further, her feelings of comfort arose despite having experienced initial tension with a colleague in the group, Mary, 55

which had been a spill-over from conflict in their nursing team. From her perspective, Karen believed that Mary had been deliberately trying not to sit next to her in the group and had at first perceived that as reflecting a fault on Mary s part. Karen, however, came to the conclusion that she was every bit as responsible: because maybe I do come across that the world revolves around me! Meanwhile Veronica reported that she had been concerned that participating in MCTN would replicate previous negative experiences of staff support groups, where she felt her charge nurse role, and colleagues responses to it, prevented her from experiencing those sessions as comfortable. Thankfully, Veronica stated that she: did feel part of MCTN, because: we were all inexperienced and so were learning, it made it so much more level. Norma also felt comfortable and in the group, but only after several sessions had passed: did I feel camaraderie? Eventually, yes. It felt a very safe group it was good to see familiar faces, it was inspiring and positive that way people were genuinely keen and everyone contributed. As important as a positive group atmosphere was, participants experiences of MCTN group practices required analysis too, to find out if the programme was useful to them. In this regard, from the author s perspective, the participants interview responses demonstrated an authentic, courageous effort to engage in techniques previously largely alien to them. Anne, for instance, stated that engaging in group practices had made her notice that she was: really tired, and that she could: fall asleep like that. She also felt that the practice had made her realise that her: mind s busy a lot of the time I ve got, like a narrative all the time. Further, she described finding herself: getting upset a few times during compassion practices, for example when visualising other people who were suffering, and remarked that MCTN has made her aware that she was : not as kind as I thought I was I ve noticed quite a lot, em, I can be quite stern, maybe I need to work on that a bit. 56

Despite these issues, and a previous brief trial of meditation practice that left Anne believing it might not: work for me at all, in MCTN Anne: learned that I can do it and that it benefitted me. She summarised the sessions as: quite precious. For Veronica, the meditation practice challenge included: nurses are very used to keeping busy, so the idea of just stopping and sitting still just to be and hang out is really strange. She too felt sleepy during group practices, but ascribed that to initially keeping her eyes shut during them. This was something the author subsequently discussed with the whole group. Then, in Veronica s words: the fact that I could actually do the exercises with my eyes open was a revelation to me. Veronica also appreciated the definition of compassion provided in MCTN, prior to which she had conceived of compassion as an: amorphous, unstructured thing that you can t really get a grip of. Like her cohort one peers, Veronica had, for instance, found it helpful to learn of Gilbert s (2010b) three-way flow of compassion: for yourself, from other people to you, and from you to other people. Despite this, and previously conceiving of herself as: a visual person, however, she sometimes found the visualisation aspects of compassion exercises challenging and reported an: exam pressure to get them right, a feeling others in the group shared. On the other hand, Veronica found that the MCTN programme also: clarified a couple of things about myself and about my tendencies to be worrying about stuff in the past that I can t actually do anything about now, em, or projecting some terribleness into the future. Norma also criticised herself sometimes during MCTN experiential exercises: 57

my brain kept challenging myself, c os every time I would sit and say have peace, have love, have com(passion) (a) bit of my head would contradict it. Immediately my head went to a: no, you don t mean this. The compassion practices nonetheless led Norma to reflect on CIN. She wondered if nurses sometimes lost compassion: because of the tough boundaries they imposed on therapeutic relationships with patients, and ended MCTN with a broader understanding of it now, even though it was a: difficult concept which nurses can be: scared of. Norma, like Anne and Veronica, also found it challenging to: have a busy schedule to then come in and just switch off. Her self-assessment in relation to mindfulness practice was that: I need to practice the being able to sit still but the gentle movement is good for me. Here, Norma was referring to the yoga and mindful walking introduced in the MCTN group programme and which were popular exercises with all cohort one participants. Although not referred to in the interview, Norma reported in a group session that she practiced mindful walking to and from her car during and immediately after work, and that doing so helped her both relax and pay more attention to her day (see the author s field notes, Appendix 9.7). Karen reported that she found some group practices relaxing too, for example during the session where the author invited participants to keep their eyes open during them. At that time she felt: drained in a nice way, really relaxed and not wanting to move. However, Karen also remarked that sometimes when she had finished a group session she was: ragin, and this irritability had been noticed by a colleague. Karen ascribed it to the tension between her and Mary and getting in touch with issues which had been troubling her. In her words: it might be subconsciously that I was thinking about things that maybe I could be changing, that I was annoyed at myself for. 58

Indeed in Karen s interview she gave examples of going on to address personal and social problems from this perspective of considering her own role in maintaining them. Those examples cannot be noted here, however, for ethical reasons. Karen, Norma, Anne and Veronica all stated that they were aspiring to be kinder towards other people, including colleagues, and the author asked cohort two and three participants if they had noticed changes in working relationships that might have been attributable to the MCTN programme. Three interview responses supported that possibility. Firstly, Susan stated that: definitely I do think that people that took part in it are more mindful of each other a lot nicer, I would say, with each other. Secondly, Jemma noticed: a couple of people who I feel were able to be more reflective in the direct conversations I had with them, and they didn t take up such defensive positions as they might have done before. Thirdly, Rachel commented that perhaps some participants who had previously been in conflict with each other were now being; more reflective. However, she also thought that this could be attributed to other factors, such as progressing through natural stages of team development, in which conflict features in early stages and group cohesion later (see, for instance, Tuckman, 1965). Further, no other interviewees in cohort two or three had noticed any particular changes. Finally, although the author encouraged it, most cohort one participants did relatively little between-session meditation practice. The author reflects on this further in Chapter 5. In the meantime, for him this finding was a reminder that MCTN was a pilot programme which participants were invited try on a voluntary basis. They did that, but perhaps were not ready for a longer-term commitment to meditation practice they may in time consider. In that respect, regardless of the relative lack of home practice, most cohort one participants wanted facilitated group mindfulness practice to continue. Norma, for instance, remarked: 59

I need to find a protected time to do it every day, em, but yeah I d quite like the teaching of it as well to continue on a weekly basis so I could protect it that way as well. 4.4 Summary of MCTN project findings Quantitative project findings suggest that while both cohorts were psychologically resilient according to the SCS, the MCTN sessions benefitted cohort one participants. Firstly, their mean SCS scores were higher at follow-up. Secondly, their mean FCS scores were significantly lower at follow-up as a cohort and compared to cohort two, whose results were unchanged. Thirdly, a social desirability bias does not appear to have played a major part in how participants completed project questionnaires. Qualitative project outcomes featured several themes related to CIN: there are mechanisms which could be available in the organisation to help nurses sustain compassion; distressing clinical experiences can instil fears of being compassionate; pressure on nurses time and pressure to be busy, whether internally driven or externally imposed, places further strain on nurses compassionate intentions; although nurses can describe personal and social coping strategies, their working environment is continually stressful; and programmes like MCTN help nurses manage stress and gain broader understanding and experience of compassion, including making important links between selfcompassion and kindness for others. For the author, project findings were authenticated by participants recounting challenges in engaging with group practices. Indeed, accounts of such experiences are generally understood by meditation teachers as necessary and ultimately positive first stages in which practitioners get in touch with how things really are (Gilbert and Choden, 2013). For some people that may mean getting in touch with how busy their minds are or their own role in interpersonal conflicts, for example, which was the case for some MCTN participants (Kabat-Zinn, 2004; 60

and Salzberg, 2002). For the interviewees, increased self-awareness led them to try to take more social and professional responsibility to be kinder to others and themselves. 61

5. Discussion 5.1 Overview This chapter reviews project findings with reference to RE and generic research theory; mindfulness training; nursing theory; and project aims. In doing so, priority is given to qualitative project data, reflecting the project s emphasis. 5.2 Project findings and RE Pawson and Tilley (1997) state that programmes work, i.e. have successful outcomes, because of the choices participants make within them. In that respect, the author believes that participants chose to experiment with meditation training in this project; they were not committing to lifelong practice or radical lifestyle changes. Also, the author s impression, captured in his field notes (Appendix 9.7), was that nurse colleagues preferred mindfulness to compassion training overall. Further, this choice seemed to be related to nurses mainly approaching MCTN as a stress reduction venture; their perception was that mindfulness practice was more effective in helping to fulfil that function than compassion meditation. The latter training was, however, arguably effective in helping participants broaden their understanding of what compassion is and was likely to have contributed to the significant reduction in their fears of compassion. Both aspects of MCTN may have therefore been useful, but it appears that the mindfulness training was the more consciously valued part of the programme. Perhaps without it participants would not have chosen to try the later compassion practices. Some RE studies culminate in comprehensive models of possible links between the research setting context(s) (C); project outcomes (O); and the underlying mechanisms (M) which facilitated those outcomes and function as intermediaries between contexts and outcomes (Pawson and Manzano-Santaella, 2102). In RE literature such models are referred to as a CMO configurations or CMOc (de Souza, 2013). This pilot project s aims, noted in Chapter 2.7, were to focus on the contexts nurses work in, therefore the tentative findings described in Chapter 4.3 would require more development to reach such a stage. Wand et al. (2011), for instance, describe using over 15 methodologies and separate scoping, theory refinement and implementation phases to conclude their research. Nonetheless, the author can offer the following basic CMOc based on project s findings, the first of two in this Chapter: 62

CMO model 1 for the MCTN project: Contexts: Nursing practice, in which compassion is expected and nurses themselves aspire to being compassionate Distressing clinical experiences Pressure on nurses time and the pressure to be busy (Unintentionally) inadequate personal, social and formal organisational support to meet the demands of the nursing role and sustain compassion Mechanism: Development of a split between being compassionate and fearing being compassionate Potential outcomes Nurses losing touch with compassionate intentions Increased stress Decreased job satisfaction Decreased role performance For the author, the above model suggests that doing nothing about CIN is not an option. Nurses need access to supportive mechanisms which can help them cope with emotionally demanding roles and sustain compassion. In that respect, programmes like MCTN could usefully support traditional options, such as clinical supervision, whilst also having the potential to facilitate enhanced understanding and even experience of compassion. However, further research could be helpful to establish the relative merits of mindfulness over compassion training more clearly. 63

RE theory also posits that successful project outcomes are connected with the appropriate ideas and opportunities (Astbury and Leeuw, 2010, p. 366) a programme offers being presented at the right time and in the right social circumstances for participants. Those ideas and opportunities are aspects of a programme s mechanisms. As Pawson (2013) describes, a mechanism: captures the way in which a programme s resources impinge on the stakeholder s reasoning (op. cit., p26). Moreover, without attempts to describe mechanisms, researchers are left with what Bezzi (2006) and Astbury and Leeuw (2010) refer to as the black box problem facing evaluative research. This is the notion that how programmes work cannot be seen or understood if an evaluation has focused only on outcomes and not what factors influenced those outcomes. For Pawson (2013), RE must consider: what works for whom, in what circumstances (op. cit., p 15). The model below places project opportunities in a second rudimentary CMOc: CMO model 2 for the MCTN project: Contexts: Nursing practice continues as described in model 1 above Mindfulness and compassion meditation group training/ practice sessions Mechanisms: Safeness, supportiveness and inspiration of the shared group experience Yoga, mindful movement and mindful walking facilitate a sense of competence in practising mindfulness and function as a good fit for busy nurses Nurses given permission and the means to reduce stress Nurses experience increased awareness of own thoughts and feelings Nurses introduced to a broader understanding of compassion, including the value of self-compassion 64

Outcomes: Reduced fears of compassion Increased or renewed aspirations to be kinder to others and to be selfcompassionate Increased responsibility for one s own thoughts, feelings and behaviour, for instance in relation to interpersonal conflict Increased interest in mindfulness practice Renewed interest in workplace support mechanisms RE further aspires to link specific chains of contexts, mechanisms and outcomes within programmes to gain greater clarity about their functioning, rather than the author s broader multiple-item approach shown above. Indeed, some RE studies have managed this (see, for instance, Byng et al., 2005). The author did not have sufficient time to analyse project findings to do that and cannot, for example, definitively link either mindfulness or compassion training to reduced fears of compassion. Indeed RE research has been criticised for the time-consuming, complex nature of developing and refining programme theories and CMOc (Walsh et al., 2007). Where the critical theory component of RE is concerned, this project identified pressure on nurses to be busy, pressure on their time and, for some participants, a lack of organisational support. These findings, however, were based on participants perceptions. Accordingly, the project may not have uncovered definitive evidence of or solutions to participants problems. Further, the author cannot imagine that nurses would gain much support by stating that they are too busy in the current healthcare context of financial cutbacks, increased scrutiny of nursing care standards, enhanced patient rights and Government-led efficiency targets (Klein, 2013; and Smith, 2012). 65

The author feels more optimistic about project findings and engaging with the compassion agenda referred to in Chapter 3.2, albeit in the long-run. This hope rests partly on RE s theory of social change. In that, RE identifies with Archer s (1995) realist concepts, in which society: is in a permanent state of self-transformation (Pawson, 2013, p. 5). Further, although in Archer s (1995) view an individual s choices within society are limited by pre-existing social structures and institutions in the here-and-now, programmes can influence the way individual make future choices. If programmes succeed in this, participants can then contribute to transforming society. Because society is constantly evolving anyway, this may not be in the precise ways envisaged by programme designers, nonetheless positive change is possible (Pawson, 2013). For the author, Archer s (1995) theory simultaneously offers a framework for understanding the political, organisational and professional pressure nurses are under currently and suggests a positive and familiar means of nurses addressing it: by developing and expressing a collective voice. Although no evidence of long-term attitudinal changes were sought or found in this pilot, the author believes project findings indicate nurses willingness and capacity to play a more central role in a compassion agenda. The author is also aware that there is not a consensus in social or healthcare research regarding, for example, the role of individual choice versus social influence in changing attitudes or behaviour and the precise mechanisms by which influence might be exerted (Elder-Vass, 2010). He is, however, persuaded by the potential power of positive group action by nurses in conjunction with building a research case strong enough to make sense to the wider profession and those in charge of it. In RE, CMOc are key aspects of developing middle range theory (Pawson, 2013). The latter term is often credited to the sociologist Merton (1949) and refers to descriptions of phenomena which in nursing link evidence and nursing knowledge with everyday professional practice (Smith and Liehr, 2013). For Smith and Liehr (2013), middle range theories have such potential value that they should be part of nursing s everyday functioning, given the profession s remit of providing holistic, sometimes complex or controversial and intimate care in the context of human ill-health. The author believes that the CMO models 66

above, while basic, represent the sort of easily understood, communicated and transferable theories Pawson (2013) values and the author has in mind for his professional practice. 5.3 Project findings and generic research theory Although it was not a project aim, in broad research terms the small sample size and consequent findings are not generalizable (Burns and Grove, 2010). As research emphasising qualitative methodologies, Burns and Grove (2010) propose that project analysis should consider: whether the findings reflected project aims; whether participants voices can be heard and the phenomenon being discussed can be understood from the findings; and whether anything new about the phenomenon can be discerned. The author believes that the first three of these questions have been satisfactorily answered in Chapters 3, 4 and 5. In relation to the project offering new perspectives, the results are mixed. First, attempting to use introspective meditation practice to sustain CIN was new, and a promising venture, as judged by quantitative outcomes and participants interview reflections. Further, the project is arguably a counter to the pessimistic view some nurses hold that training in compassion is not possible and that nurses just have compassion or do not (see, for instance, Bray et al., 2014). The author is not claiming here he transformed noncompassionate colleagues into compassionate ones. Participants difficulties were related to tensions between being compassionate and fearing being compassionate. Perhaps more accurately, therefore, this project offered new ways of addressing those fears. However, research related to nurses being busy, workplace stress management and formal reflective practice mechanisms have been discussed widely previously (Chambers and Ryder, 2012; and Smith, 2012). If, however, these are the routes into nursing or healthcare for meditation practice, then the author is content with re-reporting them. 5.4 Project findings and meditation training research and theory As stated in Chapter 3.2, existing mindfulness and compassion training research mainly focuses on quantitative findings. Further, comparing the project to existing evidence is 67

problematic given that the author s literature search only found trials which either focused on mindfulness or compassion but not both. Moreover, the project did not focus on organisational goals, such as increasing ward safety or reducing sick time (see, for instance, Brady et al., 2011), making comparison of project findings with workplace mindfulness research, referred to in Chapter 2.5, difficult too. This was a deliberate stance adopted to prevent the project being perceived as a management strategy. Arguably, however, project findings might have shown more evidence of workplace improvements than they did, for example in reducing collegial conflict. The author has already stated his belief that project participants demonstrated genuine engagement with group training exercises and hypothesised that this may have been a first practice development stage. Project findings here cohere with anecdotal accounts by meditation instructors and key theorists that compassion practice can be especially challenging. Nixon et al. (2011) and Gilbert and Choden (2013), for instance, state that compassion training is not akin to a smooth and graceful ascent to ever-higher levels of functioning for practitioners. Instead, if positive changes are to occur, participants must first descend into and resolve fears, inner conflicts and confusion regarding compassion, all of which are formed by their own perceptions, pre-existing assumptions, past experiences and psychological habits! Based on the project field notes (see Appendix 9.7) and interview findings, and the author s own meditation experience, he believes cohort one participants experienced something of that descent. Further, during the project participants nonetheless reflected on their individual, social and professional functioning and gained a broader understanding of compassion. Two further project findings can be compared to existing evidence: participants lack of engagement with home practice and their preference for mindful movement rather than long sitting meditation practice. 68

Research proposes that between-session mindfulness practice is essential and the more practice one engages in potentially the more benefits will accrue (Shapiro and Carlson, 2009; and Vettese et al, 2009). However, as Vettese et al. (2009) note, few mindfulness studies examine this issue thoroughly. In their paper, only 24 mindfulness trials out of 98 measured the impact of home practice on outcomes, and of those only 13 supported its benefits. The author did not develop or apply specific measures to account for this aspect of MCTN either, nonetheless little home practice was reported by participants. The author can only theorise that this was related to participants viewing the group sessions as weekly experiments where their overall preference was for time out and stress reduction at work. Research is also just beginning to consider more closely which meditation practices produce what kind of benefits. Here, the author notes that Sauer-Zavala et al. s (2013) mindfulness trial involving university undergraduates found that mindful movement was the practice which enhanced practitioner s sense of psychological well-being more than sitting meditation, which echoes MCTN participant views. 69

6. Implications and recommendations 6.1 Overview This chapter outlines the implications and recommendations of project findings for the author s workplace; how the author will share findings; the impact the project has had on the author s professional practice; and his hopes for future research into CIN. 6.2 Implications and recommendations for the project setting The author believes this project has both serious and positive implications for his workplace. First, the project findings indicate that although nurses aspire to being compassionate, fears of compassion arise which, without supportive intervention, could persist. This project did not seek to explore the consequences of that split for nurses health, sickness absence rates, professional standards or staff retention. However, the author is concerned about the longterm impact of high fears of compassion in CAMHS, and believes it is important that this dynamic is addressed further to protect nurses, patients and the organisation. More positively, supportive interventions might not just prevent problems but facilitate a broader, more resilient understanding and experience of CIN. Moreover, project participants valued traditional organisational supports, and the author believes cohort one colleagues also responded positively to MCTN. The author therefore recommends to colleagues that organisational supports are reviewed to assess their adequacy and if necessary re-invigorated. The author also proposes facilitating further group mindfulness training and educative input and discussion regarding compassion. If interested, colleagues could progress to separate compassion meditation training once a mindfulness foundation has been established. Further CAMHS research could also focus on comparing organisational support to mindfulness training in relation to CIN. Moreover, an action research approach could facilitate this, in which CAMHS-specific problems are identified and addressed, with each stage of the research process being agreed upon by colleagues (McNiff and Whitehead, 70

2011). This could facilitate nurses gaining more ownership of research topics and themes related to the compassion agenda for nursing. The author is also interested in including other professional disciplines in future compassion or meditation training ventures. For the ideological reasons already stated, however, he would prefer to discuss how to do so with nurse colleagues first. 6.3 Sharing project findings In order to stimulate interest in the ambitions outlined in Chapter 6.2 above and to fulfil the author s proposal promises he will disseminate project summaries to participants, management sponsors and wider CAMHS colleagues. The author is also interested in sharing project outcomes with universities involved in training nurses and who are charged by the NMC with demonstrating that their students are able to provide compassionate care (NMC, 2010b). This would be in order to engage in a dialogue about the research topic and hopefully develop project themes further. For similar reasons the author may seek to publish project findings in a nursing journal and thus contribute to profession-wide debate. Finally, the author s approach to project dissemination will be from the perspective of seeking to promote mindfulness and compassion training too, but not at the expense of considering other promising options to positively influence how CIN can be sustained. 6.4 Implications for the author The author has facilitated mindfulness practices for CAMHS patients, carers and staff previously. This was, however, CAMHS and his first explicit compassion project. During it, colleagues expressed a desire, challenging to hear initially, for senior staff to role-model compassionate attributes more. Fellow charge nurses agreed that this was important, therefore the main implication for the author is to help lead by example, and in doing so also promote further meditation training. 71

The author was further challenged during the project by colleagues descriptions of nursing practice. For instance, the author had under-estimated workplace stress and the extent to which distressing professional experiences could increase fears of compassion. Simultaneously, however, colleagues MCTN group experiences indicated that, given opportunities, nurses can address these issues effectively and sustain CIN. The author, therefore, will retain awareness of these issues and offer to facilitate further meditation training as outlined in Chapter 6.2. 72

7. Reflections and conclusions 7.1 Overview This dissertation concludes with reflections chapter reflections on the project s limitations, before briefly summarising its findings and recommendations for future research related to meditation training and CIN. 7.2 Project limitations This project s limitations include there being no consensus for key terms fundamental to its implementation: mindfulness and compassion. Further, the author is not aware of agreed research protocols to guide meditation practice projects, and meditation experiences are arguably intuitive and personal processes challenging or even impossible to accurately capture in words (Siegel et al., 2009). Projects like this one are therefore perhaps imbued with subjectivity and require conceptual leaps of faith from evaluators, who can of course bring their own impressions to bear on proceedings. Subjectivity is also present in participant interviews and the author s field notes, with both methods being susceptible to personal bias too (Burns and Grove, 2010). Further, there are no guidelines available on conducting valid RE interviews, because, as Pawson (2013) states, they do not exist. RE s strength, for the author, in being open to any method, is also arguably its weakness. In that regard, there were also no protocols for developing the CMOc referred to in Chapter 5.2 and considered central to RE (Pawson and Tilley, 1997). Ultimately the author concocted an interview and CMO model structure himself. The former combined presentation of project theories with semi-structured questioning. For the author, doing both things in the interviews was time-consuming and hypothetically could have impinged on participants opportunities to respond, including, for instance, expressing views diverging from project theories. This project also involved the author juggling charge nurse, meditation instructor and researcher roles. Separating these roles may have lent the project greater objectivity. Moreover, in the author s experience, it would be better practice for two or more instructors to facilitate meditation training courses, affording, amongst other things, greater quality 73

control. And the author made some mistakes. For example, he used what he thought was a clear, accessible recording by David Foster Wallace (2009) to illustrate facets of compassion. Some participants, however, found that the audio track disturbed the normally peaceful group atmosphere. In agreeing training plans with co-facilitators the risk of such events would arguably be minimised. 7.3 Summary of project findings and recommendations Despite limitations, this project finds that nurses can experience tension between being compassionate and fearing being compassionate. The latter can arise as a consequence of distressing clinical experiences and perceived organisational pressures. Further, it is unclear if typical individual, social, professional and organisational supports adequately help nurses manage stress, reflect on clinical practice and sustain compassion. The author therefore proposes the profession engages in further research in all of these areas and more experimentation of programmes like MCTN, given the putative centrality of compassion to nursing. Indeed, the author has an ideal future vision. In it, nurses take charge of the compassion agenda the author believes they are subject to and gain collective confidence and experience of compassion via continuous and linked research, education and practice. This effort could incorporate joint ventures with patients, carers and other disciplines. It could also involve cocreation of new approaches to compassion in handovers between generations of nurses, the old guard functioning as positive examples and mentors to the new guard, who in turn are allowed to flourish and breathe fresh life into the profession s caring intentions (Friere, 1996; and Vgotsky, 1978). That, for the author, would be wiser and healthier than waiting for further commands to be compassionate. 74

8. References ARCHER, M., (1995). Realist Social Theory: The Morphogenetic Approach. Cambridge: Cambridge University Press. ARMSTRONG, K, (2011). Twelve Steps to a Compassionate Life. London: The Bodley Head. ASTBURY, B., and LEEUW, F., (2010). Unpacking black boxes: mechanisms and theory building in evaluation. American Journal of Evaluation, 31 (3), pp. 363-381. BALLAT, J. and CAMPLING, P., (2011). Intelligent Kindness: Reforming the Culture of Healthcare. London: Royal College of Psychiatrists. BARKER, P., (2009). The nature of nursing. In: P. BARKER, ed, Psychiatric and Mental Health Nursing: The Craft of Caring, London: Hodder Arnold, pp. 3-11. BARKER, P., and BUCHANAN-BARKER, P., (2005). The Tidal Model: A Guide for Mental Health Professionals. Hove: Brunner-Routledge. BASTABLE, S., and ALT, M., (2013). Overview of education in health care. In: BASTABLE, ed, Nurse as Educator: Principles of Learning for Nursing Practice. 4 th edn. Burlington, Massachusetts: Jones & Bartlett Learning. pp. 3-30. BEARD, A., (2014). Mindfulness in the Age of Complexity. Harvard Business Publishing. Available: http://hbr.org/2014/03/mindfulness-in-the-age-of-complexity/ar/1 [Date accessed: 21 st April 2014]. 75

BEDDOE, A. and MURPHY, S., (2004). Does mindfulness decrease stress and foster empathy among nursing students? Journal of Nurse Education, 43 (7), pp. 305-312. BENTALL, R., (2009). Doctoring the Mind: Is Our Current Treatment of Mental Illness Really Any Good? New York: HarperCollins. BENTZ, V., and SHAPIRO, J., (1998). Mindful Inquiry in Social Research. London: Sage Publications, Inc. BEZZI, C., (2006). Evaluation pragmatics. Evaluation, 12 (1), pp. 56-76. BHASKAR, R., (1978). A Realist Theory of Science. 2nd edn. Brighton: Harvester. BOSTRIDGE, M., (2008). Florence Nightingale: The Woman and Her Legend. London: Penguin Books. BRADSHAW, A., (2011). Compassion: what history teaches us. Nursing Times Ethical and Compassionate Nursing Supplement. Nursing Times. Available: http://www.nursingtimes.net/journals/2011/08/24/j/y/s/nt-ethical--compassionate-care.pdf [Date accessed: 21 st April 2014]. BRADY, S., O CONNOR, N., BURGERMEISTER, D., and HANSON, P., (2011). The impact of mindfulness meditation in promoting a culture of safety on an acute psychiatric unit. Perspectives in Psychiatric Care, 48 (3), pp. 129-137. 76

BRAY, L., O BRIEN, M., KIRTON, J., ZUBAIRO, K., and CHRISTIANSEN, A., (2014). The role of professional education in developing compassionate practitioners: a mixed methods study exploring the perceptions of health professionals and pre-registration students. Nurse Education Today, 34, pp. 480-486. BRIGGS, S., (2008). Working with Adolescents and Young Adults: A Contemporary Psychodynamic Approach (Basic Texts in Counselling and Psychotherapy). Basingstoke: Palgrave Macmillan. BRITISH PSYCHOLOGICAL SOCIETY, THE, (2011). Response to the American Psychiatric Association DSM-5 Development. London: The British Psychological Society. Available: http://apps.bps.org.uk/_publicationfiles/consultation-responses/dsm- 5%202011%20-%20BPS%20response.pdf [Date accessed: 21 st April 2014]. BRUCE, N., SHAPIRO, S., CONSTANTINO, M., and MANBER, R., (2010). Psychotherapist mindfulness and the psychotherapy process. Psychotherapy Theory, Research, Practice, Training, 47, (1), pp. 83-97. BURNS, N and GROVES, S., (2010). Understanding Nursing Research. 5th edn. Maryland Heights, Missouri: Elsevier Saunders. BUTTERWORTH, T., BELL, L., JACKSON, C., and PAJNKIHAR, M., (2008). Wicked spell or magic bullet? A review of the clinical supervision literature 2001-2007. Nurse Education Today, 28, pp. 264-272. BYNG, R., NORMAN, I., and REDFERN, S., (2005). Using realistic evaluation to evaluate a practice-level intervention to improve primary healthcare for patients with long-term mental illness. Evaluation, 11 (1), pp. 69-93. 77

CAMPBELL, M., BYRNE, R., and MORRISON, A., (2013). Discrimination about psychosis: stigma, emotions and changing emotional attitudes about psychosis to improve outcomes. In: GUMLEY, A., GILLHAM, A., TAYLOR, K., and SCHWANNAUER, M., eds., Psychosis and Emotion: The Role of Emotions in Understanding Psychosis, Therapy and Recovery. Hove: Routledge. pp. 98-115. CARR, A., (2009). What Works with Children, Adolescents and Adults? A Review of the Effectiveness of Psychotherapy. Hove: Routledge. CARROLL, M., (2008). The Mindful Leader: Ten Principles for Bringing Out the Best in Ourselves and Others. Boston, Massachusetts: Trumpeter Books. CHAMBERS, C. and RYDER, E., (2012). Excellence in Compassionate Nursing Care: Leading the Change. London: Radcliffe Publishing Ltd. COETZEE, S. and KLOPPER, H., (2010). Compassion fatigue: a concept analysis. Nursing and Health Sciences, 12 (2), pp. 235-243. COHEN-KATZ, J., WILEY, S., CAPUANO, T., BAKER, D. and SHAPIRO, S., (2005a). The effects of mindfulness-based stress reduction on nurse stress and burnout, part II: a quantitative and qualitative study. Holistic Nursing Practice, 19 (1), pp. 26-35. COHEN-KATZ, J., WILEY, S., CAPUANO, T., BAKER, D. and SHAPIRO, S., (2005b). The effects of mindfulness-based stress reduction on nurse stress and burnout, part III: a quantitative and qualitative study. Holistic Nursing Practice, 19 (2), pp. 78-86. 78

COLE-KING, A., and GILBERT, P., (2011). Compassionate care: the theory and the reality. Journal of Holistic Healthcare, 8 (3), pp. 29-37. CRESWELL, J., (2014). Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 4 th edn. London: Sage Publications, Inc. CRESWELL, J., and PIANO-CLARK, V., (2011). Designing and Conducting Mixed Methods Research. 2 nd edn. London: Sage Publications, Inc. DALAI LAMA, HIS HOLINESS THE, (2001). An Open Heart: Practising Compassion in Everyday Life. London: Hodder and Stoughton. DAVIDSON, R., KABAT-ZINN, J., SCHUMACHER, J., ROSENKRANZ., M., MULLER, D., SANTORELLI, S., URBANOWSKI, F., HARRINGTON, A., BONUS, A., SHERIDAN, J., (2003). Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine, 65, pp. 564-570. DAVIS, C., and BURKE, L., (2012). The effectiveness of clinical supervision for a group of ward managers in a district general hospital: an evaluative study. Journal of Nursing Management, 20 (6), pp. 782-793. DE SOUZA, D., (2013). Elaborating the context-mechanism-outcome configuration (CMOc) in realist evaluation: a critical realist perspective. Evaluation, 19 (2), pp. 141-154. DEPARTMENT OF HEALTH (DOH), (2008). High Quality Care for All. London: The Stationary Office. 79

DEWAR, B., PULLIN, S. and TOCHER, R., (2011). Valuing compassion through definition and measurement. Nursing Management, 17 (9), pp. 32-37. DINC, L., and GASTMANS, C., (2013). Trust in nurse-patient relationships: a literature review. Nurse Ethics, 20 (5), pp. 501-516. DOBKIN, P., and HUTCHISON, T., (2013). Teaching mindfulness in medical schools: where are we now and where are we going? Medical Education, 47 (8), pp. 768-779. EDINBURGH NAPIER UNIVERSITY, and NHS LOTHIAN, (2012). Leadership in Compassionate Care Programme Final Report. Edinburgh: Edinburgh Napier University. Available: http://researchrepository.napier.ac.uk/5935/1/compcare_fin_rept_all_apr_13.pdf [Date accessed: 21st April 2014]. EDWARDS, R., BRYNING, L., and CRANE, R., (2014). Design of economic evaluations of mindfulness-based interventions: ten methodological questions of which to be mindful, Online First Published 1 st February 2014 [Available from: DOI 10.1007/s12671-014- 0282-6] [Date accessed: 21 st April 2014]. ELDER-VASS, D., (2010). The Causal Power of Social Structures: Emergence, Structure and Agency. Cambridge: Cambridge University Press. FARMER, A., (2010). Working with diagnostic uncertainty in first-episode psychosis. In: FRENCH, P., SMITH, J., SHIERS, D., REED, M., and RAYNE, M., Promoting Recovery in Early Psychoses. Oxford: Wiley-Blackwell. pp. 84-92. 80

FLEMING, P., (2012). Social desirability: not what it seems: a review of the implications for self-reports. The International Journal of Educational and Psychological Assessment, 11 (1), pp. 3-22. FRESHWATER, D., (2008). Reflective practice: the state of the art. In: FRESHWATER, D., TAYLOR, B., and SHERWOOD, G., eds, International Handbook of Reflective Practice in Nursing. Oxford: Wiley-Blackwell. pp. 1-18. FREIRE, P., (1996). Pedagogy of the Oppressed. Revised edn. London: Penguin Books. FRIEDRICH, B., EVANS-LACKO, S., LONDON, J., RHYDDERCH, D., HENDERSON, C., and THORNICROFT, G., (2013). Anti-stigma training for medical students: the education not discrimination project. The British Journal of Psychiatry, 202, pp. 89-94. GAIRDNER, W., (2002). The Ailment - 45 years later. Clinical Psychology and Psychiatry, 7 (2), pp. 288-294. GERMER, C., (2013). Mindfulness: what is it? What does it matter? In: GERMER, C., and SIEGEL, R., eds., Mindfulness and Psychotherapy. 2 nd edn, New York: The Guilford Press, pp. 3-35. GILBERT, P., (2010a). The Compassionate Mind. 2nd edn. London: Constable. GILBERT, P., (2010b). Compassion Focused Therapy. Hove: Routledge. GILBERT, P. and CHODEN, (2013). Mindful Compassion: Using the Power of Mindfulness and Compassion to Transform Our Lives. London: Constable & Robinson Ltd. 81

GILBERT, P., MCEWAN, K., MATOS, M. and RIVIS, A., (2010). Fears of compassion: development of three self-report measures. Psychology and Psychotherapy, Research and Practice, 84 (3), pp. 239-255. GILBERT, P. and TIRCH, D., (2009). Emotional memory, mindfulness and compassion. In: F. DIDONNA, ed, Clinical Handbook of Mindfulness. New York: Springer. pp. 99-110. GOETZ, J., KELTNER, D., and SIMON-THOMAS, E., (2010). Compassion: an evolutionary analysis and empirical review. Psychological Bulletin, 136 (3), pp. 351-374. GONGE, H., and BUUS, N., (2010). Individual and workplace factors that influence psychiatric nursing staff s participation in clinical supervision: a survey study and prospective longitudinal registration. Issues in Mental Health Nursing, 31 (5), pp. 345-354. HAPPELL, B., and GASKIN, C., (2013). The attitudes of undergraduate nursing students towards mental health nursing: a systematic review. Journal of Clinical Nursing, 22 (1), pp. 148-158. HATHAWAY, C., and EIRING, K., (2011). Mindfulness and Sports Psychology for Athletes: Consider Awareness Your Most Important Mental Tool. Madison, WI: lulu.com.1 HAWKINS, P., and SHOHET, R., (2012). Supervision in the Helping Professions: An Individual, Group and Organizational Approach. 4 th edn. Milton Keynes: Open University. HEFFERNAN, M., GRIFFIN, M., MCNULTY, R. and FITZPATRICK, J., (2010). Selfcompassion and emotional intelligence in nurses. International Journal of Nursing Practice, 16, pp. 366-373. 82

JAZAIERI, H., JINPA, G., MCGONIGAL, K., ROSENBERG, E., FINKELSTEIN, J., SIMON-THOMAS, E., CULLEN, M., DOTY, J., GROSS, J. and GOLDIN, P., (2012). Enhancing compassion: a randomized controlled trial of a compassion cultivation training programme. Journal of Happiness Studies, Published Online 25 th July 2012 [Available from: DOI 10.1007/s10902-012-9373z] [Date accessed: 21 st April 2014]. KABAT-ZINN, J., (2004). Full Catastrophe Living: How to Cope With Stress, Pain and Illness Using Mindfulness Meditation. 15th Anniversary edn. London: Paitikus. KENDALL, J., (2003). Designing a research project: randomised controlled trials and their principles. Emergency Medicine Journal, 20, pp. 164-168. KENG, S-L., SMOSKI, M., and ROBINS, C., (2011). Effects of mindfulness on psychological health: a review of empirical studies. Clinical Psychology Review, 31, pp. 1041-1056. KHOURY, B., LECOMTE, T., FORTIN, G., MASSE, M., THERIEU, P., BOUCHARD, V., CHAPLEAU, M-A., PAQUIN, K., and HOFMAN, S., (2013). Mindfulness-based therapy: a comprehensive meta-analysis. Clinical Psychology Review, 33 (6), pp 763-771. KLEIN, R., (2013). The New Politics of the NHS: From Creation to Reinvention. 7 th edn. London: Radcliffe Publishing Ltd. KOLB, D., (1983). Experiential Learning: Experience as the Source of Learning and Development. New Jersey: Prentice Hall, Inc. MABEN, J., LATTER, S., and CLARK, J., (2007). The sustainability of ideals, values and the nursing mandate: evidence from a longitudinal study. Nursing Inquiry, 14 (2), pp. 99-113. 83

MACBETH, A., and GUMLEY, A., (2012). Exploring compassion: a meta-analysis of the association between self-compassion and psychopathology. Clinical Psychology Review, 32, pp. 545-552. MANN, S., (2004). People-work : emotion management, stress and coping. British Journal of Guidance and Counselling, 32 (2), pp. 205-221. MCCOWN, D., REIBEL, D. and MICOZZI, M., (2010). Teaching Mindfulness: A Practical Guide for Clinicians and Educators. London: Springer. MCEVOY, P., and RICHARDS, D., (2006). A critical realist rationale for using a combination of quantitative and qualitative methods. Journal of Research in Nursing, 11 (1), pp. 66-78. MCMURTRY, D., (2014). Studies in Mindfulness Taught Programme. Aberdeen: The University of Aberdeen. Available: http://www.abdn.ac.uk/study/courses/postgraduate/taught/studies_in_mindfulness [Date accessed: 21 st April 2014]. MCNIFF, J. and WHITEHEAD, J., (2011). All You Need to Know About Action Research. 2 nd edn. London: Sage Publications Ltd. MEDICAL RESEARCH COUNCIL, (2008). Developing and Evaluating Complex Interventions: New Guidance. London: Medical Research Council. Available: http://www.mrc.ac.uk/utilities/documentrecord/index.htm?d=mrc004871 [Date accessed: 21 st April 2014]. 84

MENTAL HEALTH (CARE AND TREATMENT) (SCOTLAND) ACT (2003). The Stationary Office Ltd. Available: http://www.legislation.gov.uk/asp/2003/13/pdfs/asp_20030013_en.pdf [Date accessed: 21 st April 2014]. MENTAL HEALTH FOUNDATION, (2014a). Children and Young People, Mental Health Foundation. Available: http://www.mentalhealth.org.uk/help-information/mental-health-az/c/children-young-people/ [Date accessed: 21 st April 2014]. MENTAL HEALTH FOUNDATION, (2014b). Stigma and Discrimination, Mental Health Foundation. Available: http://www.mentalhealth.org.uk/help-information/mental-health-az/s/stigma-discrimination/ [Date accessed: 21 st April 2014]. MERTON, R., (1949). Social Theory and Social Structure. New York: The Free Press. MID STAFFORDSHIRE NHS FOUNDATION TRUST INQUIRY REPORT, (2013a). Report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry: Volume 1: Analysis of Evidence and Lessons Learnt (Part 1). London: Stationary Office. Available: http://www.midstaffspublicinquiry.com/sites/default/files/report/volume%201.pdf [Date accessed: 21 st April 2014]. MID STAFFORDSHIRE NHS FOUNDATION TRUST INQUIRY REPORT, (2013b). Report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry: Volume 2: Analysis of Evidence and Lessons Learnt (Part 2). London: Stationary Office. Available: http://www.midstaffspublicinquiry.com/sites/default/files/report/volume%202.pdf [Date accessed: 21 st April 2014]. 85

MID STAFFORDSHIRE NHS FOUNDATION TRUST INQUIRY REPORT, (2013c). Report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry: Volume 3: Present and Future Annexes. London: Stationary Office. Available: http://www.midstaffspublicinquiry.com/sites/default/files/report/volume%203.pdf [Date accessed: 21 st April 2014]. NAIRN, R., NIXON, G., CHODEN, REGAN-ADDIS, H., MCMURTRY, D., and CRAIG, L., (2010a). Aberdeen University Postgraduate Studies in Mindfulness MSc Mindfulness Weekend One. Mindfulness Association Ltd. NAIRN, R., NIXON, G., CHODEN, REGAN-ADDIS, H., and NEVEJAN, A., (2010b). Aberdeen University Postgraduate Studies in Mindfulness MSc Mindfulness Weekend Two. Mindfulness Association Ltd. NAIRN, R., NIXON, G., CHODEN, REGAN-ADDIS, H., and ADAMS, F., (2011a). Aberdeen University Postgraduate Studies in Mindfulness MSc Insight Weekend One. Mindfulness Association Ltd. NAIRN, R., NIXON, G., CHODEN, REGAN-ADDIS, H., and ADAMS, F., (2011b). Aberdeen University Postgraduate Studies in Mindfulness MSc Insight Weekend Two. Mindfulness Association Ltd. NAIRN, S., (2012). A critical realist approach to knowledge: implications for evidence-based practice in and beyond nursing. Nursing Inquiry, 19 (1), pp. 6-17. 86

NATIONAL HEALTH SERVICE EDUCATION FOR SCOTLAND (NHS NES), (2012). The National Framework for Pre-registration Mental Health Nursing Field Programmes in Scotland 2012. National Health Service Education for Scotland. Available: http://www.nes.scot.nhs.uk/media/898307/pre-reg_mh_frame.pdf [Date accessed: 21 st April 2014]. NATIONAL HEALTH SERVICE EDUCATION FOR SCOTLAND (NHS NES), (2013). Listen Learn Act: Harnessing the Power of Personal Stories to Drive Service Improvement: Information and Guidance for Staff on Story-Gathering. National Health Service Education for Scotland. Available: http://www.nes.scot.nhs.uk/media/2478328/listen-learn-act.pdf [Date accessed: 21 st April 2014]. NATIONAL HEALTH SERVICE EDUCATION FOR SCOTLAND (NHS NES), (2014). Leading Better Care- Delivering for Patients. National Health Service Education for Scotland. Available: http://www.evidenceintopractice.scot.nhs.uk/leading-better-care.aspx [Date accessed: 21 st April 2014]. NATIONAL HEALTH SERVICE EDUCATION FOR SCOTLAND (NHS NES) AND THE SCOTTISH GOVERNMENT, (2011). Mental Health in Scotland: A Guide to Delivering Evidence-Based Psychological Therapies in Scotland. National Health Services Education for Scotland and the Scottish Government. Available: http://www.nes.scot.nhs.uk/media/20137/psychology%20matrix%202013.pdf [Date accessed: 21 st April 2014]. NATIONAL HEALTH SERVICE INFORMATION SERVICES DIVISION (NHS ISD), (2014a). Child & Adolescent Mental Health Services in NHS Scotland: Workforce Information as at 30 th December 2013. National Health Services Information Services Division. Available: https://isdscotland.scot.nhs.uk/health- Topics/Workforce/Publications/2014-02-25/2014-02-25-CAMHS-Report.pdf?66816347838 [Date accessed: 21 st April 2014]. 87

NATIONAL HEALTH SERVICE INFORMATION SERVICES DIVISION (NHS ISD), (2014b). Child & Adolescent Mental Health Services (CAMHS) Benchmarking Balanced Scorecard. National Health Services Information Services Division. Available: http://www.isdscotland.org/health-topics/quality-indicators/publications/2014-03-25/2014-03-25-camhs-balanced-scorecard-report.pdf [Date accessed: 21 st April 2014]. NATIONAL HEALTH SERVICE (NHS) NATIONAL RESEARCH ETHICS SERVICE, (2010). Defining Research: NRES Guidance to Help You Decide if Your Project Requires by a Research Ethics Committee. National Health Service National Patient Safety Agency. Available: http://www.hpa.org.uk/webc/hpawebfile?hpaweb_c/1272032326180 [Date accessed: 10 th December 2012]. NATIONAL HEALTH SERVICE (NHS) SCOTLAND, (2014). KSF Guidance. National Health Services Scotland. Available: http://www.ksf.scot.nhs.uk/ [Date accessed: 21 st April 2014]. NEFF, K., (2003). Development and validation of a scale to measure self-compassion. Self and Identity, 2, pp. 223-250. NEFF, K. and GERMER, C., (2013). A pilot study and randomized controlled trial of the Mindful Self-Compassion Program. Journal of Clinical Psychology, 69 (1), pp 28-44. Published Online 15 th October 2012. [Available from: DOI 10.1002/jclp.21923] [Date accessed: 21 st April 2014]. NIGHTINGALE, F., (2000). Notes on Nursing: What it is, and What it is Not. New York: Dover Publications Inc. 88

NIXON, G., CHODEN, REGAN-ADDIS, H., and NEVEJAN, A., (2011). Aberdeen University Postgraduate Studies in Mindfulness MSc Compassion Weekend Two. Mindfulness Association Ltd. NURSING AND MIDWIFERY COUNCIL (NMC), (2008). The Code: Standards of Conduct, Performance, and Ethics for Nurses and Midwives. London: Nursing and Midwifery Council. Available: http://www.nmc-uk.org/nurses-and-midwives/the-code/thecode-in-full/ [Date accessed: 21 st April 2014]. NURSING AND MIDWIFERY COUNCIL (NMC), (2010a). Essential Skills Clusters (2010): Standards for Pre-registration Nursing Education- Annexe 3. London: Nursing and Midwifery Council. Available: http://standards.nmc- uk.org/publisheddocuments/annexe%203%20- %20Essential%20skills%20cluster%20and%20guidance%2020100916.pdf [Date accessed: 21 st April 2014]. NURSING AND MIDWIFERY COUNCIL (NMC), (2010b). Good Health and Good Character: Guidance for Approved Educational Institutions. London: Nursing and Midwifery Council. Available: http://www.nmc-uk.org/documents/guidance/nmcgood- HealthAndGoodCharacterGuidanceForApprovedEducationInstitutions.PDF [Date accessed: 21 st April 2014]. NURSING AND MIDWIFERY COUNCIL (NMC), (2010c). What is Fitness to Practice? London: Nursing and Midwifery Council. Available: http://www.nmc-uk.org/hearings/whatis-fitness-to-practise/ [Date accessed: 21 st April 2014]. 89

O HERLIHY, A., WORRALL, A., and BANERJEE, S. (2001). National Inpatient Child and Adolescent Psychiatry Study (NICAPS): Final Report to the Department of Health. London: Royal College of Psychiatrists. NURSING AND MIDWIFERY COUNCIL (NMC), (2013). NMC Response to the Francis Report: The Response of the Nursing and Midwifery Council to the Mid Staffordshire NHS Foundation Trust Public Inquiry Report. London: Nursing and Midwifery Council. Available: http://www.nmcuk.org/documents/francis%20report/nmc%20response%20to%20the%20francis%20report %2018%20July.pdf [Date Accessed: 21 st April 2014]. OWENS, P., and MEIKLE, J., (2013). Mid Staffordshire Trust inquiry report published. The Guardian: Guardian News and Media Ltd. Available: http://www.theguardian.com/society/blog/2013/feb/06/mid-staffordshire-nhs-trust-inquiryreport-published-live [Date accessed: 21 st April 2014]. PATTERSON, P., WHITTINGTON, R., and BOGG, J., (2007). Testing the effectiveness of an educational intervention aimed at changing attitudes to self-harm. Journal of Psychiatric and Mental Health Nursing, 14 (1), pp. 100-105. PAWSON, R., (2013). Realistic Evaluation: A Realist Manifesto. London: Sage Publications Ltd. PAWSON, R., and MANZANO-SANTAELLA, A., (2012). A realist diagnostic workshop. Evaluation, 18 (2), pp. 176-191. PAWSON, R. and TILLEY, N., (1997). Realistic Evaluation. London: Sage Publications Ltd. 90

PILGRIM, D., (2009). Key Concepts in Mental Health. 2 nd edn. London: Sage Publications Ltd. POLLOCK, A., (2005). NHS PLC. London: Verso. POPPER, K., (1992). The Logic of Scientific Discovery. 5 th edn. London: Routledge. RAFFERTY, A-M., (2011). We can read Nightingale as a credo for compassion. Nursing Times Ethical and Compassionate Nursing Supplement. Nursing Times. Available: http://www.nursingtimes.net/journals/2011/08/24/j/y/s/nt-ethical--compassionate-care.pdf [Date accessed: 21 st April 2014]. RANSTAD UK, (2013). Social Workers Have Among the Highest Levels of Professional Pride in the UK. Luton: Ranstad UK. Available: http://www.randstad.co.uk/care/news/socialworkers-have-among-the-highest-levels-of-professional-pride/ [Date accessed: 21 st April 2014]. REPORT OF THE WILLIS COMMISSION, (2012). Quality with Compassion: The Future of Nursing Education. London: The Royal College of Nursing. Available: http://www.williscommission.org.uk/ data/assets/pdf_file/0007/495115/willis_commission _report_jan_2013.pdf [Date accessed: 21 st April 2014]. ROBSON, C., (2010). Evaluation research. In: K. GERRITY and A. LACEY, eds, The Research Process in Nursing. 6th edn. Oxford: Wiley-Blackwell. pp. 248-256. ROSS, C., and GOLDNER, E., (2009). Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: a review of the literature. Journal of Psychiatric and Mental Health Nursing, 16 (6), pp. 558-567. 91

ROYAL COLLEGE OF NURSING (RCN), (2011). Mandatory Nurse Staffing Levels. London: Royal College of Nursing. Available: https://www.rcn.org.uk/ data/assets/pdf_file/0009/439578/03.12_mandatory_nurse_staffing _levels_v2_final.pdf [Date accessed: 21 st April 2014]. ROYAL COLLEGE OF PSYCHIATRISTS (RCP), (2014). - Improving the Lives of People with Mental Illness- The Physical Health Needs of People with Mental Health Problems. London: Royal College of Psychiatrists. Available: http://www.rcpsych.ac.uk/workinpsychiatry/qualityimprovement/qualityandaccreditation/liais onpsychiatry/plan/nohealthwithout/professionals/thephysicalhealthneeds.aspx [Date accessed: 21 st April 2014]. RUTHS, F., ZOYSA, N., HUTTON, J., WILLIAMS, J., and WALSH, J., (2012). Mindfulness-based cognitive therapy for mental health professionals- a case study, Mindfulness, Online First Published 3 rd August 2012 [Available from: DOI 10.1007/s12671-012-0127-0] [Date accessed: 21 st April 2014]. SABO, M., (2006). Compassion fatigue and nursing work: can we accurately capture the consequences of caring work? International Journal of Nursing Practice, 12 (3), pp. 134-142. SALZBERG, S., (2002). Loving-Kindness: The Revolutionary Art of Happiness. Boston, Massachusetts: Shambala Publications, Inc. SAUER-ZAVALA, S., WALSH, E., EISENLOHR-MOUL, T., and LYKINS, E., (2013). Comparing mindfulness-based intervention strategies: differential effects of sitting meditation, body scan, and mindful yoga. Mindfulness, Online First Published 12 th August 2012 [Available from: DOI 10.1007/s12671-012-0139-9] [Date accessed: 21 st April 2014]. 92

SAYER, A., (2000). Critical Realism and Social Science. London: Sage Publications Ltd. SCOTTISH EXECUTIVE, THE, (2005). Delivering for Health. The Scottish Executive. Available: http://www.scotland.gov.uk/resource/doc/76169/0018996.pdf [Date accessed: 21 st April 2014]. SCOTTISH GOVERNMENT, THE, (2010). The Healthcare Quality Strategy for NHS Scotland. The Scottish Government. Available: http://www.scotland.gov.uk/resource/doc/311667/0098354.pdf [Date accessed: 21 st April 2014]. SCOTTISH GOVERNMENT, THE, (2011). Commission on the Future Delivery of Public Services. The Scottish Government. Available: http://www.scotland.gov.uk/resource/doc/352649/0118638.pdf [Date accessed: 21 st April 2014]. SCOTTISH GOVERNMENT, THE, (2012). Mental Health Strategy for Scotland 2012-2015. The Scottish Government. Available: http://www.scotland.gov.uk/resource/0039/00398762.pdf [Date accessed: 21st April 2014]. SCOTTISH GOVERNMENT, THE, and NATIONAL HEALTH SERVICE (NHS) SCOTLAND, (2013). Everyone Matters: 2020 Workforce Vision. The Scottish Government. Available from: http://www.scotland.gov.uk/resource/0042/00424225.pdf [Date accessed: 21 st April 2014]. SCOTTISH RECOVERY NETWORK (SRN), (2014). Recovery: What is Recovery? Scottish Recovery Network. Available: http://www.scottishrecovery.net/what-is-recovery/what-isrecovery.html [Date accessed: 21 st April 2014]. 93

SCOTTISH RECOVERY NETWORK (SRN), (2009). Journeys of Recovery: Stories of Hope and Recovery From Long Term Mental Health Problems. Glasgow: Scottish Recovery Network. Available: http://www.scottishrecovery.net/related-documents/relateddocuments.html [Date accessed: 21 st April 2014]. SEGAL, Z., WILLIAMS, J. and TEASDALE, J., (2012). Mindfulness-Based Cognitive Therapy for Depression. 2nd edn. London: The Guilford Press. SHAPIRO, S., ASTIN, J., BISHOP, S., CORDOVA, M., (2005). Mindfulness-based stress reduction for professionals: results from a randomised trial. International Journal of Stress Management, 12 (2), pp 164-176. SHAPIRO, S., BROWN, K., and BIEGEL, G., (2007). Teaching self-care to caregivers: effects of mindfulness-based stress reduction on the mental health of therapists in training. Training and Education in Professional Psychology, 1 (2), pp. 105-115. SHAPIRO, S., and CARLSON, L., (2009). The Art and Science of Mindfulness. Washington, DC: American Psychological Association. SIEGEL, R., GERMER, C., and OLENDZKI, A., (2009). Mindfulness: what is it? Where did it come from? In: DIDONNA, F., ed, Clinical Handbook of Mindfulness. New York: Springer. pp. 17-35. SIMONS, L., and LATHLEAN, J., (2010). Mixed methods. In: GERRISH, K., and LACEY, A., eds, The Research Process in Nursing. 6 th edn. Oxford: Wiley-Blackwell. pp. 331-342. SIMPSON, A., (2009). The acute care setting. In: P. BARKER, ed, Psychiatric and Mental Health Nursing: The Craft of Caring. London: Hodder Arnold. pp. 403-409. 94

SMITH, M., and LIEHR, P., (2013). Middle Range Theory for Nursing. 3 rd edn. New York: Springer Publishing, LLC. SMITH, P., (2012). The Emotional Labour of Nursing Revisited: Can Nurses Still Care? Basingstoke: Palgrave MacMillan. SMITH, S., DEWAR, B., PULLIN, S. and TOCHER, R., (2010). Relationship-centred outcomes focused on compassionate care for older people within in-patient care settings. International Journal of Older People, 5 (2), pp. 128 136. SPANDLER, H., and STICKLEY, T., (2011). No hope without compassion: the importance of compassion in recovery-focused mental health services. Journal of Mental Health, 20 (6), pp. 555-566. STANLEY, E., SCHALDACH, J., KIYONAGA, A., and JHA, A., (2011). Mindfulnessbased mind fitness training: a case study of a high stress pre-deployment military cohort. Cognitive and Behavioral Practice, 18 (4), pp. 566-576. STICKLEY, T., and FRESHWATER, D., (2002). The art of loving and the therapeutic relationship. Nursing Inquiry, 9 (4), pp. 250-256. STICKLEY, T. and FRESHWATER, D., (2008). Therapeutic relationships. In: T. STICKLEY and T. BASSET, eds, Learning About Mental Health Practice. Chichester: John Wiley & Sons Ltd. pp. 439 62. STOBER, J., (2001). The Social Desirability Scale- 17 (SDS-17): convergent validity, discriminant validity, and relationship with age. European Journal of Psychology Assessment, 17, pp. 222-232. 95

TAN, C-M, (2012). Search Inside Yourself: Increase Productivity, Creativity and Happiness. London: HarperCollinsPublishers. THEODOSIUS, C., (2008). Emotional Labour in Health Care: The Unmanaged Heart of Nursing. Abingdon, Oxon: Routledge. TRAYNOR, M., (2013). Nursing in Context: Policy, Politics, Profession. London: Palgrave Macmillan. TUCKMAN, B., (1965). Developmental sequence in small groups. Psychological Bulletin, 63 (6), pp. 384-399. VAN DE MORTEL, T., (2008). Faking it: social desirability response bias in self-report research. Australian Journal of Advanced Nursing, 25 (4), pp. 40-48. VETTESE, L., TONEATTO, T., STEA, J., NGUYEN, L., and WANG, J., (2009). Do mindfulness meditation participants do their homework? And does it make a difference? A review of the empirical evidence. Journal of Cognitive Psychotherapy: An International Quarterly, 23 (3), pp. 198-225. VON DIETZE, E., and ORB, A., (2000). Compassionate care: a moral dimension of nursing. Nursing Inquiry, 7, pp. 166 174. VGOTSKY, L., (1978). Mind in Society: The Development of Higher Psychological Processes. Cambridge, Massachusetts: Harvard University Press. 96

WALLACE, D., (2009). Mp3 Audio. This is Water: The Original recording: Some Thoughts, Delivered on a Significant Occasion, About Living a Compassionate Life. Hachette Audio WALSH, K., DUKE, M., FOUREUR, M., MACDONALD, L., (2007). Designing an effective evaluation plan: a tool for understanding and planning evaluations for complex nursing contexts. Contemporary Nurse, 25, pp. 136-145. WAND, T., WHITE, K., and PATCHING, J., (2011). Realistic evaluation of an emergency department-based mental health practitioner outpatient service in Australia. Nursing and Health Sciences, 13, pp. 199-206. WATSON, H., BOOTH, J., and WHYTE, R., (2010). Observation. In: GERRISH, K., and LACEY, L., eds, The Research Process in Nursing. 6 th edn. Oxford: Wiley-Blackwell. pp. 382-394. WILLIAMS, J., and STICKLEY, T., (2010). Empathy and nurse education. Nurse Education Today, 30 (8), pp. 752-755. WILSON, G., (1996). Manual-based treatment and clinical practice. Clinical Psychology: Science and Practice, 5 (3), pp. 363-375. 97

9. Appendices 9.1 The nursing posts and NHS Agenda for Change pay bandings applicable to project participants Post Description Band Nursing assistant Untrained/ non-registered nurse Staff Nurse Registered with the NMC 5 Charge Nurse Community Psychiatric Nurse Senior Charge Nurse Nurse Manager Registered nurse with line management and clinical responsibilities Registered nurse who can work independently in community settings Registered nurse with line management, clinical and team leadership responsibilities Registered nurse with line management, service-wide leadership and strategic planning responsibilities 2 6 6 7 8 98

9.2 Mindful compassion training for nurses (MCTN) group programme themes Week 1: 5 th April 2013: An introduction to the programme An overview of current compassion training theory, research and practice. Getting to know each other as a group. Establishing group rules and expectations. Week 2: 12 th April: Preparing for compassion with mindfulness practice Using the body as a place to stay present. Introduction to the body scan practice. Practising mindfulness in everyday life Week 3: 19 th April: Deepening mindfulness support Walking mindfulness. Mindfulness practice using the support of sounds and smells. Mindfulness practice using breathing. The three minute breathing space practice. Week 4: 26 th April: Paul Gilbert s compassion-focused approach Establishing soothing rhythm breathing. How compassion training can affect emotion regulation. An introduction to compassion practices. 99

Week 5: 3 rd May: The importance of values and self-acceptance Identifying our values. Working with obstacles to mindfulness and compassion. Giving ourselves a break with self-compassion. Week 6: 17 th May: Working with thoughts and feelings Identifying and working with critical thoughts and feelings. Guided acceptance practice. Using a compassionate focus for support. Week 7: 24 th May: Loving kindness An introduction to this traditional meditation and its secular uses. Guided loving kindness practices. Week 8: 31 st May: Tonglen practice Tonglen is a traditional Buddhist practice presented here as a secular compassion meditation. Tonglen means sending and receiving compassion. As is the case for loving kindness, an overview will be given of its theory and background, followed by some guided practices. Concluding the group. 100

9.3 Participant Information Sheet Participant Information Sheet for CAMHS Nurses Study Title: An evaluation of mindful compassion training for nurses I would like to invite you to take part in my research project, which is part of an MSc degree course with Aberdeen University in Studies in Mindfulness. On that course I have been taught mindfulness and compassion-focused meditation techniques which are currently being used and researched in mainstream health settings and with the general population. In this project I would like to train nursing colleagues in those techniques and evaluate their impact and potential. You do not need to make a decision immediately about whether or not you would like to participate. Before you make your decision, it is important that you take some time to understand why I am carrying out this research and what it involves. Please read the following information carefully. If you have any questions you can speak to me in person, phone me on xxxx-xxx-xxxx or xxxxxxxxxxx, or e-mail me at gavin.cullen@xxxxxxxxxxxxxxxxxxxxxx. What is the research project about? A) Group training I would like to train between 8 and 12 nurses from the CAMHS Inpatient Unit and Day/ Intensive Treatment Services in mindful compassion techniques in 8 weekly one and a half hour groups beginning in February 2013. The techniques taught in the group have been shown in other research to help maintain and improve psychological well-being, including happiness, and physical well-being; to alleviate psychological problems, especially anxiety, depression and stress; and to enhance selfcompassion and compassion for others. Researchers are also interested in the potential mindful compassion techniques have for improving relationships, including professional, therapeutic relationships. 101

The intention behind this training is to offer you resources which may be of use to you professionally or personally and in recognition of your important clinical role in CAMHS. I will teach the techniques in the group and will also invite group participants to practice them in their own time, for a minimum of 15 minutes a day, gradually increasing to 30 minutes as the training progresses. Participants will also be given an audio recording of the main techniques to support home practice once the group is underway, and I will also provide relevant hand-outs during the training and a resource pack and certificate at the end. In addition to the weekly group sessions there will be a further optional half-day of practice for participants to reinforce the main techniques and foster group support. This would need to take place in our own time. An outline of the group training themes is attached to this information sheet as an appendix. B) Evaluation I would like to ask group participants to complete three self-report questionnaires before and after the training to try and determine what impact it has had. I would also then like to interview at least some of you on a 1:1 basis to discuss how you found the training, including what benefits or problems you had with it and whether or not you would continue with such an approach. Although of course I value the training I am offering you here, I am equally interested in what works and what does not for any of the participants. I would also like to invite nurses who were not able to participate in the group training or who did not want to do so to complete the same self-report questionnaires before and after the training takes place. As above, I would also like to follow-up those outcome measures by interviewing some of you on a 1:1 basis about the questionnaires and the project aims. This will help provide an interesting comparison and give the project more balance. Finally, I hope to recruit two Senior Charge Nurses to the project. They will also be asked to complete the same questionnaires and to take part in interviews after the training has finished to give me their impressions of the project. Why I am asking you to take part? 102

As stated above, because you are a nurse in CAMHS. As you know, I am a nurse too, and I am interested in comparing the approach to considering compassion in this project with the existing literature and research into compassion in nursing. Do you have to take part? No, it is up to you. If you decide you want to take part, I will ask you to sign a consent form. This form will be used to check that you know what you are agreeing to. You have the right to withdraw from the project at any point. Another important aspect of deciding to take part in this project is to agree participation with your line manager. Because the group training will take place in work time, the training needs to be an agreed part of your Personal Development Plan (PDP). What will happen next? If you decide to take part please let me know by the end of December 2012. You can do so in person or using the phone or e-mail contact information given above. I will also be in touch with your Senior Charge Nurse about the project and practical arrangements for it. Please let me know if you wish to participate in the group training or the evaluation-only part of the project. On receipt of this information I will then arrange to meet you to complete the self-report questionnaires and/ or to make arrangements for the group training. What will you have to do? If you are participating in the group training you will be asked to participate in 8 weekly group training sessions in mindful compassion techniques with some home practice and an optional half-day practice session, as described above. You do not have to bring anything in particular to the first group and you do not have to have prior experience of mindfulness or compassion meditation. Your clothing should of course comply with NHS Xxxxxxx dress code but it would be helpful to wear warm, comfortable clothing that you can also stretch in. You will also be asked to complete three questionnaires, which will take about 30 minutes for 103

all three, and some of you will be invited to 1:1 interviews with me. These will last for about one hour and will be audio recorded. The interviews will be semi-structured, i.e. some questions will be prepared in advance but there will be scope to consider any topic important to you. If you are participating in the evaluation-only part of the project, the same information given above applies in respect of the questionnaires and interviews. Are there downsides to taking part? The main thing to note is that you are being asked to give up some of your working time and personal time to participate in the group. You may also be concerned that by participating in the group, there will be a pressure on colleagues to keep your service going while you are doing the training. This aspect of the project has been managed by negotiating agreement with CAMHS nurse management that the training takes place and does so within the CAMHS Inpatient Unit daily handover time, between 1.00 pm and 3.00 pm. This is also one of the reasons this training needs to be part of your agreed PDP. Approval for the course will also be obtained from xxx xxxxxxxxxx, Director of Operations for the xxxxx xxxxxxxxx xxxxxxxx. There is also a possibility that participating in mindfulness or compassion meditation techniques will lead to you getting in touch with difficult thoughts and feelings. This is something which is normal for most people engaging in those practices and which we will discuss in the group training sessions. I will also be available between sessions for private discussions, you will be able to speak to your line manager about these things, and xxxxxx xxxxxx, Senior Charge Nurse, will be available as someone you can approach who is independent to the project while it is underway should you wish to discuss any problems you are having with it. Will information about you be kept confidential? Your line manager, immediate and wider CAMHS colleagues are likely to know that you are participating in the group training however I will ask all group participants to keep personal information disclosed in the group confidential. Please note that the group training is not a form of therapy; its purpose is skills training and resource-building. 104

All information gathered from outcome measures and interviews will be kept confidential and all data will be made anonymous. All participants can receive a copy of their own outcome measure data if they wish. Records and information from the project including audio recordings will be destroyed one year after the group training has ended. What are the possible benefits of taking part? There are many possible benefits, as stated above. These include: improved psychological well-being and resilience; improved physical well-being; increased self-compassion and compassion for others; and improved relationships with others, including professionally. What will happen to the results of the study? The final project report will be submitted as an MSc dissertation to Aberdeen University and a summary of this will be presented to project participants, with your agreement, and at a University conference in 2014. Summaries will also be sent to xxx xxxxxxxxxx and the people and organisations which have supported and sponsored the MSc. These are: xxxx xxxxxx, CAMHS Nurse Manager; xxxxx xxxxx, Chief Nurse, xxxx; the NHS xxxxxx Staff Lottery; and the Foundation for Professionals involved in Services for Adolescents (FPSA). Who is organising and funding the research? This project is the final part of my MSc with Aberdeen University. Although I have received funding to support my studies from NHS xxxxxx this project is not being funded directly by them. Who has reviewed the study? The project has been reviewed and given managerial approval by xxx xxxxxxxxxx and the local Research and Development Department in NHS xxxxxx. The latter department has also confirmed that the project does not require formal ethics committee approval. The project is also being supervised by Dr Graeme Nixon of Aberdeen University, whose details are provided below. 105

Thank you for reading about this project and for any further involvement you may have. Gavin Cullen Senior Charge Nurse NHS Xxxxxxx CAMHS Contact numbers: xxxx-xxx-xxxx or xxxxxxxxxxx E-mail address: gavin.cullen@xxxxxxxxxxxxxxxxxxxxx Academic supervisor at Aberdeen University: Dr Graeme Nixon Aberdeen University School of Education MacRobert Building King s College Aberdeen AB24 5UA Contact number: 01224-274776 E-mail address: g.nixon@abdn.ac.uk 106

9.4 Consent forms: Cohort 1: Evaluation of a mindful compassion training programme for nurses (MCT-N) consent form. Thank you for agreeing to consider participating in this research project. The purpose of this form is to check that you have read, considered and had a chance to talk about involvement in the project with the researcher, Gavin Cullen. Please circle yes or no in answer to the following questions and sign and date the form on page two if you are in agreement to do so: 1. I have read and understand the Participants Information Sheet for the MCTN project: YES / NO 2. I have been given enough time to consider participation in the project: YES / NO 3. I have had an opportunity to discuss and agree participation in the project with my line manager: YES / NO 4. I have had an opportunity to raise any questions or concerns I have about the MCTN programme with the researcher: YES / NO 5. I understand that although the MCTN programme is not a therapy group comments made during the group by anyone participating in it have to remain confidential within the group unless the group consents to share information: YES / NO 6. I have discussed with the researcher the main support mechanisms available to me during and after the MCTN programme: YES / NO 7. I understand that information gathered during the project about me will be retained and stored safely by the researcher for the duration of the project and for one year following its completion, i.e. until November 2014, at which point it will be destroyed: YES / NO 107

8. I agree to being interviewed by the researcher following completion of the MCTN programme: YES / NO 9. I understand that I have the right to withdraw consent and withdraw from the project at any time and if I do so information about me will be removed from the project and destroyed: YES / NO Name (print please): Signature: Date: (Version 1 10 th December 2012). 9.4 continued: Consent form for cohorts 2 and 3 Evaluation of a mindful compassion training programme for nurses (MCTN) consent form. Thank you for agreeing to consider participating in this research project. The purpose of this form is to check that you have read, considered and had a chance to talk about involvement in the project with the researcher, Gavin Cullen. Please circle yes or no in answer to the following questions and sign and date the form on page two if you are in agreement to do so: 1. I have read and understand the Participants Information Sheet for the MCTN project: YES / NO 2. I have been given enough time to consider participation in the project: YES / NO 3. I have had an opportunity to discuss and agree participation in the project with my line manager: YES / NO 4. I have had an opportunity to raise any questions or concerns I have about the MCTN programme with the researcher: YES / NO 108

5. I understand that information gathered during the project about me will be retained and stored safely by the researcher for the duration of the project and for one year following its completion, i.e. until November 2014, at which point it will be destroyed: YES / NO 6. I agree to being interviewed by the researcher following completion of the MCTN programme: YES / NO 7. I understand that I have the right to withdraw consent and withdraw from the project at any time and that if I do so information about me and will be removed from the project and destroyed: YES / NO Name (print please): Signature: Date: (Version 1 10 th December 2012). 109

9.5: Sample baseline demographic information question sheet (for cohort 1) and supplementary demographic information for cohorts one and two Copies of all baseline demographic information question sheets will be provided to Aberdeen University in a separate data file. Sample baseline demographic information question sheet Thank you for agreeing to take part in this project. I would like to gather some basic background information about all the nurses taking part in it. This will be kept in a locked cabinet in my office for the duration of the project and for one year afterwards, at which point it will be destroyed (in November 2014). No identifying information about you will appear in the final project report or project summaries. There are no wrong answers to any of the questions I ask you and you do not have to answer any question you do not want to. 1. Name: 2. Age: 3. Gender: 4. Ethnic group: 5. Relationship status: 6. Family status (i.e. children): 7. Trained or untrained nurse: 110

8. Date completed training if applicable: 9. How long have you been working in CAMHS? 10. What other services have you worked in prior to CAMHS? 11. Why do you want to participate in this project- what do you hope to get out of it? 12. Are there any things that concern you about taking part? 13. Do you have previous experience of mindfulness or compassion-focused meditation experience? 14. If the answer to question 11 is yes, can you briefly describe that experience? 15. Do you have previous experience of any form of compassion training, lectures, discussions or reading as a nurse? 16. If the answer to question 13 is yes, can you briefly describe that experience? 17. As you know, I am asking participants to practice mindfulness and compassionfocused techniques for 15 minutes a day initially then 30 minutes as the training progresses. Do you anticipate any challenges with doing that? 111

18. If the answer to question 15 is yes, can you briefly describe what those challenges might be? 19. If the answer to question 15 is no, can you briefly describe why that is the case? 20. Do you currently have any health problems? 21. If the answer to question 18 is yes, can you describe them briefly and what you are doing to manage them? Are there any health issues it would be important for us to be aware of during the group sessions (for example, lower back pain from sitting for longer periods)? 22. What things do you do to relax and look after yourself physically, psychologically or socially? 23. What things do you do to look after yourself when you are under pressure or stress? (Version 1 10th December 2012). Supplementary demographic information for cohorts one and two Information already provided in the main body of the text in Chapter 3.4: Cohort one Cohort two Combined Number of 10 10 20 participants Age range 26-53 31-51 26-53 112

Females: males Trained: untrained nurses Range of years of service Adult mental health service experience Experience of nursing in a psychiatric IPU 8:2 5:5 13:7 8:2 9:1 17:3 4-25 1-11 1-25 8 nurses 6 nurses 14 nurses 100% 100% 100% Summary of other baseline information gathered Previous experience of meditation practice: 15 out of 20 nurses between cohort one and two stated during baseline interviews they had previous experience of meditation practice, most participants meant that they had been introduced to the idea of practice through reading or one-off events, such as a mindfulness seminar held in the project setting a few years ago. No participants had tried to establish a regular practice routine previously; none had a current regular practice; and none of the participants who had attended one-off events had then tried to practice the techniques after the event. The author s view is that the participants were mostly keen on finding out more about meditation training and were familiar with mindfulness and compassion as concepts, but overall were effectively new to the terrain. Only one participant, Susan in cohort two, stated she was not interested in further training, having not enjoyed the one-off mindfulness event in the project setting. During her project interview, however, she seemed to change her mind and become more interested. 113

Previous experience of any form of compassion training, lectures, discussions or reading as a nurse: If anything, participants had even less experience of compassion in nursing than meditation experience. This may be because most participants in both cohorts had been working as nurses for several years and as such their nurse training would not have included the explicit emphasis in student nurse training today. Only two participants in cohort one stated they had encountered some form of compassion training. This was in relation to their training in the project organisational setting as trainers in management of aggression techniques, in which the value of kindness as a measure to prevent aggression was mentioned. All participants were, of course, familiar with the term compassion, and in both cohorts all participants were interested in it as a topic. Cohort one participants methods of relaxing, looking after themselves, including when they are under pressure: Method: Number of people using the method: Exercise 6 Listening to music 1 Telling someone your problem 3 By not making plans 1 Socialising/ family & friends 5 Pets 3 Baking/ cooking 2 Religious practice/ faith 1 Healthy diet 1 114

Reading 6 Watching TV 3 Holidays 1 Having a bath 1 Playing music 1 Being with partner 2 Painting 1 Playing computer games 2 Cohort two participants methods of relaxing, looking after themselves, including when they are under pressure: Method: Number of people using the method: Relaxation 1 Healthy diet 2 Reading 3 Playing music 2 Socialising/ family & friends 5 Telling someone your problem(s) 1 Exercise* 9 Being with partner 2 Attending gigs 2 Drinking beer 1 115

Being outdoors 5 Driving 1 Pets 1 *Exercise included a range of activities from walking, to yoga, to cycling, running and boxing. 116

9.6: Interview schedules (revised): Cohort 1: Thank you for agreeing to be interviewed. This will take up to an hour and, as you know, I will record it so that I can transcribe it fully later on. No identifying information about you from this interview will appear in the final project report or summaries and I will store the recordings and transcripts safely during the project. They will then be destroyed one year after the project ends, i.e. in November 2014. I would like to ask you some questions but I would also like you to feel free to say anything you would like that is related to the MCTN project or the questions I ask you. There are no wrong answers you can give me and you do not have to answer any question you do not want to. Also, I am equally interested in what things have worked for people and what things have not, so please do not feel that you have to compliment the training! As part of this interview we can also begin by taking a look at your before and after- training outcome measure scores if you would like to. This project s central focus is to answer the question: is MCTN useful to nurses in real terms? In order to explore that question there are two key project aims: To identify individual, social, professional and organisational contextual factors which influence MCTN outcomes, and To identify the key enablers and inhibitors for participants in those four domains. To explore those aims during the project so far I ve identified a number of themes that I believe impact on nurses capacity to engage with training like the MCTN programme and to engage with compassion. I d like to share those themes with you and hear your feedback about them, how they apply to you or not and whether or not they ring true for you. Following that, I might ask you some specific questions depending on how much we ve talked about already and how much time there is left. In no particular order, these are the themes: Nurses attitudes to compassion are closely linked to their clinical experience, for example violence in the IPU, self-harm or even suicide- so nurses might be fearful of being compassionate, believing that it would open them to exploitation or harm, or feel sad when they have been close to patients whose actions are then hurtful. 117

Many nurses are used to keeping busy, so the idea of stopping and sitting still to just be, or to hang out in meditation practice doing nothing seems really strange, perhaps challenging and might even make nurses feel guilty, even if sometimes it is also enjoyable to relax. Further, could keeping busy be a way of some nurses defending themselves against how they feel in response to the disturbing aspects of clinical practice? The NHS, hospital management and even your SCN all expect nurses to be keeping busy too! Nurses attitudes towards expressing feelings and looking after themselves psychologically in other ways, e.g. via personal or social behaviours such as exercise or going to the pub for a drink, are key to how they might engage with mindful compassion training. The above also overlaps with a theme of how nurses relate to self-kindness. There seem to be a range of attitudes in CAMHS nurses, from those who almost seem to be automatically kind to themselves to those who struggle with it and give themselves a hard time, and also a number of nurses who have really stopped to think about what self-kindness means. Previous experience of mindfulness or compassion meditation is also key, in that if you had never done either you might be more cautious about engaging with it. More concrete questions (if not covered already by exploring the above): What was your experience of compassion in nursing (CIN) prior to the MCTN programme? Did you think it was an important topic? If CIN is important, how could individual nurses, the nursing profession, wider CAMHS and the NHS pursue a compassion agenda? Has MCTN changed your perception of CIN? 118

Did you learn anything about yourself during the MCTN programme? Did you notice anything about how you responded psychologically or physically during group practice sessions or doing some practice in your own time? What changes, if any, do you notice about the way you think about yourself? What about the way you think about colleagues, young people, people at home or friends? How did you choose to be mindfully compassionate in your daily life? Have you changed how you interact with any of those people? Have you changed how you think about or interact with all beings? Have you noticed any changes in how other people interact with you? If you were interested in developing or maintaining the mindful compassion practices during the programme, can you identify things that helped you do so? What are the challenges of engaging with programmes like MCTN? Were there things that got in the way of you developing or maintaining the practices? 119

Do you intend to continue with mindful compassion practice? If you are, can you tell me how you are going to do this? Have there been any significant events or changes in your personal life that impacted on your ability to engage with MCTN or which MCTN supported you with? Have there been any significant events or changes in your working life that impacted on your ability to engage with MCTN or which MCTN supported you with? Is there anything else you feel we have not covered in this interview? (Version 1 10 th December 2012). 9.6 continued: interview schedule for cohort 2 (revised) Thank you for agreeing to be interviewed. This will take up to an hour and, as you know, I will record it so that I can transcribe it fully later on. No identifying information about you from this interview will appear in the final project report or summaries and I will store the recordings and transcripts safely during the project. They will then be destroyed one year after the project ends, i.e. in November 2014. I would like to ask you some questions but I would also like you to feel free to say anything you would like that is related to the MCTN project or the questions I ask you. There are no wrong answers you can give me and you do not have to answer any question you do not want to. During this interview we can also take a look at your before and after- training outcome measure scores if you would like to. This project s central focus is to answer the question: is MCTN useful to nurses in real terms? In order to explore that question there are two key project aims: To identify individual, social, professional and organisational contextual factors which influence MCTN outcomes, and 120

To identify the key enablers and inhibitors for participants in those four domains. To explore those aims during the project so far I ve identified a number of themes that I believe impact on nurses capacity to engage with training like the MCTN programme and to engage with compassion. I d like to share those themes with you and hear your feedback about them, how they apply to you or not and whether or not they ring true for you. Following that, I might ask you some specific questions depending on how much we ve talked about already and how much time there is left. In no particular order, these are the themes: Nurses attitudes to compassion are closely linked to their clinical experience, for example violence in the IPU, self-harm or even suicide- so nurses might be fearful of being compassionate, believing that it would open them to exploitation or harm, or feel sad when they have been close to patients whose actions are then hurtful. Many nurses are used to keeping busy, so the idea of stopping and sitting still to just be, or to hang out in meditation practice doing nothing seems really strange, perhaps challenging and might even make nurses feel guilty, even if sometimes it is also enjoyable to relax. Further, keeping busy could be a way of some nurses defending themselves against how they feel in response to the disturbing aspects of clinical practice. The NHS, hospital management and even your SCN all expect nurses to be keeping busy too! Nurses attitudes towards expressing feelings and looking after themselves psychologically in other ways, e.g. via personal or social behaviours such as exercise or going to the pub for a drink, are key to how they might engage with mindful compassion training. The above also overlaps with a theme of how nurses relate to self-kindness; there seem to be a range of attitudes in CAMHS nurses, from those who almost seem to be automatically kind to themselves to those who struggle with it and give themselves a hard time, and also a number of nurses who have really stopped to think about what self-kindness means 121

Previous experience of mindfulness or compassion meditation is also key, in that if you had never done either you might be more cautious about engaging with it. For participants who did not want to take part in MCTN: When we met before the MCTN programme began, you said was/ were the reason (s) you did not want to participate in the training. Has that changed in any way? Have you noticed any changes, whether those are positive or negative, in your colleagues who have completed the training? Have there been any significant events or changes in your personal life, including your health, and if so, what psychological or social resources did you use to deal with them (if any or if you needed to)? Have there been any significant events or changes in your working life and if so, what psychological, professional, organisational or social resources did you use to deal with them (if any or if you needed to)? Do you think that compassion in nursing (CIN) is an important topic? What is your experience of CIN to date? If CIN is important how could individual nurses, the nursing profession, wider CAMHS and the NHS pursue a compassion agenda? 122

Is there anything else you feel it is important to mention? For interviewees who were unable to attend the MCTN programme, the first question above would be omitted. (Version 1 10 th December 2012). 9.6 continued: interview schedule for cohort 3 line managers (revised) Thank you for agreeing to be interviewed. This will take up to an hour and, as you know, I will record it so that I can transcribe it fully later on. No identifying information about you from this interview will appear in the final project report or summaries and I will store the recordings and transcripts safely during the project. They will then be destroyed one year after the project ends, i.e. in November 2014. I would like to ask you some questions but I would also like you to feel free to say anything you would like that is related to the MCTN project or the questions I ask you. There are no wrong answers you can give me and you do not have to answer any question you do not want to. Also, I am equally interested in what things have worked for people and what things have not, so please do not feel that you have to compliment the training! This project s central focus is to answer the question: is MCT-N useful to nurses in real terms? In order to explore that question there are two key project aims: To identify individual, social, professional and organisational contextual factors which influence MCTN outcomes, and To identify the key enablers and inhibitors for participants in those four domains. To explore those aims during the project so far I ve identified a number of themes that I believe impact on nurses capacity to engage with training like the MCTN programme and to engage with compassion. I d like to share those themes with you and hear your feedback about them, how they apply to you or not and whether or not they ring true for you. Following that, I might ask you some specific questions depending on how much we ve talked about already and how much time there is left. In no particular order, these are the themes: 123

Nurses attitudes to compassion are closely linked to their clinical experience, for example violence in the IPU, self-harm or even suicide- so nurses might be fearful of being compassionate, believing that it would open them to exploitation or harm, or feel sad when they have been close to patients whose actions are then hurtful. Many nurses are used to keeping busy, so the idea of stopping and sitting still to just be, or to hang out in meditation practice doing nothing seems really strange, perhaps challenging and might even make nurses feel guilty, even if sometimes it is also enjoyable to relax. Further, keeping busy could be a way of some nurses defending themselves against how they feel in response to the disturbing aspects of clinical practice. The NHS, hospital management and even your SCN all expect nurses to be keeping busy too! Nurses attitudes towards expressing feelings and looking after themselves psychologically in other ways, e.g. via personal or social behaviours such as exercise or going to the pub for a drink, are key to how they might engage with mindful compassion training. The above also overlaps with a theme of how nurses relate to self-kindness. There seem to be a range of attitudes in CAMHS nurses, from those who almost seem to be automatically kind to themselves to those who struggle with it and give themselves a hard time, and also a number of nurses who have really stopped to think about what self-kindness means Previous experience of mindfulness or compassion meditation is also key, in that if you had never done either you might be more cautious about engaging with it. More concrete questions: Why did you agree to free staff up to participate in MCTN? Have you noticed any changes in the staff who participated, whether those are positive or negative changes? 124

Have you noticed any changes in the wider nursing group, whether those are positive or negative? Do you think that compassion in nursing (CIN) is an important topic? What is your experience of CIN to date? If CIN is important how could individual nurses, the nursing profession, wider CAMHS and the NHS pursue a compassion agenda? Were there any clinical, professional or organisational events which could have had an impact on MCTN or which MCTN could have supported nurses with? Were there any problems you, your staff or your service experienced in relation to the MCTN Programme? Have there been any significant events or changes in your personal life, including your health, and if so, what psychological or social resources did you use to deal with them (if any or if you needed to)? Have there been any significant events or changes in your working life and if so, what psychological, professional, organisational or social resources did you use to deal with them (if any or if you needed to)? Is there anything else you want to say or anything you feel we have not covered? (Version 1 10 th December 2012). 125

9.7 The researcher s field notes Please note that the same abbreviations used in the main body of the text (see page 6) have been used in the field notes below, with the undernoted additions. Pseudonyms are used for colleagues names where they appear. Some terms are explained in the notes too, and occasionally the letter X is used to retain confidentiality for the person concerned and some details have been altered for the same reason. Also, however, the grammatical, spelling and thinking errors from the original field notes have been retained. Abbreviation ACT ADHD AMBIT CMHW CMT CPN DBT EIS HOTS ITS MBLC MBRP WTE Meaning Acceptance and commitment therapy Attention deficit hyperactivity disorder Adolescent mentalisation-based integrative treatment Community mental health worker Compassionate mind training (essentially Gilbert s (2010b) CFT) Community Psychiatric Nurse Dialectical behavioural therapy Early intervention service Hospital outreach and teaching service Intensive treatment service Mindfulness-based living course Mindfulness-based response prevention Whole-time equivalent 126

Field notes begin: 6.11.12 Context notes: self-harm This morning during handover from the IPU, an alarming act of self-harm was noted: a young person had cut their face, had their wounds attended to at A and E, but later when eating the wounds had re-opened. One key thing for these notes is that this was the first self-harm act that got to the staff, I think, for a while. They/ we get used to it. Self-harm, typically cutting, but also overdosing, opening up old wounds, the slow death of anorexia, vomiting, sometimes much more extreme self-harm, such as blood-letting, this is part of the everyday working context of CAMHS nurses. 24.12.12 Project progress: coming out the closet, slowly, and surrounded by red tape To date have submitted the full proposal (4000 word limit adhered to for the main body, but with appendices, references etc., the whole thing came to about 40 pages); the edited version to the local senior NHS manager; and the Research and Development (R and D) Dept. version to, well, the local NHS R and D dept., copied in to the head research nurse. The local NHS senior manager approved the project but R and D sent back an e-mail request for about 13 corrections. This will put the project back by about month already, given that we are now into holidays and some of the requirements are the signature of my academic supervisor, his signed CV, and the signature of a separate university research sponsor. In other words, docs need posted to Aberdeen, signed, posted on to R and D, and hopefully then finally approved. The head research nurse s feedback was mainly very positive, although it had an interesting impact. She used the word "excellent", but also mentioned that, when she thought about it, I could do with offering more explanation about exactly how the quantitative and qualitative data in the WBP will integrate; how will one inform the other? Of course I then worried about my "mistake" rather than enjoy the praise. In the meantime I have by now presented to IPU colleagues, somewhat anxiously, the Senior Charge Nurses (SCN s) and Nurse Manager. I feel like I'm coming out of a closet, or that I 127

should just stay in one. Surely I'm a fraud to be suggesting I train others in compassion? Surely I will be found out as a fraud? In optimistic moments I think this might be a chance to re-present (to use mentalisation language) my professional self as compassionate. But overall I feel anxious and an impulse to procrastinate. 15.1.13 Project progress: Good news/ bad news Am in limbo until I get what turns out to be encouraging feedback from the university. Ironically, it turns out there is no score to have been worried about. And there's not only no comment that mirrors the head research nurse s, my supervisor thinks I should just leave deciding how the qualitative and quantitative date merges until I see what they both look like! I feel very inspired at receiving positive strokes, and of course not being told I'm nuts to do what am proposing. At the same time, however, I now need to actually do the project! Feck! My supervisor sensibly talked me out of using a computer programme to support coding interview data. Instead all will be hand coded and I can send him a draft to check I'm on the right lines for themes. Hand coding also allows for greater intimacy with the data. I also now have to read more about Critical Realism (CR), which I put off until I got this feedback. Started with Baskar, but quickly gave up. Moved on to Pawson and Tilley's (P and T) first, which makes much more sense. Have to work out where I stand in relation to CR's take on what can be known from research...but not get distracted by it! Have now started mindfulness practice in earnest, and am going to use the delay to get ready properly. Have several key tasks. One, practice. Two, record practices. Three, speak to all Tier 4 nurses to recruit properly. Four, read more. Five, prepare my own admin, including note keeping, systems prior to the project starting. Timeline is now as follows: Final approval should now come by end of January Pin down start date and weekly time with IPU Need to communicate with nurses ASAP during January and February. Chase recruitment and gather pre-intervention data February and March 128

MCTN in April and May Post-intervention data gathering and interviews June and July Writing-up August to November. 20.1.13 Project progress: Random notes So far the most interest from IPU nurses has been shown by 4 male nurses. What about the possible links between mentalisation, mindfulness and critical realism? For instance, mentalisation has a strong theme of curiosity, of not knowing, and of course, in the shape of AMBIT, has a fair amount to say about systems. CR has a particular view about knowledge, that there is always an aspect of the truth that cannot be known. Is there a link? Also need to look into mentalisation and learning...people learn more when they experience being mentalised. 22.1.13 Project progress: Knowing what is happening...without preference Have the first potential recruits. Sent the e-mail yesterday with the Participant Information Sheet attached. Also spoke to whole ITS this morning. Hard to gauge the response. 1.2.12 Project progress: Loss of control, loss of control Or rather, the realization, again, that there's very little in one's control. Proving hard to pin down the IPU charge nurses to a day and to a number of staff. Looks like it will be a Wednesday. Let s hope that suits the non-ipu staff. Context notes: On a separate note, EIS. Very brief summary: I worry that an over-emphasis on "the evidence", AMBIT, inter-disciplinary rivalry is putting the squeeze on two things. One, the informal / ordinary care. Two, warmth and caring for and between colleagues. And celebrating successes. Which is a third thing. AMBIT, for example, could create an even greater team meeting performance anxiety. 129

13.2.13 Project progress: Procrastinate, moi? For reasons unknown to me, I am delaying final recruitment to the MCTN group. Still have the Day Programme and EIS to go. Must do it by next week at the latest. And, oh yes, practice teaching mindfulness again! That might be why I'm delaying. Feels like too much. On the study front I'm doing the usual: reading too much around the subject and not focusing on what's essential, e.g. finding out how Excel works. Need to find research on changing employee/ nurse attitudes. 17.2.13 Project progress: The devil/ angel is in the detail (part one, I'm sure) Still not pinned down exactly who is in the group and still not found all the staff I want to invite, but the group will have the numbers am looking for. IPU is the main delay now. Also have realized that I cannot get the room I want us to be in for every session, which is the seminar room, given that in order to suit the IPU the group training has to be on a Wednesday. It's a nice big space ideal for body scan etc. I am trying to decide between having one consistent venue, which now would need to be the school room, and having two consistent venues! Maybe the deciding factor should be what practices we are going to be doing. The big advantage to the school room is that it would actually be a lot more private, just we would be a bit squished in; it's a long thin room, as opposed to the large square space of the seminar room. I need another list, so here goes, in no particular order at this point: E mail supervisor re timeline. Read over course notes and MBLC course to produce own script and session plan for MCTN Work through each practice by writing a script, practicing it, and then recording it. Practice plan is on the Participant Information Sheet. After Brach only read Gilbert and Choden book as new mindfulness material. Watch some online material for new study method. Read the Excel guidelines and practice with own budget plan for the year! Bone up on CR a bit more. Find and read the book on interviews. Read the spectacle book. 130

Find literature on staff attitude training. Get the articles referred to in the Huffington Post on how mindfulness is supposed to work (saved on to laptop favourites). Ask the HOTS unit about using their room every Wednesday afternoon for 8 weeks in April!! Do this on Tuesday. 5.3.13 Project progress: Revving up, attuning in, and hoping not to drop out Have stepped up a gear in personal practice terms; some integration at work, mindfulness practice using MBCT audio files, much of it shared with Sarah, which is especially lovely. Am also reading some more purely mindfulness books, like Tara Brach's True Refuge, which was very inspiring. On the other hand, I haven't really got organized, you know, with an actual plan. A mild bit of procrastination maybe. Really must do one...tomorrow. In fact, that's a deal. Study and practice plan tomorrow, start recording my own practices next week, along with interviewing staff pre the training. The latter must include nurses in the group and those not!! Need the same number of each. Need to copy all the outcome measures too. Shit, that's a lot of work. Keep thinking I have loads of time, which is partly because the submission date I've set myself, and been allowed to set by the university is November. So that's a very real plan then, to make a plan and then stick to it. Context notes: Lots to say here, and I need to really start paying attention to the CAMHS context. First, we have had one of two peaks in referrals per year for at least the ITS and IPU, for example in terms of young people with anorexia. The other peak is in autumn, both are in school term time. This peak coincides with the lowest staffing levels in ITS in its entire short history (speaking of which I might need to make notes on the brief history of the service and each part of it which is involved in the project). There are 3.6 WTE nurses in ITS, 1.4 WTE short. In EIS, a CPN has just suffered the death of her mother, a mere few months after her father s death. She is a volunteer for the MCTN. Will need to see what impact the loss has on her wish to participate, and participation is of course not the most important thing for her! 131

Looking after herself is, and those of us who are her colleagues need to look after her too. I'm her line manager so am in a position to do that via compassionate leave. In the IPU there is an ongoing crisis in that they are trying to have 2 extra members of staff on each shift in order to safely manage a young man who has been referred to medium secure psychiatric services. The latter are all in England where teenagers are concerned. Referrals like this are an ethical dilemma, and I was part of deciding on the issue. Am in favour of it, as are all my colleagues. Dangerous young person, and one who might not get effective treatment and rehab without long-term secure containment. In the Day Programme, the nursing team, perhaps the whole service continue to limp on. This is maybe a harsh way of expressing it, and it s certainly nobody's fault. But they have a combination of nurses who have come to CAMHS through 'change of experience', a process which cuts out normally rigorous recruitment processes; nurses who are often off unwell; and a service re-designed to the extent that it has lost certainty about its identity. Poor sods. 11.3.13 Context notes: It's too damn hot, yes, it's too damn hot Between 6.3.13 and 8.3.13, Wed to Fri last week, CAMHS Tier 4/ the WBP context reached boiling point. On 6.3 the charge nurse was off sick, so I was approached in my capacity as Senior Charge Nurse (SCN) to give advice and sort out/ contain a situation involving young person X. Staff nurses from Day Programme approached me, and the CAMHS Head of Psychology and Day Programme team member later caught me to ensure I was on the case. The young person X, diagnosed with ADHD, was charged with statutory rape about 2 weeks ago. He had been about 14 at the time of the incident and the girl 12. HIs reaction, revealed during discussion with his psychiatrist, is that the charge was "unfair', i.e. 'she wanted it'. The problem has been that the young person continues to be impulsive and make poor choices, causing staff to question whether or not he should be in our building. Last Monday he ran away from the building and jumped into a female peer's taxi. She is 13. The pair joked about this, and X does not seem to appreciate how this all looks, to be able to discern right from wrong and to accept limits. In discussion with my line manager I decided he should not be coming here until there had been a multi-agency risk review at least. This caused a furore in itself with his mother and the house manager of the supported accommodation he resides in. 132

And his social worker did not seem to like it either. Day Programme staff, however, actually cheered they were so relieved. They were not being judgemental; they were concerned for his and his peers' safety. That was Wednesday. Between then and Friday there was discussion after discussion between the different agencies. The social worker (SW) was implying things should go on as before and said she was determined to keep the young person out of secure. I got more and more frustrated with the situation, to the extent that at times I wondered if I had completely lost the plot and misunderstood something everyone else was getting. But no. The young person s issues affect Day Programme and ITS immediately, and have the potential to impact on the IPU too. As a feelings issue, it is also fair to say that just having someone who has seemingly sexually assaulted a 12 year-old girl undoubtedly throws up strong feelings, especially given the large number of vulnerable young people being seen in our building each day and towards whom the staff have sympathy and much concern. In the meantime, in the context of sick and annual leave in EIS, and staff absences in ITS due to planned leave and a secondment for health reasons, new referrals were flying in thick and fast (3 for EIS, for example) and an 11 year-old was admitted to a local children s hospital and needing CAMHS nursing input. Perhaps suffice it so say that all of these things in combination created a pressure that felt at times too much to bear (in me and others) and a sense that we were letting people down- just not getting it right. After all, these new events were on top of pre-existing contacts with young people and their families. I also had to speak to 2 especially difficult and demanding parents. I did manage to maintain a sense of kindness and understanding in those conversations, however, and also with X's mother, who did much shouting on the phone and who was surprised I didn't put the phone down on her. I genuinely felt sorry for her, powerless as she was in the face of her son's difficulties and her own emotional functioning. I also wonder what impact the ITS yet again not winning an award makes on staff in it; we laugh but are we also pissed off and maybe thinking that, yep, we're just not quite good enough. 133

Forgot to note too that ITS have interviews next week for 2 CPN posts. This in itself creates a huge amount of work, and stirs up feelings of hope but also uncertainty in the team. 10.3.13 Mindfulness4Scotland conference notes: how slick are those guys? Attended this Sunday conference on account of the organisers being MSc peers and the theme, mindfulness at work, directly relates to the work-based project (WBP). And, man, those presenters were slick, professional. Inspiring. But were they also representing mindfulness as a mainstream business proposition? In part, yes. Wonder what kind of money they all make from it. And most of the speakers seemed to be of the Kabat-Zinn lineage, so teaching compassion was given a big no-no. Some rough notes and references to follow-up: Michael Chaskalson (mindfulness-works.com) was a very smooth presenter. Started with mentioning that during the opening conference practice he had felt his scalp prickle as he thought 'what happens if I forget all my lines in the presentation'. He said that his awareness and curiosity about the thought and the related physical sensations allowed him to then let go of anxiety. MC does see mindfulness as a panacea for all ills because it allows you to work more skilfully with your mind and therefore anything you try will be the better for it. Good way of thinking about being non-judgemental: said it has 2 aspects, the wisdom to allow 'what is' and the affective component of kind, warm allowing. Described having an inner critic. His own model of mindfulness training: 6 to 8 weeks of 90 to 120 minutes group training with an expectation of 20 to 45 minutes practice a day. Realistic view that people will just do whatever home practice they fancy. 134

Great Pressure-Performance Curve diagram, which I must use and get! Also need to get the Mental Health Foundation Mindfulness Report 2010 detailing the London Underground project. Noted that one benefit of mindfulness practice is that it enhances 'working memory capacity', which is essential for good work performance. LOOK INTO THIS. Jha et al. 2010. Also related to US Marines study; Elizabeth Stanley. Workshop on positioning mindfulness in the workplace Similar themes. Use language that relates to the work context. Consider closely the relevance to the work setting of the training (which I feel I have done, even if I am breaking some people's rules by including compassion). Remember that on public course people have paid and are wanting to be there! Centre for Contemplative Organisations- CHECK OUT. This workshop made me realise that the WBP is NOT a bolt from the blue; CAMHS has seen a slow but steady increase and interest in mindfulness via DBT, ACT, etc. Between session blether Peer suggested that I repeat at least 12 times to all staff engaged in the WBP that the MCTN is building on skills they already have/ building on resilience. That is, it's not a therapy. VERY NB. Bo Heimann The Potential Project Very slick, amusing, charismatic speaker. LOOK UP project. Good quote: a serious heart needs a light mind. Their work is to change work culture and not focus on stress, performance management, etc. Interesting rules, but against compassion; said it was not realistic to do Buddhist Tonglen in workplaces and too difficult. Pish on that! Rules: Be clear about relevance Only training (in mindfulness) will deliver results. 135

Be clear and concise. (E.g. the 'ABCD' of practice: anatomy, breathing, counting, distractions). No Buddhist language. Only 2 techniques. 2! Back it all up with science. Link practice to everyday activities, for example e-mailing. One activity per group. One! In the end it's all about the attitudes (the mindfulness ones). True dat. Required outcomes are better productivity and a sense of ease. Group training better than trying to 'fix' individuals. Leaders need to participate. Their model: 90 minute weekly sessions, 9 in total, with 2 follow-ups at 1 and 2 months. Plus, plus, 10 minutes practice daily in the workplace using 'ambassadors'. mindfulness in schools-.b Excellent techniques for kids: FOFBOC: feet on the floor, bum on the chair. Bring awareness to feet; lower legs; thighs; weight of the body sitting on the chair; legs as a whole; breathing..b: stop; recognise; breathe; 'be'. Texted. When you get the text you need to do this. 7/11: breathe in for a count of 7, out for 11. Finger breathing: trace a finger up the way for the in-breath and down the way for an out breath for 1 minute. Thought buses. Other bits Liverpool mindfulness model- GET. Frontiers in neuroscience paper- GET. Connectome project. 16.3.13 Project progress: All that's missing is/ all I want for Christmas is... 136

A singing bowl! More time! A bit about CR's view about knowledge as something that always exists outside of ourselves. Thus, need to finish the chapters in the Sayer book, the Pawson realistic evaluation (RE book). Also need to be mindful of the political dimension to compassion and compassion training, including (and this is not exhaustive): MCTN is not about making unacceptable NHS practice acceptable or the business model being applied to the NHS acceptable; compassion versus mindfulness in secular literature and mindfulness as a business; nurses taking ownership of a compassion agenda. 17.3.13 Context notes: Change is the only constant (at least, for the IPU) The last week has been another frantic one. I had 2 days off, Mon and Tue, then interviews for 2 CPN posts in ITS. In the meantime, an EIS colleague remains, understandably, on leave for bereavement, not that her feelings will necessarily fit nicely into assigned time off; a CPN in EIS and a CPN in ITS were off sick and the latter was on a course following sick leave, causing a bit of sarcastic comment from her colleague Norma; and even one of the IPU charge nurses was off following a car accident (she's ok). And 2 Day Programme staff were off sick too. Those absences were supplemented by some folk finishing off their annual leave allowance. So the services in the WBP were somewhat thinly staffed. Into the ghost-ship of a service, the Tier 4 referrals and clinical crises came a-plenty! The 11 year-old in a local children s hospital continued to need support there; a 17 year-old with low mood and suicidal thinking was seen by ITS; 4 referrals came in for EIS alone; and the girl who accompanied the young person charge with rape on his jaunt last week accused him of sexual assault, leading to another cycle of crisis-driven communication. Then came the interviews. Although ultimately successful, these were disappointing. 3 people withdrew, one without telling anyone, and a further person could not attend on the day because her daughter had an epileptic seizure. Of the remaining 5 candidates, only 2 were appointable. Of those 5, 4 were from CAMHS, which means 2 CAMHS staff fared so poorly they were not in the reckoning at all. One of the failures was a guy who has worked as a Band 6 for 8 months but couldn't answer questions about developmental issues. These comments are reflective of my personal disappointment. For the wider Tier 4 service, interviews like these are a mixed bag too. 137

Norma, for example, would dearly like to be able to pick all new staff. She groomed one of the successful candidates, so was chuffed for her, but was less-impressed by the appointment of another nurse, whom she does not get on with sometimes. And so it goes. The Day Programme is relieved that none of their staff even applied, such is their desperate need for stability and forming an identity. The IPU on the other hand are losing 2 of their good and trusted staff, which is hard for them all, even if it also gives some of them hope that one day they can do likewise. I have especial empathy for the IPU charge nurses; every time they lose good staff and go through their own recruitment cycle, it unsettles the whole team and they slip back down that 'learning and development' hill once again. Finally, EIS will also feel more uncertain now that Anne is leaving- although they will be expecting me to replace her automatically. In EIS, there has been an avoidance of what it means that a valued CPN who had worked there for 10 years decided to go on secondment to Tier 3 and then there was avoidance of what it means that at one point another CPN didn't want to stay with them too. Which brings me to me. Having perhaps procrastinated a bit with really getting going with the project, work is now so busy and frenetic that I'm worried there just won't be time for it all- and when I get home I'm just too fried to work on it. Ironic really. Am also worried again that there won't be enough staff in the group. Andrew has already withdrawn, albeit with my blessing. He would have missed 3 of the first 4 groups and also wanted to do motivational interviewing (MI) training. He did ask me as his manager which training he should prioritise; ethically I had to free him up to do the MI training. Just need to get on with it all! 25.3.13 Context notes: At my signal, unleash...? A surreal week from last to this. The CPN whose mother died returned to work on Friday, raw but keen for the routine of work; some folk off on dubious sick leave; others genuinely so; some folk using up annual leave before they lose it between one leave year and the next; and the small matter of having had interviews for 2 CPN posts but no line manager in the IPU to negotiate a transfer with, as Veronica is on bereavement leave, and the other charge nurse on sick then annual leave. A kind of ghost ship but one in limbo too. Waiting. Project progress: 138

In the meantime began the pre-training information-gathering at last, and realized I should have started earlier, as each person takes between 20 and 30 minutes to get through it all and I have about 30 to do! Perhaps I need to ensure I get cohort 1 done before the group starts and catch up with the other cohorts whenever I can. There's been some interesting reactions to the outcome measures. All 5 participants so far commented on the Social Desirability Scale (SDS), wondering how their answers would reflect on how I viewed them. Was I really stepping out of a line management role? Could we all really do that? I also left in the infamous question 4 about street drugs. To their credit some of them seemed to answer it honestly, since they owned up to having taken drugs, which is a risk in nursing circles. Only later when I first tried to score the first batch of measures did I realise that I couldn't include this item since the measure creator no longer included it himself and there were no instructions for scoring it! Ah well. Live and learn. There was joking and laughter between some of the nurses after Anne and Karen had completed their measures, Karen leading the merriment with wondering if she would now be sacked for answering the questions in the way she had. Word will spread about this. Anne thought that females wouldn't come out of the compassion measures looking psychologically healthy. Karen hesitated about revealing what she believes to be true in them. Both revealed a hidden long-standing commitment to teaching compassion as part of their Violence and Aggression management training. They will give me a copy of their presentation later. Mary revealed that she prays and practices Christian contemplation. Andrew revealed a vulnerability to feeling exposed in answering the questions in the measures. Gemma worried that she didn't think about things enough. Her scores don't seem to suggest that - and they don't seem to particularly stand out. Mary s do though, and they are hard to make sense of. In the SDS for example, on the item about arguments, number 13 in the original measure, she write "I don't argue" rather than true or false as she had been asked to do. This is surely untrue, but it may be important to her how she is seen to behave. She struck me as deeply religious and proud. I later negotiated with her to mark that item down as false. She was also worried when I mentioned I would invite group training participants to take their shoes off for practices; her mother had told her not to do this when she was a child as it was associated with witch doctors in the part of Zimbawe where she grew up. During the 139

discussion we had she also revealed what sounded like traumatic memories of the death of cousins in warfare in her country. Need to keep an eye. Also started the session plan in earnest. Am concerned am trying to cram too much in. In fact I know I am. Ho-hum, same old same old. Need to get the first one under my belt to know what's what. Also need a livelier start to session one than the one I have planned so far! Maybe could play with the running order. Or find some wacky way or witty way of starting. 31.3.13 MCTN planning and preparation: In every beginning, an ending...etc. The above is potentially misleading given the subject of most of this entry; where I've got to in planning the group. But what I mean here is that as I begin to plan the MCTN in earnest, it brings to an end a period of a few years of not really teaching mindfulness in earnest to groups. Sure I've dabbled, and I had the test run recently teaching student nurses in a lecture. But this is a much more pronounced transition point; I have a feeling this is the start of a new, renewed and perhaps even busier phase of teaching than my Buddhist instructor days. I don't mean this in a big-headed "it's an automatic success" way. Just that my motor is well and truly up and running now. It's on. In concrete terms I've got the first session planned and nailed. Sarah helped by-time with changing the start but on 'boundaries and 'rules' to group 'agreements', an idea from her own recent group work and a much more positive way to start the group off, include everyone and get them talking. Make them feel like they own the space. Invitation, after all, is the watchword. Also, have realized that in MBLC they have an introduction to mindfulness a month or so before the first session proper, so they can get people thinking about motivation very early in to session 1. I can't really do that, and haven't done a preparatory session, so the guided contemplation on motivation comes towards the end of session 1. Just need to do first lot of handouts and am ready. Have been running through the practices and am excited to get going. List of things still to do for session and things to take: 140

Folders for all participants Blank paper and pen Handouts on definition of mindfulness, self-compassion and instructions on the settling the mind practice and cultivating kindness practice, and maybe the selfcompassion break Flip chart and pen Place chairs and tables together in one long thing in the school room, play with that on Monday, maybe even practice a body scan and walking mindfulness practice. On Monday can go over what inquiry is and how to do it, and start planning session 2 Monday 1st April MCTN planning and preparation: The Buddha nails it You can search the whole world for someone more deserving of love and kindness than you and you will not find them. Why so? Partly because if you care or yourself properly you will never harm another and partly because all beings everywhere are equal. Wednesday 2nd April MCTN planning and preparation: Putting the mental in mentalisation Mindful compassion training could support mentalisation in three key ways. First, mentalisation is defined as "the ability to read other people's thoughts and feelings and to reflect on one's own thoughts and feelings", a "mindfulness of minds". Second, mentalisation is only happening when there is empathy and kindness there too. Third, AMBIT promotes the team around the worker; this is an obvious opportunity to practice mindfulness and compassion. Why does compassion training help? One key thing is that it encourages you to stop thinking about yourself so much! There's also some interesting research about how focusing on selfesteem is not as good for you as bolstering self-compassion. 141

Put very brief introduction exercise at the start of session 1: turn to the person on your left, say hello, find out one thing that brought them to the training, then introduce the other person to the group. No right or wrong reasons for being here. Reiterate support available. When it comes to home practice, suggest alternating between 2 practices. Model of mind not introduced in MBLC until week 5. Wednesday 9th April Reflection on MCTN group: Striving? What striving? Session 1 Time seems to be moving too quickly for me to keep up. One moment I'm panicking about doing the first MCTN group and in a flash that's gone and I'm hurrying trying to catch up with getting the pre-training measures finished, which are now slightly "per". I didn't sleep well the night before the first group I was so anxious. And during it for the first half I was a bag of jittery foolishness. Perhaps have, or had, the anxiety is diminishing, too much riding on this. Also had that sense of responsibility about people and their health and, dare I say it, Buddha nature or path to enlightenment that I used to get as a Buddhist instructor. And that's not about how fab I am or could be as an instructor, but me wondering: what if this is there only contact with such practice and I put them off? During the group I managed to nearly drop the IPad on my head in one moment of fussy nerves. The group seemed to have sympathy in the main for this. Nonetheless, and beginning to listen to the recording of the session, I got the words out and managed to get facilitate a decent practice towards the end. And the group all turned up, some of them on their days off (Tommy and Alex), and behaved impeccably. Anne said, in astonishment, that the practice had actually got her to relax for four minutes. Alex said that the settling the mind practice was like "hanging around doing nothing". On Monday morning Karen wondered if the practice could have made her angry, which she felt straight away after the group, having felt relaxed during it, and then if it had made her vomit later that night. She has been off sick since Monday. Turns out, via Anne, that Karen is easily irritated by Mary, a 142

fellow MCTN group member. Gemma wondered if the practice could have caused her to have a migraine. She also seemed to be puzzled that she felt so relaxed at work and so stressed at home, however it turns out, as Colin later told me, that she and her partner are on the brink of bankruptcy. Norma seemed to enjoy it and Elizabeth told me she had too. So overall it's going okay...but not everyone will make it to the end, me thinks. Catching up with non-mctn participants has been humbling too. James told me he is in remission from cancer and doesn't know how long he has to live. Stevie's father died recently, then his brother killed himself, and now he has health worries of his own and is having prostrate problems checked out. These things put everything into perspective. Time to relax and enjoy the group... Friday 12th April Reflection on MCTN group and MCTN group planning: Immediate post group thoughts on session 2 People could practice mindfulness and try compassion in the group sessions. They could also use the body as a container/ safe place to come back to. Need to explain that MBSR and MBCT produce increases in self-compassion anyway. Also need to simplify the group programme. Look at that this weekend. Do some reading this weekend! Also, am not asking anyone to feel compassion for anyone that they don't want to. Ever. I hope that each practice is valuable but we are all different and will respond to each practice in our own time and our own way. Further, if we take the example of a young person physically assaulting a colleague, I'm not asking you to feel compassion there and then in the heat of that awful moment, or even after it. But I do want you to have the choice. And before you get to choosing whether or not to have co passion for the patient I want you to have compassion for yourself. If you don't have that then you can't help yourself and you run the risk of burning out and you can't help your colleagues as effectively as you could with selfcompassion. And it will be harder to carry on delivering good care. E.g. of young person X, staff divided into camps of over-compensators and punishers. Point is people in both camps are being ruled by their emotions. These practices give you a choice not to be, because one of our trickier professional tasks is to transcend extreme reactions. And our brains are not going to automatically help us do that. How so? 143

Our brains are hard-wired for survival as the top priority. The oldest parts of our brain are dedicated to our survival, to the four F s of success in surviving as a species: the ability to fight, to flee, to feed and to...reproduce. Our fight or flight response kicks n before we are consciously aware of it. So by the time we have a thought that we are afraid or angry our brain has already decided what our response is going to be. The techniques we are practicing can help balance those emotional responses. If you are struggling with compassion full-stop, you could carry on with mindfulness at home and just try the compassion practices we do here. Programme plan: group three deepening mindfulness, four on obstacles to compassion by doing three of Paul Gilbert's then doing RAIN practice. By the time we have done three Paul Gilbert exercises challenges will have arisen! Developing or sustaining compassion is also about what values you have in life (give out ACT handouts), and values, if you have worked them out, are probably better things to be concerned about than goals. You need goals and targets of course, markers, but what happens when you don't achieve them? Self-compassion is more reliable than self-esteem! Kristin Neff. Also: do a summary of what mindfulness is and what is can do, i.e. slow things down etc. Sunday 21st April Reflection on MCTN groups: Experiential avoidance, moi? Sessions 1 to 3 This entry is to focus on me feelings given that in this dairy I seem to have avoided that so far. Looking back over the groups, and I should also note here that I haven't listened to the audio recordings of each group yet either, at least not fully, I feel like I've had one group where I was anxious (session 1), then a more relaxed group where I thought things went more smoothly (session 2, where we started with the body scan), and then back to a bit of anxiety in session 3 where I put the MCTN programme into a context to explain the different paths people can take. 144

The strongest feeling is that for once in my life I miss having a co-facilitator in the group. It's hard to get objective feedback about performance and pace and hard to know yourself, also just challenging to present all the theory and the practices, to remember all the material. This is an indication that I don't embody mindfulness deeply enough yet, or feel confident about that, or that I'm just a bit rusty. It's been about 4 years since I last did this kind of thing. The practices are going well though; people are trying them in the groups, the atmosphere is good, and they are trying them at home. And they report enjoying the group, and they keep coming back and some of them come in on days off/ on their own time. I asked for feedback from some of them, and although she was as ever a little harsh in her feedback, perhaps because of the highly self-critical way she functions, 1I usefully pointed out the pacing was getting better although there may be a difference in the pace between the theory parts and the practical parts. So I take from that that I need to slow done and embody mindfulness more obviously during theory parts...and not worry so much because I do know what I'm talking about. Also, I'm not just being anxious in an ego-centric preference system (EPS) 'this must succeed' way, I'm concerned that there are very new practitioners in the group and I don't want to baffle them or lose them. Have also realized that a time-honoured pattern of mine is present, and one not helped by the absence of a co-presenter, that I have tried to pack too much material into the Programme. But, having recognized it, it stops now. Having said that, the next two groups are crucial. Session 3 was the first one in which there was chaos of the sort you'd expect in any groups, with some people arriving late, which I did address in the group, in fact people arrived in about 4 waves, and in session 4 Melissa will be on leave and she is out of the country so can't do what the others do and come in on days off. Gemma also seems to be applying for other jobs. Maybe I will lose some people now. Hmmm...the EPS is here with me. I don't want to lose people because of my teaching ability or lack thereof! Is more like the truth. 145

Timings are key. Trying to pack this course into one and a half hour sessions was very ambitious. Message to keep it simple from that mindfulness at work conference has been helpful, because that's really the only way to go. About 15 to 25 minute s theory, if they all turn up in time, and the rest practice. One other good thing: I do seem to get the whole observer undercurrent EPS thing more this time now that I have had to prep it for the group than when I encountered it as a student on the MSc. Sunday 28th April MCTN group planning and preparation: Mindfulness Teachers Practice Day Lovely day run by Heather Regan-Addis and Neil Rothwell on behalf of the Mindfulness Association at the Gillies Centre in Edinburgh. There were about 15 of us, and some kent faces nice to catch up with, including colleagues from Buddhist instructor days, and of course the 2 facilitators for the day. New faces were just as good to meet and learn from, such as the person who teaches yoga and MBSR for oncology patients and seems to have done all the MBLC stuff and is working on a PHD. Some top tips from the day, but first just to note that most of the day was practice, and a balance of body-focused and sitting practices, including mindful movement and mindful pottering/ walking in the for-once sunny outdoors. A fellow instructor showed me the MBRP Programme for addictive behaviours she uses, which included a version of the breathing space called 'SOBER' and another idea called 'urge surfing', which I thought was worth putting into MCTN. Another peer let us know about a Buddhist called Ajhan Brahm who she thought was helpful. Other practice tips included mindful movement by raising your arms on an in-breath and letting them fail on the out breath and continuing with that for as long as you wanted. You can then extend the practice by rising up on the balls of your feet and reaching higher on the upward movement. Thought this was great. Second practice was a back twist by using the momentum of the arms, which I know from martial arts training. 146

During the body scan, Neil also added a groovy twist, in the form of, once you get to the end of the head bit imagine there's a hole in the middle of the crown of your head about the size of a two pound coin. Breathe in through that hole to your naval area and breathe out into the whole of your lower body. Then you reverse the process, so you breathe in from the toes of your feet, up through the legs to your naval area then breathe out through your upper body and out through the whole in your had. Niiiice. Mindful movement in pairs...hmmmm Other tips: thoughts about the past are history, thoughts about the future are fantasy. Notice when the group you are teaching are ready for structure-less silent sitting. STOP: stop, take a breath, open and observe, proceed. Themes from discussion with peers were helpful too: letting go of attachment to a particular outcome; empty curriculum versus highly structured; embodiment means being present not being perfect (very good news!); indeed you are modelling imperfection (even better news); you are learning too as an instructor; noticing and working with your preference; allowing the group to arrive and switch from doing into being mode. Rather than be lost in thought, let us come back to our senses. Reflection on MCTN group: session 4 This session went well in terms of pacing the short teaching. Am being more mindful of that, slowing myself down and allowing the material and the group to breathe a bit with it. Have also established that the group appreciates an opportunity to stretch and move about rather than sit down for the whole session. Covered the observer and undercurrent, EPS and 8 worldly concerns. Used a snow globe to illustrate and gave handout summarizing the talk. For practice, read out an edited and secularised version of excerpt from The Tibetan Book of Living and Dying (see handout), which Elizabeth asked for a copy of afterwards. Good atmosphere in the group. 147

So far, therefore, have focused on mindfulness as a valid path in its own right and as a foundation to compassion. We've covered sitting watching the breathing, the body scan, mindful movement with standing yoga and walking, and a cultivating kindness practice as a taster. The group have also had brief guidance on the breathing space and self-compassion break. In presentations have of course presented a theory of mindfulness and its benefits, where it sits in relation to compassion, and the observer/ undercurrent model. Group are interested in watching Free the Mind movie in my absence on 10th May, and some are interested in a practice day extra to the group. Have offered that if half the group want to do this we will go ahead, towards the end of May. Now need to move on to compassion while keeping going with mindfulness and mindful movement. Hmm. Monday 29th April MCTN group planning and preparation: Love it when a plan comes together Finally have the full plan for the rest of the MCTN Programme clear: Session 5: part 1 of CMT, including place of safeness and compassionate colour as new practices. Session 6: part 2 of CMT, taking in developing a compassionate ideal and recognizing our wish to be happy as new practices. This means am following the order of the new book. Session 7: the loving kindness practice. Session 8: tonglen. Between sessions 5 and 6 there's a week s break, in which the group have a choice to watch Free the Mind movie as a group in my absence. Also, will ask them to read the first 2 chapters of the Reality Slap book and the Bulls Eye and Compass exercises from the act mindfully website as further work on acceptance and to tie in with the fourth CMT practice. Will get 2 more CDs prepared too, one for session 6, comprising CMT exercises. The second one will be for session 7 and will include my version of the loving kindness practice and tonglen. If half the group or more want a practice day that will be the weekend of session 7. Or 6! 148

Also need to compile a resource list, and email the CMT handbook and a certificate of attendance. Consider getting a snow globe for everyone. About 30 quid online for whole group. Also, note the advice that the practices are not really for clinical work unless they are an agreed part of a young person s treatment plan!!! Friday 3.5.13 Reflection on MCTN group: Immediate aftermath, session 5 Karen is keeping a diary, Alex came in on nights, Melissa off sick, Veronica ill but in group, Mary asked if she could have a river as a safe place. Need to link 8 worldly concerns to 3 emotion regulation circles. Elizabeth called away to manage an overdose, but came back to the group. Explain link between values, life having meaning and happiness, and gratitude and self-compassion. MCTN group planning and preparation: Set up video thing with school room etc. for next week. Interdependence...need to mention this next. Interdependence...nothing, no physical object, no thought, no emotion, no person, has an independent identity or existence. Everything is interrelated and things exist due to a complex coming together of particular causes and conditions. E.g. a cup, a chair. Impermanence works on objects at sub and sub sub atomic level. There is no I in team and there is no I without a team. E.g. when I pass this MSc it's not down to me as an individual. Sarah, Ruth and Naomi gave me time, as did my line manager. Trainers trained me. Peers supported me. University teaching staff supported me. Sunday 5.5.13 Project progress: Wise words from Rumi: "yesterday I was clever and wanted to change the world. Today I am wise and am changing myself". This is surely one of the themes from the WBP. Wednesday 8th May Reflection on MCTN group: Lookin back...on session 5 149

What I wrote on 3rd as an immediate set of notes partially reflects a sense of chaos I remember in the group, that in that session the moment would come when it all went to pot, that control slipped out of my anxious, sweaty hands. And it was chaotic: Veronica tried to cancel with me, kind of asking me to make the decision for me, but I just texted her back encouraging her to come on in. She had a cold and struggled to breathe. Gemma fell asleep during one of the practices, possibly due to all the stress and upheaval at home. Elizabeth did get called out to deal with an overdose, and one of the group discussions dissolved into a few sub-groups talking on their own. I did lose control of that momentarily. I didn't present the group materials as well as I wanted to, and worried during it that I had under-prepared. There were some good points too though. One was in relation to a question that Melissa raised about a mum she's working with who says she will "never" love her child. I managed to get a comment in, perhaps seconds before Elizabeth, that from a mindfulness perspective the past is history and the future a fantasy so in reality all this person can really say is: in this moment I notice I'm having thoughts and feelings that I don't love my child". All we have is now. And feelings are not facts, who was another helpful theme. A second positive was that the group seemed in the main to engage with the safe place practice, which bodes well for the next compassion practices. Context notes: Team updates In Tier 4 there has been much nursing staff movement. I recruited 2 IPU nurses for ITS and 2 more IPU nurses got CMHW jobs, with a third from Forteviot. All of these 5 folk are trained nurses, band 5, and all 4 from the IPU are experienced. So 5 have now been recruited to the IPU. That in itself is turbulent. Meanwhile the IPU charge nurses are not getting on well, and 3B from the Day Programme (DP) is going to work in another team in June, and my role is extending to include the DP. I have also let the DP nurses know this and know that we are also looking for a band 5 to act up as a 6 in the DP. That too is potentially turbulent. Particularly as rivalry may make them all apply! And I might have a key say, though hopefully not alone, in who it is. Meanwhile EIS are waiting for their vacancy to be filled. 150

And, strangest of all, the first IPU consultant visits tomorrow. He was a prime arsehole and still evokes irritation years later. It will be interesting, as they say. Or not. I seem to be flying about, presenting locally, presenting in London on Friday. May have overdone things. We will see. Sunday 9.5.13 MCTN group planning and preparation: Ex excess Rough plan for session 6 and 7: compassionate colour, image and recognizing the wish to be happy. If cannot get them all in session 6 then tonglen in the practice half day and loving kindness practice (LKP) in session 8. To-do: find practice script for safe place and colour. Record these. Scripts for image, wish to be happy, LKP. Practice yoga and sitting. Better plan. Start with the wish to be happy reflection, given the link with acceptance. Do as a quick thing. Then the logic of compassion via inter-dependence. Then colour and image, after stretches or movement. Compassion needs to start with recognizing our own suffering, or the suffering of others will remain at the conceptual level. MCTN group planning and preparation: Record next two CMT practices Write crib sheet for both Practice both twice, with me leading. Do yoga with recording and note the order of practices. Thursday 16.5.13 Context note 151

Note Anne s experience of EIS team meetings and the tensions and conflict there. Feel anxious about that. Feels dark. How does it relate to mindful compassion training? 17.5.13 Reflection on MCTN group: Immediate aftermath, session 6 No Tommy (nights), no Alex (hangover and days off), no Elizabeth (annual leave). Agreed to have follow-up practice day not during the MCTN. Approx. end June. Good discussion in the group. Asked group who was practicing, without nagging them to. Norma does so every day except Sat and Sun. Uses it to and from the car and does mindful movement more than anything. Also wears headphones to quieten down the world around her. Top tip! Karen has done so once or twice but doesn't like the idea of sitting practice. Would rather do something active too. She suggested focusing on her feet while washing the dishes. I concurred, and added a Tich Nhat Hahn reference, which will include in the reference list (mindfulness in daily life). They asked me how much practice I do daily so I told them: about an hour currently. Also good questions coming up, for instance a question about happiness/ joy in mindfulness practice and my response that hopefully mindfulness leads to feeling relaxed or calm or happy but actually the task is to be present with whatever is in the present moment without holding on to any experience, good or bad. Compassion training, on the other hand, does deliberately try and access positive emotion regulation systems. Re this weeks practice: some people found it hard to visualize the safe place and the ideal image, some found their images "jumped", others that a person who they had a problem with kept joining the party. Some looked like they might be sleeping during the practice, but afterwards, in the discussion about the David Foster Wallace (DFW) track, This is Water, they said they had enjoyed the peace, or at least that the track spoiled the peace of the group for some therefore the practice felt even more peaceful than usual. The track divided the group. And some didn't like knowing that DFW had committed suicide. I won't play it again, but actually the group were enlivened by it and agreed in the main with his sentiments. We will see. 152

Sat 18.5.13 MCTN group planning and preparation: Aftermath plans Notes for session 7: compassion is a three-way flow, from being open to the kindness of others, self-compassion and extending kindness to others. In developing compassion another 3 part list that's often used is the notion that we start by believing that we are the most important people in the universe. Then we might come to realise that others are equally important. The final stage that is talked about certainly in a spiritual context is that others are in fact more important than me as an individual. So in the New Testament there's the concept of turning the other cheek, or in Buddhism the concept of giving victory and profit to others and taking on loss yourself. This isn't about being a doormat or a softie loser! Turning the other cheek isn't necessarily even going to change the other person. It's about changing you and giving you a choice about how to respond. If, for instance, you into a dispute that goes on and on and you keep battering your clenched fist off a table and shouting "look what they did to me, look what they did to me", who suffers? You do. What turning the other cheek means is working with compassion in a way that reduces your EPS, or selfish tendencies, although the traditional approaches I'm alluding to we're also part of reducing human and tribal tendencies to keep attacking and killing each other. Somebody has to stop the fighting for peace to happen. This is the very stuff that most mainstream mindfulness or meditation trainings don't want to get into, but I think as nurses and support workers we have chosen to work in a profession where, in order to do our job well, we have to set aside our differences as colleagues and set aside our problems, which are every bit as real as patients problems, in order to properly care for our patients. As colleagues we don't always have to agree in every situation and meeting, but especially at the sharper end of delivering care we need to set aside our differences. But where our own patient contact is concerned we really do have to set aside our own issues, and preferably our EPS. So this course has been about tapping into, hopefully helping maintain or develop selfcompassion, but we are now at the very nub of my research interests and at the point of 153

pushing things a bit quicker to at least raise the question of how do we care and what do we think of our compassionate capacities? Not that I want you to answer the question now. Tonglen acts on the EPS. The practices today might nudge us into areas that we are a little uncomfortable with, and if that happens for you, as you do in mindfulness practice, just notice your reaction, and accept it. Don't try and fight it or blame yourself or indeed blame me. I have no doubt whatsoever about the kindness of all of you, but that doesn't mean that you're going to like every aspect of these practices; disliking them or having some kind of negative reaction foes not change the fact of your fundamental goodness and kindness. Equally, it's important to be honest and not pretend. Explain four immeasurables. Do 10 minute 7 stage LKP and short tonglen, but no tonglen on the CD. Compassionate mess idea. 24.5.13 Reflection on MCTN group: Immediate aftermath, session 7 Again, some absence, but overall 8 in attendance out of 10, which is great. Today Melissa and Alex we're both off sick. Tommy and Elizabeth, who missed session 6, returned. 3 practices: 2 minute sitting without a focus as an arriving into the room thing; the fuller LKP; and tonglen for another. Variety of responses. Some found the specific parts of the LKP okay, i.e. the first 4 parts, easier than the expanding LK part, and for other folk it was the other way round. Some are still finding visualization hard. Images keep jumping or unexpected guests arrive. Said this was okay. And just to notice them and return to the practice. Also, some finding that they couldn't keep extending loving kindness to the person they have a mild difficulty with. Again said to notice that and don't force the LK. Where you are at is where you are at. Mary said she didn't want to give LK herself, she got Jesus to do it. 154

Made a link with religious version of LKP where one would invoke a religious figure to begin the practice. Some found the compassionate image practice challenging from session 6. Question from group about whether or not a consistent image was needed. Said in the long-run probably better to have some consistency without being too rigid. Will need to explain one or two parts that were missing e.g. in CMT drawing on a compassionate self or part of you. Had no time really to go not that detail, so the compassion practices are tasters. Great point made arising from discussion that we don t have a limited supply of compassion for others, in relation to the Four Boundless qualities. Most of the group spoke today. Good interaction. Tommy made a grounded and witty contribution that his tonglen was cartoon-like. Norma used it for a past event. Veronica was anxious about breathing in the black smoke but relaxed into it and experienced a pleasant sensation. Elizabeth experienced something meaningful during her tonglen. Elizabeth also mentioned her safe place as being a war memorial but that it had been a sad place too, which she questioned. Said that feeling sad or sympathetic might happen and that can be a good place to start in CMT for others etc. but not to pick too sad a place in that particular practice. Mary felt too afraid to do the tonglen. She also made some remarks I can't quite remember now about how selfish she thought Christians could be in that they don't necessarily think of all beings on their practice (surely a misunderstanding). And she seemed to struggle with wishing wider colleagues LK, but it was hard to make out clearly, or to remember now. MCTN group planning and preparation: To-do list: Resource list Certificates Mindfulness only in the last session- body scan, movement, short sitting. Quite a few of the group want a practice-day follow-up at the weekend at the beginning of July. 28.5.13 155

Project progress and context notes: Random thoughts part 237, or: the loneliness of the long-distance charge nurse Conflict or disagreement inevitable in the SCN - line management relationships? How did this effect the WBP? On both parts. Can I really step out of role? Just to note, if I haven't done so already above, that one area of tension will be the temporary promotion of Susan over Gemma in Day Programme, which I have had a hand in. Gemma is in the group, and Mary is her clear ally. Karen, on the other hand, may well even be delighted by this. Gemma is reportedly furious, going to Human Resources, etc. (Turned out to be an untrue rumour). Alex is also up for an interview that I am central to, for the EIS post, although I don't imagine he will hold that against me. In the meantime some personal, or should I say even more personal stuff. First, Norma, who is in the group of course, came to ask my advice about whether or not to be in touch with her mother, with whom she has been estranged for many years. She describes her mother as "personality disordered". And her mother wrote a letter to her a long time ago dis-owning Norma. Norma knows I had been in a similar pickle with my father, now dead some 4 years. I said she needed to do what's best for her, that it was her choice, that I wasn't sure it would make any great difference, that it still hurt when I heard he had died. It was very sore in fact. But perhaps what I was hurt by was as much to do with finally having to let go of some fantasy nice dad figure, which was never going to happen anyway. Sarah made a great point later on that his death also meant that I could also let go of the pain of trying to make things right for him; there had also been that dysfunctional role reversal thing in our relationship. So I didn't have to continue to take responsibility for him anymore. Must get back to Norma about this. Of course this somewhat stirred things up. Felt sad, and went home physically unwell. Coinkidink? Doubtful. I wish I had understood that better in the past, that underneath it all I had been carrying a sense of responsibility for the old goat, despite all my loud protests. 1.6.13 Reflection on MCTN group: The day after the afternoon and night before session 8 156

So the last group has been and gone in a flash, and seemingly catching some of the group unawares. Alex and Tommy returned, and Melissa, but Elizabeth off and Gemma sick. Most said they would miss the group time. Anne et al. said they'd miss giving time to looking after themselves, that they had often relaxed so much in the group it was hard to work afterwards, and it was nice to end the week with the group (if you work Monday to Friday 9 to 5) and use the group to leave work behind. That's an idea I like, in that we are a stressed bunch, as a later conversation in the pub for a staff night out revealed vividly. There, the IPU nurses talked about the suicide last year, and the post-suicide support afterwards. It was a lovely feeling watching and sensing the group relaxing in a body scan practice, even the snoring had a gentle warmth and a sense of shared humanity about it. Will miss the group, even though am glad it's over in terms of the sheer effort it took to keep going. In the group I gave a resource list, certificate of training and a snow globe, which all seemed delighted with. There are still some odd ideas I need to follow-up on, like Gemma, according to Karen, experiencing migraines because of mindfulness, and Karen herself, who seems to struggle with sitting or staying still at all. Need to follow-up on these ASAP. And get the outcome measures out ASAP too. Also need to do this before some EIS shit hits the fan. Really would like to interview everybody!! In other news, the EIS post could not be filled, including because Alex withdrew. 7.6.13 Project progress: Ch-ch-changes? Karen gave me back her outcome measures saying they may be affected by her argument the night before with her boyfriend, but also said that she does think more about mindfulness and for example the DFW words of wisdom after she has responded habitually, a process I can 157

totally relate to. Norma actually apologized for something. There was a discussion at lunch about religion and Buddhism, and Mary is coming to see me to talk about religion. My own experience of learning mindfulness and compassion is that they grew hand in hand and indeed were taught that way. 16.6.13 Project progress: Panic part 1 Must re-read the papers behind the outcome measures now to get a fuller sense of what the scores mean and to factor a question in for the interviews, including just asking people what they found helpful or hard or meaningful in the measures. To do in the holiday: Score all measures I have and do individual comparisons!!! Read the papers behind the measures Write up an interpretation of the scores thus far Type transcripts of interviews I have Reframe interview structure if need be Transfer dairy to laptop Did Norma score her follow-up measures after she had heard the news about her mother? Hers will probably be the lowest scores, even less than Elizabeth. 28.6.13 Project progress: Panic part 2 So here is the plan, in no special order: Read through all university guidance on the dissertation, the proposal and this diary Update the outcome measures and work out who is left to give me one Start interviews in earnest, and incorporate more explicit feedback as above Transcribe the interviews I have already (2) Follow-up session??? 158

Random thought: could there be 'stages of engagement with secular mindfulness' just like there could be 'stages of faith' in religions? Context notes: Notes from work event last Tuesday and Wednesday, a service review event: collective advocacy worked noted that when a young person is on intensive 1:1 observations or even 2:1 then the other young people are worried about the staff and how they get looked after during such a crisis. Having said that, some young people do realise that in order to get attention they need to act out too. The service review event itself is noteworthy in that fairly major changes were mooted and some difficult questions raised and disagreements aired about some aspects of the service. During the last week Veronica came to see me about a few things including rumours about a colleague drinking; the stress of working in the IPU; and still being disturbed and distressed by a patient s suicide a year and a bit later. This sad event had also been mentioned by Andrew, although he isn't in the MCTN group, and I have been wondering just how much it runs through the sometimes defensive or harsher behaviours of those staff who were in the IPU at the time. 30.6.13 Project progress: Things what occurred to me while reading, and that Much emphasis on context and causal mechanism in CR. Occurs to me need to sharpen my thinking around this, and to re-read the chapter in Pawson and Tilley on interviews before I do the next one. Possible mechanisms include how pairs of friends fared in the MCTN group: Karen and Anne are similar age, background and life developmental stage, even to the extent of being engaged and soon to be married. Did they copy each other in the group? For example by not practicing between groups? Stating that it made them think during arguments etc.? What about Mary and Gemma, older women with kids? Also on the other side of the Day Program argument to Karen. Also noted that there's so much this group of nurses will have no control over, like the kind of NHS, CAMHS and nursing profession they find themselves in. (Social circumstances issues common to all research participants in a social science project). 159

NB Giddens point too, about the limits of any social actor's awareness. NB too the points about multi-method collection of data. I have questionnaires, interviews and this diary, which has attempted to observe CAMHS, the group as a whole and people within it. Also NB Brach's point about readiness or otherwise to forgive, especially for people like Norma. 2.7.13 Project progress: Performance anxiety Jemma s remark about when to complete the outcome measures indicates in its own way an anxiety probably most people felt about completing the measures. Must ask this directly in the interviews, and give people their scores. 3.7.13 Project progress: Wounded healers? Scoring the outcome measures and thinking about Pawson and Tilley s take in interviews in CR research, especially trying to work out CMOs and within that mechanisms, am struck by what a hard time nurses give themselves. This is reflected in possibly high levels of fears of compassion in Gilbert's questionnaire and high levels of self-judgement in Neff s. Also appearances are important, or at least appearing socially desirable...although the group are probably split in this regard. (If have time will need to compare low scores on the SDS with high as two groups). Possible theories: Hard to be or to be seen to be compassionate as a nurse, either because your colleagues aren't doing it, and/ or could be a weakness. The latter applies to 'dangerous' or 'deviant' patients or behaviours or for deeply personal reasons. Some nurses find it hard to be self-compassionate or perhaps to be seen to do that. Nurses need to be busy and to be seen to be busy. Perhaps it's important to have an inner critic to boss yourself around. 160

Now need to re-think interview questions and format in light of P and T reading. 10.7.13 Context notes: It s too damn hot, yes it's... A mini heat wave, or as it called in normal weather parts of the world, summer. In our case will probably only last the week, but it is truly roasting in our place of employ. By the time the day is done my brains have been boiled. In the meantime a week that exemplifies one of the key aspects of context: I've been given more to do with the same time frame in my job as SCN. So there's been one increase, massive, in taking on Day Programme in addition to ITS and EIS, and now this week have to oversee the IPU too. It's been okay because there's no major crises yet, but I feel at tipping point for pressure and information and on the borderline between calmness and kindness on one side and agitation and hysteria on the other. And I am not being a drama queen. This is reality. For now. To-do list: On Thursday use outlook to set interview dates Thursday to Sunday read CR and identify mechanisms, both enabling and inhibiting Also transcribe the interviews I have Do more interviews between 15 and 29.7 Also balance that with work priorities, which are many and varied! Also noted interesting article on "McMindfulness" from the Huffington post, saved on to favourites on the laptop. Describes how mindfulness is becoming mainstream, big business, and wonders what it might be losing in the process. And the sneaky use of mindfulness to give employees a safety valve and way of letting off steam then getting back to the business of working hard for the company. 13.7.13 Project progress: Some actual honest to goodness studying 161

Clark et al 2007 CR paper, helpful, gives an example of how to identify underlying mechanisms. In their case they used regression analysis, which isn't really necessary for the small sample I have. In my case I have baseline info, outcome measures and field notes to work at identifying CMO issues. I can do this in a kind of overall way and for each person, and take that into the next round of interviews to have them confirmed or denied! Article also helpfully points out the dearth of concrete research using CR despite its potential usefulness. Underlying mechanisms for engagement in MCTN: Nurses' clinical experience, for example violence, self-harm or even suicide. Such negative experiences could make nurses fearful of showing compassion; for example they may be concerned that doing so could lead to harm coming to them or their colleagues, either physically or psychologically. Also, just opening yourself to a patient who then might kill himself is challenging. Overlapping with the above is the culture of nurses having to be busy and to be seen to be busy. Theses dynamics make it potentially challenging to then sit in mindfulness practice and 'do nothing'. The culture of being busy is reinforced by the organisation, the profession and by the person themselves, who may feel guilty, for example if other departments are really busy and theirs is not, or being busy may serve as a defence against the more disturbing aspects of clinical practice. It is not just clinical experience that may affect compassion in nursing but one's experience of colleagues, good and bad. This harks back to the professional enquiry module finding and to Stevie's experience of having been bullied at work. Another key mechanism is nurses' attitudes towards expressing feelings and looking after themselves in relation to their existing personal and social coping behaviours. So, for instance, some staff like to exercise, some to go to the pub to let off steam, others to go to their Church, and spend time with loved ones. Another mechanism involves nurses attitudes towards self-kindness and the extent to which this is wise for them. Potentially a very sensitive area, personal. Finally, there is of course the issue of whether or not the nurses had previous experience of mindfulness or compassion meditation. Most had not. This, perhaps in combination with being faced with challenging compassion practices, which may have been mildly off-putting, may have led to little practice having been done between sessions. 162

17.7.13 Project progress: Outcomes and coming out Interesting perspective, having finally got to the end of the outcome measures, is that the biggest difference between the cohorts was the reduction in cohort 1 of fears of compassion. So, even if it was a challenge, and a mix of techniques I wouldn't do like that again (would stick to mainly mindfulness for a beginners group), there was some benefit in the programme where CIN is concerned. Hence, some folk may be coming out that compassion closet, a bit. Said I would interview 4 from each cohort, so am nearly there with cohort 1. Veronica could be asked management type questions. 21.7.13 Project progress: Life is a tale, told by an idiot... Have completed transcription of about 60 minutes worth of interviews. Am now remembering what hard work they are. Also reminded that people don't speak in nice neat sentences. Interesting comments as per though, and initial themes include the notion that CIN seems to be a double-edged sword at every turn: it's important but challenging; your colleagues can help and hinder; being in the group was helpful but then you had to sit with people whose actions annoy or upset you; being compassionate is the most important thing but it can leave you open to feeling vulnerable or increase fears of being exploited; and being busy is important, including in order to put compassion into action, but that means you don't stop to reflect, relax or be mindful. Other themes are that personal issues do affect work context, as implied by, for instance, Karen's argument with her fiancé, and Norma's feelings about her mother getting back in contact. Also, as is implied by the value placed in 'letting off steam" in the pub, work has the potential to impact on personal space and time. 25.7.13 Project progress: Wounded healer and the wisdom of youth In her interview Norma was sad, upset. Can't remember the content just now, apart from her feeling that the implication in her high-scoring Fears of Compassion (FoC) measures was that 163

she was lacking in compassion, which wasn't really the issue. Karen had a couple of great quotes. Need to interview Veronica then have all the group interviews. Need to look into rates of mental health problems, attachment issues, even suicide rates in mental health staff. Also the actual death rates for people in treatment from any cause and for suicide, and for self-harm and for aggression. 26.7.13 Context notes: Take the pledge, take the plunge Report in the media yesterday that some NHS staff are going to made to sign a pledge to be caring and compassionate and, ludicrously, to never moan about the service. We will be allowed to criticize but only if we offer solutions. Report on the radio today and in The Scotsman that the Ombudsman has had a record high number of complaints about the NHS. He will produce a report at the end of August with recommendations which I must get. He talked about compassion too, and cited the Patients Rights Act, which I must look into. Also cited the Francis Inquiry report. Increase in complaints partly related to the introduction of the Patients Rights Act. 19.8.13 Project progress: Back to life, back to reality Have been on a family holiday to France, from 31st July to 14th August, then a further 2 days off last week to recover adjust and get the clothes washed kind of thing. And perhaps to delay returning to work that bit longer. It was a great holiday in that it was a complete psychological break. I can't say that's happened during or after all the holidays we've had. Maybe it was because it was so active in comparison; we were in Paris were you have to walk everywhere and see the sights, even in temperatures so high you'd normally expect to be dosing on a lounger in. After Paris we were in the Limousin with friends, and there we just had to have a car and drive everywhere, even to get a pint of milk. And it was fun. Remember that? 164

It was very hard to drag my sorry ass into work this morning, and, although also pleasant to see long-standing colleagues with whom I feel kinship, trust and warmth, to listen to the latest tribal friction and large organization stupidity. I also have to get right back into this project, and with gusto. Aim to finish the interviews by the end of next week, and to get cracking on with transcribing. Have actually managed to create a graph on Excel. Now need to work out a) how to label it and b) how to transfer it to a word document. Have had to reconsider exactly who to interview due to their annual leave and mine. 22.8.13 Project progress: Happy days Very helpful interview with Jemma and really good question from her when we went over her outcome measures: does it make any difference if you have high FoC scores to how compassionate you are in the world? For her compassion is action. Answer from me was that although of course one can be compassionate while simultaneously having fears of being or doing so, the consequences of high fears might be that your internal processes are fraught with dysfunction. This split, between what a person experiences internally and how they act in the world may well be a summary for many nurses of their lived experience of CIN. 24.8.13 Project progress: Procrastination central Should be transcribing. Will do so tomorrow. In the meantime, here's a list of their things I could do that are meaningful but help me avoid starting that hell now: Type up an outline for MCTN i.e. for main headings/ topics Find and re-read articles which explain what the outcome measures mean Learn how to cut and paste the graphs on to a word document Reading: Ray Pawson, then Creswell and Clark, then Choden and Gilbert, quick as possible, and those outcome measure explanations. 165

30.8.13 Context notes: Mentalisation places error at the centre of communication. Communication errors are mental. Today, Karen is sent to chum a kid to school, the kid being anxious about it. At one point, there's a bell and the kids are asked to stand in line, and so is Karen. Rather than stand up for herself she stands in line, head bowed, put in her place. Right, back to business. Transcribing Saturday and Sunday; interviews Tuesday to Thursday. Also need references to CAMHS IPU; suicide in youth. 4.9.13 Project progress: Ain't nobody's fault but mine? 2 more interviews to go, although may not get them taped until next week. Should be okay as they are non-mctn colleagues. Currently confused about whether or not I have really identified and distinguished between context, mechanism and outcome, and worried that my interview questions won't capture mechanisms adequately. I do have outcomes, both numerical and verbal. Perhaps I should complete a few transcripts, check for themes (CMO) then review with my supervisor. Need to check out the black box article and the Leeow article to see if they help. Help! 15.9.13 Project progress: Planting seeds: a good theme heading for one aspect of reporting themes from the project 13.10.13 Project progress: The beginning of the end I have delayed this moment, the last, almost last entry in these notes, because in a positive sense keeping the diary going has given me genuine pause to reflect, and added a valuable spot of triangulation. 166

For example, when it comes to thorny CMO issues, this diary does note reactions in the group to the various compassion practices, which in turn links in nicely with the outcome that FOC reduced for the group participants. In a negative sense, not ending these notes sooner has been part of delaying really getting on with the academic business end of the project, a thing heightened by the realisation that I don t have to submit until the end of April 2014. But the time has come to wrap this diary up. I will move back to a handwritten reflective journal and get on with doing what needs to be done. The transcripts have been a real drag. My back hurts sitting typing for long stretches, I dislike the sound of my own voice, of course, and I worry while listening sometimes that I haven t caught any underlying mechanisms. Having said that, I now only have 2.5 to go. So somehow I ve got there. In the meantime, as a partially strange note to end this diary on, and one that probably won t appear in the final essay, I thought I should reflect on some team dynamics, especially as they include participants in the MCTN, me, and a troubling context. Context notes: The world is on fire, and if the flames don t get me, the smoke will EIS team meeting, star-date 10.10.13. A larger than normal team meeting, although not unexpectedly so given that the CAMHS senior management was due to visit later on. But Sean was there, as he often is when there s a rehearsed psychology strategy to protect their turf or gain something. One CPN, intentionally or otherwise, already tense and distressed as we soon found out, was the first person to observably raise the temperature, by questioning a decision the Psychiatrist and I had made about assessing an EIS referral. The Psychologist didn t like what we d done either. The Psychiatrist was offended by the CPN s statement that referrals like this should be seen by someone from the team, as if the Psychiatrist and I are not in the team. After the meeting the Psychologist half-jokingly said she would kick my butt if we didn t get the young man in question assessed by EIS. 167

Pretty soon after that, with the Psychiatrist s dander already up, and me trying not to get cross and caught up in conflict, perhaps avoiding one, the CPN raised the case of patient X and cried angry tears of frustration at what she perceived as a lack of support from the team, which really meant the Psychiatrist and her junior medic. And so, round two kicked off, an argument bordering on becoming personalised ensued, and at one point the CPN left the room to gather herself. During one part of an outburst she said it was likely that some of her feelings were heightened by hormones, aka the menopause. Not the full story though. When she walked out I said out loud I wanted to help but didn t know how, then had to stop things anyway in a limit-setting kind of way when they quickly became heated and unsafe after her return. Thankfully, this led to the beginning of resolving things in the moment; Sean helpfully joined the fray too, to point out that there was in fact a shared view of the case, that patient X was in crisis, and he wondered what had worked in the past to resolve such a thing. Plans were then made, but boy did the tension linger. On the plus side, this was a passionate and open conflict- i.e. at least it was not passive. But it was also like a psychological car crash, and cannot possibly be something good for anyone s health. The Psychiatrist later in the week told me she had not slept a wink that night. In the meantime senior management came and I labelled the fact we had had a tough meeting with tense disagreement. We then proceeded to agree with each other in the first half of the meeting, until the lead psychiatrist in the Exec noticed the latter process and wondered what the disagreements were about. Which we then got into. And so the tension returned, a ghost shocking us out of our collective professional veneer. I write about this here, because I wonder about events like this and compassion in health care. Of course disagreements are always going to occur but how do we keep them safe, kind and respectful? I suppose I wanted to reflect on this initially because I have been wondering if I model compassionate or mindful qualities in daily clinical/ professional practice. Now that I write this I can see that there is a least a modicum of that here. I didn t want to pick a side between the Psychiatrist and the CPN; I wanted to help them both. The CPN is a nurse I line manage, 168

works at the coal face and has had a long-term, close relationship with patient Y and his family. The Psychiatrist is over-stretched, being told to cover 3 services with over 80 cases in total and under considerable pressure to have all the answers for all of them. She s also often right, even if she speaks in a blunt and direct way, citing her Greek personality as reason for such. She s also controlling, and in these respects is similar to the CPN. Also I defy anyone to be completely certain about discerning the difference between autism and psychosis. These things went through my head, and remained there, and I did act to prevent full-scale warfare. So, a bit of equanimity and empathy. And observable intervention. The other reason for writing this is that the above incidents happened during a week when we had also convened a meeting to begin integrating ITS and Day Programme. This was also a tense affair. The question that occurred to me after that meeting, which has echoes of aspects of the EIS team meeting car crash, is: how often do we forget that as staff in an NHS health care system we are there to serve? Serve the public in particular and our particular patients. The NHS/ CAMHS is not our personal empire or business. It belongs to the public. So don t their needs come first? Staff needs are important, and without a healthy staff team we could not provide a decent service, but surely that s a second, even if a close second, to meeting the needs of service users? Surely we are consciously aware of that when we sign up for the job in the first place and then we keep reminding ourselves of it as we go? I am more certain of the former than the latter, and that s one of the themes of the project: We begin with good intentions, but something happens along the way and we forget those intentions. The something is this project s black box, perhaps. Conversely: With time and a structure for so doing, those intentions can be remembered and compassion re-invigorated, perhaps even heightened. So there is hope! Field notes end. 169

9.8 Sample interview transcript Copies of all interview transcripts will be provided to Aberdeen University in a separate date file. The transcripts use the same abbreviations and pseudonyms as the main body of the text and the field notes. The following transcript is for the interview with Anne, from Cohort 1. Interview begins: (Review of outcome measures) GC: so the top line is the first lot of outcome measures we took, and then that s the one after, c os obviously we re looking at, one of the things we re looking at is, em, has it made any difference? What things have changed? Em, and also, there s a bit all these other numbers are comparisons with other folk to show where you sit in the group of people who did the training. I haven t quite got as far as calculating where people sit in relation to the group who didn t do the training, but I m going to have that... Anne: okay GC: so what this says is that, first of all the SDS, the Social Desirability Scale, that was that challenging one with questions like: I sometimes litter. Anne: oh yeah GC: the range of scores (overall for the group) was pretty much the same before and after, 1or 2 to 14, 14 obviously being the highest score and 1 being the lowest, and that s pretty much you; you re at the lower end of that scale Anne: so I m not socially desirable? GC: well, I think it means you re an honest person and that, em, doing things for appearances sake isn t necessarily that important to you, in terms of the questions that you were asked on that outcome measure; (we re) not talking about appearances in the literal sense of how you do your hair or make up, c os obviously that is important to you, eh, but that, eh, you were 170

not really worried about how you came across in that questionnaire, which means, it points to a genuineness Anne: oh (sounding pleasantly surprised). That s nice. GC: em, however it doesn t mean that people who score 14 are necessarily disingenuous, it means they re probably a bit more anxious about how things appear, especially to a charge nurse asking nosey questions like that, em, so you went from a massive score of 2 to 1, which is really no difference, eh, for that. The two (scales) that are really directly important to compassion are all this gubbins here is the self-compassion questionnaire so you started off with 2.96 and improved massively to 3.21 Anne: there you go GC: now what that means is that you are in the moderate ranges of how kind you are towards yourself em overall, so a low would be a 1 to 2.5, 2.5 to 3.5 is where you sit, so you started off in the kind of moderate position and you ended up there too, just a slight increase, eh, so your self-kindness increased a little bit according to the questionnaire, however the way that you judge yourself when you re under pressure didn t change, nor did your sense of isolation, nor your level of mindfulness, em, the extent to which you over-identify with negative thinking when you re under pressure came down a little bit, and your senses of common humanity, that sense of we re all in this shit together, improved a bit. Any of that a surprise...it s not, I m not implying any criticisms! If you want a comparison with the group your scores are entirely normal for that group. It s the slightly higher end you started with, em, I don t know, that s roughly half-way for afterwards for your overall selfcompassion (SCS score) em, I mean the other thing about outcome measures is that this is only one way to think about things, the other way is exactly what we re going to talk about when we do the interview Anne: yeah GC: em, so I wouldn t get too carried away with this, em, the final one, the Fears of Compassion, em, now that s compassion, I ll have to remind myself exactly what.so first of all there s a scale for expressing compassion towards others, then responding to the 171

compassion of others, and then expressing kindness and compassion towards yourself, which obviously overlaps with (the) Self-Compassion (Scale), em, now this is one of the most interesting outcome measures, so the higher your score here, the more afraid you are of the particular type of compassion. Anne: okay GC: so this very first scale (FCS 1) is the one that s your biggest anxiety, is actually showing compassion for other people Anne: that s nice! (laughs) GC: so you re in the right job! No, I m only kidding Anne: oh my God! GC: no, don t worry about this, c os, em, that, if you see there that range of scores is 5 to 27, so you re halfway in that group, em, and where you end up is roughly halfway in the group as well. So there are some people with a huge amount of fear in that group, look at that: 0 to 30, 0 to 34. The people I worry about are the people at 0 and the people at 34, that s if, you know, I was gonna get managerial about it and wonder who has a problem; I think the people at 0 may be in denial and the people at 30 and 34 are needing a bit of a hand really. Anne: and where am I again? GC: you re halfway, so the one about responding to the compassion of others is 8, and kindness towards yourself- Anne: what about actually being nice towards other people? Am I not very nice to other people? GC: well, what s that s saying, no, it s not saying that (you re not compassionate), it s saying this is the one you worry about the most. 172

Anne: right GC: the one you worry about the next most is, em, expressing kindness to yourself, and receiving expressions of compassion form others, 8, but what s really interesting is, well, basically your fear of expressing compassion towards other people, expressing that yourself, goes down a little bit, this one, the self-kindness, goes down a little bit, but look at that! Apparently (FCS 2), it goes to zero. Anne: I don t know what that means. GC: neither do I (both laugh). It s just interesting, em, it s a very, very dramatic change, but I suppose the thing about outcome measures is, it s always about when you fill them in. Anne: that s true GC: there s a bit of that. Right, so, if that was confusing I ll try and make this (interview) as clear as I can, em, c os I ve got a script here (interview schedule). The type of study I m doing is called a critical realist study, which is a fancy way of saying, em, amongst other things, I need to be explicit about what my aims are and actually share a bit of the theory, em, behind what I m doing, to check that I m on the right lines sort of thing. So my project aims, are, first of all I m asking the question is MCTN useful to them in real terms? And in order to explore that what I m interested in are identifying any personal, social, professional or organisational factors which might influence how people engaged with the training and the outcomes. And within that, what are the things within those four sort of areas which enable engagement with a programme like that and what are the things that inhibit it. Whoo! That was the easy bit! Anne: okay (Discussion of research project theories regarding CIN) GC: so, em, the other thing I m supposed to do in this type of study is identify what are the underlying mechanisms for, em, particular outcomes, so themes that I ve picked up, from what people have said, from the outcome measures, and that I think about (from) having known CAMHS a bit. Em, so, I m going to run those themes by you and ask you if they 173

apply to you or if you would change them in any way, and then I ll ask you some specific questions if we haven t got to those sort of concrete details yet. Make sense? Anne: yep, sounds fine GC: so, eh, and this is in no particular order that I wrote this, and I don t know which themes are any more important than others, but what I though was, and this may be fairly obvious, is that nurses attitudes to compassion are very closely linked to what their clinical experience has been, so for example if you ve experienced violence in the IPU, young people harming themselves, or even, and I dare to mention it, the suicide last year, that will potentially influence how fearful people are of expressing compassion Anne: mm-hmm GC: does that ring true? Anne: yeah, definitely. GC: do you think it affects you that way, that? Anne: yeah. I don t think it can t not, can it? I think especially if you re talking about the suicide, of course that affected everybody and how you managed things, and how you lost confidence in what you were doing, and if you were doing the right thing; you questioned everything, so...you were probably over-compassionate, I imagine, to other people, but the probably less compassionate to (ourselves?), I think we were good in that we were very compassionate towards each other for that immediate period of time, but then it kind of loses it, don t it, when you re (busy?), when the needs of the ward pick up again, your compassion drains again, it goes, so, and it s difficult to be compassionate towards people you know have been violent to people that you work with, so.. GC: especially when some of them are your pals Anne: yeah, yeah. 174

GC: but even when they re not, I guess both are pretty horrendous... Anne: so, yeah I definitely think it affects compassion GC: what your saying is really interesting, c os there s probably a layer of this, em, I haven t thought about in exactly those terms, following the tragic event last year, the suicide, maybe there was a time when people were overly, overly compensating about that event, they re being really kind to each other as staff, and maybe being extra kind to the young people, and then it changes, and what I m wondering about is first of all, I guess what you re saying is em maybe folk burning out a bit, actually, and just getting tired with it. What I m wondering about, where I m going next with some of these themes is, em, is there then a fear if, you know, if as a nurse, em, I open myself to being compassionate, I might then get hurt in some way, either exploited in terms of violence, or young people continuing to self-harm and you think that everything s going okay, or actually the worst possible event: I don t want to get too close in case is that a possibility? Anne: yeah, definitely think so. GC: that s a bit shan Anne: it is a bit shan (laughs), I suppose, depending on how heavily you are involved with a young person you can t help but feel disappointed if something you ve put a lot of effort and time into doesn t work properly, but then I suppose that comes with experience, your much more open to that when you re newly qualified or your new on a ward, because you think that people are going to be judging you or watching you and then you feel, I think you are more, not that you re more compassionate, but you re maybe more open to it, and you re more aware of it when you re newly qualified, whereas now I m able to take a step back and say I can still be compassionate but it s not going to affect me in the same that it would have four years ago, if that makes, is that what you mean? GC: yeah. So there s both a willingness to continue to be compassionate, because, presumably, you see that as really important to nursing, but actually there s a bit more care about how you are compassionate and what that might lead to, sort of thing 175

Anne: uh-huh. GC: okay, that s really helpful. Thank you. Some of these themes over-lap, and like I say I don t think some of them are more important than others, this next one I think definitely applies to you, which is, eh, I think that one of the things that probably affects how people engage with MCTN is: you re just supposed to be busy when you re a nurse. Anne: mm-hmm. GC: and that definitely applies to you, doesn t it? Anne: (laughs) yeah, uh-huh GC: so the idea of just sitting and being is just kind of alien Anne: it s not alien, just doesn t feel as if I m doing enough, so surely if I m a nurse I should be busy, and maybe there is something about, I suppose when we get out of the inpatient unit that s when you start thinking: God, remember when that happened, remember that.., so maybe, as you say, you do leave yourself open to actually old wounds, maybe that s, maybe that s not helpful, dunno GC: well, that s exactly what I wondered next: is the busyness defending yourself against how you might feel if you weren t busy c os that, what you re describing makes mindfulness a big challenge actually, you know, c os you are just asked to, as Alex said in the group: just hang around doing nothing, see what pops into your head. Anne: yeah, I suppose it s just different. Sorry what was your question there? I got confused by...about Alex (laughs) GC: (laughs): I m so sorry about bringing Alex into it Anne: he popped into my head and I couldn t get him to leave again 176

GC: well my, I m guessing that one of the things that affects outcomes in this project is an idea that, for many nurses, yourself included, you need to be busy Anne: yeah, I d imagine it probably is a defence. Yes, I like to be busy, so yeah, probably, yes that s a difference GC: how much of it for you is a personal thing and how much of it do you think is a professional thing that you ve acquired being a nurse, if you re able to say? That s quite a difficult question Anne: em, I think it s probably a bit of both that I wanted to be a nurse in the first place? I m not as busy in my personal life as I am in my professional life. Pretty different at home than I am here GC: right? Anne: but, I dunno; I ve never really thought about it GC: okay. You don t have to know the answer; I just- Anne: yeah, it s, I m probably more professionally bound to be busy GC: right Anne: but it s not, I don t think it s from a, what s the word I m looking for? I don t feel pressure to be busy, I just think I should be; that s what my role is. I m a nurse; nurses should be busy GC: almost a moral stance? Anne: yeah. And I sometimes think: God, folk in A and E must be run off their feet and I m sitting here dossing about talking about de-doo-dee-doos, it just doesn t seem to add up, like that s not very fair, so 177

GC: I sometimes think that too. Anne: do you? GC: yeah, yeah. And our boss is a bit like that, she always thinks that area s really busy and that one s really quiet and it niggles away Anne: and I m thinking, I dunno, I always, I feel quite patriotic about towards the NHS; I think it s one of the best things our country has come up with, so surely we should be making sure everyone knows that, be taking this forward, saying this is what we do, look. We are busy! (laughs) Don t take our nurses off us! GC: I ll make sure that goes in the final report Anne: yeah, do that GC: what I was going to say next was in terms of this busyness, so what we have identified is for you, em, and I would agree with this entirely, that there might be an element of: keeping busy is a moral stance, we should be busy, em, but actually there might be a bit of defending yourself against the darker side of the job Anne: yep GC: but also the NHS, our boss, Judy, Senior Charge Nurses, we all expect nurses to be busy too Anne: yeah GC: there s lots of targets we have to meet, and in an IPU you have tasks that you have to do Anne: yeah GC: right. The next thing is, the next theme is, fairly obviously, I think that whatever attitude you have towards expressing your feelings generally and/ or looking after yourself 178

psychologically is gonna affect, em, outcomes in a project like this, so what I mean by that is, thing like: how much you value exercise as a means to let off steam, or going to the pub and having a night out. There s no implication that those things are somehow better or worse than mindfulness, certainly not in my head, em, but I m guessing that how much those are valued by you will affect how you then engage with mindfulness Anne: yep GC: has there been any change in that sense for you, in the way that you view those other things? I m not fishing for anything, I m genuinely interested Anne: it s made me, doing the mindfulness training, it s made me want to be mindful, but I do, I am trying a lot more, but I still use other things, I would still go to other things before I would go to mindfulness, I would still go, I would still go to the pub if I d had a really shot day at work, I would go to the pub, I wouldn t, just now I wouldn t go home and practice, if you know what I mean GC: yeah Anne: is that what you meant? GC: yes, and it ties in with another theme, which is: people s previous experience of mindfulness or compassion training, or any kind of meditation probably had an impact on how they engaged with the MCTN programme, because, and this is genuinely not a criticism, almost nobody did any between-sessions practice in a major way, em, and I think that s one of my comments about the outcome measure results- nobody had terribly unhealthy scores, em, but there wasn t a massive change, which you do sometimes get in, em, other projects where they do mindfulness training. That s partly to do with the between-sessions practice, but I m guessing here, for the likes of yourself, you d never done it (mindfulness) before- Anne: nope GC: em, so, maybe on your part there s a bit of wariness on your part, about what is this stuff? And just testing it out a bit 179

Anne: yeah, and like you say it s about experience, and I don t think the IPU exactly kinda model it; that s not what you do when you have a rubbish day and shift- you go the pub afterwards. It s very tasky, is very, it s an acute ward, so this is what we do and these are the tasks, and it s not about, it s not not about being compassionate to people, but that s not really brought to the forefront. I do think it is definitely based on experience, whereas comin to EPSS would be.. doubtful, given how different they can be, where you can maybe do a bit of both GC: where you ve got a bit of time, maybe? Anne: yeah, where you can do a bit of both, where you can maybe be nice to people! Sometimes, maybe! GC: yeah, yeah. So, in the inpatient unit, had a shit day, let s go and let off some steam if you ve got time, and- Anne: or go home and just not speak to anybody who you were on shift with, like that was kinda it, so ye either did the whole camaraderie thing, like let s all go to the pub, let s all have a drink, or no, actually, see yous later, see yous tomorrow, I can t bear to look at your face anymore (laughs), like I ve had enough, I ve had enough now! (laughs) I m away! GC: and does that work for you? Anne: well it worked for me down there (the IPU), yeah. GC: yeah, yep. Anne: that is true since coming out of the IPU, like part-time, and then I have looked for other ways to manage myself better, so it (the MCTN) has influenced me GC: I suppose that s, that s, well, you ve highlighted another theme I need to explore, is that one of the probable mechanisms is literally where you work and/ or where you ve recently worked, c os you, I think you re still in that sort of transition between the IPU and 180

community working, and you re beginning to realise the massive differences.so, where you work probably has a massive impact on how you engage with this kind of stuff (the MCTN programme) Anne: yeah, I would say so GC: em, c os we saw it in other people in the group, and I hate to bring A into the room again, but I think he was a bit like that Anne: yeah GC: em, right, eh. I think that s it for the fancy-dan themes Anne: have I answered them enough for you? Was that useful? (Questions from interview schedule) GC: yes, it has been helpful, c os the purpose in me describing them is if you have things to add or change or, you know, if it was completely the wrong tree to be barking up, em to talk about that em, I mean, you mentioned the word camaraderie there, em, one of the purposes behind getting a group of just nurses together was I was hoping there would be some sense of camaraderie there- d you think that happened in the group or not? Anne: I think probably it did happen without us noticing, I think I would have noticed it more if it hadn t been nurses, if that makes sense, if there was a token doctor or something, it would have changed the dynamic, em and I did think it helped that it was just nurses, it felt a bit more relaxed and more comfortable because we were all roughly the same level (of mindfulness experience), so we could understand bits and pieces from what we were talking about GC: uh-huh. I know not everyone in the group was pals with each other Anne: no, yeah GC: that was entirely obvious, but even despite that was there for you, well, was it safe? 181

Anne: oh, yeah, definitely GC: right, cool. Right. I ll just check through the rest of these questions, c os I don t think we need to go through them all (pause). I think you have touched on this; the first one here is, did the training change your perception of CIN? You touched on it a bit earlier. I think for you probably the answer is no, it was already important to you Anne: mm-hmm GC: what s changed is your thinking well, mindfulness might be useful to me, em, I m guessing you re not entirely sure about literally how to pursue that interest, but it s sort of there Anne: it s there, yes GC: the seed is there Anne: yes GC: do you think you learned anything about yourself during the training? Anne: that I m really tired! (Laughs) like, I fall asleep like that (laughs) (during mindfulness practice). em, yeah I did, I think, I probably was more reflective and more mindful than I thought I could be, c os as I said to you before I tried things before, I tried and meditation just doesn t work for me at all, I just can t, I couldn t go there, whereas here I could and it was in a group and something I thought I m not gonna manage this very well at all, I think I said that to you, I think I m gonna struggle GC: yeah Anne: but actually I ve learned that I can do it and that it benefitted me and that it s something that I do want to look into, keep looking into, and keep re-visiting, c os hopefully I will get to a stage where I can be a bit more mindful most of the time 182

GC: well, we can talk about, if you want advice about it, we can talk about that outside of this interview, because I think, this isn t part of what I planned to say in this interview, but I was really impressed by the effort you and everyone else put in, c os I could see it was a struggle sometimes, and that was why we did more of the active practices like the yoga, a) to keep people awake Anne: I did struggle with that (laughs) GC: yeah, and b) to explore different ways of being mindful, and keeping it short and snappy. Em, this is jumping about a little bit, but, em, do you think there are other things that nurses, individual nurses or the wider nursing profession or CAMHS or the NHS could do to pursue a compassion agenda? Anne: like, can I think what that would be? GC: yeah. Like, do you think enough done in your working life to promote compassion as an idea and/ or to support it? Anne: no, not at all. I think, even if you think that.no, I don t actually, c os if I think about, I said that earlier that I feel quite thingy about NHS and da-da-da-da-da and I always stick up for nurses, especially when they re busy in A and E and stuff, and I can understand they re run off their feet, but I ve never really had a good experience going into a general hospital and I wonder what people s experiences must be coming in here, I d imagine it d probably be a hundred times worse! So and I don t think, I don t think we re given the time or we re given the opportunity in order to be a lot more compassionate than we should be, and it s not until you strip it back and you think actually what s happening? And that s why I quite enjoyed the (psychological) formulations (for clinical cases) in EIS, c os it made me think it, kinda took away the layers a wee bit and actually maybe we don t need to do all these tasky bits, what we need to do is be a bit more containing or a bit kind to this person for a wee while, and you re under so much time pressure normally, so I don t think, no, I think we re too, I highlighted it all the time and they say: oh, you know, the HEAT targets and all this sort of stuff, but actually just saying it and putting it out there saying that you have to be more 183

compassionate, that means nothing, c os everybody s levels of compassion are completely different GC. Yeah. Well, again you re saying lots of different things, I think, if I ve picked you up properly. One would be that taking your time to form a more clinically substantive view of a young person and their family can really help Anne: mm-hmm GC: and not just being so task-driven all the time Anne: yep GC: so there s something about reflective practice full stop, actually having the time to do that Anne: yep GC: em, would promote kindness. Is there anything else that in a concrete way that you think needs to happen? Anne: like, staff support, de-briefs, just your run-of-the mill stuff that we all say; yeah come along to staff support on a Tuesday and it s rubbish! But that is exactly what it should be there for GC: I m not fishing for anything here again, but if you had the choice between, em, a structured mindfulness session or staff support, em, which one would you choose? Or would you want a bit of both? Anne: a bit of both GC: yep 184

Anne: definitely. C os I do think there s sometimes you do need to, you have to be able to voice maybe if something s difficult, you know, you need to say it, you need a safe space in order to get through that and for people to be kind to you and help you get through that, but also I think you need the mindfulness on top of that, in order to do all the other stuff that you need to do by yourself, sort of thing GC: yep. Cool. I came across this thing, eh, a whole bunch of books on non-violent communication and I was wondering if that s the sort of thing that might help the service in the future. Anyway, I ll come back to that another time. Right, next question. Have you noticed any changes as a result of the MCTN in the way that you think about yourself or other people? Anne: yes. (Laughs) I realised that I m actually very quite judgemental and I need to stop being so judgemental, and I m getting better because I m not verbalising it, I m saying it in my head, judging in my head, and then I work through it and I think: no, you re just being a dick, stop it. So I can (laughs), I can mentalise a wee bit, but yeah I didn t realise quite how annoyed I get at people GC: right Anne: and it s not young people, I don t usually get annoyed with young people, its staff, mostly, I think, but I have noticed that in myself GC: right Anne: (laughs) I m maybe not as kind to people as I thought I was, so I m trying to be kinder (laughs), I mean, I ve noticed quite a lot, em, I can be quite stern, maybe I need to work on that a little bit GC: I have to say that I don t find you that way Anne: yeah? I am nice to people as well 185

GC: I suppose it sounds to me like you did actually engage with mindfulness really quite well, because that it what the practice can do in the initial stages, especially when you first encounter it, it opens you to how things are in your head Anne: yeah GC: so, it sounds like what you ve noticed is: wow, I make a lot of judgements a lot of the time! Anne: yeah, my mind s busy a lot of the time, but yeah yes, and maybe I m too busy, I need to clear my head a wee bit, I ve just got, like, a narrative all the time, so GC: you need to be kind to yourself for that happening Anne: yeah, and I did, remember when N said that she just puts on headphones and walks mindfully? I did that and I managed a good minute and a half without thinking loads of nonsense GC: that s brilliant Anne: so, there you go GC: very good. Em, right. (Pause). What were the things you found most difficult about engaging with MCTN- I think you ve already said a bit about this. Anne: I didn t struggle with the group we were in or anything like that, it was more just, yeah, my own busyness in my head, really, and my own, what I take from mindfulness and what I bring to it, rather than anything external or anything anybody else could have done, c os I think as a group it worked really well, I was really pleased with it GC: and did just that sheer sense of busyness then make it difficult for you to practice between sessions? Anne: yeah, I think just now my personal life is busy, getting married 186

GC: yeah, yeah, of course Anne: but I have been thinking about mindfulness and saying maybe I should be using this because I m so busy and stressed, but I m not quite there yet in order to say I m actually going to sit down and do this, I m gonna go and do my invitations or something instead GC: yes; it s one of the major events in your life, right now, really, getting married. But if you wanted to practice at home, could you? Would you be able to say to your other half...? Anne: oh, yeah GC: he wouldn t question it or slag you for doing it? Anne: (laughs), he would, but he d accept it, though, he d just be told! GC: one of the questions here is have there been or are there any significant events going in in your personal life which could have impacted on MCTN and you ve covered that in a very nice way by mentioning getting married, of course, eh, anything significant happen in your working life, do you think, that we haven t already talked about? Anne: don t think so. GC: anything else you want to say? Anne: eh, I found, I think actually maybe I didn t answer that question properly, because I did find myself getting upset a few times, when we were doing the visualisation of the compassion to other people GC: yes Anne: I did find that quite tricky, so I don t know if I maybe even in typical terms rather than doing what you would advise choosing somebody quite neutral, I went completely overboard and did somebody who is no neutral at all, I don t know if that s advice you could push more if you re doing it again 187

GC: yeah Anne: c os I do think it opens you to something that s not helpful when you re at your work on a Friday GC: I m sorry to hear that Anne: no, it s not your fault GC: well, it s partly my responsibility, because, em, as I m sure I ve said, a lot of programmes just cover mindfulness, they don t do compassion training, and that s actually for, amongst other things, the reason you ve just said, it can actually be quite upsetting and disturbing to get in touch with memories and think about people that Anne: but you did advise that we should pick someone neutral GC: the reason I did the compassion training so directly was I thought, em, because I m interested in the topic Anne: no, I think as nurses we need that as well, it s not just about being mindful is it? and I enjoyed, other parts of it I really enjoyed, the compassionate bits, really enjoyed, and I got a lot from it, but it was just that, one or two exercises GC: yeah. I think if I was to do it again I would probably not do as much of the compassion stuff, I would do that only when people had more of a grounding in mindfulness Anne: or maybe just do it nearer the end of the course GC: uh-huh. And the people who trained me, they do a course called MBLC, and that s kinda how they do it. They introduce the idea of compassion early on but actually the practices come a bit later, em, and if I had my time over again that probably what I would do Anne: and make it so that if it is on Friday you can just leave after! C os you can t go back to do a clinical session after that, it s just too hard, it s too hard 188

GC: can you explain that a bit more? I mean, I know I felt that, but... Anne I just thought it was something that, I dunno, I found it quite helpful and quite precious, and maybe it should have been: this is your end of the week thing, this is time for you, and go and be compassionate to yourself and go home for the weekend. Rather than it be: oh, shit, it s only half-three, I better go do something. Maybe that s just me, though, again GC: I don t think you re alone in that, I think a lot of the group found that, actually, and I d have preferred that Anne: or maybe not even on a Friday, but at the end of a day, and I think that maybe people would practice more, because they would maybe go home thinking about it, rather than they had to go back to the ward or they had to go back to do notes, if you could just go, and I tried to do this sometimes, c os the mindfulness would be more in my head, so maybe if it was at the end of the day people would practice a bit more GC: I think that s a really helpful remark Anne: I think it took a while to get into it and relax and clear your mind of all the rubbish that s been going on for the week, to get there and then to have to come back up again, just to finish again half an hour later GC: it sounds like the idea of looking after yourself in that way, em, that was a very positive thing for you? Anne: oh yeah, absolutely. Although it might not be reflected in my outcome measures! (Laughs). GC: don t worry about the measures; they show you to be a healthy person! Interview ends. 189