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International Journal of Mental Health Nursing (2015) 24, 95–103
doi: 10.1111/inm.12111
Feature Article
Consumer participation in nurse education: A national survey of Australian universities Brenda Happell,1 Chris Platania-Phung,1 Louise Byrne,2 Dianne Wynaden,3 Graham Martin4 and Scott Harris2 1
Research Centre for Nursing and Midwifery Practice, University of Canberra, Faculty of Health and ACT Health, Rockhampton, 2School of Nursing and Midwifery, CQUniversity, 3School of Nursing and Midwifery, Curtin University, Perth, Western Australia, and 4Department of Psychology, University of Queensland, Brisbane, Queensland, Australia
ABSTRACT: Consumers of mental health services have an important role to play in the higher education of nursing students, by facilitating understanding of the experience of mental illness and instilling a culture of consumer participation. Yet the level of consumer participation in mental health nursing programmes in Australia is not known. The aim of the present study was to scope the level and nature of involvement of consumers in mental health nursing higher education in Australia. A cross-sectional study was undertaken involving an internet survey of nurse academics who coordinate mental health nursing programmes in universities across Australia, representing 32 universities. Seventy-eight percent of preregistration and 75% of post-registration programmes report involving consumers. Programmes most commonly had one consumer (25%) and up to five. Face-to-face teaching, curriculum development, and membership-to-programme committees were the most regular types of involvement. The content was generally codeveloped by consumers and nurse academics (67.5%). The frequency of consumer involvement in the education of nursing students in Australia is surprisingly high. However, involvement is noticeably variable across types of activity (e.g. curriculum development, assessment), and tends to be minimal and ad hoc. Future research is required into the drivers of increased consumer involvement. KEY WORDS: consumer participation, lived experience, mental health, nurse education.
INTRODUCTION The importance of consumer participation in mental health services is now clearly stated within relevant policy documentation (Australian Government 2012). This
Correspondence: Brenda Happell, Central Queensland University, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation and School of Nursing and Midwifery, Bruce Highway, Rockhampton, QLD 4702, Australia. Email: [email protected] Brenda Happell, RN, RPN, BA (Hons), Dip Ed, B Ed, M Ed, PhD. Chris Platania-Phung, BA (Hons). Louise Byrne, MA (Hons), PhD. Dianne Wynaden, RN, BAppSc, Grad Dip HSc, MSc (HSc), PhD, FACMHN, CMHN. Graham Martin, OAM, MD, FRANZCP, DPM. Scott Harris, RN, MHN(Cred), Dip Health Sci, M Ment Hlth Nurs. Accepted August 2014.
© 2015 Australian College of Mental Health Nurses Inc.
includes the National Standards for Mental Health Services (Commonwealth of Australia 2010). Consumer participation in mental health services at both individual and systemic levels is embedded throughout the document in addition to discrete attention in Standard 3, where it is stated: ‘Consumers and carers are actively involved in the development, planning, delivery and evaluation of services’ (p. 11). The criteria elaborating on this standard refer to facilitating participation through structured processes, training and support, representation, payment for involvement, mentorship, and supervision for consumers employed within mental health services. Further, the preface to the National Practice Standards for the Mental Health Workforce (Commonwealth of Australia 2002) emphasized the importance of consumer participation in relation to the education of health
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professionals as follows: ‘Of key importance is the premise that any health professional entering the mental health workforce, or completing undergraduate or postgraduate mental health courses, should have the opportunity to be educated by mental health consumers, their family members and carers about their: • ‘lived’ experiences of mental illness • requirements for adequate services and support • ability to work in partnership with mental health professionals’ (p.viii). The focus on education is a priority, given the extensive recognition that negative attitudes of health professionals are a major barrier to effective and genuine consumer participation in mental health services (Bennetts et al. 2011; Byrne et al. 2013; Happell et al. 2014; Lammers & Happell 2003; 2004; McCann et al. 2008). Although research evidence is limited, involving consumers in the education of health professional appears to influence the development of more positive attitudes (Anghel & Ramon 2009; Barnes et al. 2000; Byrne et al. 2013; Happell et al. 2003; 2014; Masters et al. 2002; McAndrew & Samociuk 2003; Thornicroft & Tansella 2005). It is clear that if Australian mental health policy is to succeed in achieving enhanced consumer engagement, particularly at broader systemic levels, consumer involvement in the education of health professions is essential. Rationale for, and strategies to facilitate consumer participation in professional education were the focus of the innovative ‘Learning Together’ project facilitated by Deakin University in the latter stages of the 1990s. An audit of consumer involvement in the education of health professionals, undertaken as part of that review, revealed very little active participation from consumers in any of the five main disciplines (nursing, occupational therapy, psychiatry, psychology, and social work), and an absence of any guidelines or overarching framework for future consumer involvement in curriculum design, implementation, or evaluation (Deakin University Human Services 1999). A later audit of consumer participation in undergraduate nursing education was conducted in 2006 as part of the Mental Health Nurse Education Taskforce (MHNET) (McCann et al. 2009). Findings indicated that the extent of consumer involvement was variable between universities, and overall remained minimal. Fewer than half the universities surveyed had any consumer involvement. Including consumers in content delivery was the most frequent response (16 universities), followed by involvement in course reviews (13 universities), member-
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ship of course committees (12 universities), and utilizing teaching materials developed by consumers (10 universities). Recommendations of the MHNET report for the development of mental health content within undergraduate Bachelor of Nursing programmes emphasized the expectation for consumer involvement in all aspects of mental health nursing curricula, including development, implementation, and evaluation (Mental Health Nurse Education Taskforce 2008). While available literature provides some evidence of consumer participation in the education of nurses and other health professionals, it is likely that published work does not represent the full extent of consumer participation. The aim of the present study was to present findings of a national survey of Schools of Nursing throughout Australia about the extent and depth of consumer involvement in preregistration comprehensive nursing programmes and post-registration mental health nursing programmes.
METHODS Design A cross-sectional online survey scoped the level and nature of consumer involvement in mental health nursing education in higher education in Australia.
Participants The ‘target’ group for the survey was nurse academics responsible for organizing or coordinating mental health nursing subjects and programmes at the university. It was deemed that these people would be best placed to respond to questions on the various aspects of consumer participation.
Materials A new survey was designed, and included both closedand open-format questions. The three major sections of the survey were mental health curriculum, nature of consumer involvement, and course content. Mental health curriculum
The first section inquired about whether the mental health curriculum had content on recovery concepts and consumer participation. It also asked whether consumers were involved in any aspect of the mental health nursing programme. Participants who indicated no involvement of consumers were asked about the reasons for this (response options, such as ‘no scope in curriculum’, and a box to provide open comments), whether their organization had a consumer previously involved in mental health © 2015 Australian College of Mental Health Nurses Inc.
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nursing teaching, and whether they anticipated consumer involvement within the next 2 years. Responses were on a four-point Likert scale, ranging from ‘very unlikely’ to ‘very likely’.
were confidential, and that there would be no identification of participating organizations without permission. They were also informed that they could withdraw from the study at any time.
Nature of consumer involvement
Procedure
The second section focused on the nature of consumer involvement. Participants were asked about the number of consumers involved, and then to focus on the nature of involvement of up to four consumers (designated as ‘consumer 1’, ‘consumer 2’ etc.). For each consumer, there were questions about type of activity (e.g. face-toface teaching, marking, and assessment), overall time spent in the programme, and type of arrangement with the organization (e.g. unpaid guest lectures, full-time contract). Course content
The third section included questions on the source of teaching content (e.g. whether ‘teach concepts or topics defined by the programme/subject team’) and manner of content development (by consumers, nurse academics, or through negotiation between them). In addition, participants were asked to list topics involving consumer educators during teaching sessions, and to describe the overall components of mental health nursing and number of subjects.
Pilot study As the survey was newly developed, a pilot study was conducted to ascertain whether questions were comprehensible, as well as usability of the online format. The pilot study involved 18 nursing education staff from various universities (n = 8 for the preregistration survey, and n = 10 for the post-registration survey). For both surveys, there was a high level of agreement that questions were clear and the format of responding was straightforward to follow. In response to feedback, minor changes were made to surveys, such as rewording of some response options.
Ethics Ethics approval was obtained from the university ethics committee to conduct the study. Prospective participants were asked for signed consent for the survey and a follow-up interview (reported elsewhere); as the survey provided important background information for interviews, participants were asked to name their highereducation organization in the survey. Prospective participants were provided with an information sheet outlining the study and were informed that data provided © 2015 Australian College of Mental Health Nurses Inc.
Heads of Schools of Nursing were contacted by the research team and asked to participate, nominating a person or persons at their university who could be approached to participate in the survey. The roles of those best informed to complete the survey included lecturers, academics, discipline heads, and heads of school. Prospective participants were then sent an email invitation that included a background to the study, information and consent forms, ethics approval, and a link to the survey relevant to them (pre-undergraduate, postgraduate, or both). There was a separate Web page for each of the three survey sections. Reminder emails were sent to invitees who did not respond to the initial email. Data collection took place in October and November 2013.
Analysis Analyses of survey responses focused on frequency distributions. The percentage of responses was assessed for each type of programme (preregistration and postregistration), as well as for all programmes combined. To analyse bivariate relationships for ordinal variables, Spearman rank correlations (rs) were examined. Following convention, probabilities under 0.05 were deemed as statistically significant. All analyses were performed in SPSS 20 (2011; IBM, Chicago, IL, USA).
FINDINGS Mental health nursing programmes There were 52 higher-education programmes from 32 universities addressed in the current study, comprised of 32 preregistration programmes and 20 post-registration programmes (these terms are used in preference to postgraduate and undergraduate, as some universities have master’s entry to practice programmes). This reflects a 91% response rate. This study was comprehensive in terms of inclusion of higher-education institutions in all states and territories of Australia. To protect anonymity of participating universities, the locations of programmes are not reported.
Programmes that involve consumers The percentage of mental health nursing programmes reported to have involved consumers of mental
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B. HAPPELL ET AL. TABLE 1:
Involvement of consumers of mental health services in mental health nursing education
Consumer involvement in mental health nursing education:
Preregistration (n = 32) n (%)
Post-registration (n = 20) n (%)
Total (n = 52) n (%)
No consumer involvement Consumer involvement
7 (21.9%) 25 (78.1%)
5 (25.0%) 15 (75.0%)
12 (23.1%) 40 (76.9%)
TABLE 2: Level of inclusion of recovery concepts and content on consumer participation in mental health curriculum Preregistration (n = 32) n (%)
Post-registration (n = 20) n (%)
Total (n = 52) n (%)
0 (0%) 5 (15.6%) 16 (50.0%) 11 (34.4%)
0 (0%) 1 (5.0%) 9 (45.0%) 10 (50.0%)
0 (0%) 6 (11.5%) 25 (48.1%) 21 (40.4%)
1 (3.1%) 10 (31.3%) 15 (46.9%) 6 (18.8%)
3 (15.0%) 1 (5.0%) 11 (55.0%) 5 (25.0%)
4 (7.7%) 11 (21.2%) 26 (50.0%) 11 (21.2%)
Recovery concepts None at all A little Moderately A lot Consumer participation None at all A little Moderately A lot
health services is shown in Table 1. For preregistration programmes, 78.1% had consumer participation. In post-registration programmes, three-quarters had consumer involvement. Of the 52 programmes covered in the present study (presenting most programmes in Australia), 23.1% did not report any consumer involvement. The number of consumers involved in mental health nursing education as a function of the number of programmes is presented in Figure 1. Overall, 13 programmes had one consumer contributing to mental health nursing education. The total count, however, did not distinguish whether the same consumer was involved in both preregistration and post-registration programmes at the same university. Nonetheless, as indicated in Figure 1, within both preregistration and postregistration programmes, one consumer was the most common number of consumers reported. It is also notable that there were up to five consumers involved in preregistration programmes and up to six in post-registration programmes.
Level of inclusion of consumer participation content and recovery concepts The frequencies and percentages on the perceived extent of content within nursing curriculum focused on recovery concepts and consumer participation are shown in
14 12 No. programmes
Inclusion of type of content in mental health curriculum:
10 8 6 4 2 0
No. consumers involved FIG. 1: Frequency of programmes as a function of number of consumers involved within a programme (preregistration, post-registration, and total). , Total; , Post-registration; , Preregistration.
Table 2. Recovery concepts were observed to be included within all programmes. For both preregistration and postregistration programmes, the most common response for recovery concept inclusion was ‘moderately’ and ‘a lot’. For 7.7% of programmes, it was judged that curricula had no content on consumer participation, and 21.2% had ‘a © 2015 Australian College of Mental Health Nurses Inc.
CONSUMER PARTICIPATION IN NURSE EDUCATION
For preregistration programmes, the inclusion of recovery concepts was significantly associated with inclusion of content on consumer participation (rs = 0.57, P < 0.05), but was not associated significantly with whether there was consumer involvement (rs = 0.14, P > 0.05). Similarly, for post-registration programmes, the presence of recovery concepts was significantly associated with the inclusion of content on consumer participation (rs = 0.56, P < 0.05), and the correlation of recovery concepts in content with consumer involvement in education was not significant (rs = 0.19, P > 0.05).
University programmes without consumer educators As earlier reported, there were 12 cases of no consumer involvement across higher education in mental health nursing. Self-reported primary reasons for not having consumer involvement did not include either ‘not considered valuable’ or ‘not an educational priority’. Difficulty in finding qualified or experienced consumers was the most common response (n = 3, 25%), followed by funding (n = 4, 33.3%), and no scope in the curriculum (n = 1, 8.3%). Other reasons indicated in the open-response option were ‘lack of consumer available contacts’ (n = 1), ‘online subjects’ (n = 1), and ‘logistics of delivering programme to over 800 students per year’ (n = 1). Three institutions had never had consumer involvement (25.0%), two had in the past (16.7%), and seven were not sure (58.3%). In response to the question: ‘In your view, will there be a consumer involved in preregistration/postregistration teaching at your organization within the next 2 years?’, one-third indicated that this was ‘unlikely’, three ‘likely’ (25.0%), and five ‘very likely’ (41.7%).
Consumer activities Participants were asked to indicate, for each consumer, the types of activities they were involved in. Based on the responses, the percentage of university programmes that had consumers involved in each type of activity was compared, and is presented in Figure 2. Twenty-two percent of programmes had involvement of consumers in face-toface teaching. Fifteen percent reported involvement in © 2015 Australian College of Mental Health Nurses Inc.
Face-to-face teaching
Type of acvity
Relationships between types of content in mental health curricula, and between type of content and consumer involvement
Curriculum development
Online teaching Marking and assessment Evaluaon of subject outcomes (or similar) Membership of subject/programme commiees Other 0
5
10
15
20
No. consumers FIG. 2: Number of consumers in preregistration and post-registration programmes involved in specific domains of activity. , Post-registration; , Preregistration.
Proporon of mental health nursing programmes (%)
little’ content. Approximately 19% of preregistration programmes reported ‘a lot’ of content on consumer participation, compared to one in four post-registration programmes.
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25
20
15
10
5
0 Curriculum development
Face-to-face teaching
Online teaching
Marking and assessment
Evaluaon of Membership of subject subject/programme outcomes (or commiees similar)
Type of acvity
FIG. 3: Percentage of university programmes with consumers involved in activities (e.g. curriculum development).
curriculum development, and 15% as members of a subject committee. The number of consumers involved in particular types of activities is not indicated in Figure 2. Cases of each type of activity were collapsed across universities to derive overall estimates of the number of consumers involved in each domain of educational activity across Australia. The number of consumers taking part in educational activities, such as curriculum development and teaching, is presented in Figure 3. In looking at Figure 3, it should be noted that there might be some repeat counts of consumers, as it is likely that a consumer might be involved in
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Time commitment to educational activities There were 85 cases where overall time commitment of a consumer to a programme was indicated. For preregistration and post-registration programmes combined, the distribution of time commitment in hours was as follows: 1–4 hours (n = 44, 51.8%), 5–8 hours (n = 19, 22.4%), 9–12 hours (n = 5, 5.9%), and 12 hours or more (n = 17, 20.0%). Four consumers in the post-registration programme were involved for at least three or more weeks.
Type of arrangement with higher-education provider
25
20
No. consumers
both preregistration and post-registration programmes. It is also noted that participants could indicate types of activity for up to four consumers, so Figure 3 does not take into account activities of the two programmes that had more than four consumers (i.e. might be an underestimate of true contributions of consumers). Face-to-face teaching was the most common activity reported (n = 18), followed by curriculum development (n = 12), and membership of subject/programme committees (n = 9). There was low participation in marking and assessment (n = 2). Notably, evaluation of subject outcomes was not found to be an activity in the preregistration subjects, only occurring at the post-registration level (n = 4). Other types of activities noted in open comments were as a collaborator in workshops, advising research and research ethics, and conducting research.
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15
10
5
0
Arrangement with higher-educaon provider
FIG. 4: Number of consumers involved in each type of arrangement with university. , Total; , Post-registration; , Preregistration.
experiences of mental illness and mental health service use. As well as this, in the majority of cases, course development was characterized as one negotiated between consumers and nurse academics: 64% for preregistration, and 73.3% in post-registration.
Topics taught by consumer educators
The staffing arrangement between consumer and the university (e.g. contract, sessional/casual) and the number of consumers in each, aggregated across programme, are shown in Figure 4. Being a guest lecturer was the most commonly-reported form of consumer involvement across the university sector. For preregistration programmes, there were 21 consumers on sessional contracts (either casual or short term). In post-registration programmes, there were only two cases of consumers in a full-time or continuing role, and for preregistration programmes, there were no consumers with such an arrangement.
When asked to openly describe teaching topics by consumers, a large range of topics was taught; for instance, reducing stigma, consumer advocacy, recoveryoriented care, psychosis, mental health legislation, carers, cultural awareness, evidence-based practice, reducing stigma, psychological first aid, and human rights. Recovery as a topic taught by consumers appeared in 52.5% of the 40 programmes, and 37.5% made reference to either ‘(lived) experience’ or ‘living with’ mental illness.
Sources of course content and nature of development
The number of preregistration programmes with particular types of mental health nursing components is shown in Table 4. Core components were much more common than elective only (68% vs 4%, respectively), and 24% indicated having both core and elective components. In addition, 64% viewed the mental health components as standalone, rather than integrated (28%).
The sources and nature of development of the content in mental health nursing courses are indicated in Table 3. In both preregistration and post-registration programmes, the teaching content was most commonly nominated to be one where the consumer talks about their personal
Types of mental health nursing components in preregistration programmes
© 2015 Australian College of Mental Health Nurses Inc.
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TABLE 3: Sources and nature of development of course content (n = 42)
Consumers’ teaching content Talk about their experiences only Teach concepts or topics defined by the programme/subject team Talk about their experiences in the context of broader aspects of the curriculum Chose the topic for the lecture No response Source of development of course By consumers By nurse academics Negotiated between consumers and nurse academics Other Missing
TABLE 4: Nature of mental health nursing components for preregistration programmes (n = 25) Type of mental health component: Choice Core Elective Both No response Level of integration Stand alone Integrated No response
n
%
17 1 6 1
68.0 4.0 24.0 4.0
16 7 2
64.0 28.0 8.0
DISCUSSION The importance of consumer participation in the education of nurses has been reflected in government policy documents and reports, including the Mental Health Nurse Education Taskforce (MHNET) (2008) and the National Practice Standards for the Mental Health Workforce (Commonwealth of Australia 2002). Findings from our research suggest an increase in the number of universities involving consumers in nursing programmes at the preregistration level, with a clear majority now following this approach. It is unclear whether this change is a consequence of the MHNET report being endorsed by the Council of Deans of Nursing and Midwifery. All areas of nursing now place importance on the provision of consumer-focused care, and this might also account for an increasing awareness of the importance of consumer participation within Schools of Nursing. The challenge is to ensure that current mental health consumer input is not replaced by consumers of physical health services to meet the objectives of the overall programme. © 2015 Australian College of Mental Health Nurses Inc.
Preregistration n (%)
Post-registration n (%)
Total n (%)
5 (20.0%) 2 (8.0%) 14 (56.0%) 3 (12.0%) 1 (4.0%)
1 (6.7%) 0 (0.0%) 10 (66.7%) 1 (6.7%) 3 (20.0%)
6 (15.0%) 2 (5.0%) 24 (60.0%) 4 (10.0%) 4 (10.0%)
4 (16.0%) 3 (12.0%) 16 (64.0%) 1 (4.0%) 1 (4.0%)
2 (13.3%) 1 (6.7%) 11 (73.3%) 0 (0.0%) 1 (6.7%)
6 (15.0%) 4 (10.0%) 27 (67.5%) 1 (2.5%) 2 (5.0%)
It is noteworthy that the majority of consumers contribute between 1 and 4 hours’ participation to a curriculum. Comparison of the quantity of consumer participation with previous work is not possible, as the data were either not collected or not reported (McCann et al. 2009). Most participation appears to be classroom based, with less involvement in curriculum development and the production of resources than previously reported (McCann et al. 2009). Consumer involvement in curriculum design, implementation, and evaluation heralds a commitment to change that moves beyond tokenism and demonstrates organizational engagement and support at individual and systemic levels. Consumer participation in the education of health professionals frequently involves storytelling, where the consumer educator describes his or her experience of mental illness, or mental health service use, or both (Meehan & Glover 2007; Repper & Breeze 2007). Story telling can be very powerful for both students and consumers (Wahl 1999). It can also be traumatic, and in some cases, tokenistic (Meehan & Glover 2007; Wahl 1999), as students focus on perceived pathology, rather than issues of stigma, discrimination, and coercion. The literature has focused on the generally ad-hoc nature of consumer participation in the education of health professionals (Happell et al. 2014; Happell & Roper 2009; Repper & Breeze 2007). This heralds the danger that universities might be acting, either currently or in the future, out of a sense of adherence to policy, rather than a genuine desire to promote the role of consumers in education and to decrease stigma towards people with mental illness. Genuine and effective involvement in the education of health professionals must go beyond classroom teaching, and provide the opportunity for lived experience to
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become embedded into curriculum (Happell & Roper 2009). The absence of clear guidelines about what does and does not signify genuine consumer participation is understandable, given the newness of this approach. However, given that the involvement of consumers appears to be on the increase, there is a need for a clear framework to guide consumer roles in education. These should include partnership and commitment; support, scope, and autonomy (Bennetts et al. 2011; Byrne et al. 2013; Happell et al. 2014; Happell & Roper 2009; Lammers & Happell 2003; 2004; McCann et al. 2008). It is difficult to see how 1–4 hours of classroom teaching could possibly meet these four criteria, raising the strong possibility that consumer participation becomes tokenistic, and limits its effectiveness in overcoming the identified attitudinal barriers on the part of health professionals (Bennetts et al. 2011; Byrne et al. 2013; Happell et al. 2014; Lammers & Happell 2003; 2004; McCann et al. 2008). The issue of determining consumer delivered content is worthy of comment. In the majority of cases, this is in partnership between nurse academics and consumers. It is pleasing that the content is not imposed in most instances; however, if autonomy is an essential component of effective consumer participation in education (Happell & Roper 2009), it would be pleasing to see more evidence of consumers determining the content of their teaching sessions. Expertise is most effective when the experts determine what knowledge is and what is not important to be transferred to the learner. These findings also raise important issues about readiness for roles as consumer educators and academics. There is recognition of the need for training and organizational support for consumer roles in mental health services more broadly (Bennetts et al. 2013; Cleary et al. 2011; Stewart et al. 2008). Education roles are equally challenging, and require educational preparation and support to maximize their effectiveness and to minimize negative impacts on the consumer educators themselves (Happell & Roper 2009).
LIMITATIONS This is a self-report study, rather than the analysis of documentation; therefore, the accuracy cannot be definitively verified. Furthermore, the survey design utilized in this research does not allow for detailed information about the roles consumers play within universities. As a policy directive, it is essential that more is known and understood about the roles consumers undertake in the
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education of health professionals, the barriers they face, and the strategies used to minimize or overcome these barriers.
CONCLUSIONS Consumer participation in mental health services and the education of health professionals are now a policy imperative. Autonomous roles for consumers as educators and academics are essential for this policy goal to be realized. The apparent proliferation in consumer roles in the education of nurses is positive; however, the ad hoc way in which these roles have been developed and implemented is cause for concern. More detailed exploration of these roles is required as a matter of urgency to determine the facilitators and barriers to their success, and to formulate guidelines to ensure these roles do not become tokenistic, and that adequate training, professional development, and other supports are implemented to maximize the benefits and effectiveness of these initiatives.
ACKNOWLEDGEMENTS The authors extend their thanks to the Health Collaborative Research Network, CQUniversity for providing the funding to allow this work to be completed. Our thanks also to the participants who took the time to complete these questionnaires.
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CONSUMER PARTICIPATION IN NURSE EDUCATION mental health sector. Advances in Mental Health, 11, 3687– 3720. Byrne, L., Happell, B., Welch, T. & Moxham, L. J. (2013). ‘Things you can’t learn from books’: Teaching recovery from a lived experience perspective. International Journal of Mental Health Nursing, 22, 195–204. Cleary, M., Horsfall, J., Hunt, G. E., Escott, P. & Happell, B. (2011). Continuing challenges for the mental health consumer workforce: A role for mental health nurses? International Journal of Mental Health Nursing, 20, 438–444. Commonwealth of Australia (2002). National Practice Standards for the Mental Health Workforce. Canberra: Australian Government. Commonwealth of Australia (2010). National Standards for Mental Health Services. Canberra: Commonwealth of Australia. Deakin University Human Services (1999). Education and Training Partnerships in Mental Health: Learning Together. Canberra: Commonwealth of Australia. Happell, B. & Roper, C. (2009). Promoting genuine consumer participation in mental health education: A consumer academic role. Nurse Education Today, 29, 575–579. Happell, B., Pinikahana, J. & Roper, C. (2003). Changing attitudes: The role of a consumer academic in the education of postgraduate psychiatric nursing students. Archives of Psychiatric Nursing, 17, 67–76. Happell, B., Byrne, L., McAllister, M. et al. (2014). Consumer involvement in the tertiary-level education of mental health professionals: A systematic review. International Journal of Mental Health Nursing, 23, 3–16. Lammers, J. & Happell, B. (2003). Consumer participation in mental health services: Looking from a consumer perspective. Journal of Psychiatric and Mental Health Nursing, 10, 385–392. Lammers, J. & Happell, B. (2004). Mental health reforms and their impact on consumer and carer participation: A perspective from Victoria, Australia. Issues in Mental Health Nursing, 25, 261–276.
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103 McAndrew, S. & Samociuk, G. A. (2003). Reflecting together: Developing a new strategy for continuous user involvement in mental health nurse education. Journal of Psychiatric & Mental Health Nursing, 10, 616–621. McCann, T. V., Baird, J., Clark, E. & Lu, S. (2008). Mental health professionals’ attitudes towards consumer participation in inpatient units. Journal of Psychiatric And Mental Health Nursing, 15, 10–16. McCann, T. V., Moxham, L., Usher, K., Crookes, P. A. & Farrell, G. (2009). Mental health content of comprehensive pre-registration nursing curricula in Australia. Journal of Research in Nursing, 14, 519–530. Masters, H., Forrest, S., Harley, A., Hunter, M., Brown, N. & Risk, I. (2002). Involving mental health service users and carers in curriculum development: Moving beyond ‘classroom’ involvement. Journal of Psychiatric And Mental Health Nursing, 9, 309–316. Meehan, T. & Glover, H. (2007). Telling our story: Consumer perceptions of their role in mental health education. Psychiatric Rehabilitation Journal, 31, 152–154. Mental Health Nurse Education Taskforce (2008). Final Report: Mental Health in Pre-registration Nursing Courses. Final Report. Mental Health in Pre-registration Nursing Courses, Melbourne, Victoria. Repper, J. & Breeze, J. (2007). User and carer involvement in the training and education of health professionals: A review of the literature. International Journal of Nursing Studies, 44, 511–519. Stewart, S., Watson, S., Montague, R. & Stevenson, C. (2008). Set up to fail? Consumer participation in the mental health service system. Australasian Psychiatry, 16, 348– 353. Thornicroft, G. & Tansella, M. (2005). Growing recognition of the importance of service user involvement in mental health service planning and evaluation. Epidemiologia E Psichiatria Sociale, 14, 1–3. Wahl, O. F. (1999). Telling Is Risky Business: Mental Health Consumers Confront Stigma. New Brunswick, NJ: Rutgers University Press.
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International Journal of Mental Health Nursing (2015) 24, 95–103
doi: 10.1111/inm.12111
Feature Article
Consumer participation in nurse education: A national survey of Australian universities Brenda Happell,1 Chris Platania-Phung,1 Louise Byrne,2 Dianne Wynaden,3 Graham Martin4 and Scott Harris2 1
Research Centre for Nursing and Midwifery Practice, University of Canberra, Faculty of Health and ACT Health, Rockhampton, 2School of Nursing and Midwifery, CQUniversity, 3School of Nursing and Midwifery, Curtin University, Perth, Western Australia, and 4Department of Psychology, University of Queensland, Brisbane, Queensland, Australia
ABSTRACT: Consumers of mental health services have an important role to play in the higher education of nursing students, by facilitating understanding of the experience of mental illness and instilling a culture of consumer participation. Yet the level of consumer participation in mental health nursing programmes in Australia is not known. The aim of the present study was to scope the level and nature of involvement of consumers in mental health nursing higher education in Australia. A cross-sectional study was undertaken involving an internet survey of nurse academics who coordinate mental health nursing programmes in universities across Australia, representing 32 universities. Seventy-eight percent of preregistration and 75% of post-registration programmes report involving consumers. Programmes most commonly had one consumer (25%) and up to five. Face-to-face teaching, curriculum development, and membership-to-programme committees were the most regular types of involvement. The content was generally codeveloped by consumers and nurse academics (67.5%). The frequency of consumer involvement in the education of nursing students in Australia is surprisingly high. However, involvement is noticeably variable across types of activity (e.g. curriculum development, assessment), and tends to be minimal and ad hoc. Future research is required into the drivers of increased consumer involvement. KEY WORDS: consumer participation, lived experience, mental health, nurse education.
INTRODUCTION The importance of consumer participation in mental health services is now clearly stated within relevant policy documentation (Australian Government 2012). This
Correspondence: Brenda Happell, Central Queensland University, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation and School of Nursing and Midwifery, Bruce Highway, Rockhampton, QLD 4702, Australia. Email: [email protected] Brenda Happell, RN, RPN, BA (Hons), Dip Ed, B Ed, M Ed, PhD. Chris Platania-Phung, BA (Hons). Louise Byrne, MA (Hons), PhD. Dianne Wynaden, RN, BAppSc, Grad Dip HSc, MSc (HSc), PhD, FACMHN, CMHN. Graham Martin, OAM, MD, FRANZCP, DPM. Scott Harris, RN, MHN(Cred), Dip Health Sci, M Ment Hlth Nurs. Accepted August 2014.
© 2015 Australian College of Mental Health Nurses Inc.
includes the National Standards for Mental Health Services (Commonwealth of Australia 2010). Consumer participation in mental health services at both individual and systemic levels is embedded throughout the document in addition to discrete attention in Standard 3, where it is stated: ‘Consumers and carers are actively involved in the development, planning, delivery and evaluation of services’ (p. 11). The criteria elaborating on this standard refer to facilitating participation through structured processes, training and support, representation, payment for involvement, mentorship, and supervision for consumers employed within mental health services. Further, the preface to the National Practice Standards for the Mental Health Workforce (Commonwealth of Australia 2002) emphasized the importance of consumer participation in relation to the education of health
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professionals as follows: ‘Of key importance is the premise that any health professional entering the mental health workforce, or completing undergraduate or postgraduate mental health courses, should have the opportunity to be educated by mental health consumers, their family members and carers about their: • ‘lived’ experiences of mental illness • requirements for adequate services and support • ability to work in partnership with mental health professionals’ (p.viii). The focus on education is a priority, given the extensive recognition that negative attitudes of health professionals are a major barrier to effective and genuine consumer participation in mental health services (Bennetts et al. 2011; Byrne et al. 2013; Happell et al. 2014; Lammers & Happell 2003; 2004; McCann et al. 2008). Although research evidence is limited, involving consumers in the education of health professional appears to influence the development of more positive attitudes (Anghel & Ramon 2009; Barnes et al. 2000; Byrne et al. 2013; Happell et al. 2003; 2014; Masters et al. 2002; McAndrew & Samociuk 2003; Thornicroft & Tansella 2005). It is clear that if Australian mental health policy is to succeed in achieving enhanced consumer engagement, particularly at broader systemic levels, consumer involvement in the education of health professions is essential. Rationale for, and strategies to facilitate consumer participation in professional education were the focus of the innovative ‘Learning Together’ project facilitated by Deakin University in the latter stages of the 1990s. An audit of consumer involvement in the education of health professionals, undertaken as part of that review, revealed very little active participation from consumers in any of the five main disciplines (nursing, occupational therapy, psychiatry, psychology, and social work), and an absence of any guidelines or overarching framework for future consumer involvement in curriculum design, implementation, or evaluation (Deakin University Human Services 1999). A later audit of consumer participation in undergraduate nursing education was conducted in 2006 as part of the Mental Health Nurse Education Taskforce (MHNET) (McCann et al. 2009). Findings indicated that the extent of consumer involvement was variable between universities, and overall remained minimal. Fewer than half the universities surveyed had any consumer involvement. Including consumers in content delivery was the most frequent response (16 universities), followed by involvement in course reviews (13 universities), member-
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ship of course committees (12 universities), and utilizing teaching materials developed by consumers (10 universities). Recommendations of the MHNET report for the development of mental health content within undergraduate Bachelor of Nursing programmes emphasized the expectation for consumer involvement in all aspects of mental health nursing curricula, including development, implementation, and evaluation (Mental Health Nurse Education Taskforce 2008). While available literature provides some evidence of consumer participation in the education of nurses and other health professionals, it is likely that published work does not represent the full extent of consumer participation. The aim of the present study was to present findings of a national survey of Schools of Nursing throughout Australia about the extent and depth of consumer involvement in preregistration comprehensive nursing programmes and post-registration mental health nursing programmes.
METHODS Design A cross-sectional online survey scoped the level and nature of consumer involvement in mental health nursing education in higher education in Australia.
Participants The ‘target’ group for the survey was nurse academics responsible for organizing or coordinating mental health nursing subjects and programmes at the university. It was deemed that these people would be best placed to respond to questions on the various aspects of consumer participation.
Materials A new survey was designed, and included both closedand open-format questions. The three major sections of the survey were mental health curriculum, nature of consumer involvement, and course content. Mental health curriculum
The first section inquired about whether the mental health curriculum had content on recovery concepts and consumer participation. It also asked whether consumers were involved in any aspect of the mental health nursing programme. Participants who indicated no involvement of consumers were asked about the reasons for this (response options, such as ‘no scope in curriculum’, and a box to provide open comments), whether their organization had a consumer previously involved in mental health © 2015 Australian College of Mental Health Nurses Inc.
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nursing teaching, and whether they anticipated consumer involvement within the next 2 years. Responses were on a four-point Likert scale, ranging from ‘very unlikely’ to ‘very likely’.
were confidential, and that there would be no identification of participating organizations without permission. They were also informed that they could withdraw from the study at any time.
Nature of consumer involvement
Procedure
The second section focused on the nature of consumer involvement. Participants were asked about the number of consumers involved, and then to focus on the nature of involvement of up to four consumers (designated as ‘consumer 1’, ‘consumer 2’ etc.). For each consumer, there were questions about type of activity (e.g. face-toface teaching, marking, and assessment), overall time spent in the programme, and type of arrangement with the organization (e.g. unpaid guest lectures, full-time contract). Course content
The third section included questions on the source of teaching content (e.g. whether ‘teach concepts or topics defined by the programme/subject team’) and manner of content development (by consumers, nurse academics, or through negotiation between them). In addition, participants were asked to list topics involving consumer educators during teaching sessions, and to describe the overall components of mental health nursing and number of subjects.
Pilot study As the survey was newly developed, a pilot study was conducted to ascertain whether questions were comprehensible, as well as usability of the online format. The pilot study involved 18 nursing education staff from various universities (n = 8 for the preregistration survey, and n = 10 for the post-registration survey). For both surveys, there was a high level of agreement that questions were clear and the format of responding was straightforward to follow. In response to feedback, minor changes were made to surveys, such as rewording of some response options.
Ethics Ethics approval was obtained from the university ethics committee to conduct the study. Prospective participants were asked for signed consent for the survey and a follow-up interview (reported elsewhere); as the survey provided important background information for interviews, participants were asked to name their highereducation organization in the survey. Prospective participants were provided with an information sheet outlining the study and were informed that data provided © 2015 Australian College of Mental Health Nurses Inc.
Heads of Schools of Nursing were contacted by the research team and asked to participate, nominating a person or persons at their university who could be approached to participate in the survey. The roles of those best informed to complete the survey included lecturers, academics, discipline heads, and heads of school. Prospective participants were then sent an email invitation that included a background to the study, information and consent forms, ethics approval, and a link to the survey relevant to them (pre-undergraduate, postgraduate, or both). There was a separate Web page for each of the three survey sections. Reminder emails were sent to invitees who did not respond to the initial email. Data collection took place in October and November 2013.
Analysis Analyses of survey responses focused on frequency distributions. The percentage of responses was assessed for each type of programme (preregistration and postregistration), as well as for all programmes combined. To analyse bivariate relationships for ordinal variables, Spearman rank correlations (rs) were examined. Following convention, probabilities under 0.05 were deemed as statistically significant. All analyses were performed in SPSS 20 (2011; IBM, Chicago, IL, USA).
FINDINGS Mental health nursing programmes There were 52 higher-education programmes from 32 universities addressed in the current study, comprised of 32 preregistration programmes and 20 post-registration programmes (these terms are used in preference to postgraduate and undergraduate, as some universities have master’s entry to practice programmes). This reflects a 91% response rate. This study was comprehensive in terms of inclusion of higher-education institutions in all states and territories of Australia. To protect anonymity of participating universities, the locations of programmes are not reported.
Programmes that involve consumers The percentage of mental health nursing programmes reported to have involved consumers of mental
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B. HAPPELL ET AL. TABLE 1:
Involvement of consumers of mental health services in mental health nursing education
Consumer involvement in mental health nursing education:
Preregistration (n = 32) n (%)
Post-registration (n = 20) n (%)
Total (n = 52) n (%)
No consumer involvement Consumer involvement
7 (21.9%) 25 (78.1%)
5 (25.0%) 15 (75.0%)
12 (23.1%) 40 (76.9%)
TABLE 2: Level of inclusion of recovery concepts and content on consumer participation in mental health curriculum Preregistration (n = 32) n (%)
Post-registration (n = 20) n (%)
Total (n = 52) n (%)
0 (0%) 5 (15.6%) 16 (50.0%) 11 (34.4%)
0 (0%) 1 (5.0%) 9 (45.0%) 10 (50.0%)
0 (0%) 6 (11.5%) 25 (48.1%) 21 (40.4%)
1 (3.1%) 10 (31.3%) 15 (46.9%) 6 (18.8%)
3 (15.0%) 1 (5.0%) 11 (55.0%) 5 (25.0%)
4 (7.7%) 11 (21.2%) 26 (50.0%) 11 (21.2%)
Recovery concepts None at all A little Moderately A lot Consumer participation None at all A little Moderately A lot
health services is shown in Table 1. For preregistration programmes, 78.1% had consumer participation. In post-registration programmes, three-quarters had consumer involvement. Of the 52 programmes covered in the present study (presenting most programmes in Australia), 23.1% did not report any consumer involvement. The number of consumers involved in mental health nursing education as a function of the number of programmes is presented in Figure 1. Overall, 13 programmes had one consumer contributing to mental health nursing education. The total count, however, did not distinguish whether the same consumer was involved in both preregistration and post-registration programmes at the same university. Nonetheless, as indicated in Figure 1, within both preregistration and postregistration programmes, one consumer was the most common number of consumers reported. It is also notable that there were up to five consumers involved in preregistration programmes and up to six in post-registration programmes.
Level of inclusion of consumer participation content and recovery concepts The frequencies and percentages on the perceived extent of content within nursing curriculum focused on recovery concepts and consumer participation are shown in
14 12 No. programmes
Inclusion of type of content in mental health curriculum:
10 8 6 4 2 0
No. consumers involved FIG. 1: Frequency of programmes as a function of number of consumers involved within a programme (preregistration, post-registration, and total). , Total; , Post-registration; , Preregistration.
Table 2. Recovery concepts were observed to be included within all programmes. For both preregistration and postregistration programmes, the most common response for recovery concept inclusion was ‘moderately’ and ‘a lot’. For 7.7% of programmes, it was judged that curricula had no content on consumer participation, and 21.2% had ‘a © 2015 Australian College of Mental Health Nurses Inc.
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For preregistration programmes, the inclusion of recovery concepts was significantly associated with inclusion of content on consumer participation (rs = 0.57, P < 0.05), but was not associated significantly with whether there was consumer involvement (rs = 0.14, P > 0.05). Similarly, for post-registration programmes, the presence of recovery concepts was significantly associated with the inclusion of content on consumer participation (rs = 0.56, P < 0.05), and the correlation of recovery concepts in content with consumer involvement in education was not significant (rs = 0.19, P > 0.05).
University programmes without consumer educators As earlier reported, there were 12 cases of no consumer involvement across higher education in mental health nursing. Self-reported primary reasons for not having consumer involvement did not include either ‘not considered valuable’ or ‘not an educational priority’. Difficulty in finding qualified or experienced consumers was the most common response (n = 3, 25%), followed by funding (n = 4, 33.3%), and no scope in the curriculum (n = 1, 8.3%). Other reasons indicated in the open-response option were ‘lack of consumer available contacts’ (n = 1), ‘online subjects’ (n = 1), and ‘logistics of delivering programme to over 800 students per year’ (n = 1). Three institutions had never had consumer involvement (25.0%), two had in the past (16.7%), and seven were not sure (58.3%). In response to the question: ‘In your view, will there be a consumer involved in preregistration/postregistration teaching at your organization within the next 2 years?’, one-third indicated that this was ‘unlikely’, three ‘likely’ (25.0%), and five ‘very likely’ (41.7%).
Consumer activities Participants were asked to indicate, for each consumer, the types of activities they were involved in. Based on the responses, the percentage of university programmes that had consumers involved in each type of activity was compared, and is presented in Figure 2. Twenty-two percent of programmes had involvement of consumers in face-toface teaching. Fifteen percent reported involvement in © 2015 Australian College of Mental Health Nurses Inc.
Face-to-face teaching
Type of acvity
Relationships between types of content in mental health curricula, and between type of content and consumer involvement
Curriculum development
Online teaching Marking and assessment Evaluaon of subject outcomes (or similar) Membership of subject/programme commiees Other 0
5
10
15
20
No. consumers FIG. 2: Number of consumers in preregistration and post-registration programmes involved in specific domains of activity. , Post-registration; , Preregistration.
Proporon of mental health nursing programmes (%)
little’ content. Approximately 19% of preregistration programmes reported ‘a lot’ of content on consumer participation, compared to one in four post-registration programmes.
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25
20
15
10
5
0 Curriculum development
Face-to-face teaching
Online teaching
Marking and assessment
Evaluaon of Membership of subject subject/programme outcomes (or commiees similar)
Type of acvity
FIG. 3: Percentage of university programmes with consumers involved in activities (e.g. curriculum development).
curriculum development, and 15% as members of a subject committee. The number of consumers involved in particular types of activities is not indicated in Figure 2. Cases of each type of activity were collapsed across universities to derive overall estimates of the number of consumers involved in each domain of educational activity across Australia. The number of consumers taking part in educational activities, such as curriculum development and teaching, is presented in Figure 3. In looking at Figure 3, it should be noted that there might be some repeat counts of consumers, as it is likely that a consumer might be involved in
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Time commitment to educational activities There were 85 cases where overall time commitment of a consumer to a programme was indicated. For preregistration and post-registration programmes combined, the distribution of time commitment in hours was as follows: 1–4 hours (n = 44, 51.8%), 5–8 hours (n = 19, 22.4%), 9–12 hours (n = 5, 5.9%), and 12 hours or more (n = 17, 20.0%). Four consumers in the post-registration programme were involved for at least three or more weeks.
Type of arrangement with higher-education provider
25
20
No. consumers
both preregistration and post-registration programmes. It is also noted that participants could indicate types of activity for up to four consumers, so Figure 3 does not take into account activities of the two programmes that had more than four consumers (i.e. might be an underestimate of true contributions of consumers). Face-to-face teaching was the most common activity reported (n = 18), followed by curriculum development (n = 12), and membership of subject/programme committees (n = 9). There was low participation in marking and assessment (n = 2). Notably, evaluation of subject outcomes was not found to be an activity in the preregistration subjects, only occurring at the post-registration level (n = 4). Other types of activities noted in open comments were as a collaborator in workshops, advising research and research ethics, and conducting research.
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15
10
5
0
Arrangement with higher-educaon provider
FIG. 4: Number of consumers involved in each type of arrangement with university. , Total; , Post-registration; , Preregistration.
experiences of mental illness and mental health service use. As well as this, in the majority of cases, course development was characterized as one negotiated between consumers and nurse academics: 64% for preregistration, and 73.3% in post-registration.
Topics taught by consumer educators
The staffing arrangement between consumer and the university (e.g. contract, sessional/casual) and the number of consumers in each, aggregated across programme, are shown in Figure 4. Being a guest lecturer was the most commonly-reported form of consumer involvement across the university sector. For preregistration programmes, there were 21 consumers on sessional contracts (either casual or short term). In post-registration programmes, there were only two cases of consumers in a full-time or continuing role, and for preregistration programmes, there were no consumers with such an arrangement.
When asked to openly describe teaching topics by consumers, a large range of topics was taught; for instance, reducing stigma, consumer advocacy, recoveryoriented care, psychosis, mental health legislation, carers, cultural awareness, evidence-based practice, reducing stigma, psychological first aid, and human rights. Recovery as a topic taught by consumers appeared in 52.5% of the 40 programmes, and 37.5% made reference to either ‘(lived) experience’ or ‘living with’ mental illness.
Sources of course content and nature of development
The number of preregistration programmes with particular types of mental health nursing components is shown in Table 4. Core components were much more common than elective only (68% vs 4%, respectively), and 24% indicated having both core and elective components. In addition, 64% viewed the mental health components as standalone, rather than integrated (28%).
The sources and nature of development of the content in mental health nursing courses are indicated in Table 3. In both preregistration and post-registration programmes, the teaching content was most commonly nominated to be one where the consumer talks about their personal
Types of mental health nursing components in preregistration programmes
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TABLE 3: Sources and nature of development of course content (n = 42)
Consumers’ teaching content Talk about their experiences only Teach concepts or topics defined by the programme/subject team Talk about their experiences in the context of broader aspects of the curriculum Chose the topic for the lecture No response Source of development of course By consumers By nurse academics Negotiated between consumers and nurse academics Other Missing
TABLE 4: Nature of mental health nursing components for preregistration programmes (n = 25) Type of mental health component: Choice Core Elective Both No response Level of integration Stand alone Integrated No response
n
%
17 1 6 1
68.0 4.0 24.0 4.0
16 7 2
64.0 28.0 8.0
DISCUSSION The importance of consumer participation in the education of nurses has been reflected in government policy documents and reports, including the Mental Health Nurse Education Taskforce (MHNET) (2008) and the National Practice Standards for the Mental Health Workforce (Commonwealth of Australia 2002). Findings from our research suggest an increase in the number of universities involving consumers in nursing programmes at the preregistration level, with a clear majority now following this approach. It is unclear whether this change is a consequence of the MHNET report being endorsed by the Council of Deans of Nursing and Midwifery. All areas of nursing now place importance on the provision of consumer-focused care, and this might also account for an increasing awareness of the importance of consumer participation within Schools of Nursing. The challenge is to ensure that current mental health consumer input is not replaced by consumers of physical health services to meet the objectives of the overall programme. © 2015 Australian College of Mental Health Nurses Inc.
Preregistration n (%)
Post-registration n (%)
Total n (%)
5 (20.0%) 2 (8.0%) 14 (56.0%) 3 (12.0%) 1 (4.0%)
1 (6.7%) 0 (0.0%) 10 (66.7%) 1 (6.7%) 3 (20.0%)
6 (15.0%) 2 (5.0%) 24 (60.0%) 4 (10.0%) 4 (10.0%)
4 (16.0%) 3 (12.0%) 16 (64.0%) 1 (4.0%) 1 (4.0%)
2 (13.3%) 1 (6.7%) 11 (73.3%) 0 (0.0%) 1 (6.7%)
6 (15.0%) 4 (10.0%) 27 (67.5%) 1 (2.5%) 2 (5.0%)
It is noteworthy that the majority of consumers contribute between 1 and 4 hours’ participation to a curriculum. Comparison of the quantity of consumer participation with previous work is not possible, as the data were either not collected or not reported (McCann et al. 2009). Most participation appears to be classroom based, with less involvement in curriculum development and the production of resources than previously reported (McCann et al. 2009). Consumer involvement in curriculum design, implementation, and evaluation heralds a commitment to change that moves beyond tokenism and demonstrates organizational engagement and support at individual and systemic levels. Consumer participation in the education of health professionals frequently involves storytelling, where the consumer educator describes his or her experience of mental illness, or mental health service use, or both (Meehan & Glover 2007; Repper & Breeze 2007). Story telling can be very powerful for both students and consumers (Wahl 1999). It can also be traumatic, and in some cases, tokenistic (Meehan & Glover 2007; Wahl 1999), as students focus on perceived pathology, rather than issues of stigma, discrimination, and coercion. The literature has focused on the generally ad-hoc nature of consumer participation in the education of health professionals (Happell et al. 2014; Happell & Roper 2009; Repper & Breeze 2007). This heralds the danger that universities might be acting, either currently or in the future, out of a sense of adherence to policy, rather than a genuine desire to promote the role of consumers in education and to decrease stigma towards people with mental illness. Genuine and effective involvement in the education of health professionals must go beyond classroom teaching, and provide the opportunity for lived experience to
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become embedded into curriculum (Happell & Roper 2009). The absence of clear guidelines about what does and does not signify genuine consumer participation is understandable, given the newness of this approach. However, given that the involvement of consumers appears to be on the increase, there is a need for a clear framework to guide consumer roles in education. These should include partnership and commitment; support, scope, and autonomy (Bennetts et al. 2011; Byrne et al. 2013; Happell et al. 2014; Happell & Roper 2009; Lammers & Happell 2003; 2004; McCann et al. 2008). It is difficult to see how 1–4 hours of classroom teaching could possibly meet these four criteria, raising the strong possibility that consumer participation becomes tokenistic, and limits its effectiveness in overcoming the identified attitudinal barriers on the part of health professionals (Bennetts et al. 2011; Byrne et al. 2013; Happell et al. 2014; Lammers & Happell 2003; 2004; McCann et al. 2008). The issue of determining consumer delivered content is worthy of comment. In the majority of cases, this is in partnership between nurse academics and consumers. It is pleasing that the content is not imposed in most instances; however, if autonomy is an essential component of effective consumer participation in education (Happell & Roper 2009), it would be pleasing to see more evidence of consumers determining the content of their teaching sessions. Expertise is most effective when the experts determine what knowledge is and what is not important to be transferred to the learner. These findings also raise important issues about readiness for roles as consumer educators and academics. There is recognition of the need for training and organizational support for consumer roles in mental health services more broadly (Bennetts et al. 2013; Cleary et al. 2011; Stewart et al. 2008). Education roles are equally challenging, and require educational preparation and support to maximize their effectiveness and to minimize negative impacts on the consumer educators themselves (Happell & Roper 2009).
LIMITATIONS This is a self-report study, rather than the analysis of documentation; therefore, the accuracy cannot be definitively verified. Furthermore, the survey design utilized in this research does not allow for detailed information about the roles consumers play within universities. As a policy directive, it is essential that more is known and understood about the roles consumers undertake in the
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education of health professionals, the barriers they face, and the strategies used to minimize or overcome these barriers.
CONCLUSIONS Consumer participation in mental health services and the education of health professionals are now a policy imperative. Autonomous roles for consumers as educators and academics are essential for this policy goal to be realized. The apparent proliferation in consumer roles in the education of nurses is positive; however, the ad hoc way in which these roles have been developed and implemented is cause for concern. More detailed exploration of these roles is required as a matter of urgency to determine the facilitators and barriers to their success, and to formulate guidelines to ensure these roles do not become tokenistic, and that adequate training, professional development, and other supports are implemented to maximize the benefits and effectiveness of these initiatives.
ACKNOWLEDGEMENTS The authors extend their thanks to the Health Collaborative Research Network, CQUniversity for providing the funding to allow this work to be completed. Our thanks also to the participants who took the time to complete these questionnaires.
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