bs_bs_banner
Perspectives in Psychiatric Care
ISSN 0031-5990
Exploring the Scope of Consumer Participation in Mental Health Nursing Education: Perspectives From Nurses and Consumers Brenda Happell, RN, RPN, BA (Hons), DipEd, BEd , MEd, PhD, Wanda Bennetts, Dip Teaching (Primary), BEd, Grad Dip Children’s Lit, Grad Dip TESOL, MEd, Chris Platania-Phung, BA (Hons), PhD, and Jenny Tohotoa, PhD, MSc, Grad Dip, BSc Brenda Happell, RN, RPN, BA (Hons), DipEd, BEd , MEd, PhD, is Executive Director, Research Centre for Nursing and Midwifery Practice, Faculty of Health, University of Canberra; Executive Director, ACT Health, Research Centre for Nursing and Midwifery Practice, Canberra Hospital, Canberra, Australian Capital Territory, Australia; Wanda Bennetts, Dip Teaching (Primary), BEd, Grad Dip Children’s Lit, Grad Dip TESOL, MEd, is Senior Policy Advisor Consumer Portfolio, Consumer, Carer and National Relations, Mental Health Branch, Mental Health, Wellbeing & Ageing Division, Department of Health, Melbourne, Victoria, Australia; Chris Platania-Phung, BA (Hons), PhD, is Research Fellow, Research Centre for Nursing and Midwifery Practice, Faculty of Health, University of Canberra and ACT Health, Canberra, Australian Capital Territory, Australia; and Jenny Tohotoa, PhD, MSc, Grad Dip, BSc, is Research Associate, School of Nursing and Midwifery, School of Public Health and Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia.
Search terms: Consumer participation, education, mental health, nursing Author Contact: [email protected], with a copy to the Editor: [email protected] Conflict of Interest Statement The authors report no actual or potential conflicts of interest. First Received September 19, 2014; Final Revision received January 29, 2015; Accepted for publication February 19, 2015. doi: 10.1111/ppc.12113
PURPOSE: Exploration of the views and experiences of nurse academics and consumer academics and educators regarding the scope of consumer participation in mental health nursing education. DESIGN AND METHODS: A qualitative, exploratory inquiry into the description and views of mental health nurse academics and consumer educators about these roles FINDINGS: A significant variation in roles from guest speaker to substantive academic positions was evident, with most involvement brief and specifically teaching focused. Consumer participation in education was generally valued but noted to be limited in breadth and scope. Some concern was raised about the relevance of consumer academic roles, with a clear conceptualization of the consumer academic role necessary to facilitate their contribution to the education of health professionals. PRACTICE IMPLICATIONS: Mental health consumer involvement in the education of nurses has been shown to impact positively on the attitudes of health professionals to people with mental illness. Advocacy for increased, meaningful input from consumers into nursing education is therefore necessary to improve practice.
Nursing distinguishes itself from other health professions through its claim to approach client care from a holistic perspective (Povlsen & Borup, 2011). Holism requires a clear understanding of the impact of ill health on the person, with a focus on the subjective experience rather than purely on the physical impact of the illness and injury in terms of signs and symptoms (Jones, 2010). Nurse academics may be committed to educating students from a holistic perspective; however, new graduates have reported difficulties practicing holistically, with addressing mental health needs identified as particularly challenging (Sharrock & Happell, 2006). A qualitative study of consumer perspectives suggested consumers were disappointed that the nurse– consumer relationship was not as they had expected, and their ability to seek help through this relationship was minimal (Stenhouse, 2011). Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.
Promoting a holistic approach to nursing practice is highly compatible with the philosophical underpinnings of Australian mental health policy, which espouses consumer participation in all aspects of mental health services (Australian Government, 2012; Commonwealth of Australia, 2010). Holistic practice is enhanced when care is actively directed by those accessing services (Byrne, Happell, Welch, & Moxham, 2013a; Noble, Bradley, & Freed, 2007) and indeed in Australia the active involvement of consumers in the education of nurses was identified as a guiding principle in the framework for nursing preparation programs (Mental Health Nurse Education Taskforce, 2008). Preregistration nursing programs are charged with the responsibility of preparing nurses for practice in mental health settings (Happell & Cutcliffe, 2011). It would therefore seem a reasonable expectation that curricula reflect broader policy 1
Exploring the Scope of Consumer Participation in Mental Health Nursing Education: Perspectives From Nurses and Consumers
expectations. The research suggests otherwise (Happell, Byrne, McAllister, et al., 2014). A national survey of preregistration programs found consumer involvement to be variable but generally minimal and frequently confined to classroom teaching despite policy stipulation that consumers should be involved in all aspects, including curriculum design, implementation, assessment, and evaluation (McCann, Moxham, Usher, Crookes, & Farrell, 2009). Restricting involvement to classroom teaching can be tokenistic where consumers have very little capacity to influence teaching content (Hossack & Wall, 2005; Meehan & Glover, 2007; Simons et al., 2007). Determining the optimal level of consumer participation is not straightforward, particularly in the absence of guidelines and recommendations. There are no formalized statements about minimum or maximum hours. The focus has tended to reflect the scope of the role, allowing consumers to go beyond describing their own lived experience and have opportunity to influence the development, content, and evaluation of curricula (Happell & Roper, 2009). The implementation of academic positions for consumers of mental health services has been one strategy to provide meaningful consumer input into the education of nurses (Happell & Roper, 2003; Schneebeli, O’Brien, Lampshire, & Hamer, 2010; Simons et al., 2007) at all levels, including teaching, assessment, curriculum development, and research and evaluation (Happell & Roper, 2009). To date, consumer academic roles have been very few in number and confined to mental health settings. Research findings suggest these positions are effective not only in influencing more positive attitudes to people experiencing significant mental health challenges (Byrne, Happell, Welch, & Moxham, 2013b; Happell, Pinikahana, & Roper, 2003; Schneebeli et al., 2010; Simons et al., 2007), but also in enhancing a holistic approach to practice that is relevant in any healthcare setting (Byrne et al., 2013a). More recently, research has suggested consumer participation can influence more positive attitudes toward mental health nursing as a career (Happell, Byrne, PlataniaPhung, et al., 2014). While Australia has led the world in this development, there are currently only three known substantiative positions in place across two universities, suggesting a committed and systematic approach to consumer participation in education has not as yet been prioritized (Happell, Byrne, McAllister, et al., 2014; McCann et al., 2009). To date, there is a paucity of research examining the impact of consumer participation in the education of health professionals from the perspective of nurses and consumers (Happell, Byrne, McAllister, et al., 2014). For the goal of increased participation, the experiences of consumers undertaking these roles and the perspective of nurse academics must be understood. The aim of this study was to solicit these views and experiences to enhance understanding of the current scope of consumer involvement in the delivery of mental health nursing content. 2
Methods Design A qualitative exploratory design was undertaken for this study. Stebbens (2001) recommends this approach for researchers investigating topics that have not been extensively researched, and therefore limited knowledge is available to guide different methodological approaches. Qualitative exploratory methods are highly suitable as a platform for encouraging participants to contribute their perceptions and opinions to ensure the findings reflect their views. Participants The study included two participant groups. The first comprised nurse academics teaching and/or coordinating mental health nursing within preregistration or post-registration programs in Australian universities. Thirty-four nurse participants represented 27 universities. Some universities had two participants, one representing preregistration and one representing post-registration. The second group included consumers who had a role in the education of nurses undertaking these subjects and programs. A total of 12 consumers participated, including those employed casually (n = 9) and those holding a designated academic position (n = 3). Setting This was an Australian-based study of universities involved in teaching nursing at preregistration and post-registration levels. Currently, 34 universities offer nursing programs accredited for registration as a nurse. Of these universities, 23 also offer postgraduate programs with a specialist focus in mental health nursing. Specialist qualifications are not mandatory for nursing practice in mental health settings; however, they are required at the minimum level of postgraduate diploma as a requirement for recognition by the Australian College of Mental Health Nursing and as a specialist mental health nurse (Deacon & Cleary, 2013). Recruitment Nurses. All Heads of Schools of Nursing in Australia were contacted via email. The text included a summary of the study and a specific request for the name and contact details of the academic staff member best suited to inform this study. An email invitation was sent to the 38 identified staff. The correspondence included a copy of the plain language statement and consent form. Recipients were asked to contact the research assistant if they were interested in contributing to the study. All participants initially made contact. Telephone interviews were arranged with 36; two subsequently were not available at the time of interview. Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.
Exploring the Scope of Consumer Participation in Mental Health Nursing Education: Perspectives From Nurses and Consumers
Consumers. Where nurse participants identified the involvement of consumers in any capacity within the mental health nursing component(s), they were asked for names and contact details of the consumer educators they worked with, with the prior consent of the consumers themselves. An email outlining the study was sent to 20 potential participants. The email included the plain language statement and consent form. Telephone interviews were arranged with the 12 participants who agreed to participate by the research assistant for a time of mutual convenience. Procedure Interviews were conducted by telephone due to vast geographical distances. To ensure an accurate account of interviews, they were audio-recorded with full disclosure to and consent of participants. The interviews were undertaken by two research assistants. Nurse participants were interviewed by a mental health nurse with expertise in research. Consumer participants were interviewed by an experienced researcher who identifies as and has worked extensively from a consumer perspective. Participants were asked to describe their opinions of, and experiences with, consumer involvement in the education. For example, participants were asked to describe the role that consumers play in mental health nursing, particularly relating to the depth and breadth of the role, and to identify the strengths, barriers, challenges, and enablers to this involvement.
subthemes were examined by the team and variations were deliberated until agreement was reached. The depth and breadth of consumer input was one main theme and will be described in this paper. The focus of this paper is the depth and breadth of consumer input, including the subthemes: next to nothing, getting involved, being part of the team, and conflicting attitudes.
Trustworthiness and Credibility The trustworthiness and credibility of the research findings was established through several means. Firstly, using the highly experienced interviewers, nurse participants were interviewed by an experienced mental health nurse researcher and consumer participants were interviewed by an experienced consumer researcher. This relevant expertise enhanced the researcher’s understanding of the issues raised by the participants and use of probing questions to elicit more information. While expertise is highly useful, it also brings the need for bracketing, a conscious and reflective activity, where the researcher acknowledges his/her preconceptions about the research topic. The researchers then set aside their beliefs, attitudes, and judgments to consider the topic with a fresh and new approach (Polit & Beck, 2013) The research team met regularly throughout the study to monitor all aspects. The interview transcripts were independently reviewed by at least two members of the team, and differences were discussed and negotiated until consensus could be reached.
Ethical Issues Ethical clearance was obtained from the university committees representing the research team. All principles of the ethical conduct of research were adhered to. Participants were fully informed that they could choose whether or not to participate, and could withdraw their consent at any time. Participants were assured that the confidentiality of their data would be maintained and names were replaced with participant numbers to prevent them from being identified. Participants’ numbers were assigned as NP (nurse participant) and CP (consumer participant). Data Analysis Data were analyzed thematically using a verbatim transcript of each interview. In the first instance, all transcripts were read and reread to enhance familiarization with the content and the recognition of themes and subthemes. A conceptual map (see Figure 1) was developed based on the identified themes and quotes representing the main ideas were noted. At this point, significant time was taken to comprehend, synthesize, theorize, and recontextualize data. The draft themes and Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.
Findings Depth and Breadth of Consumer Input Next to Nothing. The consumer involvement in the education of nursing students ranged from no face-to-face contact to substantive academic positions within some universities. Nurses. At several universities, there was no face-to-face consumer contact and students’ only experience was through virtual interviews: The only consumer contact they have in the classroom is consumer interviews on videos and things like that. (NP15) In most instances, involvement was brief, usually involving the provision of guest lectures, primarily based on their experiences, for example: We always invite a consumer to talk about recovery and the consumer experience (NP33). They . . . provide that lived experience (NP30). 3
Exploring the Scope of Consumer Participation in Mental Health Nursing Education: Perspectives From Nurses and Consumers
Depth and breadth of consumer involvement
next to nothing
getting involved
no face to face
ad hoc
approximately twice a year
been involved in curriculum development
guest lectures
reviewing and revising policy documents
half an hour speaking time
members of executive advisory committees
being part of the team
I teach a recovery approach in mental health
getting students to really think from a consumer perspective
substantive academic positions
a voice for people who don’t necessarily have a voice
talk to the students
Similarly: We do have somebody that had a mental health issue in their formative years talk to the students about how they overcame their illness and how well they’re doing now, sort of thing. (NP16) In most cases, there was only one consumer guest lecturer; however, one participant described using four consumers to contribute to student learning: We run a full day consumer-led workshop, and there are four consumers who come on that day. I just facilitate the consumers in what they want to teach to students and what they think is important in a nurse. (NP18) One reason for the small amount of consumer participation related to the sheer number of students in the undergraduate programs: We actually use nine clinical schools, so getting a consumer to teach across all that complexity is really difficult. (NP22) 4
conflicting attitudes
it's a good thing and the right thing to do
I want the nurses to have the connection with the grass roots
there is a place for consumers as academics I don’t see any benefit of having a consumer on curriculum planning
look at the nature of people’s stories and their trauma
Figure 1. Conceptual Mapping of Data Analysis
Some staff thought consumers in education, while potentially desirable, were a fantasy and they were not confident this could ever take place: It would be interesting to see if we could ever have consumers as tutors. (NP33) Consumers. Consumer participants also described considerable variation in the degree and scope of their involvement in the education of nurses. For most, the involvement was limited in time and scope: I go in and speak to the nurses approximately twice a year and it’s basically from a consumer point of view from being in a psychiatric hospital. (CP9) Similarly: . . . it’s just been those two lectures that I was approached to do . . . The first one I did . . . I was allocated an hour but the previous speaker went overtime and then invited another speaker, so that was decreased to half an hour speaking time. (CP2) Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.
Exploring the Scope of Consumer Participation in Mental Health Nursing Education: Perspectives From Nurses and Consumers
Involvement tended to be ad hoc and based on established relationships rather than recognized as an important and inherent part of the program: Each time it’s been through somebody that I know who has decided that it would be a good thing to have that consumer bit happening in their course, and they tap you on the shoulder . . . I’ve got to know those people through the consumer consultancy work and the consumer educator role work that I’ve done over the last 12 to 14 years. (CP4) Getting Involved. Nurses. Most universities utilized consumers in teaching roles. However, a small number involved them at a broader level, for example, as members of executive advisory committees: [and] not in a tokenistic way, they were actually part of the panel in terms of decision making. (NP15) Another university included consumers in reviewing and revising policy documents: we’ve just been through [program] accreditation and had quite a lot of consumer input into those documents. (NP32) Although consumer involvement was acknowledged as important, it was not always possible to achieve. The following participant explained that issues of funding, university processes, and the absence of champions to lead the cause impacted on actual change: We have tried to have consumer involvement on our panels . . . the aim has been to have people on the committees, that hasn’t been met. (NP13) Consumers. Most consumers were employed casually and primarily asked to talk about their experiences of the system and ways the care they were provided might be more consumer focused: Basically, how I was treated. The good and bad. What I felt they needed to know . . . Things that would have helped me . . . and just mostly my experiences. Involvement in aspects of education rather than direct teaching was generally limited, for example: I’ve been involved in curriculum development . . . on the odd occasions . . . but that’s only happened three or four times ever. I haven’t been involved in assessments, but we did set the assessment questions for [name of consumer academic]. (CP4) Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.
The opportunity to engage in research was also limited for most: I have been involved in research, mainly on the edges, and I’ve done a little bit of my own, but more that it’s just been a bit ad hoc, here and there. (CP4) Being Part of the Team. Nurses. At the other end of the spectrum, two universities employed consumers in specific academic roles, which meant more time was available for much greater involvement in curriculum design and implementation. One participant provided an example of benefits arising from this increased capacity: They have a look at the whole curriculum for respectful language . . . They have also specifically designed some of the content around ethics in particular, a debate around involuntary treatment, issues of coercive practice and around recovery and recovery oriented practice. (NP2) The benefits of having an academic on staff with a “lived” experience of mental illness not only enriched student learning, but was a potential agent of social change. As one participant stated: Our consumer academic is a voice for people who don’t necessarily have a voice, and it’s very powerful. (NP18) One participant explained their understanding of the difference between guest speaker and consumer academic: The idea is to be getting students to really think from a consumer perspective and think about recovery and the importance of hope rather than having a session where somebody comes in and talks for an hour about how they became unwell and what happened to them in the mental health system. It’s the sort of thing that students learn without you teaching them in a way. It’s subliminal almost. (NP17) Consumers. Three consumer participants were employed in a consumer or lived experience role. One university employed a consumer academic part-time to teach postgraduate mental health nursing students and she described the scope of her work and the subject she teaches and coordinates: it’s an introduction to the consumer movement and where it came from, what it’s concerns are, so we look at different frameworks . . . human rights frameworks and . . . the first module is really looking at relationships . . . an approach to distress . . . and . . . different ways to think about what gets called mental illness . . . and look at the nature of people’s stories and their trauma and that kind of thing. (CP6) 5
Exploring the Scope of Consumer Participation in Mental Health Nursing Education: Perspectives From Nurses and Consumers
This autonomous role is further supported with some limited support from other consumers: [name of subject] gets reviewed with the additional consumer perspective . . . every couple of years, so it’ll be two or three people assisting with that . . . and also guest consumer lectures, as needed in the classroom . . . there isn’t a huge budget for that . . . two hours of face to face teaching time . . . (CP6) One university employed two full-time consumer academics. One had the autonomous role of coordinating and teaching the consumer-led “Recovery for Mental Health Practice” subject: I teach a recovery approach in mental health and it’s very clearly positioned from a lived experience recovery perspective, and it’s underlined consistently both in the fact that I teach it and in the materials that I use . . . it’s quite radical for a university course. (CP5) The other lived experience educator from this university commenced with casual teaching in the Recovery course followed by a full-time contract to teach professional communication skills. Working with another person with lived experience was considered an advantage: . . . there’s my own experiences which give me some ability to input and share. However, also recognising that everybody’s experience is so very different that you can’t ever generalise . . . So I think, having a few different people is really good. (CP9) However, to avoid a singular perspective, the sense remained that maybe this alone was not enough: . . . if there’s just one or two people you could get a bit of a narrow-minded perspective. (CP9) Conflicting Attitudes. Nurses. Some universities had no consumer content at all and some participants expressed their disappointment about this: It’s disheartening because in the literature, everything demonstrates that [consumer involvement] it’s a good thing and the right thing to do. (NP20) However, not all participants agreed with the concept of consumer involvement in mental health student learning as the following participant expressed: I don’t know whether the course would benefit by having a consumer as a consultant, especially if we’ve got experts that have worked in the area, I don’t see any benefit of having a consumer on curriculum planning. (NP4) 6
Another participant expressed interest in consumers only assisting in the teaching: I haven’t been planning on having any input of consumers into what’s in the curriculum other than having them teaching part of it. (NP25) Additionally, a participant explained the potential risk of using mental health consumers to engage nursing students: If we’re trying to attract people into the service and we bring in a whole string of people saying well, the mental health service is completely stuffed and why would anybody do anything and look at the torture they inflict on poor innocent human beings. Then why would some of them put their arm up to work in that area? (NP25) Consumers. Some participants discussed the potential benefits of consumer academic positions and there was wide support for this role. At the same time, there were some concerns raised: of course there is a place for consumers as academics. It shows the staff that someone with a mental illness can be . . . an active staff member, . . . secondly it shows that some consumers are being taken seriously but . . . the problem is that . . . people who get into academic jobs—(I hate this term but) are highly functioning. . . . So symbolically it’s important to have consumer academics but it’s not a realistic proposition for everyone to attain . . . (CP3) For another participant, the concern was much greater and the extent to which consumers were in touch with the “real world” was questioned: . . . I want the nurses to have the connection with the grass roots consumers . . . not the researchers, not the academics, not the people that have professionalised themselves so much as researchers. They’re too far removed from what really happens. They can’t give that true and genuine and meaningful experience. Only the grass roots consumers and carers can do that . . . They [consumer academics] can still have them there, but they’re not the peer; they’re not the lived experienced people I’m talking about that’s required in unis. (CP7) Discussion The findings from the study confirm the ad hoc and variable nature of consumer participation in the education of nurses (Happell, Byrne, McAllister, et al., 2014; McCann et al., 2009). The responses of both nurse and consumer participants suggest that consumers generally played an important but quite minor role, usually limited to delivery of course content, and most commonly involving the telling of their story (Meehan & Glover, 2007). This practice may assist in Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.
Exploring the Scope of Consumer Participation in Mental Health Nursing Education: Perspectives From Nurses and Consumers
promoting a greater understanding of people who experience significant mental health challenges and facilitate a more holistic approach to nursing care (Byrne et al., 2013a, 2013b; Meehan & Glover, 2007; Schneebeli et al., 2010). However, the capacity to strongly influence more positive attitudes and facilitative approaches to enhancing consumer participation within services may well be minimal in light of limited involvement. It has been argued that effective consumer involvement in the education of health professionals requires four components: (a) partnership and commitment, (b) support, (c) scope, and (d) autonomy (Happell & Roper, 2009). It is difficult to see how this can be achieved with a small component of classroom-based involvement. Where consumer participation is contained in this manner, the likely outcome is tokenism (Forrest, Risk, Masters, & Brown, 2000; Meehan & Glover, 2007; Simons et al., 2007). The responses of consumer participants suggest their involvement is frequently of short duration and nominal. Most nurse participants expressed the view that an increased role for consumers would be beneficial in producing a higher quality education program. Two universities had already made substantial achievements in this area. One university employs one, and the other two consumer academics. The incumbents of two positions have quite autonomous roles at least commensurate with nurse academics, convening a course specifically related to the lived experience of mental health challenges, thereby satisfying the four components required for effective consumer participation (Happell & Roper, 2009). An academic position for a consumer of mental health services was originally developed to enhance the capacity for consumer perspective to be embedded in nursing curricula for the education of nurses for practice in the mental health field (Happell & Roper, 2002). The vision for the role extended beyond classroom teaching to encompass curriculum development, assessment, and also to include research, evaluation, and other scholarly activities generally expected of academics. The evidence base in support of the value of these positions is emerging (Byrne et al., 2013b; Happell & Roper, 2003; Happell et al., 2003; Happell, Byrne, McAllister, et al., 2014; Happell, Byrne, Platania-Phung, et al., 2014); however, it is not clear how likely these roles are to expand, particularly given the ever increasing financial constraints in Australian universities (De Brennan, 2006). One finding of particular interest was the consumer academic vs. “ordinary” consumer issue. Although consumer participants expressed some support for consumer academic positions, concerns were raised. One concern was that consumer academics may be too “removed” from the experiences and opinions of “grass roots” consumers and therefore may not appropriately reflect the issues of greatest importance to consumers currently dealing with mental health challenges and accessing mental health services. Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.
The nurse participants in this research did not raise concerns about academic elitism; however, this has been suggested elsewhere (Happell, 2008; Happell & Roper, 2003; Happell et al., 2003). The role of consumer academic was identified as discriminatory and labeling and likely to increase the stigma associated with mental illness (Happell & Roper, 2003; Happell et al., 2003). In another example, consumer academics were identified as “not real consumers,” apparently reflecting the assumption that they were no longer accessing services and therefore no longer in touch with the experiences. These concerns seem to relate at least in part to the issue of representativeness. Consumers in dedicated roles based on their lived experiences have been criticized for not being representative of broader consumer views (Happell & Roper, 2006). This reflects an apparent assumption that consumers with active involvement in participatory roles may not be representative of consumers more broadly, particularly those consumers currently using mental health services (Tobin, Chen, & Leathley, 2002). This argument is frequently advanced despite limited research to verify its degree of accuracy (Crawford & Rutter, 2004; Forrest et al., 2000; Happell & Roper, 2006). While there needs to be a clear conceptualization of the consumer academic role involving multiple stakeholders from the consumer movement, it is crucial that this is undertaken with a cohesive and cooperative approach. Internal dissention was recently identified as an issue in an in-depth qualitative study of consumers employed in various roles within the mental health system (Byrne, 2014) and was referred to as “infighting.” Concerns were raised that the movement was in danger of becoming fractured due to ideological and philosophical differences that led to individuals questioning the credibility and suitability of colleagues, rather than working together to create a workforce that reflects diversity and values differences. Furthermore, there is no reason to suggest the consumer academic should occur instead of guest lecturers; ideally, other consumer roles would be utilized to complement and enrich the consumer academic perspective. Limitations As a qualitative exploratory study, the views expressed in this research are theirs alone and not necessarily reflective of a broader constituency. While the number of nurse participants recruited was very pleasing, we were only able to interview a much smaller number of consumer participants, further limiting the generalizability of these findings. Conclusions Consumer participation in the education of nurses in Australia varies considerably in breadth and scope. Most roles have 7
Exploring the Scope of Consumer Participation in Mental Health Nursing Education: Perspectives From Nurses and Consumers
limited involvement, suggesting the goals of increased consumer participation in the education of health professionals and within the mental health services are not likely to be effectively achieved. Consumer academic roles have the capacity to be more influential, providing the organizational environment is supportive and roles are able to develop autonomously. Some concern was raised that consumer academics may be removed from the issues facing consumers who are currently using mental health services and therefore these roles may not be the best way to approach educational roles for consumers. The prospect that infighting may weaken the consumer movement is disturbing, conceptualizing the role of consumer academics in relation to the broader consumer movement may contribute to clarity of understanding and a stronger sense of cohesion. Increasing opportunities for meaningful participation in the education of nurses will require significant capacity development in the consumer educator and academic workforce. Education and training is imperative to ensure consumers are adequately prepared for these roles. Effective capacity building must also involve the provision of appropriate resources and support mechanisms to enhance the ability of consumer educators and academics to contribute confidently and competently to the education of nurses. An understanding of the scope of current roles is an important starting point to exploring these issues.
Recommendations for Practice and Research To date, the research regarding consumer involvement in the education of nurses is limited. The findings presented in this paper suggest the need for further research and discussion to consider the concept of representativeness and its potential influence in the development of a consumer education workforce. Research should also be undertaken to consider the education and training, and support and resource needs of consumers seeking the opportunity for an education or academic role in the future. Demonstrating relationships between consumer involvement in education and improved outcomes for students and for mental health care delivery should be a crucial component of any research agenda. Nurse academics are well positioned to play an important part in promoting and facilitating the development of positions for consumers to contribute to the education of nurses.
Acknowledgments The authors extend their thanks to the Health Collaborative Research Network, CQUniversity for providing the funding to allow this work to be completed. The authors also thank the participants who took the time to participate in these interviews and share their thoughts and opinions. 8
References Australian Government. (2012). The Roadmap for National Mental Health Reform 2012–2022. Canberra: Author. Retrieved from http://www.coag.gov.au/sites/default/files/ The%20Roadmap%20for%20National%20Mental%20 Health%20Reform%202012-2022.pdf.pdf, http://www.coag.gov.au/node/482 Byrne, L. (2014). A grounded theory study of lived experience mental health practitioners within the wider workforce (PhD thesis). Central Queensland University, Rockhampton, Australia. Byrne, L., Happell, B., Welch, A., & Moxham, L. (2013a). Reflecting on holistic nursing: The contribution of an academic with lived experience of mental health service use. Issues in Mental Health Nursing, 34(4), 265–272. doi:10.3109/01612840.2012.745038 Byrne, L., Happell, B., Welch, T., & Moxham, L. J. (2013b). “Things you can’t learn from books”: Teaching recovery from a lived experience perspective. International Journal of Mental Health Nursing, 22(3), 195–204. doi:10.1111/j.1447-0349.2012.00875.x Commonwealth of Australia. (2010). National standards for mental health services. Canberra: Author. Crawford, M. J., & Rutter, D. (2004). Are the views of members of mental health user groups representative of those of “ordinary” patients? A cross-sectional survey of service users and providers. Journal of Mental Health, 13, 561. De Brennan, S. (2006). Out by more than one degree: Politics and organizational change within an Australian University. Educational Research for Policy and Practice, 5(2), 73– 100. Deacon, M., & Cleary, M. (2013). The reality of teamwork in an acute mental health ward. Perspectives in Psychiatric Care, 49(1), 50–57. doi:10.1111/j.1744-6163.2012.00340.x Forrest, S., Risk, I., Masters, H., & Brown, N. (2000). Mental health service user involvement in nurse education: Exploring the issues. Journal of Psychiatric and Mental Health Nursing, 7, 51–57. doi:10.1046/j.1365-2850.2000.00262.x Happell, B. (2008). Polarisation and political correctness: Subtle barriers to consumer participation in mental health services. Advances in Mental Health, 7(3), 150–156. Happell, B., & Cutcliffe, J. R. (2011). A broken promise? Exploring the lack of evidence for the benefits of comprehensive nursing education. International Journal of Mental Health Nursing, 20(5), 328–336. doi:10.1111/j.1447-0349.2011.00745.x Happell, B., & Roper, C. (2002). Promoting consumer participation through the implementation of a consumer academic position. Nurse Education In Practice, 2, 73–79. doi:10.1054/nepr.2002.0068 Happell, B., & Roper, C. (2003). The role of a mental health consumer in the education of postgraduate psychiatric nursing students: The students’ evaluation. Journal of Psychiatric and Mental Health Nursing, 10, 343–350. doi:10.1046/j.1365-2850.2003.00599.x
Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.
Exploring the Scope of Consumer Participation in Mental Health Nursing Education: Perspectives From Nurses and Consumers
Happell, B., & Roper, C. (2006). The myth of representation: The case for consumer leadership, AeJAMH (Australian e-Journal for the Advancement of Mental Health). Australia: Auseinet (Australian Network for Promotion, Prevention and Early Intervention for Mental Health). Happell, B., & Roper, C. (2009). Promoting genuine consumer participation in mental health education: A consumer academic role. Nurse Education Today, 29(6), 575–579. doi: 10.1016/j.nedt.2008.01.004 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. doi:10.1053/apnu.2003.00008 Happell, B., Byrne, L., McAllister, M., Lampshire, D., Roper, C., Gaskin, C. J., & Hamer, H. (2014). Consumer involvement in the tertiary-level education of mental health professionals: A systematic review. International Journal of Mental Health Nursing, 23(1), 3–16. doi:10.1111/inm.12021 Happell, B., Byrne, L., Platania-Phung, C., Harris, S., Bradshaw, J., & Davies, J. (2014). Lived-experience participation in nurse education: Reducing stigma and enhancing popularity. International Journal of Mental Health Nursing, 23, 427–434. Hossack, A., & Wall, G. (2005). Service users: Undervalued and underused? Psychologist, 18(3), 134–136. Jones, T. L. (2010). A holistic framework for nursing time: Implications for theory, practice, and research. Nursing Forum, 45(3), 185–196. doi:10.1111/j.1744-6198.2010.00180.x 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. doi:10.1177/1744987109347041 Meehan, T., & Glover, H. (2007). Telling our story: Consumer perceptions of their role in mental health education. Psychiatric Rehabilitation Journal, 31, 152–154. doi:10.2975/31.2.2007.152.154
Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.
Mental Health Nurse Education Taskforce. (2008). Final report: Mental health in pre-registration nursing courses. Melbourne: Final Report: Mental Health in Pre-registration Nursing Courses. Noble, H., Bradley, R., & Freed, N. (2007). Nursing philosophy. A patient survey of nursing practice philosophy in 2001 and 2005. British Journal of Nursing, 16(14), 892–895. Polit, D. F., & Beck, C. T. (2013). Essentials of nursing research: Appraising evidence for nursing practice. Philadelphia: Lippincott Williams & Wilkins. Povlsen, L., & Borup, I. K. (2011). Holism in nursing and health promotion: Distinct or related perspectives?—A literature review. Scandinavian Journal of Caring Sciences, 25(4), 798–805. doi: 10.1111/j.1471-6712.2011.00885.x Schneebeli, C., O’Brien, A., Lampshire, D., & Hamer, H. P. (2010). Service user involvement in undergraduate mental health nursing in New Zealand. International Journal of Mental Health Nursing, 19, 30–35. doi:10.1111/j.1447-0349.2009.00642.x Sharrock, J., & Happell, B. (2006). Competence in providing mental health care: A grounded theory analysis of nurses’ experiences. Australian Journal of Advanced Nursing, 24(2), 9–15. Simons, L., Tee, S., Lathlean, J., Burgess, A., Herbert, L., & Gibson, C. (2007). A socially inclusive approach to user participation in higher education. Journal of Advanced Nursing, 58, 246–255. doi:10.1111/j.1365-2648.2007.04216.x Stebbens, R. (2001). Exploratory research in the social sciences: Qualitative research methods (Vol. 48). London: Sage. Stenhouse, R. C. (2011). “They all said you could come and speak to us”: Patients’ expectations and experiences of help on an acute psychiatric inpatient ward. Journal of Psychiatric & Mental Health Nursing, 18(1), 74–80. doi:10.1111/j.1365-2850.2010.01645.x Tobin, M., Chen, L., & Leathley, C. (2002). Consumer participation in mental health services: Who wants it and why? Australian Health Review, 25(3), 91–100.
9
Perspectives in Psychiatric Care
ISSN 0031-5990
Exploring the Scope of Consumer Participation in Mental Health Nursing Education: Perspectives From Nurses and Consumers Brenda Happell, RN, RPN, BA (Hons), DipEd, BEd , MEd, PhD, Wanda Bennetts, Dip Teaching (Primary), BEd, Grad Dip Children’s Lit, Grad Dip TESOL, MEd, Chris Platania-Phung, BA (Hons), PhD, and Jenny Tohotoa, PhD, MSc, Grad Dip, BSc Brenda Happell, RN, RPN, BA (Hons), DipEd, BEd , MEd, PhD, is Executive Director, Research Centre for Nursing and Midwifery Practice, Faculty of Health, University of Canberra; Executive Director, ACT Health, Research Centre for Nursing and Midwifery Practice, Canberra Hospital, Canberra, Australian Capital Territory, Australia; Wanda Bennetts, Dip Teaching (Primary), BEd, Grad Dip Children’s Lit, Grad Dip TESOL, MEd, is Senior Policy Advisor Consumer Portfolio, Consumer, Carer and National Relations, Mental Health Branch, Mental Health, Wellbeing & Ageing Division, Department of Health, Melbourne, Victoria, Australia; Chris Platania-Phung, BA (Hons), PhD, is Research Fellow, Research Centre for Nursing and Midwifery Practice, Faculty of Health, University of Canberra and ACT Health, Canberra, Australian Capital Territory, Australia; and Jenny Tohotoa, PhD, MSc, Grad Dip, BSc, is Research Associate, School of Nursing and Midwifery, School of Public Health and Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia.
Search terms: Consumer participation, education, mental health, nursing Author Contact: [email protected], with a copy to the Editor: [email protected] Conflict of Interest Statement The authors report no actual or potential conflicts of interest. First Received September 19, 2014; Final Revision received January 29, 2015; Accepted for publication February 19, 2015. doi: 10.1111/ppc.12113
PURPOSE: Exploration of the views and experiences of nurse academics and consumer academics and educators regarding the scope of consumer participation in mental health nursing education. DESIGN AND METHODS: A qualitative, exploratory inquiry into the description and views of mental health nurse academics and consumer educators about these roles FINDINGS: A significant variation in roles from guest speaker to substantive academic positions was evident, with most involvement brief and specifically teaching focused. Consumer participation in education was generally valued but noted to be limited in breadth and scope. Some concern was raised about the relevance of consumer academic roles, with a clear conceptualization of the consumer academic role necessary to facilitate their contribution to the education of health professionals. PRACTICE IMPLICATIONS: Mental health consumer involvement in the education of nurses has been shown to impact positively on the attitudes of health professionals to people with mental illness. Advocacy for increased, meaningful input from consumers into nursing education is therefore necessary to improve practice.
Nursing distinguishes itself from other health professions through its claim to approach client care from a holistic perspective (Povlsen & Borup, 2011). Holism requires a clear understanding of the impact of ill health on the person, with a focus on the subjective experience rather than purely on the physical impact of the illness and injury in terms of signs and symptoms (Jones, 2010). Nurse academics may be committed to educating students from a holistic perspective; however, new graduates have reported difficulties practicing holistically, with addressing mental health needs identified as particularly challenging (Sharrock & Happell, 2006). A qualitative study of consumer perspectives suggested consumers were disappointed that the nurse– consumer relationship was not as they had expected, and their ability to seek help through this relationship was minimal (Stenhouse, 2011). Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.
Promoting a holistic approach to nursing practice is highly compatible with the philosophical underpinnings of Australian mental health policy, which espouses consumer participation in all aspects of mental health services (Australian Government, 2012; Commonwealth of Australia, 2010). Holistic practice is enhanced when care is actively directed by those accessing services (Byrne, Happell, Welch, & Moxham, 2013a; Noble, Bradley, & Freed, 2007) and indeed in Australia the active involvement of consumers in the education of nurses was identified as a guiding principle in the framework for nursing preparation programs (Mental Health Nurse Education Taskforce, 2008). Preregistration nursing programs are charged with the responsibility of preparing nurses for practice in mental health settings (Happell & Cutcliffe, 2011). It would therefore seem a reasonable expectation that curricula reflect broader policy 1
Exploring the Scope of Consumer Participation in Mental Health Nursing Education: Perspectives From Nurses and Consumers
expectations. The research suggests otherwise (Happell, Byrne, McAllister, et al., 2014). A national survey of preregistration programs found consumer involvement to be variable but generally minimal and frequently confined to classroom teaching despite policy stipulation that consumers should be involved in all aspects, including curriculum design, implementation, assessment, and evaluation (McCann, Moxham, Usher, Crookes, & Farrell, 2009). Restricting involvement to classroom teaching can be tokenistic where consumers have very little capacity to influence teaching content (Hossack & Wall, 2005; Meehan & Glover, 2007; Simons et al., 2007). Determining the optimal level of consumer participation is not straightforward, particularly in the absence of guidelines and recommendations. There are no formalized statements about minimum or maximum hours. The focus has tended to reflect the scope of the role, allowing consumers to go beyond describing their own lived experience and have opportunity to influence the development, content, and evaluation of curricula (Happell & Roper, 2009). The implementation of academic positions for consumers of mental health services has been one strategy to provide meaningful consumer input into the education of nurses (Happell & Roper, 2003; Schneebeli, O’Brien, Lampshire, & Hamer, 2010; Simons et al., 2007) at all levels, including teaching, assessment, curriculum development, and research and evaluation (Happell & Roper, 2009). To date, consumer academic roles have been very few in number and confined to mental health settings. Research findings suggest these positions are effective not only in influencing more positive attitudes to people experiencing significant mental health challenges (Byrne, Happell, Welch, & Moxham, 2013b; Happell, Pinikahana, & Roper, 2003; Schneebeli et al., 2010; Simons et al., 2007), but also in enhancing a holistic approach to practice that is relevant in any healthcare setting (Byrne et al., 2013a). More recently, research has suggested consumer participation can influence more positive attitudes toward mental health nursing as a career (Happell, Byrne, PlataniaPhung, et al., 2014). While Australia has led the world in this development, there are currently only three known substantiative positions in place across two universities, suggesting a committed and systematic approach to consumer participation in education has not as yet been prioritized (Happell, Byrne, McAllister, et al., 2014; McCann et al., 2009). To date, there is a paucity of research examining the impact of consumer participation in the education of health professionals from the perspective of nurses and consumers (Happell, Byrne, McAllister, et al., 2014). For the goal of increased participation, the experiences of consumers undertaking these roles and the perspective of nurse academics must be understood. The aim of this study was to solicit these views and experiences to enhance understanding of the current scope of consumer involvement in the delivery of mental health nursing content. 2
Methods Design A qualitative exploratory design was undertaken for this study. Stebbens (2001) recommends this approach for researchers investigating topics that have not been extensively researched, and therefore limited knowledge is available to guide different methodological approaches. Qualitative exploratory methods are highly suitable as a platform for encouraging participants to contribute their perceptions and opinions to ensure the findings reflect their views. Participants The study included two participant groups. The first comprised nurse academics teaching and/or coordinating mental health nursing within preregistration or post-registration programs in Australian universities. Thirty-four nurse participants represented 27 universities. Some universities had two participants, one representing preregistration and one representing post-registration. The second group included consumers who had a role in the education of nurses undertaking these subjects and programs. A total of 12 consumers participated, including those employed casually (n = 9) and those holding a designated academic position (n = 3). Setting This was an Australian-based study of universities involved in teaching nursing at preregistration and post-registration levels. Currently, 34 universities offer nursing programs accredited for registration as a nurse. Of these universities, 23 also offer postgraduate programs with a specialist focus in mental health nursing. Specialist qualifications are not mandatory for nursing practice in mental health settings; however, they are required at the minimum level of postgraduate diploma as a requirement for recognition by the Australian College of Mental Health Nursing and as a specialist mental health nurse (Deacon & Cleary, 2013). Recruitment Nurses. All Heads of Schools of Nursing in Australia were contacted via email. The text included a summary of the study and a specific request for the name and contact details of the academic staff member best suited to inform this study. An email invitation was sent to the 38 identified staff. The correspondence included a copy of the plain language statement and consent form. Recipients were asked to contact the research assistant if they were interested in contributing to the study. All participants initially made contact. Telephone interviews were arranged with 36; two subsequently were not available at the time of interview. Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.
Exploring the Scope of Consumer Participation in Mental Health Nursing Education: Perspectives From Nurses and Consumers
Consumers. Where nurse participants identified the involvement of consumers in any capacity within the mental health nursing component(s), they were asked for names and contact details of the consumer educators they worked with, with the prior consent of the consumers themselves. An email outlining the study was sent to 20 potential participants. The email included the plain language statement and consent form. Telephone interviews were arranged with the 12 participants who agreed to participate by the research assistant for a time of mutual convenience. Procedure Interviews were conducted by telephone due to vast geographical distances. To ensure an accurate account of interviews, they were audio-recorded with full disclosure to and consent of participants. The interviews were undertaken by two research assistants. Nurse participants were interviewed by a mental health nurse with expertise in research. Consumer participants were interviewed by an experienced researcher who identifies as and has worked extensively from a consumer perspective. Participants were asked to describe their opinions of, and experiences with, consumer involvement in the education. For example, participants were asked to describe the role that consumers play in mental health nursing, particularly relating to the depth and breadth of the role, and to identify the strengths, barriers, challenges, and enablers to this involvement.
subthemes were examined by the team and variations were deliberated until agreement was reached. The depth and breadth of consumer input was one main theme and will be described in this paper. The focus of this paper is the depth and breadth of consumer input, including the subthemes: next to nothing, getting involved, being part of the team, and conflicting attitudes.
Trustworthiness and Credibility The trustworthiness and credibility of the research findings was established through several means. Firstly, using the highly experienced interviewers, nurse participants were interviewed by an experienced mental health nurse researcher and consumer participants were interviewed by an experienced consumer researcher. This relevant expertise enhanced the researcher’s understanding of the issues raised by the participants and use of probing questions to elicit more information. While expertise is highly useful, it also brings the need for bracketing, a conscious and reflective activity, where the researcher acknowledges his/her preconceptions about the research topic. The researchers then set aside their beliefs, attitudes, and judgments to consider the topic with a fresh and new approach (Polit & Beck, 2013) The research team met regularly throughout the study to monitor all aspects. The interview transcripts were independently reviewed by at least two members of the team, and differences were discussed and negotiated until consensus could be reached.
Ethical Issues Ethical clearance was obtained from the university committees representing the research team. All principles of the ethical conduct of research were adhered to. Participants were fully informed that they could choose whether or not to participate, and could withdraw their consent at any time. Participants were assured that the confidentiality of their data would be maintained and names were replaced with participant numbers to prevent them from being identified. Participants’ numbers were assigned as NP (nurse participant) and CP (consumer participant). Data Analysis Data were analyzed thematically using a verbatim transcript of each interview. In the first instance, all transcripts were read and reread to enhance familiarization with the content and the recognition of themes and subthemes. A conceptual map (see Figure 1) was developed based on the identified themes and quotes representing the main ideas were noted. At this point, significant time was taken to comprehend, synthesize, theorize, and recontextualize data. The draft themes and Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.
Findings Depth and Breadth of Consumer Input Next to Nothing. The consumer involvement in the education of nursing students ranged from no face-to-face contact to substantive academic positions within some universities. Nurses. At several universities, there was no face-to-face consumer contact and students’ only experience was through virtual interviews: The only consumer contact they have in the classroom is consumer interviews on videos and things like that. (NP15) In most instances, involvement was brief, usually involving the provision of guest lectures, primarily based on their experiences, for example: We always invite a consumer to talk about recovery and the consumer experience (NP33). They . . . provide that lived experience (NP30). 3
Exploring the Scope of Consumer Participation in Mental Health Nursing Education: Perspectives From Nurses and Consumers
Depth and breadth of consumer involvement
next to nothing
getting involved
no face to face
ad hoc
approximately twice a year
been involved in curriculum development
guest lectures
reviewing and revising policy documents
half an hour speaking time
members of executive advisory committees
being part of the team
I teach a recovery approach in mental health
getting students to really think from a consumer perspective
substantive academic positions
a voice for people who don’t necessarily have a voice
talk to the students
Similarly: We do have somebody that had a mental health issue in their formative years talk to the students about how they overcame their illness and how well they’re doing now, sort of thing. (NP16) In most cases, there was only one consumer guest lecturer; however, one participant described using four consumers to contribute to student learning: We run a full day consumer-led workshop, and there are four consumers who come on that day. I just facilitate the consumers in what they want to teach to students and what they think is important in a nurse. (NP18) One reason for the small amount of consumer participation related to the sheer number of students in the undergraduate programs: We actually use nine clinical schools, so getting a consumer to teach across all that complexity is really difficult. (NP22) 4
conflicting attitudes
it's a good thing and the right thing to do
I want the nurses to have the connection with the grass roots
there is a place for consumers as academics I don’t see any benefit of having a consumer on curriculum planning
look at the nature of people’s stories and their trauma
Figure 1. Conceptual Mapping of Data Analysis
Some staff thought consumers in education, while potentially desirable, were a fantasy and they were not confident this could ever take place: It would be interesting to see if we could ever have consumers as tutors. (NP33) Consumers. Consumer participants also described considerable variation in the degree and scope of their involvement in the education of nurses. For most, the involvement was limited in time and scope: I go in and speak to the nurses approximately twice a year and it’s basically from a consumer point of view from being in a psychiatric hospital. (CP9) Similarly: . . . it’s just been those two lectures that I was approached to do . . . The first one I did . . . I was allocated an hour but the previous speaker went overtime and then invited another speaker, so that was decreased to half an hour speaking time. (CP2) Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.
Exploring the Scope of Consumer Participation in Mental Health Nursing Education: Perspectives From Nurses and Consumers
Involvement tended to be ad hoc and based on established relationships rather than recognized as an important and inherent part of the program: Each time it’s been through somebody that I know who has decided that it would be a good thing to have that consumer bit happening in their course, and they tap you on the shoulder . . . I’ve got to know those people through the consumer consultancy work and the consumer educator role work that I’ve done over the last 12 to 14 years. (CP4) Getting Involved. Nurses. Most universities utilized consumers in teaching roles. However, a small number involved them at a broader level, for example, as members of executive advisory committees: [and] not in a tokenistic way, they were actually part of the panel in terms of decision making. (NP15) Another university included consumers in reviewing and revising policy documents: we’ve just been through [program] accreditation and had quite a lot of consumer input into those documents. (NP32) Although consumer involvement was acknowledged as important, it was not always possible to achieve. The following participant explained that issues of funding, university processes, and the absence of champions to lead the cause impacted on actual change: We have tried to have consumer involvement on our panels . . . the aim has been to have people on the committees, that hasn’t been met. (NP13) Consumers. Most consumers were employed casually and primarily asked to talk about their experiences of the system and ways the care they were provided might be more consumer focused: Basically, how I was treated. The good and bad. What I felt they needed to know . . . Things that would have helped me . . . and just mostly my experiences. Involvement in aspects of education rather than direct teaching was generally limited, for example: I’ve been involved in curriculum development . . . on the odd occasions . . . but that’s only happened three or four times ever. I haven’t been involved in assessments, but we did set the assessment questions for [name of consumer academic]. (CP4) Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.
The opportunity to engage in research was also limited for most: I have been involved in research, mainly on the edges, and I’ve done a little bit of my own, but more that it’s just been a bit ad hoc, here and there. (CP4) Being Part of the Team. Nurses. At the other end of the spectrum, two universities employed consumers in specific academic roles, which meant more time was available for much greater involvement in curriculum design and implementation. One participant provided an example of benefits arising from this increased capacity: They have a look at the whole curriculum for respectful language . . . They have also specifically designed some of the content around ethics in particular, a debate around involuntary treatment, issues of coercive practice and around recovery and recovery oriented practice. (NP2) The benefits of having an academic on staff with a “lived” experience of mental illness not only enriched student learning, but was a potential agent of social change. As one participant stated: Our consumer academic is a voice for people who don’t necessarily have a voice, and it’s very powerful. (NP18) One participant explained their understanding of the difference between guest speaker and consumer academic: The idea is to be getting students to really think from a consumer perspective and think about recovery and the importance of hope rather than having a session where somebody comes in and talks for an hour about how they became unwell and what happened to them in the mental health system. It’s the sort of thing that students learn without you teaching them in a way. It’s subliminal almost. (NP17) Consumers. Three consumer participants were employed in a consumer or lived experience role. One university employed a consumer academic part-time to teach postgraduate mental health nursing students and she described the scope of her work and the subject she teaches and coordinates: it’s an introduction to the consumer movement and where it came from, what it’s concerns are, so we look at different frameworks . . . human rights frameworks and . . . the first module is really looking at relationships . . . an approach to distress . . . and . . . different ways to think about what gets called mental illness . . . and look at the nature of people’s stories and their trauma and that kind of thing. (CP6) 5
Exploring the Scope of Consumer Participation in Mental Health Nursing Education: Perspectives From Nurses and Consumers
This autonomous role is further supported with some limited support from other consumers: [name of subject] gets reviewed with the additional consumer perspective . . . every couple of years, so it’ll be two or three people assisting with that . . . and also guest consumer lectures, as needed in the classroom . . . there isn’t a huge budget for that . . . two hours of face to face teaching time . . . (CP6) One university employed two full-time consumer academics. One had the autonomous role of coordinating and teaching the consumer-led “Recovery for Mental Health Practice” subject: I teach a recovery approach in mental health and it’s very clearly positioned from a lived experience recovery perspective, and it’s underlined consistently both in the fact that I teach it and in the materials that I use . . . it’s quite radical for a university course. (CP5) The other lived experience educator from this university commenced with casual teaching in the Recovery course followed by a full-time contract to teach professional communication skills. Working with another person with lived experience was considered an advantage: . . . there’s my own experiences which give me some ability to input and share. However, also recognising that everybody’s experience is so very different that you can’t ever generalise . . . So I think, having a few different people is really good. (CP9) However, to avoid a singular perspective, the sense remained that maybe this alone was not enough: . . . if there’s just one or two people you could get a bit of a narrow-minded perspective. (CP9) Conflicting Attitudes. Nurses. Some universities had no consumer content at all and some participants expressed their disappointment about this: It’s disheartening because in the literature, everything demonstrates that [consumer involvement] it’s a good thing and the right thing to do. (NP20) However, not all participants agreed with the concept of consumer involvement in mental health student learning as the following participant expressed: I don’t know whether the course would benefit by having a consumer as a consultant, especially if we’ve got experts that have worked in the area, I don’t see any benefit of having a consumer on curriculum planning. (NP4) 6
Another participant expressed interest in consumers only assisting in the teaching: I haven’t been planning on having any input of consumers into what’s in the curriculum other than having them teaching part of it. (NP25) Additionally, a participant explained the potential risk of using mental health consumers to engage nursing students: If we’re trying to attract people into the service and we bring in a whole string of people saying well, the mental health service is completely stuffed and why would anybody do anything and look at the torture they inflict on poor innocent human beings. Then why would some of them put their arm up to work in that area? (NP25) Consumers. Some participants discussed the potential benefits of consumer academic positions and there was wide support for this role. At the same time, there were some concerns raised: of course there is a place for consumers as academics. It shows the staff that someone with a mental illness can be . . . an active staff member, . . . secondly it shows that some consumers are being taken seriously but . . . the problem is that . . . people who get into academic jobs—(I hate this term but) are highly functioning. . . . So symbolically it’s important to have consumer academics but it’s not a realistic proposition for everyone to attain . . . (CP3) For another participant, the concern was much greater and the extent to which consumers were in touch with the “real world” was questioned: . . . I want the nurses to have the connection with the grass roots consumers . . . not the researchers, not the academics, not the people that have professionalised themselves so much as researchers. They’re too far removed from what really happens. They can’t give that true and genuine and meaningful experience. Only the grass roots consumers and carers can do that . . . They [consumer academics] can still have them there, but they’re not the peer; they’re not the lived experienced people I’m talking about that’s required in unis. (CP7) Discussion The findings from the study confirm the ad hoc and variable nature of consumer participation in the education of nurses (Happell, Byrne, McAllister, et al., 2014; McCann et al., 2009). The responses of both nurse and consumer participants suggest that consumers generally played an important but quite minor role, usually limited to delivery of course content, and most commonly involving the telling of their story (Meehan & Glover, 2007). This practice may assist in Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.
Exploring the Scope of Consumer Participation in Mental Health Nursing Education: Perspectives From Nurses and Consumers
promoting a greater understanding of people who experience significant mental health challenges and facilitate a more holistic approach to nursing care (Byrne et al., 2013a, 2013b; Meehan & Glover, 2007; Schneebeli et al., 2010). However, the capacity to strongly influence more positive attitudes and facilitative approaches to enhancing consumer participation within services may well be minimal in light of limited involvement. It has been argued that effective consumer involvement in the education of health professionals requires four components: (a) partnership and commitment, (b) support, (c) scope, and (d) autonomy (Happell & Roper, 2009). It is difficult to see how this can be achieved with a small component of classroom-based involvement. Where consumer participation is contained in this manner, the likely outcome is tokenism (Forrest, Risk, Masters, & Brown, 2000; Meehan & Glover, 2007; Simons et al., 2007). The responses of consumer participants suggest their involvement is frequently of short duration and nominal. Most nurse participants expressed the view that an increased role for consumers would be beneficial in producing a higher quality education program. Two universities had already made substantial achievements in this area. One university employs one, and the other two consumer academics. The incumbents of two positions have quite autonomous roles at least commensurate with nurse academics, convening a course specifically related to the lived experience of mental health challenges, thereby satisfying the four components required for effective consumer participation (Happell & Roper, 2009). An academic position for a consumer of mental health services was originally developed to enhance the capacity for consumer perspective to be embedded in nursing curricula for the education of nurses for practice in the mental health field (Happell & Roper, 2002). The vision for the role extended beyond classroom teaching to encompass curriculum development, assessment, and also to include research, evaluation, and other scholarly activities generally expected of academics. The evidence base in support of the value of these positions is emerging (Byrne et al., 2013b; Happell & Roper, 2003; Happell et al., 2003; Happell, Byrne, McAllister, et al., 2014; Happell, Byrne, Platania-Phung, et al., 2014); however, it is not clear how likely these roles are to expand, particularly given the ever increasing financial constraints in Australian universities (De Brennan, 2006). One finding of particular interest was the consumer academic vs. “ordinary” consumer issue. Although consumer participants expressed some support for consumer academic positions, concerns were raised. One concern was that consumer academics may be too “removed” from the experiences and opinions of “grass roots” consumers and therefore may not appropriately reflect the issues of greatest importance to consumers currently dealing with mental health challenges and accessing mental health services. Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.
The nurse participants in this research did not raise concerns about academic elitism; however, this has been suggested elsewhere (Happell, 2008; Happell & Roper, 2003; Happell et al., 2003). The role of consumer academic was identified as discriminatory and labeling and likely to increase the stigma associated with mental illness (Happell & Roper, 2003; Happell et al., 2003). In another example, consumer academics were identified as “not real consumers,” apparently reflecting the assumption that they were no longer accessing services and therefore no longer in touch with the experiences. These concerns seem to relate at least in part to the issue of representativeness. Consumers in dedicated roles based on their lived experiences have been criticized for not being representative of broader consumer views (Happell & Roper, 2006). This reflects an apparent assumption that consumers with active involvement in participatory roles may not be representative of consumers more broadly, particularly those consumers currently using mental health services (Tobin, Chen, & Leathley, 2002). This argument is frequently advanced despite limited research to verify its degree of accuracy (Crawford & Rutter, 2004; Forrest et al., 2000; Happell & Roper, 2006). While there needs to be a clear conceptualization of the consumer academic role involving multiple stakeholders from the consumer movement, it is crucial that this is undertaken with a cohesive and cooperative approach. Internal dissention was recently identified as an issue in an in-depth qualitative study of consumers employed in various roles within the mental health system (Byrne, 2014) and was referred to as “infighting.” Concerns were raised that the movement was in danger of becoming fractured due to ideological and philosophical differences that led to individuals questioning the credibility and suitability of colleagues, rather than working together to create a workforce that reflects diversity and values differences. Furthermore, there is no reason to suggest the consumer academic should occur instead of guest lecturers; ideally, other consumer roles would be utilized to complement and enrich the consumer academic perspective. Limitations As a qualitative exploratory study, the views expressed in this research are theirs alone and not necessarily reflective of a broader constituency. While the number of nurse participants recruited was very pleasing, we were only able to interview a much smaller number of consumer participants, further limiting the generalizability of these findings. Conclusions Consumer participation in the education of nurses in Australia varies considerably in breadth and scope. Most roles have 7
Exploring the Scope of Consumer Participation in Mental Health Nursing Education: Perspectives From Nurses and Consumers
limited involvement, suggesting the goals of increased consumer participation in the education of health professionals and within the mental health services are not likely to be effectively achieved. Consumer academic roles have the capacity to be more influential, providing the organizational environment is supportive and roles are able to develop autonomously. Some concern was raised that consumer academics may be removed from the issues facing consumers who are currently using mental health services and therefore these roles may not be the best way to approach educational roles for consumers. The prospect that infighting may weaken the consumer movement is disturbing, conceptualizing the role of consumer academics in relation to the broader consumer movement may contribute to clarity of understanding and a stronger sense of cohesion. Increasing opportunities for meaningful participation in the education of nurses will require significant capacity development in the consumer educator and academic workforce. Education and training is imperative to ensure consumers are adequately prepared for these roles. Effective capacity building must also involve the provision of appropriate resources and support mechanisms to enhance the ability of consumer educators and academics to contribute confidently and competently to the education of nurses. An understanding of the scope of current roles is an important starting point to exploring these issues.
Recommendations for Practice and Research To date, the research regarding consumer involvement in the education of nurses is limited. The findings presented in this paper suggest the need for further research and discussion to consider the concept of representativeness and its potential influence in the development of a consumer education workforce. Research should also be undertaken to consider the education and training, and support and resource needs of consumers seeking the opportunity for an education or academic role in the future. Demonstrating relationships between consumer involvement in education and improved outcomes for students and for mental health care delivery should be a crucial component of any research agenda. Nurse academics are well positioned to play an important part in promoting and facilitating the development of positions for consumers to contribute to the education of nurses.
Acknowledgments The authors extend their thanks to the Health Collaborative Research Network, CQUniversity for providing the funding to allow this work to be completed. The authors also thank the participants who took the time to participate in these interviews and share their thoughts and opinions. 8
References Australian Government. (2012). The Roadmap for National Mental Health Reform 2012–2022. Canberra: Author. Retrieved from http://www.coag.gov.au/sites/default/files/ The%20Roadmap%20for%20National%20Mental%20 Health%20Reform%202012-2022.pdf.pdf, http://www.coag.gov.au/node/482 Byrne, L. (2014). A grounded theory study of lived experience mental health practitioners within the wider workforce (PhD thesis). Central Queensland University, Rockhampton, Australia. Byrne, L., Happell, B., Welch, A., & Moxham, L. (2013a). Reflecting on holistic nursing: The contribution of an academic with lived experience of mental health service use. Issues in Mental Health Nursing, 34(4), 265–272. doi:10.3109/01612840.2012.745038 Byrne, L., Happell, B., Welch, T., & Moxham, L. J. (2013b). “Things you can’t learn from books”: Teaching recovery from a lived experience perspective. International Journal of Mental Health Nursing, 22(3), 195–204. doi:10.1111/j.1447-0349.2012.00875.x Commonwealth of Australia. (2010). National standards for mental health services. Canberra: Author. Crawford, M. J., & Rutter, D. (2004). Are the views of members of mental health user groups representative of those of “ordinary” patients? A cross-sectional survey of service users and providers. Journal of Mental Health, 13, 561. De Brennan, S. (2006). Out by more than one degree: Politics and organizational change within an Australian University. Educational Research for Policy and Practice, 5(2), 73– 100. Deacon, M., & Cleary, M. (2013). The reality of teamwork in an acute mental health ward. Perspectives in Psychiatric Care, 49(1), 50–57. doi:10.1111/j.1744-6163.2012.00340.x Forrest, S., Risk, I., Masters, H., & Brown, N. (2000). Mental health service user involvement in nurse education: Exploring the issues. Journal of Psychiatric and Mental Health Nursing, 7, 51–57. doi:10.1046/j.1365-2850.2000.00262.x Happell, B. (2008). Polarisation and political correctness: Subtle barriers to consumer participation in mental health services. Advances in Mental Health, 7(3), 150–156. Happell, B., & Cutcliffe, J. R. (2011). A broken promise? Exploring the lack of evidence for the benefits of comprehensive nursing education. International Journal of Mental Health Nursing, 20(5), 328–336. doi:10.1111/j.1447-0349.2011.00745.x Happell, B., & Roper, C. (2002). Promoting consumer participation through the implementation of a consumer academic position. Nurse Education In Practice, 2, 73–79. doi:10.1054/nepr.2002.0068 Happell, B., & Roper, C. (2003). The role of a mental health consumer in the education of postgraduate psychiatric nursing students: The students’ evaluation. Journal of Psychiatric and Mental Health Nursing, 10, 343–350. doi:10.1046/j.1365-2850.2003.00599.x
Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.
Exploring the Scope of Consumer Participation in Mental Health Nursing Education: Perspectives From Nurses and Consumers
Happell, B., & Roper, C. (2006). The myth of representation: The case for consumer leadership, AeJAMH (Australian e-Journal for the Advancement of Mental Health). Australia: Auseinet (Australian Network for Promotion, Prevention and Early Intervention for Mental Health). Happell, B., & Roper, C. (2009). Promoting genuine consumer participation in mental health education: A consumer academic role. Nurse Education Today, 29(6), 575–579. doi: 10.1016/j.nedt.2008.01.004 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. doi:10.1053/apnu.2003.00008 Happell, B., Byrne, L., McAllister, M., Lampshire, D., Roper, C., Gaskin, C. J., & Hamer, H. (2014). Consumer involvement in the tertiary-level education of mental health professionals: A systematic review. International Journal of Mental Health Nursing, 23(1), 3–16. doi:10.1111/inm.12021 Happell, B., Byrne, L., Platania-Phung, C., Harris, S., Bradshaw, J., & Davies, J. (2014). Lived-experience participation in nurse education: Reducing stigma and enhancing popularity. International Journal of Mental Health Nursing, 23, 427–434. Hossack, A., & Wall, G. (2005). Service users: Undervalued and underused? Psychologist, 18(3), 134–136. Jones, T. L. (2010). A holistic framework for nursing time: Implications for theory, practice, and research. Nursing Forum, 45(3), 185–196. doi:10.1111/j.1744-6198.2010.00180.x 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. doi:10.1177/1744987109347041 Meehan, T., & Glover, H. (2007). Telling our story: Consumer perceptions of their role in mental health education. Psychiatric Rehabilitation Journal, 31, 152–154. doi:10.2975/31.2.2007.152.154
Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.
Mental Health Nurse Education Taskforce. (2008). Final report: Mental health in pre-registration nursing courses. Melbourne: Final Report: Mental Health in Pre-registration Nursing Courses. Noble, H., Bradley, R., & Freed, N. (2007). Nursing philosophy. A patient survey of nursing practice philosophy in 2001 and 2005. British Journal of Nursing, 16(14), 892–895. Polit, D. F., & Beck, C. T. (2013). Essentials of nursing research: Appraising evidence for nursing practice. Philadelphia: Lippincott Williams & Wilkins. Povlsen, L., & Borup, I. K. (2011). Holism in nursing and health promotion: Distinct or related perspectives?—A literature review. Scandinavian Journal of Caring Sciences, 25(4), 798–805. doi: 10.1111/j.1471-6712.2011.00885.x Schneebeli, C., O’Brien, A., Lampshire, D., & Hamer, H. P. (2010). Service user involvement in undergraduate mental health nursing in New Zealand. International Journal of Mental Health Nursing, 19, 30–35. doi:10.1111/j.1447-0349.2009.00642.x Sharrock, J., & Happell, B. (2006). Competence in providing mental health care: A grounded theory analysis of nurses’ experiences. Australian Journal of Advanced Nursing, 24(2), 9–15. Simons, L., Tee, S., Lathlean, J., Burgess, A., Herbert, L., & Gibson, C. (2007). A socially inclusive approach to user participation in higher education. Journal of Advanced Nursing, 58, 246–255. doi:10.1111/j.1365-2648.2007.04216.x Stebbens, R. (2001). Exploratory research in the social sciences: Qualitative research methods (Vol. 48). London: Sage. Stenhouse, R. C. (2011). “They all said you could come and speak to us”: Patients’ expectations and experiences of help on an acute psychiatric inpatient ward. Journal of Psychiatric & Mental Health Nursing, 18(1), 74–80. doi:10.1111/j.1365-2850.2010.01645.x Tobin, M., Chen, L., & Leathley, C. (2002). Consumer participation in mental health services: Who wants it and why? Australian Health Review, 25(3), 91–100.
9
