- Email: [email protected]
Changing attitudes: the role of a consumer academic in the education of postgraduate psychiatric nursing students
Changing Attitudes: The Role of a Consumer Academic in the Education of Postgraduate Psychiatric Nursing Students Brenda Happell, Jaya Pinikahana, and Cath Roper Consumer participation in health care is increasingly becoming an expectation within mental health services. Consumer involvement in the education of mental health professionals, including nurses is considered crucial to achieving this aim. This article describes the impact of a mental health consumer academic on the attitudes of postgraduate psychiatric nursing students towards consumer participation. A questionnaire was administered to students before (n ⴝ 25) and following (n ⴝ 19) exposure to the teaching of the consumer academic. Comparison of results suggests that support for consumer participation increases after exposure to the consumer academic reinforcing the value of mental health consumers in psychiatric nursing education. © 2003 Elsevier Inc. All rights reserved.
A
CHANGE IN THE focus of mental health policy in Australia over the last decade, has been accompanied by an increasing expectation that consumers of mental health services be provided the opportunity to become more actively involved in the design, delivery, and evaluation of these services. Consumer participation was officially recognized through the Commonwealth National Mental Health Plan (Australian Health Ministers, 1992). However the Report of the National Inquiry into the Rights of People with a Mental Illness (Human Rights and Equal Opportunity Commission, 1993) emphasized the extent of the discrimination against people with mental illness and provided the climate for the issue of consumer participation to be debated. The importance of consumers becoming active participants in all facets of their mental health care was enshrined in the National Standards for Mental Health (Commonwealth of Australia, 1997), as reflected by the statement that: “Consumers and Carers are involved in the planning, implementation and evaluation of mental health services” (p. 10). These policy changes acknowledged increased consumer participation in health as a right. However, the involvement of consumers at a number of levels has been found to improve the standard of
health care in the general health system (Draper & Hill, 1995; Draper & Silburn, 1999). More specific to mental health the enhancement of consumer involvement has impacted positively on service delivery at both individual and organisational levels (Kent & Read, 1998; Lefley, 1990). Perhaps most importantly it facilitates the responsiveness of services to consumer needs (Mowbray et al, 1996) and to the development of the therapeutic relationship between consumer and service provider, which further enhances the empowerment of consumers (Segal et al, 1993). Furthermore, Fox and Hilton (1994) assert that “by developing the role of the consumer as provider, the programs are stretching conventional roles, relationships, and
From the Centre for Psychiatric Nursing Research and Practice, School of Postgraduate Nursing, University of Melbourne, Carlton, Victoria, Australia. Address reprint requests to Brenda Happell, RN, PhD, Associate Professor, Centre for Psychiatric Nursing Research and Practice, School of Postgraduate Nursing. University of Melbourne, Level 1, 723 Swanson St, Carlton, Victoria, Australia 3010. E-mail: b.happell@ nursing.unimelb.edu.au 䊚 2003 Elsevier Inc. All rights reserved. 0883-9417/03/1702-0003$30.00/0 doi:10.1053/apnu.2003.00008
Archives of Psychiatric Nursing, Vol. XVII, No. 2 (April), 2003: pp 67-76
67
68
boundaries in the mental health system, as well as combating the roots of stigma.” Although a stated commitment to greater consumer participation in health care is plausible, there is no automatic guarantee that the desired goal will become a reality. The attitudes of health professionals for example, have been regarded as a significant barrier to the realisation of consumer participation. This is particularly evident in specific health care areas such as aged care (Department of Human Services Victoria, 1994) the care of people from ethnic minorities (Bhatti-Sinclair, 1999) and people with disabilities (Meehan & Hanson, 1999). Although it is clear that this situation affects the opportunity for all consumers of health services to become actively involved in health care issues, by virtue of their specific health care needs the views of consumers of mental health services are more easily disregarded on the basis of their mental state (Porter, 1996). Consumers frequently report the discriminatory attitudes of mental health professionals to be more debilitating than the mental illness itself (Caldwell & Jorn, 2000; Meagher, 1995; Mirabi et al, 1985). These attitudes were identified as a major barrier to the reform of mental health delivery in the evaluation of the First National Mental Health Strategy (Commonwealth of Australia, 1998). The introduction of strategies to positively influence these attitudes has subsequently been advocated. Although the available research is helpful in identifying the existence of negative attitudes and pessimistic views among mental health professionals toward people diagnosed with a mental illness, it does little to address the question of why or how these attitudes are developed. For example, are these characteristics learned or developed by professionals during the education process or as a result of socialization into the workplace and professional culture? Alternatively, are they characteristic of those people who chose to become mental health professionals? The relationship between the attitudes of mental health professionals and the education and training they receive was the focus of the Commonwealth funded Education and Training Partnerships in Mental Health Project (Deakin University, 1999). This project included the conduct of a national audit of current undergraduate and postgraduate education for mental health professionals in Aus-
HAPPELL, PINIKAHANA, AND ROPER
tralia. The results suggested that consumer participation was at best minimal bur more commonly nonexistent. Consumer involvement was sometimes found through the provision of occasional guest lectures, which usually involved a description of their own individual experience of their illness and of the mental health system. Some isolated examples of consumer involvement in course advisory committees were found at postgraduate level. Clearly, the need for greater consumer involvement in the education of mental health professionals was identified. The education of mental health professionals needs to provide the basis from which a more consumer-focused approach can be developed. This could not occur in the absence of a high level of consumer involvement in professional education. A consumer academic position was established at the Centre for Psychiatric Nursing Research and Practice (CPNRP) within the School of Postgraduate Nursing at the University of Melbourne. This position was funded by the Commonwealth Department of Health and Aged Care, and developed from a partnership between the CPNRP and the Melbourne Consumer Consultants Group. From the time of her appointment, the consumer academic has become an integral member of the team participating in all aspects of the CPNRP’s activities including research projects and the education and training of psychiatric nurses at postgraduate level. Given the importance attributed to the attitude of mental health professionals and the absence of research measuring the outcomes of a position of this kind, a thorough evaluation of the impact of the consumer academic’s teaching role on the attitudes of psychiatric nursing students to consumer participation was essential. METHODS
Instrument An extensive search of the literature did not uncover an instrument suitable for the purposes of this study. The authors subsequently developed the Mental Health Consumer Participation Questionnaire (MHCPQ), based on the Consumer Participation Questionnaire (CPQ) developed by Kent and Read (1998). The CPQ had been specifically developed to examine consumer participation in service delivery and required modification to be suitable for educational research.
CHANGING ATTITUDES
The CPQ was originally used to survey the opinions and perceptions of mental health professionals in a New Zealand Crown Health Enterprise (CHE). The MHCPQ consists of 24 items based on a five point Likert scale, with responses ranging from strongly agree to strongly disagree. Three additional questions require a yes/no response and seek further comments. The questions were divided into six subsets relating to consumer participation in health care, these are: management, treatments, planning, service delivery, the consumer academic position and the consumer perspective. These questions enabled the scope for a broad understanding of the students’ views regarding consumer participation in health care. A pilot of the questionnaire was conducted with 10 registered nurses who had recently completed a postgraduate course in psychiatric nursing. The responses of the pilot participants confirm the validity and reliability of this instrument. Sample The questionnaire was first administered to postgraduate psychiatric nursing students of the School of Postgraduate Nursing, the University of Melbourne on their first day of class in February 2001 (pretest). A total of 25 questionnaires were distributed and all were returned securing a return rate of 100%. At the time of administration the students had not been in contact with the consumer academic or given any information about this position. The same questionnaire was readministered to these students on their last day of class in October 2001 (posttest). Twenty questionnaires were distributed and 19 completed questionnaires were returned (one student declined to participate), securing a return rate of 95%. Data Analysis Data analysis was conducted using the Statistical Package for Social Sciences (SPSS; Chicago, IL). The data were analyzed by means of descriptive statistics. A content analysis approach was used to analyze the qualitative data derived from the open-ended questions. The major themes were identified from the data, coded and entered into the SPSS database. A Chi-square test was applied to measure whether there is statistically significant difference in attitudes to consumer participation between pre and post intervention scores.
69
FINDINGS
This section presents the findings of both preand posttest stages. These results provide valuable information about students’ attitudes to consumer participation at the beginning of their formal professional education in psychiatric nursing and subsequent changes following their exposure to a “consumer academic.” Characteristics of Respondents Demographic data collected during the pretest stage indicates that 68% of respondents (n ⫽ 17) were women and 32 (n ⫽ 8) were men. The mean age of respondents was 33.5 years. The average length of nursing experience was 11 years. In terms of their preregistration nursing education, 32% (n ⫽ 8) had hospital-based certificates and 60% (n ⫽ 15) hold a tertiary degree. Two (2) had not disclosed their qualifications. Forty percent (n ⫽ 10) held postregistration qualifications, 6 respondents hold a postregistration Bachelor of Nursing degree, 3 have postgraduate certificates, and 1 a postgraduate diploma. THE MENTAL HEALTH CONSUMER PARTICIPATION QUESTIONNAIRE RESULTS
Management Table 1 presents a detailed analysis of student responses to these questions at pre- and posttest stage. All students supported the statement that: “mental health consumer involvement and participation should be fully supported by all mental health services” with 100% reporting agreement at both stages of data collection. At pretest only 20% agreed with the statement that consumers should be involved in the process for the hiring of all new staff of mental health services but this increased to 68% at posttest (p ⬍ .001). Differences in opinions as to whether people with a mental illness can handle too much responsibility were also detected, with a higher level of disagreement at posttest. A small increase was noted in the posttest responses in support for the inclusion of at least one consumer member on all mental health service committees (72% in the presurvey and 89% postsurvey). A significant change was noted regarding the statement that mental health services work as well as they can and we should not use valuable resources trying to change them. Disagreement in-
70
HAPPELL, PINIKAHANA, AND ROPER
Table 1. Responses to the Questions on Consumer Involvement in Management in Mental Health Services Agreement
Statement
Mental health consumer involvement and participation should be fully supported by all mental health services Consumers should be involved in the process for the hiring of all new staff of mental health services People will mental illness can not handle too much responsibility All mental health service committees should have at least one consumer member Mental health services work as well as they can and we should not use valuable resources trying to change them Consumers should be the ones to decide what a quality mental health service is Consumers use mental health services because they need help and therefore they should not be burdened with how these services are being provided. Mental health services would not change significantly if consumers were employed by the services Increased consumer involvement in mental health services would probably increase the stress levels for service providers Consumers do not understand the language and complexities of mental health services, which makes it difficult for them to have meaningful input
Disagreement
Percent Frequency Presurvey (N ⫽ 25)
Percent Frequency Postsurvey (N ⫽ 19)
Percent Frequency Presurvey
Percent Frequency Postsurvey
25 (100)
18 (94)
0
0
5 (20)
13 (68)
15 (60)
3 (12)
1 (5)
17 (68)
15 (60) NS
18 (72)
17 (89)
2 (8)
0
5 (20)
1 (5)
9 (36)
11 (44)
15 (78)
5 (20)
1 (5) NS
1 (4)
1 (5)
19 (76)
16 (84) NS
2 (8)
2 (10)
17 (68)
14 (73) NS
5 (20)
6 (31)
12 (48)
10 (52) NS
5 (20)
3 (15)
19 (76)
13 (52) NS
2 (10)*
18 (94)*
Abbreviation: NS, nonsignificant. NOTE. The comparison was made between pre and post scores by chi-squared test. *p ⬍ .001
creased from 36% at pretest to 94% at posttest (p ⬍ .001). Seventy eight percent of the students at post-test as compared to 44% at pretest agreed that consumers should be the ones to decide what a quality mental health service (p ⬍ .001). More students at posttest stage disagreed with the notion that consumers use mental health services because they need help and therefore they should not be burdened with how these services are being provided (76% pretest, 84% posttest). A slight increase in
disagreement of the view that mental health services would not change significantly if consumers were employed by the services was also observed at posttest. More respondents at posttest disagreed with the idea that increased consumer involvement in mental health services would be likely to increase the stress levels for service providers. However less respondents disagreed with the statement that “Consumers do not understand the language and complexities of mental health services, which
CHANGING ATTITUDES
71
Table 2. Responses to the Questions on Consumer Involvement in Treatment Agreement
Statement
Consumers should be involved in identifying the goals for their treatment Consumers should always be involved in the evaluation and diagnosis of their presenting problems Consumers should have the opportunity for genuine input into the planning of their own treatment Consumers should be encouraged to contribute to the writing of their own notes and records Consumers are already given sufficient opportunity to participate in the care they receive The medications used in mental health are very complex and consumers should only have limited input into deciding the most appropriate medications to be used Medications should be explained in detail to consumers in ways that they can understand so they are fully informed and can make choices
Disagreement
Percent Frequency Presurvey (N ⫽ 25)
Percent Frequency Postsurvey (N ⫽ 19)
Percent Frequency Presurvey
Percent Frequency Postsurvey
25 (100)
18 (94)
0
0
21 (84)
17 (89)
1 (4)
0
21 (84)
18 (94)
0
0
7 (28)
6 (31)
13 (52)
9 (47) NS
6 (24)
2 (10)
11 (44)
14 (73)*
7 (28)
0
14 (56)
14 (73)*
23 (92)
18 (94)
1 (4)
0
Abbreviation: NS, nonsignificant. NOTE. The comparison was made between pre and post scores by chi-squared test. *p ⬍ .001
makes it difficult for them to have meaningful input” at posttest (76% pretest, 52% posttest). Treatments Table 2 presents a detailed analysis of student responses to these questions at pre- and posttest. All respondents at pretest agreed that consumers should be actively involved in identifying the goals for their treatment but in the postsurvey this was reduced to 94%, with one student taking a neutral stance. A slight increase in agreement to the statement that consumers should always be involved in the evaluation and diagnosis of their presenting problems was noted (84% pretest, 89% posttest). A
larger increase was recorded for the view that consumers should have the opportunity for genuine input into the planning of their own treatment (84% pretest, 94% posttest). The majority of respondents did not consider it appropriate for consumers to be encouraged to contribute to the writing of their own notes and records with only a small increase in approval for this notion in the posttest stage. However, a significant difference was noted in students’ views of whether consumers are already given sufficient opportunity to participate in the care they receive (44% disagreed pretest as compared with 73% posttest) (p ⬍ .001). All students at the posttest stage disagreed with the idea that the medications
72
HAPPELL, PINIKAHANA, AND ROPER
Table 3. Responses to the Questions on Consumer Involvement in Mental Health Care Planning Agreement
Statement
Consumer input should be central in the planning of mental health services Consumers should be involved in the planning and delivery of all staff education and professional development sessions Mental health services would be likely to improve if consumers were involved in the planning and delivery of those services Consumers do not have enough self-confidence to become involved in the planning and delivery of mental health services
Disagreement
Percent Frequency Presurvey (N ⫽ 25)
Percent Frequency Postsurvey (N ⫽ 19)
Percent Frequency Presurvey
Percent Frequency Postsurvey
22 (88)
19 (100)
0
0
8 (32)
15 (78)
13 (52)
18 (72)
16 (84)
3 (12)
3 (12)
0
18 (72)
3 (15) NS
2 (10)*
14 (73) NS
Abbreviation: NS, nonsignificant. NOTE. The comparison between pre and post scores was made by chi-squared test. *p ⬍ .001
used in mental health are so complex that consumers should only have limited input into deciding the most appropriate medications to be used, as compared with 28% disagreement in the pretest stage (p ⬍ .001). No significant change was observed in relation to the statement that medications should be explained in detail to consumers in ways that they can understand so they are fully informed and can make choices. A high level of support for this strategy was observed at both stages. Planning Table 3 presents a detailed analysis of student responses to these questions. The concept of consumer involvement in the planning of mental health services was well supported in both pre- and postsurveys (Increased from 88% pretest to 100% posttest). A significant difference was found in responses to the statement that mental health services would be likely to improve if consumers were involved in the planning and delivery of those services (32% pretest, 78% posttest) (p ⬍ .001). The majority of respondents at both stages of the research considered that consumers have enough self-confidence to become involved in the planning and delivery of mental health services.
Consumer Academic Position Table 4 presents a detailed analysis of student responses to these questions. At the pretest stage a slight majority of respondents (56%) endorsed the concept of consumer academic involvement in psychiatric nursing education by agreeing that a consumer academic should be a member of staff in all psychiatric nursing courses. This endorsement was further increased to 86% in the postsurvey results. However, the disagreement remains the same both in pre- and postsurvey results (16% and 15%). The approval of the idea that “an experienced psychiatric nursing academic can present a good understanding of the consumer perspective,” was increased by 7% (40% pretest, 47% posttest). There was a 17% increase in approval for the statement: “I need to be taught by a consumer academic to more fully understand how a consumer might experience the mental health system.” It is interesting to note that this view appears to contrast markedly with the views in the previous question. Service Delivery In response to the question, “Do you think consumers should be active in the delivery of services?”,
CHANGING ATTITUDES
73
Table 4. Response to the Consumer Academic Position Agreement
Statement
A consumer academic should be a member of staff in all psychiatric courses An experienced psychiatric nursing academic can present a good understanding of the consumer perspective I need to be taught by a consumer academic to more fully understand how a consumer might experience the mental health system
Disagreement
Percent Frequency Presurvey (N ⫽ 25)
Percent Frequency Postsurvey (N ⫽ 19)
Percent Frequency Presurvey
Percent Frequency Postsurvey
14 (56)
16 (84)
4 (16)
3 (15) NS
10 (40)
9 (47)
6 (24)
8 (42) NS
18 (72)
17 (89)
3 (12)
0 NS
Abbreviation: NS, nonsignificant.
76% responded ‘yes’ and 24% ‘no’ in the presurvey. This approval was increased to 94.7% in the postsurvey. This view is illustrated by the additional comments made by respondents at the poststage, for example: “Who else understands them better than they do?”
and “Be involved in planning, staff recruitment and staff education”
involvement in psychiatric undergraduate and postgraduate planning meetings. In response to the question, “Please list three factors you consider to be most important in developing collaborative relationship between health care providers and consumers,” the following factors were reported: “Being open, listening, nonjudgmental to views, being upfront with roles, expectations, respecting common goals, mutual respect, and friendly atmosphere” “Respect, open-truthful interactions, and honesty”
There was only one negative comment made as follows:
“Honesty, advocacy, and flexibility.”
DISCUSSION “They may abuse the system.”
In response to the question, “Please describe briefly what consumer participation in mental health care means to you,” the perceptions were expressed in the following terms: “Help to teach me to use another perspective other than from a professional level” “Consumer participation means allowing the users/clients of the service to have valuable input into better practice standards and delivery of care” “Being forced to reflect on my practice at all times.”
Some students suggested that consumer involvement should be expanded to include consumer
The study was designed to examine the effect of exposure to a consumer academic on postgraduate psychiatric nursing students’ views on consumer participation in mental health service delivery in general and a consumer academic involvement in psychiatric nursing academia in particular. The results from the postsurvey indicate that students’ approval rating of consumer participation has increased in all areas surveyed including mental health service management, treatment, planning, and service delivery following exposure to a consumer academic. It is particularly significant that more respondents in the postsurvey stated that consumers should always be involved in the evaluation and
74
diagnosis of their presenting problems which suggests the changing paradigm of professional hegemony in relation to the evaluation and diagnosis of health problems. Consumer empowerment is a vital component of mental health services where clients are provided with a greater accessibility to involve in treatment strategies. Similarly more students in the postsurvey believed very strongly that consumers should have the opportunity for genuine input into the planning of their own treatment. The finding that medications should be explained in detail to consumers in ways that they can understand and make choices reflecting the emerging view regarding medical treatment. The integration of consumers into the planning process in mental health services is crucial to the success of service improvement and reflects current government policy in Australia (Commonwealth of Australia, 1997; 1998). The findings that consumer input should be central in the planning of mental health services and mental health services would be likely to improve if consumers were involved in the planning and delivery of those services support the view that consumers should be involved in all aspects of service delivery including service planning. The fact that the majority in both phases of study rejected the view that mental health services would not change significantly if consumers were employed by the services indicates positive attitudes towards consumer participation in mental health service management. The higher endorsement of consumer competency in understanding the language and complexities of mental health services reflects the changing nature of professional views of consumer competency. A greater support indicated for the involvement of consumers in the process for the hiring of all new staff of mental health services in the postsurvey suggests the change in perception after the exposure to a consumer academic. The majority of students (68%) consider that consumer participation should extend to staff recruitment. Diverse views were expressed to the idea that consumers use mental health services because they need help and therefore they should not be burdened with how these services are being provided. This suggests that for some students the argument in health service delivery, which distinguishes patient from the service provider keeping the client as
HAPPELL, PINIKAHANA, AND ROPER
a passive recipient of health services, still remains at least to some degree. This is further suggested through the finding that the majority of respondents still consider that consumers should not be encouraged to contribute to the writing of their own notes and records. These two views combined reflect, as Kent and Read (1998) suggest, an attitude of paternalism. On a more positive note, the majority of respondents at post-test felt that consumers should be involved in the planning and delivery of staff education and professional development sessions (p ⫽ .001). The key to understanding their changing perception in the postsurvey with consumer involvement in staff education and training may lie in the first hand knowledge they acquired through the consumer academic’s involvement in teaching An increase in support for the involvement of a consumer academic in psychiatric nursing education was also observed. This finding is particularly significant in terms of accepting new teaching approaches not only to psychiatric nursing but to the mental health professions more broadly. Furthermore, it has potential to destigmatize psychiatric illness within nursing (and other mental health professional) education programs. It was interesting to note that an increased number of students supported the view that an experienced psychiatric nursing academic can present a good understanding of consumer perspectives at posttest stage. This appears to be in contradiction with the almost unanimous agreement with the idea that they need to be taught by a consumer academic to more fully understand how a consumer might experience the mental health system. It is possible that while the students’ recognize the importance of a consumer academic’s role they believe this can be supported by an experienced nurse academic who promotes a positive consumer perspective. The findings of this preliminary study have implications for further research and education. Further longitudinal research with a large cohort of students could be undertaken to examine the longer impact of this project on the practice of these individual nurses. LIMITATIONS
The present study has several limitations that must be acknowledged. The major weakness of this study is the small sample size and the conve-
CHANGING ATTITUDES
nience method of sampling. The study was conducted in one university in Victoria, which makes it difficult to determine the extent to which the results reflect that course specifically rather than exposure to the consumer academic. The initial design of the project sought a control group from another Victorian university. Unfortunately this aim could not be achieved. Only one other Victorian university conducts a course with a face to face as opposed to a distance learning approach. Although attempts were made to engage this university, their involvement in the study did not eventuate. CONCLUSION
In summary, this article reports a pre- and postsurvey data on attitudes toward consumer participation in response to exposure to a consumer academic in a postgraduate psychiatric nursing course. The findings show the attitudinal status of respondents before and after the consumer academic involvement and particularly the attitudinal changes in the postsurvey findings. The findings of both phases of the survey show positive attitudes among postgraduate nursing students towards consumer participation and consumer academic involvement at some levels of service provision, however limitations to consumer participation remain particularly with regard to consumer contribution to the writing of their own notes and records. The research was set within a psychiatric nursing education framework that rhetorically promotes consumer involvement in planning, service delivery, and training. It is noted that the study was small in scale and had some methodological limitations. The concept of consumer involvement is complex in some areas of health care including psychiatric nursing, therefore further research with a large cohort of students is needed. Nevertheless, in a more encompassing sense, this research with its admitted limitations suggests that consumer involvement in education is an affective strategy in influencing the attitudes of nurses to consumer participation in mental health care. ACKNOWLEDGMENT The authors acknowledge and thank the Commonwealth Department of Health and Aged Care, for providing the funding to make the dream of this position become a reality. They also express gratitude for the involvement and support of Ross Findlay and Merinda Epstein, Melbourne Consumer Consult-
75
ants’ Group, in inspiring the project and developing the initial funding application; To Bernie McCormack and Margaret Yii the consumer representatives, and Greg Miller the academic representative on the project team, your contributions have made this work. Finally to the consumer participants in the Education and Training Partnerships in Mental Health who changed the way of thinking of at least one mental health academic forever.
REFERENCES Australian Health Ministers (1992). The National Mental Health Plan. Canberra: Australian Government Printers. Bhatti-Sinclair, K. (1999). Evaluating social work and medical practice with black and ethnic minority groups using the clinical audit model. British Journal of Social Work, 29, 303-320. Caldwell, T.M., & Jorm, A.F. (2000). Mental health nurses’ beliefs about interventions for schizophrenia and depression: a comparison with psychiatrists and the public. Australian & New Zealand Journal of Psychiatry, 34, 602-11. Commonwealth of Australia (1997). National Standards for Mental Health. Canberra: Australian Government Printer. Commonwealth of Australia (1998). Evaluation of the National Mental Health Strategy. Canberra: Australian Government Publishing Service. Deakin University (1999). Human Services Education and Training Partnerships in Mental Health. Melbourne: Deakin University. Department of Human Services Victoria (1999). A guide to participation by older Victorians. Melbourne: Victorian Government Publishing Service. Draper, M., & Hill, S. (1995). The role of patient satisfaction surveys in a national approach to hospital quality management. Canberra: Australian Government Publishing Service. Draper, M., & Silburn, K. (1999). Improving hospital care by involving consumers: report on a national program of workshops on consumer participation. Canberra: Australian Government Printing Service. Fox, L., & Hilton, D. (1994). Response to “consumers as service providers: The promise and challenge”. Community Mental Health Journal, 30 627-629. Human Rights and Equal Opportunity Commission (1993). Report of the National Inquiry into the Human Rights of People with Mental Illness. Canberra: Australian Government Printer. Kent, H., & Read, J. (1998). Measuring consumer participation in mental health services: Are attitudes related to professional orientation? International Journal of Social Psychiatry, 44, 295-31 Lefley, H.P. (1990). Culture and chronic mental illness. Hospital and Community Psychiatry, 41, 277-286 Meagher, J. (1995). Partnership or Pretence-A handbook of empowerment and self-advocacy for consumers/users and survivors of Psychiatric Services. Strawberry Hills, Australia: Psychiatric Rehabilitation Association. Meehan, E., & Hanson, K. (1999). Three-D: a preliminary report on sexual and occupational health of NESB
76
women with disabilities. Fitzroy: Women in Industry and Community Health Inc. Mirabi, M., Weinman, M.L., Magnetti, S.M., & Keppler, K.N. (1985). Professional attitudes toward the chronic mentally ill. Hospital and Community Psychiatry, 36, 404-5. Mowbray, C.T., Moxley, D.P., Thrasher, S., Bybee, D., McCrohan, N., Harris, S., & Clover, G. (1996). Consumers as community support providers: Issues created by role
HAPPELL, PINIKAHANA, AND ROPER
innovation. Community Mental Health Journal, 32, 47-67 Porter, R (1996). A social history of madness: stories of the insane. London: Phoenix Giant. Segal, S.P., Silverman, C., Temkin, T. (1993). Characteristics and service use of long term members of self help agencies for mental health clients. Psychiatric Services, 46, 269-274
A
CHANGE IN THE focus of mental health policy in Australia over the last decade, has been accompanied by an increasing expectation that consumers of mental health services be provided the opportunity to become more actively involved in the design, delivery, and evaluation of these services. Consumer participation was officially recognized through the Commonwealth National Mental Health Plan (Australian Health Ministers, 1992). However the Report of the National Inquiry into the Rights of People with a Mental Illness (Human Rights and Equal Opportunity Commission, 1993) emphasized the extent of the discrimination against people with mental illness and provided the climate for the issue of consumer participation to be debated. The importance of consumers becoming active participants in all facets of their mental health care was enshrined in the National Standards for Mental Health (Commonwealth of Australia, 1997), as reflected by the statement that: “Consumers and Carers are involved in the planning, implementation and evaluation of mental health services” (p. 10). These policy changes acknowledged increased consumer participation in health as a right. However, the involvement of consumers at a number of levels has been found to improve the standard of
health care in the general health system (Draper & Hill, 1995; Draper & Silburn, 1999). More specific to mental health the enhancement of consumer involvement has impacted positively on service delivery at both individual and organisational levels (Kent & Read, 1998; Lefley, 1990). Perhaps most importantly it facilitates the responsiveness of services to consumer needs (Mowbray et al, 1996) and to the development of the therapeutic relationship between consumer and service provider, which further enhances the empowerment of consumers (Segal et al, 1993). Furthermore, Fox and Hilton (1994) assert that “by developing the role of the consumer as provider, the programs are stretching conventional roles, relationships, and
From the Centre for Psychiatric Nursing Research and Practice, School of Postgraduate Nursing, University of Melbourne, Carlton, Victoria, Australia. Address reprint requests to Brenda Happell, RN, PhD, Associate Professor, Centre for Psychiatric Nursing Research and Practice, School of Postgraduate Nursing. University of Melbourne, Level 1, 723 Swanson St, Carlton, Victoria, Australia 3010. E-mail: b.happell@ nursing.unimelb.edu.au 䊚 2003 Elsevier Inc. All rights reserved. 0883-9417/03/1702-0003$30.00/0 doi:10.1053/apnu.2003.00008
Archives of Psychiatric Nursing, Vol. XVII, No. 2 (April), 2003: pp 67-76
67
68
boundaries in the mental health system, as well as combating the roots of stigma.” Although a stated commitment to greater consumer participation in health care is plausible, there is no automatic guarantee that the desired goal will become a reality. The attitudes of health professionals for example, have been regarded as a significant barrier to the realisation of consumer participation. This is particularly evident in specific health care areas such as aged care (Department of Human Services Victoria, 1994) the care of people from ethnic minorities (Bhatti-Sinclair, 1999) and people with disabilities (Meehan & Hanson, 1999). Although it is clear that this situation affects the opportunity for all consumers of health services to become actively involved in health care issues, by virtue of their specific health care needs the views of consumers of mental health services are more easily disregarded on the basis of their mental state (Porter, 1996). Consumers frequently report the discriminatory attitudes of mental health professionals to be more debilitating than the mental illness itself (Caldwell & Jorn, 2000; Meagher, 1995; Mirabi et al, 1985). These attitudes were identified as a major barrier to the reform of mental health delivery in the evaluation of the First National Mental Health Strategy (Commonwealth of Australia, 1998). The introduction of strategies to positively influence these attitudes has subsequently been advocated. Although the available research is helpful in identifying the existence of negative attitudes and pessimistic views among mental health professionals toward people diagnosed with a mental illness, it does little to address the question of why or how these attitudes are developed. For example, are these characteristics learned or developed by professionals during the education process or as a result of socialization into the workplace and professional culture? Alternatively, are they characteristic of those people who chose to become mental health professionals? The relationship between the attitudes of mental health professionals and the education and training they receive was the focus of the Commonwealth funded Education and Training Partnerships in Mental Health Project (Deakin University, 1999). This project included the conduct of a national audit of current undergraduate and postgraduate education for mental health professionals in Aus-
HAPPELL, PINIKAHANA, AND ROPER
tralia. The results suggested that consumer participation was at best minimal bur more commonly nonexistent. Consumer involvement was sometimes found through the provision of occasional guest lectures, which usually involved a description of their own individual experience of their illness and of the mental health system. Some isolated examples of consumer involvement in course advisory committees were found at postgraduate level. Clearly, the need for greater consumer involvement in the education of mental health professionals was identified. The education of mental health professionals needs to provide the basis from which a more consumer-focused approach can be developed. This could not occur in the absence of a high level of consumer involvement in professional education. A consumer academic position was established at the Centre for Psychiatric Nursing Research and Practice (CPNRP) within the School of Postgraduate Nursing at the University of Melbourne. This position was funded by the Commonwealth Department of Health and Aged Care, and developed from a partnership between the CPNRP and the Melbourne Consumer Consultants Group. From the time of her appointment, the consumer academic has become an integral member of the team participating in all aspects of the CPNRP’s activities including research projects and the education and training of psychiatric nurses at postgraduate level. Given the importance attributed to the attitude of mental health professionals and the absence of research measuring the outcomes of a position of this kind, a thorough evaluation of the impact of the consumer academic’s teaching role on the attitudes of psychiatric nursing students to consumer participation was essential. METHODS
Instrument An extensive search of the literature did not uncover an instrument suitable for the purposes of this study. The authors subsequently developed the Mental Health Consumer Participation Questionnaire (MHCPQ), based on the Consumer Participation Questionnaire (CPQ) developed by Kent and Read (1998). The CPQ had been specifically developed to examine consumer participation in service delivery and required modification to be suitable for educational research.
CHANGING ATTITUDES
The CPQ was originally used to survey the opinions and perceptions of mental health professionals in a New Zealand Crown Health Enterprise (CHE). The MHCPQ consists of 24 items based on a five point Likert scale, with responses ranging from strongly agree to strongly disagree. Three additional questions require a yes/no response and seek further comments. The questions were divided into six subsets relating to consumer participation in health care, these are: management, treatments, planning, service delivery, the consumer academic position and the consumer perspective. These questions enabled the scope for a broad understanding of the students’ views regarding consumer participation in health care. A pilot of the questionnaire was conducted with 10 registered nurses who had recently completed a postgraduate course in psychiatric nursing. The responses of the pilot participants confirm the validity and reliability of this instrument. Sample The questionnaire was first administered to postgraduate psychiatric nursing students of the School of Postgraduate Nursing, the University of Melbourne on their first day of class in February 2001 (pretest). A total of 25 questionnaires were distributed and all were returned securing a return rate of 100%. At the time of administration the students had not been in contact with the consumer academic or given any information about this position. The same questionnaire was readministered to these students on their last day of class in October 2001 (posttest). Twenty questionnaires were distributed and 19 completed questionnaires were returned (one student declined to participate), securing a return rate of 95%. Data Analysis Data analysis was conducted using the Statistical Package for Social Sciences (SPSS; Chicago, IL). The data were analyzed by means of descriptive statistics. A content analysis approach was used to analyze the qualitative data derived from the open-ended questions. The major themes were identified from the data, coded and entered into the SPSS database. A Chi-square test was applied to measure whether there is statistically significant difference in attitudes to consumer participation between pre and post intervention scores.
69
FINDINGS
This section presents the findings of both preand posttest stages. These results provide valuable information about students’ attitudes to consumer participation at the beginning of their formal professional education in psychiatric nursing and subsequent changes following their exposure to a “consumer academic.” Characteristics of Respondents Demographic data collected during the pretest stage indicates that 68% of respondents (n ⫽ 17) were women and 32 (n ⫽ 8) were men. The mean age of respondents was 33.5 years. The average length of nursing experience was 11 years. In terms of their preregistration nursing education, 32% (n ⫽ 8) had hospital-based certificates and 60% (n ⫽ 15) hold a tertiary degree. Two (2) had not disclosed their qualifications. Forty percent (n ⫽ 10) held postregistration qualifications, 6 respondents hold a postregistration Bachelor of Nursing degree, 3 have postgraduate certificates, and 1 a postgraduate diploma. THE MENTAL HEALTH CONSUMER PARTICIPATION QUESTIONNAIRE RESULTS
Management Table 1 presents a detailed analysis of student responses to these questions at pre- and posttest stage. All students supported the statement that: “mental health consumer involvement and participation should be fully supported by all mental health services” with 100% reporting agreement at both stages of data collection. At pretest only 20% agreed with the statement that consumers should be involved in the process for the hiring of all new staff of mental health services but this increased to 68% at posttest (p ⬍ .001). Differences in opinions as to whether people with a mental illness can handle too much responsibility were also detected, with a higher level of disagreement at posttest. A small increase was noted in the posttest responses in support for the inclusion of at least one consumer member on all mental health service committees (72% in the presurvey and 89% postsurvey). A significant change was noted regarding the statement that mental health services work as well as they can and we should not use valuable resources trying to change them. Disagreement in-
70
HAPPELL, PINIKAHANA, AND ROPER
Table 1. Responses to the Questions on Consumer Involvement in Management in Mental Health Services Agreement
Statement
Mental health consumer involvement and participation should be fully supported by all mental health services Consumers should be involved in the process for the hiring of all new staff of mental health services People will mental illness can not handle too much responsibility All mental health service committees should have at least one consumer member Mental health services work as well as they can and we should not use valuable resources trying to change them Consumers should be the ones to decide what a quality mental health service is Consumers use mental health services because they need help and therefore they should not be burdened with how these services are being provided. Mental health services would not change significantly if consumers were employed by the services Increased consumer involvement in mental health services would probably increase the stress levels for service providers Consumers do not understand the language and complexities of mental health services, which makes it difficult for them to have meaningful input
Disagreement
Percent Frequency Presurvey (N ⫽ 25)
Percent Frequency Postsurvey (N ⫽ 19)
Percent Frequency Presurvey
Percent Frequency Postsurvey
25 (100)
18 (94)
0
0
5 (20)
13 (68)
15 (60)
3 (12)
1 (5)
17 (68)
15 (60) NS
18 (72)
17 (89)
2 (8)
0
5 (20)
1 (5)
9 (36)
11 (44)
15 (78)
5 (20)
1 (5) NS
1 (4)
1 (5)
19 (76)
16 (84) NS
2 (8)
2 (10)
17 (68)
14 (73) NS
5 (20)
6 (31)
12 (48)
10 (52) NS
5 (20)
3 (15)
19 (76)
13 (52) NS
2 (10)*
18 (94)*
Abbreviation: NS, nonsignificant. NOTE. The comparison was made between pre and post scores by chi-squared test. *p ⬍ .001
creased from 36% at pretest to 94% at posttest (p ⬍ .001). Seventy eight percent of the students at post-test as compared to 44% at pretest agreed that consumers should be the ones to decide what a quality mental health service (p ⬍ .001). More students at posttest stage disagreed with the notion that consumers use mental health services because they need help and therefore they should not be burdened with how these services are being provided (76% pretest, 84% posttest). A slight increase in
disagreement of the view that mental health services would not change significantly if consumers were employed by the services was also observed at posttest. More respondents at posttest disagreed with the idea that increased consumer involvement in mental health services would be likely to increase the stress levels for service providers. However less respondents disagreed with the statement that “Consumers do not understand the language and complexities of mental health services, which
CHANGING ATTITUDES
71
Table 2. Responses to the Questions on Consumer Involvement in Treatment Agreement
Statement
Consumers should be involved in identifying the goals for their treatment Consumers should always be involved in the evaluation and diagnosis of their presenting problems Consumers should have the opportunity for genuine input into the planning of their own treatment Consumers should be encouraged to contribute to the writing of their own notes and records Consumers are already given sufficient opportunity to participate in the care they receive The medications used in mental health are very complex and consumers should only have limited input into deciding the most appropriate medications to be used Medications should be explained in detail to consumers in ways that they can understand so they are fully informed and can make choices
Disagreement
Percent Frequency Presurvey (N ⫽ 25)
Percent Frequency Postsurvey (N ⫽ 19)
Percent Frequency Presurvey
Percent Frequency Postsurvey
25 (100)
18 (94)
0
0
21 (84)
17 (89)
1 (4)
0
21 (84)
18 (94)
0
0
7 (28)
6 (31)
13 (52)
9 (47) NS
6 (24)
2 (10)
11 (44)
14 (73)*
7 (28)
0
14 (56)
14 (73)*
23 (92)
18 (94)
1 (4)
0
Abbreviation: NS, nonsignificant. NOTE. The comparison was made between pre and post scores by chi-squared test. *p ⬍ .001
makes it difficult for them to have meaningful input” at posttest (76% pretest, 52% posttest). Treatments Table 2 presents a detailed analysis of student responses to these questions at pre- and posttest. All respondents at pretest agreed that consumers should be actively involved in identifying the goals for their treatment but in the postsurvey this was reduced to 94%, with one student taking a neutral stance. A slight increase in agreement to the statement that consumers should always be involved in the evaluation and diagnosis of their presenting problems was noted (84% pretest, 89% posttest). A
larger increase was recorded for the view that consumers should have the opportunity for genuine input into the planning of their own treatment (84% pretest, 94% posttest). The majority of respondents did not consider it appropriate for consumers to be encouraged to contribute to the writing of their own notes and records with only a small increase in approval for this notion in the posttest stage. However, a significant difference was noted in students’ views of whether consumers are already given sufficient opportunity to participate in the care they receive (44% disagreed pretest as compared with 73% posttest) (p ⬍ .001). All students at the posttest stage disagreed with the idea that the medications
72
HAPPELL, PINIKAHANA, AND ROPER
Table 3. Responses to the Questions on Consumer Involvement in Mental Health Care Planning Agreement
Statement
Consumer input should be central in the planning of mental health services Consumers should be involved in the planning and delivery of all staff education and professional development sessions Mental health services would be likely to improve if consumers were involved in the planning and delivery of those services Consumers do not have enough self-confidence to become involved in the planning and delivery of mental health services
Disagreement
Percent Frequency Presurvey (N ⫽ 25)
Percent Frequency Postsurvey (N ⫽ 19)
Percent Frequency Presurvey
Percent Frequency Postsurvey
22 (88)
19 (100)
0
0
8 (32)
15 (78)
13 (52)
18 (72)
16 (84)
3 (12)
3 (12)
0
18 (72)
3 (15) NS
2 (10)*
14 (73) NS
Abbreviation: NS, nonsignificant. NOTE. The comparison between pre and post scores was made by chi-squared test. *p ⬍ .001
used in mental health are so complex that consumers should only have limited input into deciding the most appropriate medications to be used, as compared with 28% disagreement in the pretest stage (p ⬍ .001). No significant change was observed in relation to the statement that medications should be explained in detail to consumers in ways that they can understand so they are fully informed and can make choices. A high level of support for this strategy was observed at both stages. Planning Table 3 presents a detailed analysis of student responses to these questions. The concept of consumer involvement in the planning of mental health services was well supported in both pre- and postsurveys (Increased from 88% pretest to 100% posttest). A significant difference was found in responses to the statement that mental health services would be likely to improve if consumers were involved in the planning and delivery of those services (32% pretest, 78% posttest) (p ⬍ .001). The majority of respondents at both stages of the research considered that consumers have enough self-confidence to become involved in the planning and delivery of mental health services.
Consumer Academic Position Table 4 presents a detailed analysis of student responses to these questions. At the pretest stage a slight majority of respondents (56%) endorsed the concept of consumer academic involvement in psychiatric nursing education by agreeing that a consumer academic should be a member of staff in all psychiatric nursing courses. This endorsement was further increased to 86% in the postsurvey results. However, the disagreement remains the same both in pre- and postsurvey results (16% and 15%). The approval of the idea that “an experienced psychiatric nursing academic can present a good understanding of the consumer perspective,” was increased by 7% (40% pretest, 47% posttest). There was a 17% increase in approval for the statement: “I need to be taught by a consumer academic to more fully understand how a consumer might experience the mental health system.” It is interesting to note that this view appears to contrast markedly with the views in the previous question. Service Delivery In response to the question, “Do you think consumers should be active in the delivery of services?”,
CHANGING ATTITUDES
73
Table 4. Response to the Consumer Academic Position Agreement
Statement
A consumer academic should be a member of staff in all psychiatric courses An experienced psychiatric nursing academic can present a good understanding of the consumer perspective I need to be taught by a consumer academic to more fully understand how a consumer might experience the mental health system
Disagreement
Percent Frequency Presurvey (N ⫽ 25)
Percent Frequency Postsurvey (N ⫽ 19)
Percent Frequency Presurvey
Percent Frequency Postsurvey
14 (56)
16 (84)
4 (16)
3 (15) NS
10 (40)
9 (47)
6 (24)
8 (42) NS
18 (72)
17 (89)
3 (12)
0 NS
Abbreviation: NS, nonsignificant.
76% responded ‘yes’ and 24% ‘no’ in the presurvey. This approval was increased to 94.7% in the postsurvey. This view is illustrated by the additional comments made by respondents at the poststage, for example: “Who else understands them better than they do?”
and “Be involved in planning, staff recruitment and staff education”
involvement in psychiatric undergraduate and postgraduate planning meetings. In response to the question, “Please list three factors you consider to be most important in developing collaborative relationship between health care providers and consumers,” the following factors were reported: “Being open, listening, nonjudgmental to views, being upfront with roles, expectations, respecting common goals, mutual respect, and friendly atmosphere” “Respect, open-truthful interactions, and honesty”
There was only one negative comment made as follows:
“Honesty, advocacy, and flexibility.”
DISCUSSION “They may abuse the system.”
In response to the question, “Please describe briefly what consumer participation in mental health care means to you,” the perceptions were expressed in the following terms: “Help to teach me to use another perspective other than from a professional level” “Consumer participation means allowing the users/clients of the service to have valuable input into better practice standards and delivery of care” “Being forced to reflect on my practice at all times.”
Some students suggested that consumer involvement should be expanded to include consumer
The study was designed to examine the effect of exposure to a consumer academic on postgraduate psychiatric nursing students’ views on consumer participation in mental health service delivery in general and a consumer academic involvement in psychiatric nursing academia in particular. The results from the postsurvey indicate that students’ approval rating of consumer participation has increased in all areas surveyed including mental health service management, treatment, planning, and service delivery following exposure to a consumer academic. It is particularly significant that more respondents in the postsurvey stated that consumers should always be involved in the evaluation and
74
diagnosis of their presenting problems which suggests the changing paradigm of professional hegemony in relation to the evaluation and diagnosis of health problems. Consumer empowerment is a vital component of mental health services where clients are provided with a greater accessibility to involve in treatment strategies. Similarly more students in the postsurvey believed very strongly that consumers should have the opportunity for genuine input into the planning of their own treatment. The finding that medications should be explained in detail to consumers in ways that they can understand and make choices reflecting the emerging view regarding medical treatment. The integration of consumers into the planning process in mental health services is crucial to the success of service improvement and reflects current government policy in Australia (Commonwealth of Australia, 1997; 1998). The findings that consumer input should be central in the planning of mental health services and mental health services would be likely to improve if consumers were involved in the planning and delivery of those services support the view that consumers should be involved in all aspects of service delivery including service planning. The fact that the majority in both phases of study rejected the view that mental health services would not change significantly if consumers were employed by the services indicates positive attitudes towards consumer participation in mental health service management. The higher endorsement of consumer competency in understanding the language and complexities of mental health services reflects the changing nature of professional views of consumer competency. A greater support indicated for the involvement of consumers in the process for the hiring of all new staff of mental health services in the postsurvey suggests the change in perception after the exposure to a consumer academic. The majority of students (68%) consider that consumer participation should extend to staff recruitment. Diverse views were expressed to the idea that consumers use mental health services because they need help and therefore they should not be burdened with how these services are being provided. This suggests that for some students the argument in health service delivery, which distinguishes patient from the service provider keeping the client as
HAPPELL, PINIKAHANA, AND ROPER
a passive recipient of health services, still remains at least to some degree. This is further suggested through the finding that the majority of respondents still consider that consumers should not be encouraged to contribute to the writing of their own notes and records. These two views combined reflect, as Kent and Read (1998) suggest, an attitude of paternalism. On a more positive note, the majority of respondents at post-test felt that consumers should be involved in the planning and delivery of staff education and professional development sessions (p ⫽ .001). The key to understanding their changing perception in the postsurvey with consumer involvement in staff education and training may lie in the first hand knowledge they acquired through the consumer academic’s involvement in teaching An increase in support for the involvement of a consumer academic in psychiatric nursing education was also observed. This finding is particularly significant in terms of accepting new teaching approaches not only to psychiatric nursing but to the mental health professions more broadly. Furthermore, it has potential to destigmatize psychiatric illness within nursing (and other mental health professional) education programs. It was interesting to note that an increased number of students supported the view that an experienced psychiatric nursing academic can present a good understanding of consumer perspectives at posttest stage. This appears to be in contradiction with the almost unanimous agreement with the idea that they need to be taught by a consumer academic to more fully understand how a consumer might experience the mental health system. It is possible that while the students’ recognize the importance of a consumer academic’s role they believe this can be supported by an experienced nurse academic who promotes a positive consumer perspective. The findings of this preliminary study have implications for further research and education. Further longitudinal research with a large cohort of students could be undertaken to examine the longer impact of this project on the practice of these individual nurses. LIMITATIONS
The present study has several limitations that must be acknowledged. The major weakness of this study is the small sample size and the conve-
CHANGING ATTITUDES
nience method of sampling. The study was conducted in one university in Victoria, which makes it difficult to determine the extent to which the results reflect that course specifically rather than exposure to the consumer academic. The initial design of the project sought a control group from another Victorian university. Unfortunately this aim could not be achieved. Only one other Victorian university conducts a course with a face to face as opposed to a distance learning approach. Although attempts were made to engage this university, their involvement in the study did not eventuate. CONCLUSION
In summary, this article reports a pre- and postsurvey data on attitudes toward consumer participation in response to exposure to a consumer academic in a postgraduate psychiatric nursing course. The findings show the attitudinal status of respondents before and after the consumer academic involvement and particularly the attitudinal changes in the postsurvey findings. The findings of both phases of the survey show positive attitudes among postgraduate nursing students towards consumer participation and consumer academic involvement at some levels of service provision, however limitations to consumer participation remain particularly with regard to consumer contribution to the writing of their own notes and records. The research was set within a psychiatric nursing education framework that rhetorically promotes consumer involvement in planning, service delivery, and training. It is noted that the study was small in scale and had some methodological limitations. The concept of consumer involvement is complex in some areas of health care including psychiatric nursing, therefore further research with a large cohort of students is needed. Nevertheless, in a more encompassing sense, this research with its admitted limitations suggests that consumer involvement in education is an affective strategy in influencing the attitudes of nurses to consumer participation in mental health care. ACKNOWLEDGMENT The authors acknowledge and thank the Commonwealth Department of Health and Aged Care, for providing the funding to make the dream of this position become a reality. They also express gratitude for the involvement and support of Ross Findlay and Merinda Epstein, Melbourne Consumer Consult-
75
ants’ Group, in inspiring the project and developing the initial funding application; To Bernie McCormack and Margaret Yii the consumer representatives, and Greg Miller the academic representative on the project team, your contributions have made this work. Finally to the consumer participants in the Education and Training Partnerships in Mental Health who changed the way of thinking of at least one mental health academic forever.
REFERENCES Australian Health Ministers (1992). The National Mental Health Plan. Canberra: Australian Government Printers. Bhatti-Sinclair, K. (1999). Evaluating social work and medical practice with black and ethnic minority groups using the clinical audit model. British Journal of Social Work, 29, 303-320. Caldwell, T.M., & Jorm, A.F. (2000). Mental health nurses’ beliefs about interventions for schizophrenia and depression: a comparison with psychiatrists and the public. Australian & New Zealand Journal of Psychiatry, 34, 602-11. Commonwealth of Australia (1997). National Standards for Mental Health. Canberra: Australian Government Printer. Commonwealth of Australia (1998). Evaluation of the National Mental Health Strategy. Canberra: Australian Government Publishing Service. Deakin University (1999). Human Services Education and Training Partnerships in Mental Health. Melbourne: Deakin University. Department of Human Services Victoria (1999). A guide to participation by older Victorians. Melbourne: Victorian Government Publishing Service. Draper, M., & Hill, S. (1995). The role of patient satisfaction surveys in a national approach to hospital quality management. Canberra: Australian Government Publishing Service. Draper, M., & Silburn, K. (1999). Improving hospital care by involving consumers: report on a national program of workshops on consumer participation. Canberra: Australian Government Printing Service. Fox, L., & Hilton, D. (1994). Response to “consumers as service providers: The promise and challenge”. Community Mental Health Journal, 30 627-629. Human Rights and Equal Opportunity Commission (1993). Report of the National Inquiry into the Human Rights of People with Mental Illness. Canberra: Australian Government Printer. Kent, H., & Read, J. (1998). Measuring consumer participation in mental health services: Are attitudes related to professional orientation? International Journal of Social Psychiatry, 44, 295-31 Lefley, H.P. (1990). Culture and chronic mental illness. Hospital and Community Psychiatry, 41, 277-286 Meagher, J. (1995). Partnership or Pretence-A handbook of empowerment and self-advocacy for consumers/users and survivors of Psychiatric Services. Strawberry Hills, Australia: Psychiatric Rehabilitation Association. Meehan, E., & Hanson, K. (1999). Three-D: a preliminary report on sexual and occupational health of NESB
76
women with disabilities. Fitzroy: Women in Industry and Community Health Inc. Mirabi, M., Weinman, M.L., Magnetti, S.M., & Keppler, K.N. (1985). Professional attitudes toward the chronic mentally ill. Hospital and Community Psychiatry, 36, 404-5. Mowbray, C.T., Moxley, D.P., Thrasher, S., Bybee, D., McCrohan, N., Harris, S., & Clover, G. (1996). Consumers as community support providers: Issues created by role
HAPPELL, PINIKAHANA, AND ROPER
innovation. Community Mental Health Journal, 32, 47-67 Porter, R (1996). A social history of madness: stories of the insane. London: Phoenix Giant. Segal, S.P., Silverman, C., Temkin, T. (1993). Characteristics and service use of long term members of self help agencies for mental health clients. Psychiatric Services, 46, 269-274