Reconceptualizingthe theory-practice gap in mental health nursing

Reco nce ptual izi ng the theory-practice gap in mental health

nursing JohnHopton The purpose of this paper is to identify the key problems in bridging the gap between theory and practice in the education of mental health nurses and to propose a strategy for overcoming these problems. The paper begins by reviewing the existing literature on the subject of the theory-practice gap, and identifying the unique problems which mental health nursing faces in attempting to address them. It then goes on to propose a unified model of clinical nursing practice, nurse education and user involvement, which would place nurse educators at the forefront of radical reform of mental health services.

INTRODUCTION

John Hopton RMN, RCNT, HA, Nurse Teacher, Northern College of Nursing, Midwifery & Health Studies, Grreater Manchester, UK

(Requests for offprints to JH, 64 Peveril Close, Whitefield, Manchester M45 6NR, UK) Manuscript accepted 15 March 1995

In nurse education, one of the most frequently discussed concepts is the 'theory-practice gap'. The articles on this subject which have appeared in Nurse Education Today can be divided into those which are philosophical discussions about the nature of theory and the relationship of theory to practice (e.g. Champion 1991, Draper 1991, Ashworth & Longmate 1993); those which address the question of the role o f nurse teachers in the practice setting (e.g. Armitage & Burnard 1991, Gerrish 1992) and those which discuss the impact o f Project 2000 nurse education programmes on either or both of these two issues (e.g. Orr 1990, Schr6ck 1990, Ashworth &Morrison 1991, Porter 1992, Elkan & Robinson 1993). However, whereas the emphasis in the literature is on the gap between theoretical knowledge and clinical skills per se; a more significant issue in the case of mental health nursing

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is the failure of mental health nurses to respond to critiques o f mental health care provision through radical reform o f nursing practice. This absence of prams may be demonstrated with reference to the occurrence o f serious human rights abuses within British psychiatric hospitals (see Beardshaw 1981, Martin 1984, BlomCooper t992) long after the training of registered mental nurses had supposedly been influenced by Russell Barton's (1959) n'eatise Institutional Neurosis (Martin 1984, Nolan 1993), and by nurses' continuing inability to provide the kind o f counselling and psychotherapy interventions demanded by service users despite the emphasis put on such skills in the Syllabus of Training 1982: (Registered Mental Nurses) (Nolan 1993, R.ogers et al 1993). The prevalence o f the debate around the 'theory-practice gap' in nurse education, and the corresponding absence o f literature by nurses which challenges the failure of mental health nursing to respond effectively to critiques of mental health services, provides students of mental health nursing on Project 2000 courses with an excuse for not using their theoretical knowledge to question the wisdom of existing approaches to mental health care. Instead, they may perceive that many teachers of mental health nursing have not been directly involved in providing care for many years, and recognize that clinical nurses who seek to develop radical change in approaches to care are frequently compromised by a lack of resources. In response to the frustration that these circumstances create in chnical staff, students may recognize that attacking nurse teachers for lack o f chnical credibility is a short cut to establishing their own credibility with clinical nursing staff. Thus. instead of applying theoretical knowledge to the practical problems of developing a truly client-centred mental health service, this "new breed' of mental health nurses can allow themselves to become immersed in the pessimistic occupational culture of mental health nursing so that the status quo is preserved. The first o f these problems would be addressed if all nurse teachers were to become directly involved in giving care. However, this would be meaningless unless the clinical practice of nurse teachers is orientated towards the development of practices which challenge the current situation within mental health services where - despite a rhetoric of user empowerm e n t - many service users feel that existing services fail to meet their needs (e.g. Ussher 1991, Rogers et al 1993, Sashidharan 1994), and nurses find it difficult to be innovative. This paper is concerned with identifying a possible strategy for teachers of mental health nursing to unite theory and practice by work-

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THE FALSE PROMISE OF THE 1982 RMN SYLLABUS

~Although the critiques of psychiatry associated with Thomas Szasz and the British school of anti-psychiatry (of which R.D. Laing is probably the best known member) are often discussed as if they spoke with one united voice, a close comparison of the critiques reveals that the perspectives of Szasz and the other anti-psychiatrists were very different.

The 1982 syllabus of training for mental health nurses was ostensibly a radical departure from previous syllabi. For the first time, a revision of the syllabus of training for mental health nurses was undertaken without the involvement of the Royal College of Psychiatrists (formerly the [Royal] Medico-psychological Association). Accordingly, it emphasized self-awareness and interpersonal skills, rather than the theoretical imperatives of medical psychiatry (Nolan 1993). However, although these changes seemed to reflect concern among mental health nurses about the poor human rights records of British psychiatric and 'mental handicap' hospitals throughout the 1960s and 1970s (Beardshaw 1981, Martin 1984) and the damning indictment of the closely related discipline of 'mental handicap' nursing in the 1979 Jay Report (Nolan 1993), the 1982 R M N syllabus is profoundly ahistorical. Instead of taking account of the various critiques of psychiatry and mental health institutions which had been developed since the late 1950s (e.g. Barton 1959, Foucault 1965, Laing 1967, Szasz 1971) and developing a strategy for mental health nursing based on a dialectical analysis of these competing critiques 1, the architects of the 1982 syllabus put the emphasis on humanistic psychology. This approach implicitly blamed medical psychiatry for the failings of British mental health services, but failed to address the structural contradictions which characterize the relationship between medical psychiatry and mental health nursing (see Beardshaw 1981). Although the 1982 syllabus has been superseded by the implementation of Project 2000 nurse education programmes, the impression one gets when reviewing Project 2000 mental health branch programmes and/or talking to teachers of mental health nursing, is that these branch programmes are substantially informed by the ideologies which underpinned the 1982 syllabus. Similarly, the recently published review of mental health nursing emphasizes that nurses should work in partnership with their clients, but only in the context of relationships between individuals, rather than in terms of working together towards structural change (Department of Health 1994). Consequently, there is an emphasis on the individualistic approaches to mental health implicit in humanistic psychology, at the expense of a socio-politically orientated approach to mental

health. Considering that analyses of traditional ideologies of mental health have been developed through the 1980s and 1990s which show them to be exploitative of vulnerable individuals (Masson 1990) and rooted in racist eugenics (laernando 1991), misogynistic patriarchy (Ussher 1991) and heterosexism (Kitzinger 8: Perkins 1993), this is even more disturbing now than it was in 1982. In this context, demanding that nurse teachers are actively engaged in clinical practice before a new strategy for mental health nursing is developed cannot lead to a worthwhile narrowing of the gap between theory and practice. Instead, it can only result in the perpetuation and legitimation of approaches to mental health care which have their ideological roots in the classical liberalism and institutionalised social prejudices of the 19th century.

TOWARDS A TRULY CLIENTCENTRED APPROACH TO MENTAL HEALTH NURSING On the other hand, if nurse teachers remain detached from clinical practice they will continue to lack credibility in the eyes of both their students and established clinical practitioners. Thus, however well developed their critiques of current mental health nursing practice may become, these will inevitably be ignored. The only way forward for teachers of mental health nursing which will bridge the gap between theory and practice while simultaneously facilitating radical change is to adopt a twin strategy of working collaboratively with users of mental health services on new approaches to training and educating mental health nurses and working collaboratively with service users to provide user-led mental health services. However, despite the existence of a political climate which valorizes active citizenship and user participation in the management of welfare services (e.g. Barbalet 1988, Barker 1994) - and the existence of appropriate psychotherapeutic models (Bulhan 1985, Newman 1991) - it may be dit~icult to implement such a strategy in practice. The first potential obstacle is that members of the users' movement may be sceptical about the motives of nurse educationalists who seek to develop collaborative working practices with them. Historically, many of the schemes which have claimed to be inspired by professional concern to work collaboratively with service users have resulted in only tokenistic consultation with users (Barker 8: Peck 1987, Rogers & Pilgrim 1991), while traditionally, mental health professionals - including mental

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health nurses - often deny service users the right to define the significance of their own experiences by imposing their own ideas about mental distress on their clients (e.g. Lindow 1990, Rogers & Pilgrim 1991). In its most extreme manifestation, this takes the form of professionals redefining users'justifiable anger and frustration at this denial as symptoms of a presumed psychopathology (Lowson 1988, Croft & Beresford 1992). Similarly, mental health professionals sometimes refuse to acknowledge the validity of the grievances of service users by dismissing activists in the user movement as being unrepresentative of the majority of service users (Rogers & Pilgrim 1991). Any misgivings on the part of service users could be obviated by linking their greater involvement in nurse education to collaboration between nurse educationalists and activists within the mental health service users' movement in developing mental health services which would focus on the socio-political dimensions of mental health. Such a development could render meaningless the current debates around the theory and practice gap by directly involving service users in shaping the training and education of aspiring mental health nurses. Most importantly, though, it would constitute a significant shift in the ideological basis of mental health nursing. Whereas there have hitherto been splits between the theoretical instruction of mental health nurses and clinical mental health nursing practice, and between the theoretical and operational imperatives of mental health nurses and the perspective of service users, the strategy for mental health nursing proposed here opens up the possibility of radical reform. Specifically, it would constitute a move towards the sort of oppositional psychiatry rooted in a synthesis of the theories of Lev Vygotsky and Frantz Fanon, which is implicit in the work of Fred Newman (e.g. Newman 1.991) and S.P. Sashidharan (e.g. Sashidharan 1994). According to the principles of Vygotskian psychology, the basis of human development is the involvement of individuals in collective activity to promote socioenvironmental change for the common good; the activity of developing frameworks for such social change is inseperable from the practicalpolitical activity of implementing such change, and social roles are negotiated freely so that people can create their own activities to enable them to overcome emotional problems and/or meet their cognitive needs (Newman & Holzman 1993). The work of Frantz Fanon has a different emphasis to that of Vygotsky, but shares with it the concept that oppressed individuals do not transcend their feelings of alienation by simply

talking about their symptoms, but by engaging in practical political activity. In terms of the organization of mental health services, Fanonian psychology suggests that users of mental health services may only become empowered by developing an understanding of the relationship between the psychiatric system and the political status quo, and resisting 'therapeutic' interventions which they experience as oppressive. In terms of mental health nursing, the demands which Fanonian psychology makes of mental health nurses is that they should question the links between their practice and the maintenance of the political status quo; question their role in the system and recognize that for many users of mental health services, challenging their categorizing as being 'mad' may be the most therapeutic activity which they could engage in (Hopton 1994). If nurse teachers decide to comply with the recommendation that they should engage in clinical practice by merely spending one day a week working within existing services (Department of Health 1994), the opportunity to make a radical break with the past history of mental health nursing by developing such an oppositional psychiatry will be missed. For all its rhetoric about user involvement, the development of innovative mental health nursing, the importance of research into mental health care, and the problems associated with the theory-practice gap, the recent review of mental health nursing (Department of Health 1994) does not constitute the clear commitment to progressive reform which it purports to be. O f the 30 members of the review team, at least 15 were from a nursing background and 11 of the others had a strong connection with existing mental health services. It is therefore unsurprising that the report glosses over official inquiries and academic reports which have criticized nursing practice since the publication of the last review of mental health nursing in 1968 and promotes a positive image of developments in nurse education. Instead it talks in vague terms of innovative practices by mental health nurses, while hinting at resentment at mental health nursing being researched from perspectives other than those developed and/or championed within university nursing departments: Graduate mental health nurses are already emerging from a number of university courses and further programmes are planned. Two centres provide accelerated registration programmes for graduates. A supply of potential researchers can be drawn from these programmes and a number already go on to receive postgraduate studentships or to work as university

230 NurseEducationToday researchers. Many other mental health nurses are obtaining graduate and postgraduate awards on a full- or part-time basis, from a variety of subject programmes. It is important to note that some badly supervised, student-led studies are of a poor quality and, as such, are damaging the potential for more properly constructed research. (Department of Health 1994, p38). The discourse here is illuminating. While it is axiomatic that badly supervised student-led research will often be of poor quality, it is implicit in this statement that respectable academics who are not nurses are not competent to supervise research in mental health nursing. This is reminiscent of recent developments in critical criminology where certain professors whose analysis has moved closer towards official (i.e. governmental) discourses of crime have falsely accused those who continue to work in an authentically critical framework of being incompetent idealists whose work is informed by political dogma rather than by empirical research (see Stenson & Cowell 1991). Bearing in mind that all the published research into nursing practice by non-nurses is in some sense critical of mental health nursing (e.g. Goffrnan 1968, Beardshaw 1981, Martin 1984, Rogers et al 1993), a possible interpretation of the statement in the Review o f Mental Health Nursing is that the nursing establishment does not welcome critical research, and prefers nursing research to be undertaken under the auspices o f university nursing departments which will ensure that official discources of mental health nursing remain unchallenged. If this is indeed the intended meaning, it is unlikely that funding could be obtained from official sources for a project along the lines proposed in this paper. Similarly, any move towards the development o f such a strategy for unifying research, theory and practice in mental health nursing by stealth would be compromised by the political economy of health professional education. Since preregistration nursing diploma courses (Project 2000) began to replace traditional nurse training schemes in 1989 and have now almost completely replaced them, colleges o f nursing have amalgamated with each other and many nurse teachers have been made redundant. Against this background, it would seem unlikely that new teaching posts would be created in nurse education for mental health service users, or that nurse teachers would readily accept any vacant posts for nurse teachers being filled by non-nurses, even though there are service users who would be more than competent to teach mental health care at diploma and degree level (see Wallcraft 1987, Lindow 1993).

CONCLUSION Although the recent review of mental health nursing has explicitly addressed the question of the theory-practice gap, it has done so from the traditional solipsistic perspective of mental health (psychiatric) nursing which ignores wider socio-political contexts or any critical analysis o f nursing itself.. Consequently, the question of transforming critiques of mental health services into radical reform of the services themselves has not been addressed in the report of the review team. If there is a sincere commitment on the part of the mental health nursing establishment to the substantive empowerment of mental health service users, this cannot be achieved by the self-aggrandizement of mental health nursing. Rather, the empowerment of service users is to some extent dependent upon the willingness o f mental health professionals to relinquish some - if not all - of their own power. The successful implementation of such a strategy would be dependent upon mental health professionals working in close collaboration with service users to develop services wherein the self-identified needs of service users are paramount. The position put forward in this paper is that nurse teachers could and should play an active part in developing such services for the following reasons. 1. Teachers of mental health nursing are often familiar with theoretical critiques o f mental health care and mental health services. 2. The lack of clinical involvement on the part o f teachers mitigates against them having any credibility with practitioners when they expound these critiques. 3. The problem o f using critiques of mental health nursing practice to transform it is not an issue which is explicitly addressed in the existing literature pertaining to the theorypractice gap in nurse education. 4. In order to assist practitioners with applying critiques of mental health care and mental health services to clinical practice, teachers of mental health nursing need to be involved in clinical practice. 5. Because the success of any project which seeks to transform existing mental health services is dependent upon substantive user involvement, it is important that 'experimental' mental health units are established which are free of interference from the nursing and medico-psychiatric establishments. 6. Within such environments it would be possible to have meaningful collaboration between service users, lecturer-practitioners in mental health nursing and student nurses,

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to build a service and develop ways o f working which would be congruent with the principles o f the liberating psychological philosophies o f Frantz Fanon and Lev Vygotsky. 7. Once such a model o f care could be implemented in an environment free o f external interference, it could possibly be adopted within mainstream mental health services. 8. The adoption o f a strategy such as this may be successful in making the break with the past history of mental health nursing which the 1982 R M N syllabus promised, but failed to deliver. 9. Unless the quest to eliminate the gap between the theory and practice o f mental health nursing breaks flee from the solipsism o f current nursing theory to respond to critiques o f mental health care and mental health services which originate elsewhere, any attempt to close this theory-practice gap will be futile. These issues could be addressed most effectively through nurse educators and service users cooperating to establish alternative mental health services where new approaches to m e n tal health care could be developed and researched. However, there is no obvious source o f funding for such a project; the creation o f such a service could create tension between nurse teachers and other mental health nurses; and service users might be wary o f the motives o f academics seeking to become involved in running services which would supposedly be user-led. The issue o f funding could be resolved by applying to one o f the various organizations that fund independent research initiatives. This would ensure that any project successful in obtaining funding would be practicable, and had a clear research strategy (otherwise funding would not be granted). Furthermore, any bid could take account o f the need to 'buy in' teachers to cover the commitments o f teachers involved in the project. Even if funding were obtained, however, three closely linked major problems would remain: the relationship between the proposed 'experimental' service and mainstream services; the relationship between nurse educators and service users involved in the project; and legal and ethical considerations. Most o f these problems could be overcome if any proposed service operated on the principles o f self-referral and sessional a n d / o r day care. T h e first advantage o f this approach is that it would facilitate the development o f a service which would be complementary to existing services, rather than in competition with them. Secondly, the nurse teachers working within the service would be

free from the structural and ideological contradictions o f traditional psychiatric nursing (see H o p t o n 1993). However, whereas previous radical alternatives to traditional mental health care such as the Arbours Association (see Berke et al 1995) have been completely separate from statutory services, this service - through the involvement o f nurse teachers - w o u l d still have structural links with the mainstream. These links should make it possible for the new approaches to care pioneered in the new p r o ject to be shared with nurses working in mainstream services who could then adapt these approaches to develop their o w n practice p r o gressively. Finally, in the context o f a non-residential self-referral service, mental health nurse teachers would not be compromised by the coercive aspects o f the Mental Health Act, but would be bound only by a legal duty o f care. Thus there would be no Chidden' power relations between them and the service users. This would ensure that service users would be able to be 'in control' both at the level o f individual relationships and at the structural level o f planning, monitoring and evaluating service provision. The advantage o f involving nurse educationalists would be that the priorities o f service users would then be fed back into the initial and ongoing education and training o f mental health nurses by teachers who were conjointly involved with service users in developing innovative but practical approaches to mental health care. REFERENCES ArmitageP, Burnard P 1991 Mentors or preceptors? Narrowing the theory-practice gap. Nurse Education Today 11:223-229 Ashworth P D, LongxnateM A 1993 Theory and practice: beyond the dichotomy. Nurse Education Today 13: 321-327 Ashworth P, Morrison P 1991 Problems of competencebased nurse education. Nurse Education Today 11: 256-260 BarbaletJ 1988 Citizenship. Open University Press, Milton Keynes Barker I, Peck E 1987 Power in strange places. GPMH, London Barker P 1994 A partnershipfor change. Nursing Times 90:62 Barton !K 1959 InstitutionalNeurosis.J. Wright, Bristol Bear&haw V 1981 Conscientiousobjectors at work. Social Audit, London BerkeJ H, MasoliverC, Ryan T J 1995 Sanctuary. Process Press, London Blom-Cooper L 1992 Report of the committee of inquiry into Ashworth Hospital. HMSO, London Bulhan H A 1985 Frantz Fanon and the psychologyof oppression. Plenum Press, New York Champion t< 1991 Educationalaccountability- what ho the 1990s1Nurse Education Today 11:407-414 Croft S, BeresfordP 1992 The politics of participation. Critical SocialPolicy 12:20-44 Department of Health 1994 Working in partnership: a collaborativeapproach. HMSO, London

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