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The client as educator: learning about mental illness through the eyes of the expert
Article
The client as educator: learning about mental illness through the eyes of the expert Lorna Bennett and Kenneth Baikie
Increasingly, educators are asking clients who have a mental illness to make a contribution to nursing students’ learning as a way of informing their attitudes towards persons experiencing mental illness and thus enhancing care delivery. The nature of clients’ involvement in the classroom and the quality of learning by students through this approach has rarely been questioned. This paper discusses a model of client/nurse educator collaboration in a mental health course with undergraduate nursing students. It draws on the nursing education experiences of the first author, and the personal views of the second author, a user of mental health services. Specifically, it addresses positive features of collaboration as perceived by students, client, and nurse educator and analyzes some of the challenges/issues for the nurse educator. In addition, it outlines helpful aspects of the collaborative process for both nurse educator and client, in particular, its impact on the client’s personal well being. This kind of analysis is essential if we are to develop education models of such collaboration that are beneficial for all partners in the learning process. ª 2003 Elsevier Science Ltd. All rights reserved.
Introduction Lorna Bennett RN, MN, Associate Professor, Memorial University of Newfoundland, School of Nursing, St. John’s, NF, Canada, A1B 3V6. Tel.: +1-709-7777332; Fax: +1-709-7777037 E-mail: [email protected] Kenneth Baikie Co-educator for undergraduate nursing, Mental Health Nursing (Requests for offprints to LB) Manuscript accepted: 16 September 2002
The idea of using client perspectives of mental illness and mental health services as a means for educating health care providers and the general public is not new. In more recent times, partly due to the impact of the client/ consumer/survivor advocacy movement greater attention has been focused on the client’s perspective, both in the mental health literature and in the classroom. The voice of those experiencing mental illness has been heard to some extent, particularly in reference to concerns about the nature of treatment, the violation of client rights, attitudes of society, and views about forced treatment of the mentally ill (Champ 1998; Frese 2000; Obletz 2000). Less has been said about the day-to-day experience of mental illness from the perspective of clients, including their views about best practice and treatment and their role
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in the education process. A focus on the client is essential from the perspective of both the educator and researcher given that the best ‘‘evidence’’ for providing direction for practice begins with the client (Gamble & Brennan 2000). Moreover, educational methods that engage students in Psychiatric Mental Health Nursing (P/MH) in meaningful ways could increase the likelihood of students pursuing a career in this specialty (Happell & Rushworth 2000). The possibilities for the role of the client as educator and the nature of this participation for clients experiencing a range of health problems has already generated some discussion in the literature. While it needs it be recognized that there is, as yet, little empirical evidence to support or refute current positions, the consensus among health professionals is that clients in educator roles are able to
0260-6917/03/$ - see front matter ª 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0260-6917(02)00193-4
The client as educator: learning about mental illness through the eyes of the expert
increase students’ awareness of clients’ expertise, sensitize health care providers about the issue and challenges, support person-hood and strengthen relationships between clients, their families, and caregivers (Barker 1996; Clinton 1999; Hutchings 1999; Kelly & Wykurz 1998; Small & Sudar 1995). The role of client educators in student nurse education, in particular, the potential benefits of collaboration between client educators and nurse educators is a critical issue to consider particularly for students enrolled in psychiatric mental health nursing courses (Clinton 1999; Forrest et al. 2000). Clinton (1999) reports that collaborative education is useful for breaking down social stereotypes and helping to promote positive attitudes towards those experiencing mental illness an important goal of undergraduate nursing education. This paper will identify selected literature pertinent to client/nurse educator collaboration as well as describe a model for, and discuss the impact of, client/nurse educator collaboration for third year undergraduate degree students enrolled in a Psychiatric Mental Health Nursing course. In addition, the paper will highlight some of the challenges and issues for client/nurse educator collaboration when educating students about serious mental illness, focusing on a client educator with a diagnosis of schizophrenia. Finally, critical aspects of the collaboration between nurse educator and client in preparing this paper for publication will be briefly outlined.
Models of collaboration Collaborative methods for involving clients in the education of health professionals have been gaining momentum in the past decade (Forrest et al. 2000). In order to change attitudes towards the mentally ill and to advance practice, we need to develop educationally useful, ethically appropriate models for involvement of clients in the education process. A study by Kelly and Wykurz (1998) used a ‘‘patient–partner attachment’’ clinical education model which involved medical students negotiating their learning objectives with clients and obtaining feedback on their clinical performance. The researchers reported
ª 2003 Elsevier Science Ltd. All rights reserved.
that this collaborative effort enhanced students’ empathy and communication skills and ‘‘enabled students to deepen their understanding of the factors and circumstances that influence health and health-care of patients, and to elevate the status of patients within the educational process’’ (p. 371). Hutchings (1999) described a collaborative educational strategy bringing together nurse educators and clients in joint in-service education sessions. Hutchings stressed the value of this approach for promoting client empowerment and for influencing an ‘‘attitudinal shift’’ which facilitated changes in staff practices (p. 131). The importance of client involvement for promoting attitude change is particularly important in mental health nursing education. A two-year collaborative education project by Clinton (1999), using a quasi-experimental design with comparison groups, brought together study participants with severe mental illness and undergraduate nursing students in joint education sessions focused on learning about mental illness. Based on the findings of this study the researchers concluded that their collaborative model was effective in changing stereotypical or negative attitudes of the nursing students towards persons with psychiatric disability. The success of this model was attributed to the opportunity for achieving ‘‘status equalization’’ and enhancing social interaction between student nurses and persons with mental illness (p. 101). Others have stressed the importance of involving clients at the level of curriculum design and delivery. A study by Rudman (1996) using grounded theory sought the views of users of mental health services for the purpose of shaping a new nursing curriculum. Similarly, Forrest et al. (2000) using focus group interviews highlighted a number of the issues inherent in promoting respectful models of client/nurse educator collaboration in particular the need for a ‘‘more radical approach to challenging and shifting the traditional power base and achieving involvement at the levels of curriculum planning, curriculum delivery – and curriculum evaluation.’’ (p. 55). The emphasis on participation at the curriculum design level and the benefits this can afford is a departure
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from more traditional ways of involving clients in the education process and takes ‘partnership’ with users of mental health services to a more meaningful level (Butterworth & Rushworth 1995; Rudman 1996).
The client in the role of educator In the clinical setting clients assume a passive role in the education of students although increasingly some clients do exercise their right to refuse consent to be assigned to students. In the classroom the client has clearly consented to be in the service of students’ learning and accepts responsibility for this role. Typically, a person with a mental illness or mental health issue is invited to speak about their own unique experience and is given an opportunity to discuss the nature of services provided, personal ways of coping and his or her perceptions of the nurse’s role. My own experience as a nurse educator suggests that it is not always clear how effective these sessions are and; moreover, whether there is mutual benefit for the client and the student. Lyons and Ziviani (1998) citing the work of Atkinson noted that notwithstanding the valuable learning that students may gain through exposure to clients both in the classroom and in clinical settings, there are often unplanned and unintended consequences of education practices referred to as the ‘‘hidden curriculum’’ (p. 105). They point out that students are not passive learners but are influenced by their learning goals, expectations, attitudes, values, and previous socialization experiences. These no doubt impact on what they see and hear in the classroom. Similarly, Mclaughlin (1997) pointed out that exposure to persons with mental illness does not necessarily lead to more positive attitudes towards mental illness. Mclaughlin refers to several studies where nursing students and/or nurses reported more negative attitudes with increased client contact. Attempting to consider and subsequently determine the most valuable educational contacts with clients in the classroom and to consider the nature of less visible consequences of this learning is perhaps worth pursuing, both from a practice and research perspective.
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Clearly, this dimension of learning is more difficult to measure. Research methods appropriate for accessing the role of experience and attitudes in student learning would inform understanding here. Some of the questions driving my own interest in this area include the following: How should we use clients in the classroom setting? Do we consider only their role as educator or should we not consider as well the potential implications, benefits, and risks for the clients/ consumers in carrying out the role as educator? What are the issues/challenges for nurse educators? Is the practice of using clients in the classroom educationally sound or even ethical? Attention to all these questions is beyond the scope of this paper. However a discussion of some of the issues/challenges for educators and the benefits of collaboration for the client educator is perhaps a helpful place to begin. For the past three years I have invited Kenneth Baikie, as a guest speaker in the Psychiatric Mental Health Nursing course I teach at Memorial University of Newfoundland to third year Bachelor of Nursing degree students. Ken was diagnosed with schizophrenia at age 18 and had had more than 30 admissions to hospital by age 29. The usual format for this class is a presentation by Ken who provides a brief history of his illness, a description of some of his conflicts with the health care and justice systems, and a discussion of his ways of coping with the challenges associated with the illness. I have been curious about the impact of these education sessions on Ken and on the students, over and beyond meeting course objectives. In particular, I’ve been interested in how much time he takes to prepare for the class, his stress level prior to the class and whether he personally gains anything from the experience. In preparation for his presentation Ken often comes to my office and chats with me about his plan for the ‘‘lecture’’. During these talks we share aspects of our personal philosophies and worldviews. His knowledge of, and love for, literature and the humanities have both challenged and inspired me. I have learned much about him as a person and also about mental illness but most importantly he has increased my awareness of my own biases and
ª 2003 Elsevier Science Ltd. All rights reserved.
The client as educator: learning about mental illness through the eyes of the expert
barriers to real understanding about mental illness. During one of these preparatory talks he did not look physically well to me. He admitted that doing these classes was stressful for him and he had to get ready, emotionally, for it. I learned much later that, at the time he was not eating or sleeping well, largely because he had been struggling with his current living arrangement. Each year he participates I have been impressed by his level of commitment to the task and impressed as well with the highly positive feedback from students; many students identifying his talk as their ‘‘most helpful learning experience’’. I did not, however, wish to make assumptions about the impact this educational endeavor had on students; neither did I like to think that his participation compromised his personal health and well-being.
Learning about the impact on students The impact of the client’s role in the classroom can be determined in part through course evaluations. I was interested in the more hidden dimensions of learning that Lyons and Ziviani (1998) referred to and I believed it would be useful to ask students to respond to a question on the final exam focused on Ken’s presentation. To this end, students in two consecutive years enrolled in the mental health course were asked to reflect on Ken’s presentation in considering the impact of a severe and persistent mental illness on personal well being. At a later point students were informed that I would be collaborating with Ken on a publication about his involvement in their learning. At this time permission was sought to include excerpts of their exam responses in a paper for publication. Specifically, the question on the final exam was posed as follows: Consider the following statement: ‘Having a mental illness affects personhood in a way that other forms of illness do not. A person may have a heart problem or other forms of chronic illness and preserve the integrity of the self. This is less likely for the person with schizophrenia. Do you agree or disagree with this statement and why?’
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Using Ken’s presentation to inform their exam responses placed value on the contribution he made to their learning and also permitted critical reflection on their individual learning particularly their understanding about mental illness. A reflective process is essential to learning in psychiatric nursing not only because it enhances critical thinking but also because it increases self-knowledge (Lyons 1999) and enhances the development of personal attributes needed for work with persons experiencing mental illness. Student’s responses showed evidence of empathy and an increased awareness of their own attitudes. Examples of responses included the following: ‘‘Ken’s descriptions of the things he faced i.e. his statement that the schizophrenic lives in a ‘pocket universe’ in which they create their own reality, reveals the sense of isolation and devastation that the individual with a mental illness experiences.’’ ‘‘What really touched me was that he said he was a writer, but it was now so difficult and draining that he could no longer do it.’’ ‘‘I was greatly touched and inspired to know that this man had gone through so much and how much he had to cope with. It was amazing to hear the experiences he had and how simple things, such as art therapy which many of us take for granted, helps him to focus on reality.’’ ‘‘He said he has always been a social outcast for example, he said ‘nice girls don’t date schizophrenics’. I think I even hold some of this stigma.’’ Other responses expressed insights gained with respect to how mental illness was lived on a daily basis and how these challenges must be met. Students’ comments included the following: ‘‘I believe the most profound impact. . .was the realization of just how amazingly difficult it is for someone suffering from a mental illness to deal with life. He left me with a respect and admiration for
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survivors of mental illness, a compassion for those still fighting, and a desire to help those who can’t fight anymore, that wasn’t there before.’’ ‘‘Although he (Ken) wasn’t what one would describe as a powerful or commanding orator his words evoked powerful emotions in me. . .’’ ‘‘The main thing I got from Ken’s presentation is that we as nurses often want to change peoples environments, involve them in more activities in an effort to improve their quality of life. But I now feel. . .we have to be willing to work with clients on their terms. It is often the simple things that make the biggest difference.’’ ‘‘My understanding of mental illness has changed. I had previously believed that because of the difficult symptoms and chronicity of mental illness, an affected person could have no understanding, acceptance or hope for a fulfilling life. Mr. Baikie has changed this.’’
Exploring the issues and challenges The primary challenge in using the client as educator is to provide a learning experience that will broaden the student’s understanding of mental illness, while simultaneously providing an opportunity for the client to enhance personal well-being and recovery. Campbell (1998) suggested that the way mental health educators involve client educators may not always be in the interest of students or clients themselves. He argued ‘‘service providers, while inviting users into positive influence, control the nature of the relationship and offer identities that merely enable a client status’’ (p. 240). My experience working with Ken, the co-author of this paper and contributor to my course Concepts of Mental Health, has helped me to re-examine notions about ‘appropriate’ client educator roles. During my association with Ken he has expressed himself as an educator in every sense. He is interested in the work of Socrates, the arts and the humanities, and has a personal
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philosophy of education. He speaks of his illness as a ‘vocation’ and as a way of ministering to others and of expressing himself. This represents I think a meaningful conceptualization of his illness which has enabled him to come to terms with it in ways he had been unable to, early in his illness trajectory. He described what he believed to be his unique contribution in the classroom: ‘‘In presenting material on schizophrenia I have used a variety of methods, i.e., lectures to appeal to young people who in most cases are encountering mental illness for the first time. I use many humorous anecdotes about institutional life, particularly where nurses and nursing students are involved; I allude to great writers and poetry that features psychotic characters and titles of books, i.e., ‘Crime and punishment’ by Dostoevsky, ‘Little Doritt’ by Charles Dickens, and many philosophical works. Perhaps most appealing of all were the stories I tell of visions, and voices, or of seeing ‘gods’, saints, and Jesus. . . And how I was learning to express the things I felt and saw through art and literature, humble as my efforts might be – I found that an important discovery in the classroom with university student nurses was that they have issues in their own lives; 19 years old experiencing fear of the big city, sex and longing for sex and many other anxieties that unsettle the mind. These were to some extent addressed by my stories of illness and recovery and the faith that overcomes it.’’ Client/nurse educator partnerships are about establishing relationships, enlarging perceptions, and assisting students not only to learn about mental illness but also to find common ground and empathy with the experience of others. As an educator I have been aware of gradual changes in my own perceptions about what constituted appropriate material for inclusion in Ken’s presentation. Initially I questioned the value of Ken including detailed description of previous delusional ideation and/or hallucinatory experiences in his presentations because of my concern with perhaps ‘‘reinforcing’’ or
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The client as educator: learning about mental illness through the eyes of the expert
validating these ideas. For example, he had stated at one point during a presentation that he had not entirely ‘‘let go of the Messianic mission. . .my long held delusion that I am a Messiah, a Savior type, a blend of the Hindu Avatar and the Christian Jesus, and Jewish King David.’’ He later explained his use of this idea in terms of his Christian faith and belief system. He writes: This is actually more like being a literary model or typology of Christ in a story that is played out. It is having the mind of Christ and learning to validate one’s life by seeing a pattern in one’s experience that identifies oneself with the most powerful ‘myth figure’ in human consciousness in human form – it is after all a suffering man’s response to Jesus’ invitation to ‘learn of me’. Ken argued that there is nothing wrong with validating dimensions of pathology in illness. He asks: ‘‘Who can say that a person has not experienced a valid theophany or obtained relevant insights during the course of an acute illness?’’ His comments here clarified his views about the meaning and role of his symptoms in a way not understood prior to our collaboration.
gaining ground’’ were often surprising. (p. 583). Ken’s compelling self reflections and unique way of describing his illness trajectory, his emphasis on stories highlighting his experiences and the dignity and meaning he found in his illness, echo sentiments about the individuality of recovery and the recovery journey. In particular, Ken believed that the opportunity to talk to nursing students in a classroom environment helped him to reconcile past experiences. He wrote: ‘‘Having left university with an incomplete Bachelor of Arts Program and having had the experience of being an alienated youth with no real peer group I found returning in the capacity of guest lecturer to be most refreshing. To be a benevolent wise old man (tongue in cheek, he’s just 36) instructing 19 year olds, had the effect of reconciling myself to the years of psychosis that began with university in my late teens. A schizophrenic is not used to being call Sir or Mr. Baikie by young adults. By and large it has had the effect of making me enjoy young people in a way I never did when I was young myself.’’
Facilitating client recovery
Benefits of collaboration
Another issue important for the nurse educator is how the client’s involvement in the classroom may contribute to the client’s ongoing recovery, health and well-being. Understanding of the role of illness in shaping the client’s identity, self concept and ever-changing perspectives in the process of recovery is especially important in this regard. Champ (1998) recalls the gradual process of coming to terms with his schizophrenia and his relationship to it. For example, he speaks of embracing the label of ‘schizophrenic’ with pride and acceptance at one point in his illness trajectory, and at another point rejecting this view, seeing the illness as influencing but not defining him. Similarly, Deegan (1997) speaks of ‘‘recovery as a journey not a destination, or cure’’ (p. 11). Chadwick (1997) speaks of the individuality of recovery observing that ‘‘the individual differences in the path people have found to both staying sane and genuinely
The most valuable aspect of the education model described in this paper, for me, was the collaborative opportunity which included: preparation for involvement in the classroom, actual participation, and the consultation necessary for preparing this manuscript for publication purposes. In addition to my review of Ken’s ideas he also reviewed my drafts and critiqued them for validation and literary purposes. Ken’s arts and humanities background proved to be invaluable. However, it was his critique of my assumptions, and perceptions about the education process as it related to his role, as well as our discussion about the integration of, and balance between, pathology and personhood which proved to be most valuable. His comments in reaction to my concern about the possibility of the possible exploitation of clients as educators were both enlightening and sobering! He wrote:
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‘‘Your anxieties are largely unfounded and reflect a sort of white man’s burden or rather a ‘sane man’s burden’ toward ‘poor silly people’ who need to be lifted from the dust. You are in the position of missionary mennonite nurse in Labrador telling an Innu elder how to think ethically and morally when you are in fact showing a paternal/maternal attitude to someone you believe can’t fend for himself but who has an equally valid set of values.’’ The collaborative process also provided him with an opportunity to review and comment on many of the students’ responses to the exam questions. He expressed appreciation for their reference to details of his contribution to the course and he acknowledged respectfully their individual observations about him as well as their personal learning and insights. He commented, for example, that some students’ reflections conveyed an understanding or empathy for his experience, which he knew to be true but which he hadn’t thought about at the time. He noted as well that it was particularly satisfying for a person with schizophrenia ‘‘to elicit such fine sentiments from a class of 50 nineteen year old young women and indeed some of that ‘‘isolation’’ the students referred to as applying to him ‘‘was bridged in these classrooms, the rubble reconstructed’’ so to speak. In response to my comment that his views had changed my own perceptions he commented wryly, ‘‘the fact that a schizophrenic can change anyone’s perceptions on anything is a sign that he has developed a healthy or rather stronger link in his recovery don’t you think?’’
Conclusion The role of the client as educator in the classroom has implications for changing views about mental illness, for enhancing nursing practice and most importantly for preserving personhood. As educators we may have lofty goals about listening to and using the views of clients to shape health policy decisions and to bring about meaningful changes in practice. It may be a more reasonable goal to be clear about what is happening at the classroom level. Ideally, students who learn about clients’ perspectives should do so in ways that
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enhance their understanding of their shared humanity with those experiencing mental illness. This may require the nurse educator to move away from traditional ways of involving clients in the learning process. That is, deciding on what the focus should be, what questions need to be asked and how these should be addressed. It is clear that the client with a mental illness has much to contribute in the classroom both in terms of knowledge about the specifics of the disorder and its effects; but more importantly understanding about the nature of lived experience, and personhood as it relates to the illness. Although the classroom and education exists primarily for students, with educational experiences designed primarily to enhance learning and broaden perspectives for students, why should not it also serve to facilitate the searching and questioning about the illness in the process of recovery for the client educator? Client/nurse educator partnerships that respect and give voice to the client’s identity as a person and not just as a user of mental health services could go a long way toward bridging the gulf students often believe exists between the so-called ‘mentally healthy’ and the ‘mentally unhealthy’. These partnerships can correct and challenge distortions, inequities and beliefs typically part of the socialization experiences of students. Through working with Ken I have become increasingly aware of the need to move beyond setting the agenda for his involvement and to allow for more spontaneity and serendipity in the classroom. His contribution to the education of nursing students in our recent collaboration, which included: dialogue about the learning process and learning needs of nursing students; decision-making about the nature of his participation, the opportunity to respond to students’ questions about many aspects of his life, not just his illness; and his reflection and comment on student exam responses as we worked together on this paper, was in every sense a reciprocal relationship process that served the goals of client and nurse educator. Most importantly, I have come to value the client educator’s unique position of expertise at both the classroom and curriculum levels.
ª 2003 Elsevier Science Ltd. All rights reserved.
The client as educator: learning about mental illness through the eyes of the expert
In the final analysis involving clients in nursing education has the potential to be a transformative learning process for students and nurse educators. Barker (1996) noted ‘‘Having learned what to do for the patient, from the patient, nurses often gain some understanding or insight which changes them imperceptibly. This small change in their professional demeanor influences their next interaction and so on ad infinitum’’ (p. 5). This kind of learning is more likely to be possible when models of collaboration promote mutual influence and respect. Ultimately the goal of collaborative models is to facilitate this process in an ethically responsible way in order to advance practice. References Barker PS 1996 The logic of experience: developing appropriate care through effective collaboration. Australian and New Zealand Journal of Mental Health Nursing 5: 3–12 Butterworth T, Rushforth D 1995 Working in partnership with people who use services; reaffirming the foundations of practice for mental health nursing. International Journal of Nursing Studies 32: 373–385 Campbell 1998 Listening to clients. In: Barker PJ, Davidson B (eds). Ethical Strife. Arnold Press, London, pp. 237– 248 Chadwick PK 1997 Recovery from psychosis: learning more from patients. Journal of Mental Health 6(6): 577–588 Champ S 1998 A most precious thread. Australian and New Zealand Journal of Mental Health Nursing 7: 54–59 Clinton M 1999 Collaborative education and social stereotypes. Australian and New Zealand Journal of Mental Health Nursing 8: 100–103
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Deegan PE 1997 Recovery and empowerment for people with psychiatric disabilities. Social Work in Health Care 25(3): 11–24 Forrest S, Risk I, Masters & Brown N 2000 Mental health service user involvement in nurse education: exploring the issues. Journal of Psychiatric Mental Health Nursing 7: 51–57 Frese FS 2000 My name is Fred and I am ‘‘schizophrenic’’. Journal of the California Alliance for the Mentally Ill 9(1): 17–18 Gamble C, Brennan G 2000 Working with Serious Mental Illness: A Manual for Clinical Practice. Bailliere Tindall, Toronto Happell B, Rushworth L 2000 Can educational methods influence the popularity of psychiatric nursing? Nurse Education Today 20(4): 318–326 Hutchings D 1999 Partnership in education: an example of client and educator collaboration. The Journal of Continuing Education in Nursing 30(3): 128–131 Kelly D, Wykurz G 1998 Patients as teachers: a new perspective in medical education. Education for Health 11(3): 369–377 Lyons J 1999 Reflective education for professional practice: discovering knowledge from experience. Nurse Education Today 19: 29–34 Lyons M, Ziviani J 1998 I’m allowed to experiment: the role of people with psychiatric disorders in facilitating students’ learning. Occupational Therapy International 5(2): 104–117 McLaughlin C 1997 The effect of classroom theory and contact with patients on the attitudes of student nurses towards mentally ill people. Journal of Advanced Nursing 26: 1221–1228 Obletz P 2000 Onward from change of mind. Journal of the California Alliance of the Mentally Ill 6(2): 56–58 Rudman MJ 1996 User involvement in the nursing curriculum: seeking users’ views. Journal of Psychiatric and Mental Health Nursing 3: 195–200 Small RD, Sudar M 1995 Islands of brilliance. Psychosocial Rehabilitation Journal 18(3): 37–50
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The client as educator: learning about mental illness through the eyes of the expert Lorna Bennett and Kenneth Baikie
Increasingly, educators are asking clients who have a mental illness to make a contribution to nursing students’ learning as a way of informing their attitudes towards persons experiencing mental illness and thus enhancing care delivery. The nature of clients’ involvement in the classroom and the quality of learning by students through this approach has rarely been questioned. This paper discusses a model of client/nurse educator collaboration in a mental health course with undergraduate nursing students. It draws on the nursing education experiences of the first author, and the personal views of the second author, a user of mental health services. Specifically, it addresses positive features of collaboration as perceived by students, client, and nurse educator and analyzes some of the challenges/issues for the nurse educator. In addition, it outlines helpful aspects of the collaborative process for both nurse educator and client, in particular, its impact on the client’s personal well being. This kind of analysis is essential if we are to develop education models of such collaboration that are beneficial for all partners in the learning process. ª 2003 Elsevier Science Ltd. All rights reserved.
Introduction Lorna Bennett RN, MN, Associate Professor, Memorial University of Newfoundland, School of Nursing, St. John’s, NF, Canada, A1B 3V6. Tel.: +1-709-7777332; Fax: +1-709-7777037 E-mail: [email protected] Kenneth Baikie Co-educator for undergraduate nursing, Mental Health Nursing (Requests for offprints to LB) Manuscript accepted: 16 September 2002
The idea of using client perspectives of mental illness and mental health services as a means for educating health care providers and the general public is not new. In more recent times, partly due to the impact of the client/ consumer/survivor advocacy movement greater attention has been focused on the client’s perspective, both in the mental health literature and in the classroom. The voice of those experiencing mental illness has been heard to some extent, particularly in reference to concerns about the nature of treatment, the violation of client rights, attitudes of society, and views about forced treatment of the mentally ill (Champ 1998; Frese 2000; Obletz 2000). Less has been said about the day-to-day experience of mental illness from the perspective of clients, including their views about best practice and treatment and their role
104 Nurse Education Today (2003) 23, 104–111
in the education process. A focus on the client is essential from the perspective of both the educator and researcher given that the best ‘‘evidence’’ for providing direction for practice begins with the client (Gamble & Brennan 2000). Moreover, educational methods that engage students in Psychiatric Mental Health Nursing (P/MH) in meaningful ways could increase the likelihood of students pursuing a career in this specialty (Happell & Rushworth 2000). The possibilities for the role of the client as educator and the nature of this participation for clients experiencing a range of health problems has already generated some discussion in the literature. While it needs it be recognized that there is, as yet, little empirical evidence to support or refute current positions, the consensus among health professionals is that clients in educator roles are able to
0260-6917/03/$ - see front matter ª 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0260-6917(02)00193-4
The client as educator: learning about mental illness through the eyes of the expert
increase students’ awareness of clients’ expertise, sensitize health care providers about the issue and challenges, support person-hood and strengthen relationships between clients, their families, and caregivers (Barker 1996; Clinton 1999; Hutchings 1999; Kelly & Wykurz 1998; Small & Sudar 1995). The role of client educators in student nurse education, in particular, the potential benefits of collaboration between client educators and nurse educators is a critical issue to consider particularly for students enrolled in psychiatric mental health nursing courses (Clinton 1999; Forrest et al. 2000). Clinton (1999) reports that collaborative education is useful for breaking down social stereotypes and helping to promote positive attitudes towards those experiencing mental illness an important goal of undergraduate nursing education. This paper will identify selected literature pertinent to client/nurse educator collaboration as well as describe a model for, and discuss the impact of, client/nurse educator collaboration for third year undergraduate degree students enrolled in a Psychiatric Mental Health Nursing course. In addition, the paper will highlight some of the challenges and issues for client/nurse educator collaboration when educating students about serious mental illness, focusing on a client educator with a diagnosis of schizophrenia. Finally, critical aspects of the collaboration between nurse educator and client in preparing this paper for publication will be briefly outlined.
Models of collaboration Collaborative methods for involving clients in the education of health professionals have been gaining momentum in the past decade (Forrest et al. 2000). In order to change attitudes towards the mentally ill and to advance practice, we need to develop educationally useful, ethically appropriate models for involvement of clients in the education process. A study by Kelly and Wykurz (1998) used a ‘‘patient–partner attachment’’ clinical education model which involved medical students negotiating their learning objectives with clients and obtaining feedback on their clinical performance. The researchers reported
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that this collaborative effort enhanced students’ empathy and communication skills and ‘‘enabled students to deepen their understanding of the factors and circumstances that influence health and health-care of patients, and to elevate the status of patients within the educational process’’ (p. 371). Hutchings (1999) described a collaborative educational strategy bringing together nurse educators and clients in joint in-service education sessions. Hutchings stressed the value of this approach for promoting client empowerment and for influencing an ‘‘attitudinal shift’’ which facilitated changes in staff practices (p. 131). The importance of client involvement for promoting attitude change is particularly important in mental health nursing education. A two-year collaborative education project by Clinton (1999), using a quasi-experimental design with comparison groups, brought together study participants with severe mental illness and undergraduate nursing students in joint education sessions focused on learning about mental illness. Based on the findings of this study the researchers concluded that their collaborative model was effective in changing stereotypical or negative attitudes of the nursing students towards persons with psychiatric disability. The success of this model was attributed to the opportunity for achieving ‘‘status equalization’’ and enhancing social interaction between student nurses and persons with mental illness (p. 101). Others have stressed the importance of involving clients at the level of curriculum design and delivery. A study by Rudman (1996) using grounded theory sought the views of users of mental health services for the purpose of shaping a new nursing curriculum. Similarly, Forrest et al. (2000) using focus group interviews highlighted a number of the issues inherent in promoting respectful models of client/nurse educator collaboration in particular the need for a ‘‘more radical approach to challenging and shifting the traditional power base and achieving involvement at the levels of curriculum planning, curriculum delivery – and curriculum evaluation.’’ (p. 55). The emphasis on participation at the curriculum design level and the benefits this can afford is a departure
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from more traditional ways of involving clients in the education process and takes ‘partnership’ with users of mental health services to a more meaningful level (Butterworth & Rushworth 1995; Rudman 1996).
The client in the role of educator In the clinical setting clients assume a passive role in the education of students although increasingly some clients do exercise their right to refuse consent to be assigned to students. In the classroom the client has clearly consented to be in the service of students’ learning and accepts responsibility for this role. Typically, a person with a mental illness or mental health issue is invited to speak about their own unique experience and is given an opportunity to discuss the nature of services provided, personal ways of coping and his or her perceptions of the nurse’s role. My own experience as a nurse educator suggests that it is not always clear how effective these sessions are and; moreover, whether there is mutual benefit for the client and the student. Lyons and Ziviani (1998) citing the work of Atkinson noted that notwithstanding the valuable learning that students may gain through exposure to clients both in the classroom and in clinical settings, there are often unplanned and unintended consequences of education practices referred to as the ‘‘hidden curriculum’’ (p. 105). They point out that students are not passive learners but are influenced by their learning goals, expectations, attitudes, values, and previous socialization experiences. These no doubt impact on what they see and hear in the classroom. Similarly, Mclaughlin (1997) pointed out that exposure to persons with mental illness does not necessarily lead to more positive attitudes towards mental illness. Mclaughlin refers to several studies where nursing students and/or nurses reported more negative attitudes with increased client contact. Attempting to consider and subsequently determine the most valuable educational contacts with clients in the classroom and to consider the nature of less visible consequences of this learning is perhaps worth pursuing, both from a practice and research perspective.
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Clearly, this dimension of learning is more difficult to measure. Research methods appropriate for accessing the role of experience and attitudes in student learning would inform understanding here. Some of the questions driving my own interest in this area include the following: How should we use clients in the classroom setting? Do we consider only their role as educator or should we not consider as well the potential implications, benefits, and risks for the clients/ consumers in carrying out the role as educator? What are the issues/challenges for nurse educators? Is the practice of using clients in the classroom educationally sound or even ethical? Attention to all these questions is beyond the scope of this paper. However a discussion of some of the issues/challenges for educators and the benefits of collaboration for the client educator is perhaps a helpful place to begin. For the past three years I have invited Kenneth Baikie, as a guest speaker in the Psychiatric Mental Health Nursing course I teach at Memorial University of Newfoundland to third year Bachelor of Nursing degree students. Ken was diagnosed with schizophrenia at age 18 and had had more than 30 admissions to hospital by age 29. The usual format for this class is a presentation by Ken who provides a brief history of his illness, a description of some of his conflicts with the health care and justice systems, and a discussion of his ways of coping with the challenges associated with the illness. I have been curious about the impact of these education sessions on Ken and on the students, over and beyond meeting course objectives. In particular, I’ve been interested in how much time he takes to prepare for the class, his stress level prior to the class and whether he personally gains anything from the experience. In preparation for his presentation Ken often comes to my office and chats with me about his plan for the ‘‘lecture’’. During these talks we share aspects of our personal philosophies and worldviews. His knowledge of, and love for, literature and the humanities have both challenged and inspired me. I have learned much about him as a person and also about mental illness but most importantly he has increased my awareness of my own biases and
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The client as educator: learning about mental illness through the eyes of the expert
barriers to real understanding about mental illness. During one of these preparatory talks he did not look physically well to me. He admitted that doing these classes was stressful for him and he had to get ready, emotionally, for it. I learned much later that, at the time he was not eating or sleeping well, largely because he had been struggling with his current living arrangement. Each year he participates I have been impressed by his level of commitment to the task and impressed as well with the highly positive feedback from students; many students identifying his talk as their ‘‘most helpful learning experience’’. I did not, however, wish to make assumptions about the impact this educational endeavor had on students; neither did I like to think that his participation compromised his personal health and well-being.
Learning about the impact on students The impact of the client’s role in the classroom can be determined in part through course evaluations. I was interested in the more hidden dimensions of learning that Lyons and Ziviani (1998) referred to and I believed it would be useful to ask students to respond to a question on the final exam focused on Ken’s presentation. To this end, students in two consecutive years enrolled in the mental health course were asked to reflect on Ken’s presentation in considering the impact of a severe and persistent mental illness on personal well being. At a later point students were informed that I would be collaborating with Ken on a publication about his involvement in their learning. At this time permission was sought to include excerpts of their exam responses in a paper for publication. Specifically, the question on the final exam was posed as follows: Consider the following statement: ‘Having a mental illness affects personhood in a way that other forms of illness do not. A person may have a heart problem or other forms of chronic illness and preserve the integrity of the self. This is less likely for the person with schizophrenia. Do you agree or disagree with this statement and why?’
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Using Ken’s presentation to inform their exam responses placed value on the contribution he made to their learning and also permitted critical reflection on their individual learning particularly their understanding about mental illness. A reflective process is essential to learning in psychiatric nursing not only because it enhances critical thinking but also because it increases self-knowledge (Lyons 1999) and enhances the development of personal attributes needed for work with persons experiencing mental illness. Student’s responses showed evidence of empathy and an increased awareness of their own attitudes. Examples of responses included the following: ‘‘Ken’s descriptions of the things he faced i.e. his statement that the schizophrenic lives in a ‘pocket universe’ in which they create their own reality, reveals the sense of isolation and devastation that the individual with a mental illness experiences.’’ ‘‘What really touched me was that he said he was a writer, but it was now so difficult and draining that he could no longer do it.’’ ‘‘I was greatly touched and inspired to know that this man had gone through so much and how much he had to cope with. It was amazing to hear the experiences he had and how simple things, such as art therapy which many of us take for granted, helps him to focus on reality.’’ ‘‘He said he has always been a social outcast for example, he said ‘nice girls don’t date schizophrenics’. I think I even hold some of this stigma.’’ Other responses expressed insights gained with respect to how mental illness was lived on a daily basis and how these challenges must be met. Students’ comments included the following: ‘‘I believe the most profound impact. . .was the realization of just how amazingly difficult it is for someone suffering from a mental illness to deal with life. He left me with a respect and admiration for
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survivors of mental illness, a compassion for those still fighting, and a desire to help those who can’t fight anymore, that wasn’t there before.’’ ‘‘Although he (Ken) wasn’t what one would describe as a powerful or commanding orator his words evoked powerful emotions in me. . .’’ ‘‘The main thing I got from Ken’s presentation is that we as nurses often want to change peoples environments, involve them in more activities in an effort to improve their quality of life. But I now feel. . .we have to be willing to work with clients on their terms. It is often the simple things that make the biggest difference.’’ ‘‘My understanding of mental illness has changed. I had previously believed that because of the difficult symptoms and chronicity of mental illness, an affected person could have no understanding, acceptance or hope for a fulfilling life. Mr. Baikie has changed this.’’
Exploring the issues and challenges The primary challenge in using the client as educator is to provide a learning experience that will broaden the student’s understanding of mental illness, while simultaneously providing an opportunity for the client to enhance personal well-being and recovery. Campbell (1998) suggested that the way mental health educators involve client educators may not always be in the interest of students or clients themselves. He argued ‘‘service providers, while inviting users into positive influence, control the nature of the relationship and offer identities that merely enable a client status’’ (p. 240). My experience working with Ken, the co-author of this paper and contributor to my course Concepts of Mental Health, has helped me to re-examine notions about ‘appropriate’ client educator roles. During my association with Ken he has expressed himself as an educator in every sense. He is interested in the work of Socrates, the arts and the humanities, and has a personal
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philosophy of education. He speaks of his illness as a ‘vocation’ and as a way of ministering to others and of expressing himself. This represents I think a meaningful conceptualization of his illness which has enabled him to come to terms with it in ways he had been unable to, early in his illness trajectory. He described what he believed to be his unique contribution in the classroom: ‘‘In presenting material on schizophrenia I have used a variety of methods, i.e., lectures to appeal to young people who in most cases are encountering mental illness for the first time. I use many humorous anecdotes about institutional life, particularly where nurses and nursing students are involved; I allude to great writers and poetry that features psychotic characters and titles of books, i.e., ‘Crime and punishment’ by Dostoevsky, ‘Little Doritt’ by Charles Dickens, and many philosophical works. Perhaps most appealing of all were the stories I tell of visions, and voices, or of seeing ‘gods’, saints, and Jesus. . . And how I was learning to express the things I felt and saw through art and literature, humble as my efforts might be – I found that an important discovery in the classroom with university student nurses was that they have issues in their own lives; 19 years old experiencing fear of the big city, sex and longing for sex and many other anxieties that unsettle the mind. These were to some extent addressed by my stories of illness and recovery and the faith that overcomes it.’’ Client/nurse educator partnerships are about establishing relationships, enlarging perceptions, and assisting students not only to learn about mental illness but also to find common ground and empathy with the experience of others. As an educator I have been aware of gradual changes in my own perceptions about what constituted appropriate material for inclusion in Ken’s presentation. Initially I questioned the value of Ken including detailed description of previous delusional ideation and/or hallucinatory experiences in his presentations because of my concern with perhaps ‘‘reinforcing’’ or
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The client as educator: learning about mental illness through the eyes of the expert
validating these ideas. For example, he had stated at one point during a presentation that he had not entirely ‘‘let go of the Messianic mission. . .my long held delusion that I am a Messiah, a Savior type, a blend of the Hindu Avatar and the Christian Jesus, and Jewish King David.’’ He later explained his use of this idea in terms of his Christian faith and belief system. He writes: This is actually more like being a literary model or typology of Christ in a story that is played out. It is having the mind of Christ and learning to validate one’s life by seeing a pattern in one’s experience that identifies oneself with the most powerful ‘myth figure’ in human consciousness in human form – it is after all a suffering man’s response to Jesus’ invitation to ‘learn of me’. Ken argued that there is nothing wrong with validating dimensions of pathology in illness. He asks: ‘‘Who can say that a person has not experienced a valid theophany or obtained relevant insights during the course of an acute illness?’’ His comments here clarified his views about the meaning and role of his symptoms in a way not understood prior to our collaboration.
gaining ground’’ were often surprising. (p. 583). Ken’s compelling self reflections and unique way of describing his illness trajectory, his emphasis on stories highlighting his experiences and the dignity and meaning he found in his illness, echo sentiments about the individuality of recovery and the recovery journey. In particular, Ken believed that the opportunity to talk to nursing students in a classroom environment helped him to reconcile past experiences. He wrote: ‘‘Having left university with an incomplete Bachelor of Arts Program and having had the experience of being an alienated youth with no real peer group I found returning in the capacity of guest lecturer to be most refreshing. To be a benevolent wise old man (tongue in cheek, he’s just 36) instructing 19 year olds, had the effect of reconciling myself to the years of psychosis that began with university in my late teens. A schizophrenic is not used to being call Sir or Mr. Baikie by young adults. By and large it has had the effect of making me enjoy young people in a way I never did when I was young myself.’’
Facilitating client recovery
Benefits of collaboration
Another issue important for the nurse educator is how the client’s involvement in the classroom may contribute to the client’s ongoing recovery, health and well-being. Understanding of the role of illness in shaping the client’s identity, self concept and ever-changing perspectives in the process of recovery is especially important in this regard. Champ (1998) recalls the gradual process of coming to terms with his schizophrenia and his relationship to it. For example, he speaks of embracing the label of ‘schizophrenic’ with pride and acceptance at one point in his illness trajectory, and at another point rejecting this view, seeing the illness as influencing but not defining him. Similarly, Deegan (1997) speaks of ‘‘recovery as a journey not a destination, or cure’’ (p. 11). Chadwick (1997) speaks of the individuality of recovery observing that ‘‘the individual differences in the path people have found to both staying sane and genuinely
The most valuable aspect of the education model described in this paper, for me, was the collaborative opportunity which included: preparation for involvement in the classroom, actual participation, and the consultation necessary for preparing this manuscript for publication purposes. In addition to my review of Ken’s ideas he also reviewed my drafts and critiqued them for validation and literary purposes. Ken’s arts and humanities background proved to be invaluable. However, it was his critique of my assumptions, and perceptions about the education process as it related to his role, as well as our discussion about the integration of, and balance between, pathology and personhood which proved to be most valuable. His comments in reaction to my concern about the possibility of the possible exploitation of clients as educators were both enlightening and sobering! He wrote:
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‘‘Your anxieties are largely unfounded and reflect a sort of white man’s burden or rather a ‘sane man’s burden’ toward ‘poor silly people’ who need to be lifted from the dust. You are in the position of missionary mennonite nurse in Labrador telling an Innu elder how to think ethically and morally when you are in fact showing a paternal/maternal attitude to someone you believe can’t fend for himself but who has an equally valid set of values.’’ The collaborative process also provided him with an opportunity to review and comment on many of the students’ responses to the exam questions. He expressed appreciation for their reference to details of his contribution to the course and he acknowledged respectfully their individual observations about him as well as their personal learning and insights. He commented, for example, that some students’ reflections conveyed an understanding or empathy for his experience, which he knew to be true but which he hadn’t thought about at the time. He noted as well that it was particularly satisfying for a person with schizophrenia ‘‘to elicit such fine sentiments from a class of 50 nineteen year old young women and indeed some of that ‘‘isolation’’ the students referred to as applying to him ‘‘was bridged in these classrooms, the rubble reconstructed’’ so to speak. In response to my comment that his views had changed my own perceptions he commented wryly, ‘‘the fact that a schizophrenic can change anyone’s perceptions on anything is a sign that he has developed a healthy or rather stronger link in his recovery don’t you think?’’
Conclusion The role of the client as educator in the classroom has implications for changing views about mental illness, for enhancing nursing practice and most importantly for preserving personhood. As educators we may have lofty goals about listening to and using the views of clients to shape health policy decisions and to bring about meaningful changes in practice. It may be a more reasonable goal to be clear about what is happening at the classroom level. Ideally, students who learn about clients’ perspectives should do so in ways that
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enhance their understanding of their shared humanity with those experiencing mental illness. This may require the nurse educator to move away from traditional ways of involving clients in the learning process. That is, deciding on what the focus should be, what questions need to be asked and how these should be addressed. It is clear that the client with a mental illness has much to contribute in the classroom both in terms of knowledge about the specifics of the disorder and its effects; but more importantly understanding about the nature of lived experience, and personhood as it relates to the illness. Although the classroom and education exists primarily for students, with educational experiences designed primarily to enhance learning and broaden perspectives for students, why should not it also serve to facilitate the searching and questioning about the illness in the process of recovery for the client educator? Client/nurse educator partnerships that respect and give voice to the client’s identity as a person and not just as a user of mental health services could go a long way toward bridging the gulf students often believe exists between the so-called ‘mentally healthy’ and the ‘mentally unhealthy’. These partnerships can correct and challenge distortions, inequities and beliefs typically part of the socialization experiences of students. Through working with Ken I have become increasingly aware of the need to move beyond setting the agenda for his involvement and to allow for more spontaneity and serendipity in the classroom. His contribution to the education of nursing students in our recent collaboration, which included: dialogue about the learning process and learning needs of nursing students; decision-making about the nature of his participation, the opportunity to respond to students’ questions about many aspects of his life, not just his illness; and his reflection and comment on student exam responses as we worked together on this paper, was in every sense a reciprocal relationship process that served the goals of client and nurse educator. Most importantly, I have come to value the client educator’s unique position of expertise at both the classroom and curriculum levels.
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The client as educator: learning about mental illness through the eyes of the expert
In the final analysis involving clients in nursing education has the potential to be a transformative learning process for students and nurse educators. Barker (1996) noted ‘‘Having learned what to do for the patient, from the patient, nurses often gain some understanding or insight which changes them imperceptibly. This small change in their professional demeanor influences their next interaction and so on ad infinitum’’ (p. 5). This kind of learning is more likely to be possible when models of collaboration promote mutual influence and respect. Ultimately the goal of collaborative models is to facilitate this process in an ethically responsible way in order to advance practice. References Barker PS 1996 The logic of experience: developing appropriate care through effective collaboration. Australian and New Zealand Journal of Mental Health Nursing 5: 3–12 Butterworth T, Rushforth D 1995 Working in partnership with people who use services; reaffirming the foundations of practice for mental health nursing. International Journal of Nursing Studies 32: 373–385 Campbell 1998 Listening to clients. In: Barker PJ, Davidson B (eds). Ethical Strife. Arnold Press, London, pp. 237– 248 Chadwick PK 1997 Recovery from psychosis: learning more from patients. Journal of Mental Health 6(6): 577–588 Champ S 1998 A most precious thread. Australian and New Zealand Journal of Mental Health Nursing 7: 54–59 Clinton M 1999 Collaborative education and social stereotypes. Australian and New Zealand Journal of Mental Health Nursing 8: 100–103
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Deegan PE 1997 Recovery and empowerment for people with psychiatric disabilities. Social Work in Health Care 25(3): 11–24 Forrest S, Risk I, Masters & Brown N 2000 Mental health service user involvement in nurse education: exploring the issues. Journal of Psychiatric Mental Health Nursing 7: 51–57 Frese FS 2000 My name is Fred and I am ‘‘schizophrenic’’. Journal of the California Alliance for the Mentally Ill 9(1): 17–18 Gamble C, Brennan G 2000 Working with Serious Mental Illness: A Manual for Clinical Practice. Bailliere Tindall, Toronto Happell B, Rushworth L 2000 Can educational methods influence the popularity of psychiatric nursing? Nurse Education Today 20(4): 318–326 Hutchings D 1999 Partnership in education: an example of client and educator collaboration. The Journal of Continuing Education in Nursing 30(3): 128–131 Kelly D, Wykurz G 1998 Patients as teachers: a new perspective in medical education. Education for Health 11(3): 369–377 Lyons J 1999 Reflective education for professional practice: discovering knowledge from experience. Nurse Education Today 19: 29–34 Lyons M, Ziviani J 1998 I’m allowed to experiment: the role of people with psychiatric disorders in facilitating students’ learning. Occupational Therapy International 5(2): 104–117 McLaughlin C 1997 The effect of classroom theory and contact with patients on the attitudes of student nurses towards mentally ill people. Journal of Advanced Nursing 26: 1221–1228 Obletz P 2000 Onward from change of mind. Journal of the California Alliance of the Mentally Ill 6(2): 56–58 Rudman MJ 1996 User involvement in the nursing curriculum: seeking users’ views. Journal of Psychiatric and Mental Health Nursing 3: 195–200 Small RD, Sudar M 1995 Islands of brilliance. Psychosocial Rehabilitation Journal 18(3): 37–50
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