International Journal of Psychosocial Rehabilitation
new system of mental health practice
in Coping (PinC)
Maureen Jubb.MN, BN, PG Cert CMHN.
Community Mental Health Nurse
Great Southern Mental Health Service
Albany, Western Australia, Australia.
Eamon Shanley.PhD, MSc, BA(Hons), CMHN.
Old Nornalup Hospital,South
Nornalup,Western Australia, Australia 6398.
Jubb, M & Shanley, E
(2005). In the PinC - Trialing of a new system of mental health practice
(Partnership in Coping (PinC).
Rehabilitation. 10 (1), 19-26.
P.O. Box 290,WALPOLE Western Australia 6398Australia
This paper describes the
trialing of a system of mental health practice (Partnership in Coping).
The system was formulated to translate the philosophy of the recovery
model into a practical day-to-day approach to be used by mental health
workers. The purpose of the research was to refine the operation of the
Partnership in Coping (PinC) system using the subjective experiences of
clients and mental health nurses participating in the project.Action
research was employed. Data collected by individual interviews and
Focus Group meetings were analysed using thematic content analysis.The
results of the study were that changes were made to the paperwork and
four main changes made to the documentation protocol. An indication of
the appreciation of the PinC system was that the nurses and clients
requested to continue to use the PinC system after the trial was over.
This was approved by management within the health service.
Keywords: Partnership in
Coping, rehabilitation, mental health workers, mental health nursing,
psychiatric nursing, action research.
The purpose of this study was to refine the operation of the PinC
system using the subjective experiences of clients and mental health
nurses employing Action Research. Action Research, using the technical
collaborative approach was considered to be the most appropriate method
of research for this project because it is grounded in practice, uses
real life situations, is collaborative and action orientated and
designed to initiate change in clinical practice. The use of Action
Research in this study was also seen as an empowering experience for
participants, who played an integral part in the change process.
This method of research is commensurate with the PinC philosophy in
that clients take an active part in the refinement of a system that had
been tailor-made to address their concerns.
Currently mental health services reflect the approach of the
traditional medical model in providing a pathological perspective. This
view sees people who experience mental illness as being passive with
little regard for their views, opinions or wishes. Mental health
nursing practice has been criticised as being biometrically orientated
to the detriment of the humanistic focus (Barker, 1995; Cole &
Shanley, 1998; Cutcliffe, 2000; Dawson, 1997; Horsfall, 1997; Horsfall
& Stuhlmiller, 2000). Shepherd et al (1994) pointed out that
clinicians emphasise compliance with medication regimes and monitoring
of mental state whilst clients focus on social and practical aspects of
their lives. The process of nursing diagnosis fails to take into
account the client’s understanding of his/her own personal situation in
a language that is familiar. A consequence is that there is a loss of
control of the situation by the client as he/she is forced to accept
the expert’s redefinition of his/her concern within a medical paradigm
using unfamiliar terminology (Williams, 1990).
Whilst some approaches to mental health care contain some elements to
commend them no one approach adequately reflects mental health nurses’
holistic perspective, the length and nature of their informal contacts,
the ‘ordinariness’ of the nurse’s relationship with clients and the
nurse’s knowledge of the client’s social and physical environment
(Shanley et al, 2003). Most importantly they fail to provide a
framework that sees clients as active participants in the decision
making processes relating to their care. PinC was developed as a system
of mental health nursing to address these shortcomings.
Rotter’s (1971) Social Learning Theory asserts that a person’s
behaviour is determined by his/her goals, and that the prediction of a
person’s behaviour is based on the nature of a given situation in which
that person is a part of, as well as his/her past experience (Rotter
& Hochreich, 1975). Research that has been carried out in relation
to Rotter’s theory has indicated that beliefs about personal control
can influence behaviour (Lefcourt, 1976). One concept that is central
to Rotter’s theory is that of locus of control. Locus of control refers
to how far individuals see themselves as in control and responsible for
the course of both desirable and undesirable occurrences which are
experienced (Lefcourt, 1976). Rotter states that there exists both an
internal and external locus of control. Internal locus of control
refers to the perception of events as being a consequence of one’s own
actions and thereby potentially under personal control. In contrast,
external locus of control is referred to as the perception of events as
being unrelated to one’s own behaviour and therefore beyond personal
control (Lefcourt, 1976). The study gives responsibility for deciding
on changes that they may wish to make to the people who are to be most
directly involved in the PinC system. According to Stringer (1996,
p32), action research ‘gives people the sense that they are in control
of their own lives and … supports them as they take systematic action
to improve their circumstances’. These aspects formed the basis of the
theoretical framework for this study. The role of the researcher is to
facilitate the provision of feedback from clients and nurses and to
arrange for the changes that are recommended by clients and nurses to
The approach used in this study is commensurate with the theoretical
framework of the PinC system. The PinC system of mental health nursing
practice sees mental health clients as the experts in their illness
(Shanley et al, 2003). Because this system focuses on maximising the
mental health clients’ own understanding of their concerns and their
strengths in coping with their mental illness they are likely to
experience a greater degree of internal control over their lives.
Aim of the study
The purpose of this study was to refine the PinC paperwork and
documentation protocol, through action research, on clients’ and
nurses’ reported experiences and recommendations.
The study was conducted in a community mental health clinic that
services a rural population. A three day education programme was
carried out with nurse participants prior to the commencement of the
study to assist them to operate the PinC system.
The Advisory/Steering Group, set up to oversee the project, consisted
of the Clinical Coordinator for the nurse participants, the manager and
an allied health representative of the service, a nurse participant,
two consumer representatives and the developer of the PinC system.
The remit of the Advisory/Steering Group was to:
Receive feedback from the Focus Group meetings and to consider
and act on the changes recommended by the focus groups, and
• Act in an advisory capacity and
as a resource in facilitation the progress of the Action research
The design of the technical collaborative approach of Action Research
involved three cycles of planned intervention over the three month
period. Each cycle of planned intervention involved the use of four
activities, plan, act, observe and reflect. These activities interlink
with each other with each activity forming the basis for the next
activity (Kemmis & McTaggert, 1992). Reflection for this study
involved the use of individual interviews as well as Focus Groups.
Changes were made at the end of each cycle in response to feedback from
the participants of the study.
The sampling method used is classified as convenience sampling as it
involves the selection of the most conveniently available people for
use as participants in a study.
Eight Community Mental Health Nurses (CMHNs), three female and one
male, from different geographical locations within the same service
were recruited for the study. Two were based in the major town in the
area and two from the outlying rural areas. The CMHNs involved in the
study were experienced practitioners each of whom had more than 15
years service as mental health nurses.
Only those clients whose health, in the opinion of the treating team,
would not be adversely affected were asked to participate. The clients’
ages ranged from early twenties to mid fifties. Typical case selection
(Le Compte, Preissle & Tesch 1993) was employed in excluding
clients with unusual characteristics. Those who participated had
diagnoses of the most common forms of mental illness. Clients were
approached by the researcher who explained the study details and
provided a description of the proposed study in writing. Written
consent from each client was obtained From the twelve client
participants who initially agreed to participate ten took part, four
females and six males.
Individual interviews were audio-taped and transcribed then analysed
using thematic content analysis. During the study three interview
cycles took place approximately one month apart.
Separate Focus Groups for nurses and clients were held to give
participants the opportunity to voice their opinions without feeling
inhibited because of the presence of their nurse or client.
The analysis of interviews used techniques of thematic content
analysis which allows the researcher to categorise and codify interview
Data were collected in the form of individual, semi-structured, taped
interviews and also Focus Groups using mostly open ended questions.
These methods of data collection were aimed at obtaining knowledge of
each participant’s own perception of the PinC paperwork and
documentation protocol as well as generating ideas for changes that
might improve these protocols and documentation.
In keeping with practices of qualitative research the discussion within
each of the three cycles of the findings is integrated with their
description (Holloway & Wheeler, 1996).
In the initial interview participants were asked questions centred on
possible changes to the PinC paperwork. Seven main categories resulted
from these questions. These categories included sequencing of sections,
number of concerns, sharing of documents, presentation, involvement of
the client, goal setting and coping.
These resulted from the open coding technique (Burnard, 1991) of
deconstructing the relevant information and assigning subcategories to
First Focus Group Meetings
Nurses and clients in their respective groups were presented with the
seven categories derived from questions asked in the first interviews.
The categories were discussed with participants to generate ideas for
changes that needed to occur. From their responses several changes to
the PinC paperwork and documentation protocol were made.
For example, all the participants felt that there was an expectation
that six concerns needed to be documented by the client because the
paperwork contained space and numbering for six concerns, despite this
not being intended in the design of the documentation. One participant
‘I have gone for three concerns because this seems
workable. I find it not too time consuming’
As a result of this discussion it was agreed that clients should not be
expected to conform to a minimum or maximum number of concerns with a
notation being placed on the paperwork that expressed this. Further
changes made during this cycle were that both nurse and client
participants agreed that the sharing of documents was desirable. The
focus groups decided that the client’s sense of ownership could be
further enhanced by the provision of copies of the documentation to the
client, including a copy of the shortened version of the Practitioner’s
guide. This view was demonstrated in the following statement:
‘The Practitioner’s Guide (to the PinC
system) is helpful, I use it frequently. My clients wanted to look at
it I made some copies for them’.
All participants commended the fact that clients have a major role in
the decision making processes in the management of their care. This
perception concurs with the PinC philosophy and is reflected in the
PinC paperwork and documentation protocol. Clients acknowledged that
their nurse used the client’s own perspective to guide their practices.
This approach is a radical change from both the clients’ and nurses’
previous experiences in mental health services. Usually the clinician
is seen as the expert in mental illness with the client a passive
recipient of the treatment (Williams, 1990). Participants stated that
the PinC system was a new and exciting alternative to the way the
existing system operates. Comments made by both nurses and clients
powerfully supported the PinC philosophy:
‘It reverses the role, when the clinician
works with the client to document their concerns, the client is in
control not me.’
‘I typed up the forms
for the client and then gave the paperwork to the client to read and
they give their approval.’
‘I liked sitting
down with the client and using their own words in the document, their
concerns, their goals and strategies.’
New information obtained at the first Focus Group meeting was used as a
basis for questions for the second individual interviews.
This information centred on issues related to the level of support a
client may require when using the PinC system. Other issues to emerge
from the first Focus Group interviews were how the PinC paperwork and
documentation protocol assisted clients with problem solving, coping,
new concerns and having control and influence over their treatment.
Following analysis of the data derived from the second individual
interviews four main categories emerged. They included ongoing support,
problem solving, coping and client ownership.
Second Focus Group Meetings
Participants were presented with the four categories derived from
responses to questions asked in the first Focus Group interviews. The
categories were discussed with participants to generate ideas for
changes to the paperwork and documentation protocol.
Client participants wanted the option of documenting unhelpful as well
as helpful coping strategies because they felt they could learn from
these experiences. Several participants also felt that these unhelpful
coping strategies could act as a trigger for them to take alternative
Another issue to emerge was related to the clients’ active involvement
in their own treatment – namely the setting up of home file systems.
One client participant remarked;
‘‘That would be good, I need something as a reminder
because sometimes I’m not doing the things I should be doing. At the
end of the day I can go back and look at it.’
There was agreement amongst all participants that a home file system
would assist by, reminding the client of their plan, improving
continuity of care, reinforcing the clients efforts and increase the
clients ownership of their treatment and care. As highlighted by
Henderson and Laugharne (2003), home files, where the client holds some
records relating to their care and illness are now quite common.
Stafford and Hannigan (1997) asserted that client held records can
empower mental health clients and also assist clinicians to share
information. However, several studies into client held records found
that there was no general positive or negative effects associated with
the use of client held records (Currell, Wainwright & Urquhart,
The use of home files was not within the remit of the study namely to
refine the PinC paperwork and documentation protocol and therefore this
proposal was not acted on, though home files may be adopted in further
Details of new topics raised at the second Focus Group meetings were
presented to interviewees and their responses elicited through the use
of open ended questions. The new topics related to the PinC evaluation
paperwork and the provision of feedback to clients after meeting with
their nurse. Clients felt that the evaluation process worked well.
Several clients felt that the second question in the evaluation sheet
(If you, nurse or client, were to address this concern again what would
you have done differently?) was particularly helpful as it gave ideas
for future coping and also encouraged the client to think more deeply
about the issue. This was evident in the following quote from a nurse
‘It does help to talk about what could
have been done differently. My client identified that she could do more
diary writing. The existing (sic previous) system doesn’t have a set
review system. It’s too loose’
evaluation was straight forward. We did it together’ ‘I think it is
good. You can separate what’s achieved and what’s not’
Following analysis of the data derived from the personal interviews one
category emerged, this was, receiving feedback. The issue of ‘feedback’
was the major topic presented to the third Focus Group Meeting.
Third Focus Group Meetings
The participants expressed satisfaction with what they had been doing
with no new comments or concerns about the PinC paperwork and
documentation protocol emerging.
The participants were then presented with the category of ‘receiving
An idea was put forward by one participant that a feedback summary
would be helpful each time the nurse and client met However after some
discussion the participants did not feel that it was necessary to
compile a summary of information or decisions that are made at each
nurse – client meeting. Participants believed that the structure of the
PinC paperwork, in particular the review process, allowed for decisions
to be made together (by both nurse and client) and therefore both
parties would be fully conversant with what had been decided at each
contact. The response by the focus groups to this issue confirmed the
views expressed in the individual interviews.
As no new topics or concerns emanated from the Focus Group meetings,
‘saturation’ was considered to have been arrived at. Hence no further
cycles of Action Research were required.
The aim of this study was to refine the PinC paperwork and
documentation protocol. The conclusion is that the study achieved its
aim. Changes identified earlier were made and participants commented
positively on these modifications.
An indication of their positive attitude was their request to the
developer of the system and the service managers to continue to use the
PinC system with the amended paperwork even though the study had
finished. Approval to continue was given.
The use of Action Research as a means of achieving the aim of the study
has been shown to be an appropriate method. Its major attraction was
that it is context specific, problem focused and participative (Hart,
1996). The use of individual interviews and focus groups in a cyclical
process ensured that no major issues or concerns were missed. The
capturing of major concerns about the paperwork and the documentation
protocol was evidenced by the ‘drying up’ of new data, particularly
recommendations for change, as the process of data collection in each
Within each cycle the use of Burnard (1991) thematic content analysis
provided a useful structure in which to analyse the data and
facilitated a stepwise method of organising participants in exploring,
discussing and recommending changes to the PinC paperwork and
As well as changes to the paperwork there were four main changes made
to the documentation protocol. These changes included:
Provision of a shortened version of the Practitioners Guide to
PinC to clients.
Each of these changes was intended to ensure, in
varying ways, that clients were to take responsibility for their plan
of care. The nurse’s role was to assist them. It is evident that these
documentation protocol changes related to the issue of sense of
control, with clients clearly wanting to have more influence over what
happens with their treatment.
• A copy of the completed
paperwork is given to clients using this system.
• Any number of concerns may be
prioritised by the client.
• Unhelpful coping strategies may
be included in the plan of care unless the client does not wish to
Apart from the success in refining the paperwork and documentation
protocol other interesting issues emerged. For example although the
majority of the findings from both clients and nurses related to
changes in presentation and format there were some differences in
emphasis between them. Nurses focused, in the main, on improving
documentation clarity whilst clients focused on content, for example,
the opportunity to include unhelpful as well as helpful strategies in
the PinC paperwork. These proposals from clients allowed changes to be
made that resulted in a greater sense of control over their treatment
situation. The implications for mental health nursing practice of this
study, in which clients, nurses and managers had played a crucial role
in producing changes, means that it is likely that the modified PinC
system would also be accepted by other major stakeholders as applicable
and appropriate for their needs.
Theoretical Framework in light of Findings
The Action Research approach used in this study has been shown to be
commensurate with Rotter’s (1971) locus of control concept which formed
the theoretical framework for the study. Giving participants the
responsibility to make changes in the documentation conveys a sense of
control (internal locus of control) that has immediate and direct
relevance to them. An example of internal locus of control can be seen
in cycle one of the Action Research where participants recommended that
a client should not be forced into identifying a limited number of
concerns. As a result of this a notation was placed on the first sheet
of the paperwork that reads ‘Any number of concerns may be
Several issues emerged from the study that may warrant further
investigation; firstly investigation into the perception that having a
shared plan gives the clients a sense of feeling empowered and secondly
research into the advantages and disadvantages of using home files when
working with mental health clients.
Because this study was carried out in a community setting no
conclusions can be drawn about its applicability to inpatient settings.
Replication of the study within an inpatient setting would therefore be
required to ensure the paperwork and documentation protocol is adapted
to suit the needs of this setting.
As indicated earlier in the project report the next step in the
development of the PinC system is to carry out a full trial across a
mental health area.
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