The International Journal of Psychosocial Rehabilitation

‘In the PinC’
 Trialing of a new system of mental health practice
(Partnership 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.
Director
Old Nornalup Hospital,South Coast Highway
Nornalup,Western Australia, Australia 6398.
    


  Citation:
Jubb, M & Shanley, E (2005). In the PinC - Trialing of a new system of mental health practice
 (Partnership in Coping (PinC).
  International Journal of Psychosocial Rehabilitation.
10 (1), 19-26.


Contact:
P.O. Box 290,WALPOLE Western Australia 6398Australia


Abstract

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.


Introduction
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.

BACKGROUND
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.

THEORETICAL FRAMEWORK
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 be implemented.

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.

METHODOLOGY

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.

Study Design
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 project.

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.

Sample

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.

Interviews
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.

Focus Groups
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.

Analysis
The analysis of interviews used techniques of thematic content analysis which allows the researcher to categorise and codify interview transcripts.

DATA COLLECTION

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.

FINDINGS/DISCUSSION
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).

First Cycle
Initial Interview
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 this data.

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 remarked:

‘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.’

Second Cycle
Initial Interview
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 action themselves.

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, 2003).
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 trialing.

Third Cycle
Initial Interview
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 participant;

‘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’

‘The 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 feedback’.

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.

CONCLUSION
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 cycle continued.

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 documentation protocol.

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.
•    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 include them.

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.

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 prioritised’.

Future Research
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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