The context of practice

Chapter 2 The context of practice



Vicki Stanton, Barbara Tooth




Key points


• The context of mental health nursing practice is dynamic and ever-changing, responding to new ideas about what people need in order to have a meaningful life.

• The ultimate goal of mental health practice is to value the worth and facilitate the capacity of all people to be active participants in society, and to provide the range of resources that will help them to remain active citizens in the community of their choice, even during periods of mental distress.

• The quality of a person’s relationships is a key determinant of their quality of life.

• Theories of mental health and mental health practice aim to influence people’s attitudes, values and beliefs.

• Mental health nursing practice is ultimately influenced by the attitudes, values and beliefs of the nurse, and is developed through general life experiences, education and interaction with people who experience mental distress.

• The ability to think critically and develop self-awareness is central to nursing practice.

• The recovery paradigm addresses the issues necessary for people to have a meaningful life and provides the context and guiding principles for all mental health practice.

• The recovery paradigm reconceptualises the roles of mental health professionals.

• National and international laws protecting people’s basic human rights provide the legal context for recovery-oriented practice within the recovery paradigm.

• Mental health policy and plans provide the socio-political context for practice and the implementation of services that, ideally, are based on the recovery paradigm.

Key terms


• citizenship

• community

• consumers

• deficits

• dualism

• health and wellness

• holism

• illness

• multidisciplinary teams

• non-government organisations

• partnerships

• recovery

• rehabilitation

• resilience

• self-help

• stigma

• strengths

Learning outcomes


The material in this chapter will assist you to:
• demonstrate an understanding of the role that your attitudes, values and beliefs play as key factors in what you say and do when you work with people, and of the role of theories and life experiences in this process

• begin to appreciate the complex interaction between the current contexts that influence mental health practice

• identify the key differences in the way nurses conceptualise their role and their practice between the recovery and medical paradigms

• describe the principles of recovery-oriented practice

• explain the rationale for the shift in mental health to the recovery paradigm, which values the primary role of expert knowledge that comes from the lived experience of severe mental health distress

• identify the underlying concepts of dichotomous practices such as holism/dualism, wellness/illness and strengths/deficits

• appreciate the value of reflective practice and continually developing self-awareness

• understand the importance of maintaining a person’s citizenship rights and the implications for recovery-oriented practice.


Introduction


This chapter discusses some of the fundamental concepts and principles underlying what nurses do and say when they work with people, particularly people with mental health needs. It builds on the previous chapter by reinforcing the importance of reflection in order for nurses to become competent practitioners, and it provides a context for the chapters that follow.


To make sense of mental health nursing practice requires an understanding of the factors that can influence it. These include mental health policy and plans, current theories about the various aspects of mental health and mental health practice, social and cultural factors, and the attitudes, values and beliefs that guide our thinking. People’s thinking changes over time and this is determined by the experiences they have had and by changes in thinking about what constitutes appropriate practice. In mental health in the past few decades, the rate of change in thinking about practice has been significant. This chapter addresses some of the major shifts in thinking that influence our under standing of what mental health nursing practice entails, the rationale behind why it is approached in this way, how it is put into practice, and the settings where nurses are likely to practise.


It can be tempting to think that mental health nursing is a discrete area of practice of little value to the general nurse, but this is far from the truth. The fundamental concepts and principles underlying mental health nursing are considered so important to general practice that they have been incorporated into undergraduate nursing courses in Australia and New Zealand. The comprehensive course is intended to provide a holistic approach to nursing care and a basis for later specialist practice. In addition, one in five people in Australia will experience mental distress severe enough to be diagnosed and warrant intervention from a mental health professional. Physical illness exacerbates such distress and people cannot isolate parts of themselves in their interactions with general health professionals. It stands to reason therefore that general nurses frequently work with people in mental distress.



The relationship between theory and practice


To begin to make sense of professional nursing practice requires an understanding of the relationship between theory and practice.




What is a theory?


Theories provide the rationale for the actions that guide our practice.


• A theory is a set of constructs, hypotheses, principles and propositions about specific phenomena and how they relate to one another.

• A theory is not a statement of fact, nor is it the whole truth, because it excludes what it judges to be of little or no importance.

• A theory is therefore only one perspective.

• Theories can be either formal (written with detailed support and presented to others in the field) or informal (residing in people’s conscious or subconscious thoughts).

• Theories generate hypotheses about specific phenomena that can be tested to determine the theory’s usefulness, predictive ability or ‘fit’.

The last point is important to understand because theo ries can be revised, built on by others or disproved as a result of applying the principles of the theory to practice and evaluating their usefulness and ‘fit’. For example, theories promoting dualism (mind and body as separate and independent entities) were dominant in medicine for some time but their limitations are now widely acknowledged. Holism (mind and body cannot be separated) now provides the best ‘fit’.


The concepts of dualism and holism will be discussed later, but the example illustrates the fact that theories are not static. They are time and context specific and tell the reader about the theorist’s thoughts on a subject based on their comprehensive knowledge and experience in a specific topic at that time. Theories also give us insights into how individual theorists make sense of their world—behind every theory is the person who proposed it. Knowing something of the person’s background and experience can help to put the theory into context and provide a framework for making sense of the range of theories about certain phenomena. This framework also helps to demystify theories and their role in practice.


In fact we are all theorists (albeit informal theorists). Consciously or subconsciously we make hypotheses (propositions to explain specific phenomena) about ourselves, others, situations and larger world events, and we make predictions about what will happen in the future based on our past life experiences. Testing these hypotheses will either support our predictions or make it clear that we need to revise them. This also holds true in nursing practice, where nurses have been found to be theorisers of their everyday practice (Cox, Hickson & Taylor 1991; Graham 2000).



Which theory best guides practice?


How do beginning practitioners determine which formal theory is most appropriate for their nursing practice? It is not a question of deciding which theory is right or wrong, but rather of appreciating that there can be a number of ways of understanding a particular phenomenon. Nursing is just one of a number of disciplines in the field of mental health. There is a general body of knowledge in mental health and each discipline draws on this to expand the understanding of practice issues. In turn there are discipline-specific theories that add to the existing body of knowledge. These various theories can complement or contradict each other, or express similar ideas but use different language to do so, but all theories expand our understanding of specific phenomena, and each has valid points. They can provide richness and depth that is invaluable in professional practice and life in general. However, theories and perspectives are time-limited because nothing is static and change is inevitable.



Nursing theorists


A significant number of nurses have written about nursing practice, beginning with Florence Nightingale. It is only recently, however, that nurses have moved from writing about what they do, to writing about how and why they do it. There are now a number of nursing theorists who provide a broad range of ideas, and this can be overwhelming for the student nurse. It is the application of these theories to practice that determines their usefulness. To help make sense of nursing theorists, Alligood & Tomey (2002) have outlined a method of ranking the different theorists into three categories:


• philosophies—this category uses higher-order constructs and propositions about the nature of nursing. An example is Rogers (1970), who defines nursing as a holistic science of human nature and development.

• conceptual models/grand theories—these theories are more practically derived and suppose an outcome. Examples are Henderson’s theory (1966), which focuses on outcomes of nursing care, and Orem’s theory (1971), which establishes the notion of self-care as integral to nursing.

• middle-range theories—these more closely describe practice issues for nursing (McEwan & Wills 2002). Peplau’s 1952 theory (reprinted in 1988) focuses on therapeutic interpersonal processes in the nurse–client relationship, and has been very influential in mental health nursing.

The Tidal Model (Barker 2001) draws heavily from the body of knowledge in the emerging recovery paradigm and is an appropriate theory to guide mental health nursing practice. It was originally developed for psychiatric nursing because of the need for a paradigm shift in mental healthcare. It now extends to all disciplines and areas of mental health. The Tidal Model acknowledges that the concept of ‘mental illness’ can be viewed in a number of ways, but asserts the value of seeing such phenomena primarily as problems of living rather than as the consequence of a mysterious illness (Barker & Buchanan-Barker 2004). ‘By emphasising the centrality of the lived-experience, of the person and his/her significant others, the need for mutual understanding between nurse and the person in care is also acknowledged and the need for a personally appropriate, contextually bound form of care, established’ (Barker & Buchanan-Barker 2004, p 7). Basically the Tidal Model is moving from solving problems for the person to finding solutions with the person. The Tidal Model develops Peplau’s theory on the nurse–patient relationship, with emphasis on finding pragmatic ways in which people learn what works for them and why (Buchanan-Barker 2004).


As mentioned previously, theories reflect the theorist’s world view at the time of writing. So a comparison of Florence Nightingale with a recent nursing theorist would demonstrate the constantly evolving nature of theory within a dynamic social context and in response to reflections on nursing practice. Theorists have contributed to the body of knowledge that describes nursing practice, leading to improvements in the discipline of nursing.



Incorporating theory into practice: the personal context


How then do beginning practitioners make sense of what they read and incorporate this into their practice? This requires the ability to:


• think critically

• continually develop your self-awareness

• identify your values, beliefs and attitudes and appreciate their origin

• modify your values, beliefs and attitudes

• tolerate and even embrace ambiguity

• actively participate in the quest for knowledge

• remain open to the need to modify your practice and your role in light of the above.

The ability to think critically is essential. Critical thinking is an ongoing process that requires an open mind on a whole range of views. Just as important as the ability to think critically is the awareness that we are more likely to favour those theories that provide the ‘best fit’ with our already developed world-view. We do this to alleviate the anxiety we will experience if we choose a theory that is inconsistent with our already established thoughts. This is a normal subconscious process but it can trap the nurse in a comfort zone that leads to lack of awareness, narrow and blinkered approaches to practice, and a reluctance to be open to new ideas and practices. This is an important concept to understand in the lifelong activity of becoming more self-aware.


The requirement to be self-aware and to think critically about the basis for practice can be frustrating for beginning practitioners because there is no clear step-by-step ‘cookbook’. Understandably, when nursing students, both undergraduate and postgraduate, come into a course they want to be told what it is they need to learn and do in this new area so they can be effective and feel competent. It is not uncommon for students to want to collect a ‘bag of skills’ to prepare them for everyday practice. Nurses want to know what they can do to people so they can feel competent and alleviate the ambiguity about their practice and their own anxiety. Students can become impatient and disgruntled if these skills are not given up front, and the course can be seen as ‘airy fairy’ or even useless. This is more likely to occur in students who prefer to be passive recipients rather than active participants in their professional development.


Very little of what professionals know comes from books. Your attitudes, values and beliefs underlie what you do and say when you work with people. It is these personal informal theories developed through your life experiences, both personal and professional, that provide the foundation for practice and determine which formal theories are more appealing to you. It is only with increasing self-awareness, critical thinking and reflection that the continual process of construction and reconstruction takes place and competent professional nursing practices develop. This is a lifelong process.



The importance of reflection


Teaching skills by themselves will not improve clinical competence or performance. Reflection, also discussed in Chapter 1, has been classified as a core competency at all levels of clinical practice by the Australian Nursing and Midwifery Council. Reflective practice involves learning from our experiences and from others and developing our practice as a result (Jasper & Elliot 2006). Reflection affects nurses’ individual understanding of a range of practice issues, increases awareness and clarifies aspects of themselves and their role. It involves being open to new challenges and seeking new opportunities. This very much reflects a nurse’s capacity and willingness to be open to change in attitude and thinking.


Within the emerging recovery paradigm, a significant amount of learning is gained from our interactions and relationships with people who have the lived experience of mental distress. Mental health professionals have much to learn from them about the nature of mental distress and the most important factors in helping them to get on with their lives in a way that is meaningful to them. We also learn about how we help, and frequently hinder, their self-directed recovery. Reflection, critical thinking and analysis are essential skills enabling all those involved in mental healthcare to evaluate and incorporate evolving knowledge into their practice.


Reflection is a personal activity. When reflection takes place in groups (reflexivity), important dialogue between nurses about what they have learned can affect the shared meaning of the group. It enables not only the development of tacit (unspoken) knowledge in the beginning practitioner but also its articulation by experienced nurses. Welsh & Lyons (2001) found that if nurses were asked why they performed in certain ways they were able to provide a rationale. Intuition comes with exposure to a whole range of situations and people over time, and this tacit knowledge comple ments nursing knowledge. It is ‘increasingly evident that it is far more than just theoretical knowledge that informs the practice of expert nurses’ (Crook 2001, p 4). Articulation of experienced nurses’ tacit knowledge allows it to be examined and verified (Welsh & Lyons 2001). This helps validate more of what actually happens in practice and thereby complements evidence-based practice.



Putting theory into practice: the wider context


The implementation of practice based on theory is not straightforward. Practice settings can be complex because they require mediation between people with different views, philosophies, beliefs and ways of interpreting what is required for effective mental health practice. Added to this is the influence of political, social, cultural and environmental constraints. Some political imperatives are short-lived, while others are more embedded in the economic and social fabric of politics. These are more significant than management trends and far less open to modification. The current political imperative for evidence-based practice is one such trend. It has particular implications for mental health practice, and these are discussed here.



Demand for evidence-based practice


Within Australia and New Zealand, and indeed most of the Western world, there is a demand that only those practices that have been shown to be effective be sanctioned in the provision of healthcare. This is known as evidence-based practice. Although there is a valid argument for this and intuitively it makes sense, it can be problematic in the provision of truly effective and meaningful mental healthcare, and it raises a number of issues that warrant further discussion.



Issues for discussion



1. Evidence-based practice is based solely on observable practices validated using the scientific method—The scientific method requires that practices, their rationale and the theories behind them be clearly identified and documented. The only form of practice (treatment) that meets this criterion is that which can be observed and measured (this is known as quantitative research). The ‘treatment’ must then be ‘tested’ (this is known as empirical evidence) and this is usually done through ‘randomised controlled trials’. In such studies, consumers of health services are divided into two groups. The first group is known as the treatment group and, as the name suggests, they receive the treatment that is the object of the study. The second group is known as the control group—they are matched to the treatment group for factors such as age, gender and status but they do not receive the treatment. Both groups are monitored for changes in exactly the same way, usually by various types of well-defined outcome measures. Only that which can be ‘objectively’ observed or measured is considered valid and reliable. The measures for the two groups are then compared to determine whether the treatment has been effective.

Although there is a valid argument for this approach, there is an equally strong argument that interpersonal relationships, intuition and tacit knowledge (unspoken knowledge), which are ignored by the scientific method, are invaluable in improving the quality of mental healthcare and nursing care in particular. For example, the nature of the interactions between nurses and the people with whom they work is very important in determining outcome. This has not been comprehensively studied within nursing but it has in research on the outcomes of psychotherapy, which is very similar in nature. This research has consistently found that the ‘non-specifics of psychotherapy’ (genuineness, respect, being human, using non-possessive warmth and unconditional love) are the most important in determining outcome (Hubble, Duncan & Miller 1999). These findings are important for the following reasons:


• It is not the (measurable) techniques that the professional uses, but factors to do with the nature of the relationship between professional and person, that are critical.

• In their relationships with people, professionals do use their intuition and unspoken knowledge base (tacit knowledge).

• What appears to be the key factor in determining a good outcome is the ability to use our humanness in a way that is healing.

• The above cannot be measured using the quantitative scientific method required for evidence-based practice as described above.

2. Evidence-based practice comes from the validated expert knowledge of professionals—Evidence-based practice is derived from the expert knowledge of professionals and what they believe to be important in treatment. Professionals decide what is important to study and they also devise the treatments used in research. Evidence-based practice does not come from the expert knowledge of people with the lived experience of mental distress and what works for them.

In contrast, phenomenological researchers suspend this expert position and are more interested in exploring and describing individual meanings about phenomena, or their narratives about experience. In similar contrast to the reductionism of the quantitative scientific method, qualitative researchers tend to cast a much broader net to help in understanding the much bigger picture of all the complexities that make up people’s lives within a social and cultural context. Unfortunately it is all too common for ‘professional experts’ to discount people’s lived experience as unimportant because it is subjective and cannot be validated, and therefore it is omitted. Yet there is strong evidence (Roberts 2000) that valuing people’s stories is essential to improving outcome, and this is the essence of the narrative approach in mental health.


3. Resolving the tension—There is no debate about whether people have the right to interventions/practices that have been shown to be effective. There is debate about what constitutes sound methodology, appropriate areas of research and types of interventions/practices to be studied. In reality there has always been tension between those who support the quantitative scientific method and those who support qualitative methods and believe that, due to the complexity and uniqueness of what it means to be human, such experimental research is meaningless. Qualitative research is the predominant methodology in recovery research.

Rather than arguing for the benefit of one approach over the other, it is more useful to acknowledge the tension between the two approaches and then move on to appreciating how they may complement one another. For example, there is a wealth of information in first person accounts of people’s recovery that has led to a consensus about the values and principles of service delivery that promote recovery. Farkas et al (2005) argue for evidence-based practices to be implemented in a manner that is compatible with recovery, by researching the dimensions of recovery practice—including the program’s mission, policies, procedures, record keeping, staff selection, training and supervision, quality assurance, physical setting and network—to determine whether it is recovery oriented. Such dimensions could be the subject of quantitative research, while qualitative research of people’s experience of such services would provide a more complete overview of the service and its impact.


The following section outlines some of the major changes in thinking about mental health practice and continues the theme of providing a context for understanding nursing practice issues.



Changing beliefs about the focus of nursing practice




From dualism to holism


Dualism is derived from the Cartesian idea (Rene Descartes 1596–1650) that there is a mind–body duality, the body being a passive agent or vehicle with an immortal soul separate and absolutely distinct from the body. The concept of dualism has made the body the domain of medicine, and the soul or moral features (mind) of the individual the domain of religion and philosophy.


Failure to see the interdependence (holism) of the mind and body has led to the view of the body as a machine, with technical advances in science considered the necessary interest of medicine. This view suggests that only scientifically observable phenomena and technical knowledge are valued (Short, Sharman & Speedy 1994). This view forms the basis of the argument for evidence-based medicine. Within this paradigm medicine, including psychiatry, has increasingly focused on the person’s symptoms to the exclusion of most other things.



Dualism: issues for mental health practice


In a dualistic approach to mental health practice:


• Health professionals are taught to look for syndromes (a collection of symptoms) and to value only that which can be observed (the basis of evidence-based practice).

• The focus is on deficits within the functioning of the brain, and this objectifies the person and their problems.

• The mind is not seen as influencing the physical body and vice versa.

• Traditionally, professionals have not been taught to value the meaning of the symptom(s) for the person or to understand the impact of the symptom(s) on the person’s life.

• Meaning and purpose are considered to be within the realm of the mind, subjective and therefore of no scientific value because they are difficult to measure and standardise.

This dualistic position is no longer tenable because people with lived experience of mental distress have not found the focus on symptoms and problems helpful. What helps is an understanding of the meaning people make of their experience of mental distress, and the impact of this on their lives (Tooth et al 2003). It is important to assist people to get on with their lives in a way that is meaningful to them and to participate fully in community life (Kalyanasundaram, unpublished manuscript, 2004).


Holistic practice within nursing has as its main goal the healing of the whole person, recognising the importance of the interrelationships between biological, psychological, social and spiritual aspects of the individual.



Holism: issues for mental health practice


According to a holistic approach to mental health practice:


• It is meaningless to separate out the ‘parts’ of a person as if they were discrete entities. A fundamental tenet is that the whole is greater than the sum of its parts (for example, a person’s social needs cannot be separated out for treatment, but must be considered in relation to all aspects of the person).

• Attention is paid to all aspects of the individual and the interrelationship between them.

• Holistic practice attends to the person’s relationships with themselves, others, society, and their citizenship within the greater cultural context of the community.

• Principles underlying such practice include trust, hope, respect for individual freedom and allowing people to exercise their rights as citizens.

• A person’s rights include their civil, social and personal rights, including the right of choice and the ‘dignity of risk’.

The significant shift in thinking away from dualism towards an acceptance of holism has brought with it a much richer nursing experience that validates the complexity of life and cultural experience. Yet even our understanding of holistic practice has changed over time. In the past decade, holistic practice was promoted under the banner of bio-psychosocial care. However, the increasing emphasis on recovery-oriented practice has outdated this concept by focusing on the more inclusive citizenship agenda that moves the debate beyond the medical versus social model. Bracken (2003, p 2) states that ‘being a citizen is about being regarded as a full human being, entitled to expect the same from life and the society in which one finds oneself as everyone else. On a basic level it involves being free from discrimination, exclusion and oppression … it means being able to define one’s own identity and to celebrate this identity in different ways’. As citizens, people who have the lived experience of mental distress want what we all want. Within the recovery paradigm, a primary focus is



Nurse’s story: the limitations of dualistic practice


When the authors of this chapter began mental health nursing (in the 1970s), which at the time was undertaken predominantly in large psychiatric institutions, our tasks were to observe people’s signs and symptoms and document them in the person’s file so the extent of the deficits could be noted and treated by the psychiatrists. The basic aim was to alleviate symptoms, primarily through medication, so the person could return to their home environment. People often stayed within the institutions for many years. During this time, the meaning and impact of these symptoms for the person were considered irrelevant. In fact, conversations along such lines were actively discouraged because it was believed that this would make the person’s condition much worse.


One of the authors has a very vivid recollection of working in a ‘back ward’ (a ward for people with supposedly chronic and disabling illnesses requiring long-term care over many years) where one of the patients had exhibited a fixed delusion since she was admitted at the age of seventeen. At the time she was twenty-four years old and the ‘delusion’ was still just as distressing. The woman believed that her stepfather was the devil; she would become highly distressed whenever he visited with her mother, and the distress continued long after he left. The staff believed it was a delusion because they perceived the stepfather to be very caring and concerned about the woman’s welfare. A young female doctor new to the ward decided to take up this woman’s case because the delusion had not responded to medication. She went through the woman’s file since admission and found that no one had actually talked to the woman about the content of the delusion (what it meant for her). When the doctor finally asked, the woman told her that she had been sexually abused by her stepfather from a very young age, and that for her he represented the devil.


Although this is a dramatic example, it illustrates the need for holistic practice and the need to include the meaning of the experience for the person and not limit practice to the observation of signs and symptoms.



Nurse’s story: holistic practice within a mainstream setting


Nurses working in the inpatient mental health facility of Alice Springs Hospital are continually challenged to provide holistic mental healthcare to Indigenous people of the Central Australian region, who comprise approximately half of all admissions. Holistic practices include the encouragement of traditional Indigenous practices alongside Western medicine. The mental health nurse provides Western treatment and counselling alongside Indigenous traditional healers when the family indicates that this is necessary for the wellbeing of the person. The traditional healer, or nangkeri, is considered a crucial part of the care provided to Indigenous people to address the cultural and spiritual issues for Indigenous people receiving mental healthcare in Central Australia.


maintaining people’s engagement in meaningful work that fulfils a whole range of a person’s needs.


Internationally, mental healthcare is moving to embrace the recovery paradigm, yet tensions still remain between the medical profession and nurses about having the now well-accepted complementary therapies included in people’s healthcare choices. This is an expression of the tension between different theories discussed above. Therapies that are commonly used within main stream society include: massage and a range of other body therapies; counselling; acupuncture; therapeutic touch; homeopathy; imagery; and spiritual healing, to name a few. Respecting the individual’s right to choose what type of healthcare they receive, and exploring the range of available options with them fully informs the individual not only of options but also of their consequences, and is empowering practice. Far beyond this, people want to get on with leading ‘normal’ lives following experiences of mental distress, just like every other citizen.


Challenges arise for the mental health nurse practising a holistic approach within the mainstream health system as the latter is based primarily on a medical, scientific approach geared to dualistic thinking rather than holistic thinking. In many practice settings, workforce shortages and pressure within health systems may present challenges to implementing holistic practice. (These issues are discussed in greater detail later in the text—see the index.)

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Feb 19, 2017 | Posted by in NURSING | Comments Off on The context of practice

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