"They are Us-We are Them": Transformative learning through nursing education leadership.

Stigmatization towards persons with mental illnesses is a major quality of care concern. Unfortunately, nurses are no less implicated than other health professions. This article reports the results of an evaluation of a learning intervention for psychiatric nursing students in partnership between Brandon University and the Mental Health Commission of Canada. We describe this intervention as an example of transformational learning through nursing education leadership and suggest its use as a promising model for cultural change in healthcare practice. Leaders and managers are encouraged to explore how such a model may be adaptable or implementable for their own organizations and departments.

Introduction

Stigmatization towards persons with mental illnesses is a major quality of care concern.[1-6] A recent systematic review emphasized the growing body of evidence pointing to various manifestations of stigmatization. The resulting negative consequences affect patients across the spectrum, from access to care and treatment, to outcomes.[2] For example, individuals and families living with mental illness have recounted time and again experiences in which they believed their personal rights and freedoms had been violated: being spoken to as if they were children; being excluded from important decisions; being made to wait excessively long times; feeling ignored or dismissed; having medical concerns being incorrectly attributed to their mental illness (diagnostic overshadowing); being told they would never get better; and feeling “patronized, punished, or humiliated” during their interactions with health professionals.[2-6] This brings into relief a certain uncomfortable reality, namely, that the problem of stigmatization is largely a problem of devaluation and dehumanization.[5-6]

Unfortunately, nurses are no less implicated than other health professionals. A recent study measuring attitudes and behavioural intentions towards persons with a mental illness across various healthcare groups in Canada found that nurses, along with physicians, displayed the highest levels of stigma of all groups measured.[7] Furthermore, a recent literature review of stigmatization within the nursing profession found a number of problematic realities from negative attitudes such as blame and hostility or fear, to devaluation of mental healthcare needs, to pessimistic attitudes towards client prognoses and outcomes, and a lack of skills and educational base.[8] Thankfully, there are bright spots within this challenging context.

Since 2007, the Mental Health Commission of Canada (MHCC) has been evaluating programs and approaches to stigma reduction in healthcare through its Opening Minds (OM) anti-stigma initiative.[9,10] The OM strategy involves seeking out existing anti-stigma programs, identifying what works and why, then sharing those learnings so that effective programs, tools, and best practices can be more broadly implemented.[9-11]

One important learning from this research is the knowledge that “small things can make a big difference” for persons seeking help for a mental illness.[12] This research tells us that those “small things” are often none other than health providers who listened and cared—a nurse who sat with the individual and provided comfort, a nurse who offered words of hope, a nurse who brought a patient something to eat while he or she was stuck in a hospital room, a nurse who took the time to listen, and a nurse who provided reassurance that things were going to get better.

It is all about compassion … there was one who would put his arms round me and say “we will sort it out together.” And that lifted me up out of the hell.[13]

Imagine if this characterized the healthcare experiences of all patients with mental illnesses. With this future goal in mind, we report the results of an evaluation of a learning intervention for psychiatric nursing students conducted from September 2012 to April 2013, a partnership between Brandon University and MHCC. We describe this intervention as an example of transformational learning[14] (ie, the expansion of consciousness through the shifting of one’s perspective or worldview) and suggest its use as a promising model for the possibilities of cultural change in healthcare practice, not only for student populations but also for practicing healthcare providers.

Implementation of anti-stigma initiatives in healthcare settings can be a challenge, as the problem of stigma remains an unperceived learning need for many healthcare organizations and professions, and engagement is limited by competing priorities, time constraints, and low perceived need.[1,2] The intervention described in this article exemplifies the integration of nursing education leadership and nursing leadership in practice and policy development, providing a basis for nurses to be able to “lead where they land” as they transition from students to practicing professionals.[15] The model can be easily adapted and implemented for practicing healthcare providers as a key method through which to improve patient–provider interactions and quality of care for patients with mental illnesses.[1]

The recovery narrative assignment

Professors Renée Robinson and Jane Karpa developed (and teach) a course on Psychiatric Rehabilitation and Recovery, which students take in the fourth and final year of a degree program in psychiatric nursing at Brandon University. A key component of this course is the Recovery Narrative Assignment,[16] whereby students are matched with a person with lived experience of a mental illness in the community whom they meet over the course of the term and for whom they construct a recovery narrative. The intent is for students to get to know clients on a personal level, enabling them to gain an in-depth understanding of their experiences. The assignment is a key element preparing students for practice.

Students and clients meet regularly throughout the term. Meetings are approximately 1 hour in length and are conducted in-person at a time and location of the client’s choosing. Students are provided guidelines about discussion topics, but the main objective is for them to learn about the client’s life and experiences. Students then prepare a 15-20 page “recovery narrative,” describing the client’s life story. Clients review and provide feedback on the content of the completed narrative. Grading is based primarily on the client’s assessment and feedback. Further details about the program are available upon request.

Program impacts

Program impact was measured in three ways: (1) quantitative pre-, post-, and follow-up assessment of stigma reduction among student participants (note 1) using the OM Scale for Healthcare Providers, a 15-item validated scale that captures attitudes and behavioural intentions of healthcare providers towards persons with a mental illness[7], (2) qualitative interviews with 10 students regarding their experience with the Recovery Narrative Assignment, and (3) qualitative interviews with 16 clients regarding their experience with the Recovery Narrative Assignment (note 2).

Quantitative results

Results of a paired t test showed a statistically significant improvement in stigma scores from pre- to posttest (t 23 = 2.69, P = .013), which was sustained to the time of the 3-month follow-up (Figure 1). The observed difference in score from baseline to follow-up represents a 7.4% relative improvement, and an effect size (Cohen’s d) of .39, which is considered a moderate effect. This result was particularly encouraging given that this particular group of nursing students already showed relatively low levels of stigma at baseline, among the lowest OM has observed to date.[7]

Figure 1.

Narrative Recovery Assignment program: Participant mean scores at pre-program, post-program, and 3-month follow-up on the Opening Minds Stigma Scale for Healthcare Providers (OMS-HC-15). n = 24 (matched); mean scores can range from 1 to 5; lower scores indicate lower levels of stigma. Pretest standard deviation (SD) = .41; post-test SD = .39; follow-up SD = .38.

Qualitative results: Student interviews

The major theme arising from the analysis (note 3) of student interviews was “They are Us—We are Them.” Students described how the Recovery Narrative Assignment changed their perceptions of how they viewed individuals with severe and persistent mental illnesses. The assignment allowed them to reach a level of recognition that these individuals were living full and meaningful lives much the same as the students themselves.The “They are Us—We are Them” theme was supported by a number of sub-themes, helping to articulate the underlying processes through which the students came to this new understanding.

It helped to reduce stigma because it just helped me realize that they’re a real person, that they have real issues not just issues related to their mental illness, that they have a life. That idea of our clients being us … our mothers, fathers, those around us … It helps reduce the ‘us and them’ feeling that we might have … it reduces those barriers, you see them as a real person.

Attitude change through development of a broader perspective

Being able to know “the whole story” and having a “broader perspective” of clients’ experiences emerged as a key part of the transformative learning process.

When you see somebody on a ward you’re just seeing them in the moment, and you don’t really think about how they were as a child … it [the recovery narrative] makes you see the whole story.

Increasing opportunities to engage with individuals living with a mental illness promotes attitude change

Students expressed that they would appreciate even more opportunities for individuals to share recovery stories, as they believed it was a valuable means by which to change attitudes about people living with significant mental health issues.

People need more exposure to positive experiences of seeing people in recovery … when they do their energy level and the environment is different …

Seeing client relationships as partnerships

Having clients evaluate student performance provided an opportunity for reversal of traditional roles. They acknowledged the clients’ power and right to evaluate the narrative and saw it as a positive experience. It helped them see the client–nurse relationship as a partnership. Students expressed an awareness that the evaluation process was linked to the quality of the relationship they were building with the client.

He evaluated my work at a series of points by running lines through things, and I got really upset and pissed off because my initial reaction was to think this is my work but then I had an epiphany that we are a partnership my perspective was changed so in the end it was okay.

Impacting current and future practice

Students felt the experience made them pay attention to several psychiatric nursing skill areas, and that it had a notable influence on how they intended to practice.

It changed my perspective on what nursing is … it is a partnership as opposed to telling them what they are going to do …

Qualitative results: Client interviews

Three main themes emerged from the client interviews, all of which pertained to their participation in the Narrative Recovery Assignment.

Therapeutic benefits

The assignment was not specifically designed to provide therapeutic benefits to client participants. However, almost every client reported benefits, including increased confidence and self-esteem; increased awareness of personal strengths, growth, and recovery; being more aware of other people and better able to engage with them; and being able to view their experience in different ways.Importantly, a few clients did indicate that bringing up old emotions was stressful even though the discussion became an opportunity for growth. The most important recommendation for improving the Recovery Narrative Assignment was to ensure that clients had ongoing support in the event that discussion brought up distressing issues.

I think what it actually has done in that sense is that it has given me more confidence and definitely lack of confidence was a big problem for me. So I think I understand myself better and I know I can deal with it.

Relationship with the student

Clients described looking forward to seeing the student, enjoying consistent contact, feeling comfortable with the student, and valuing the way students listened. A number of clients reported that meeting over the course of the term provided continuity and helped to combat social isolation. They used words such “approachable,” “safe,” “comfortable,” and “very human” to describe how they felt when speaking with the students, saying also that they felt “listened to.”For many, participating in the assignment also led to positive changes in their attitudes toward service providers more generally.

She was listening. That was a huge, huge thing. It wasn’t like I thought the other professionals weren’t listening, but, they also had their own agenda. They had stuff they wanted to tell me.

I think, I’ve gotten back some old patience that I had lost. I had little patience often with the system … Little patience with the … the individuals that were trying to help me.

Helping to change the system

Most client participants mentioned feeling a strong sense of satisfaction that they were helping to educate future health professionals. They felt they were making a contribution to system change. They viewed participation in the Recovery Narrative Assignment as a means to serve as a role model and to influence students’ future practice.

I think they saw an aspect of mental health that they need and may not have expected to find. I think they … could be inspired.

… knowing that I was sitting with someone and having … an impact on what their future’s going to be is kind of neat.

Discussion

It has been argued that the problem of stigma can be viewed through a quality of care lens.[1] This perspective takes the view that stigmatization is, at least in part, a core attitudinal and behavioural barrier to quality of care for persons with mental illnesses.[1] One way to tackle the quality chasm of mental healthcare (eg, see[17]) is thus through interventions that have the potential to improve the way healthcare providers “see,” understand, and interact with their patients. In our opinion, the Narrative Recovery model embodies this need precisely.

While the positive quantitative outcomes support program efficacy, it is the qualitative findings that we find particularly compelling. The impact of the Narrative Recovery Assignment on students’ perceptions and practice intentions creates a space for them to be able to “lead where they land,”[18] as they transition from students to practicing professionals. Indeed, anecdotal feedback from graduates supports this idea that the experience fundamentally shifted their perspective, gave them a more fulsome understanding of recovery, and influenced their approach for how they work with patients.

There are definitely sharp points that still stay with me. That assignment built the foundation for how I understand recovery. And this for sure influenced my approach for how I work with patients. (Joshua Bray, in conversation with S. Knaak, RPN on November 25, 2015)

Importantly, the narrative recovery model also empowers the experiences and voices of those impacted by stigmatization, which is well-identified in the literature as integral for any true understanding of quality improvement needs.[13]

While the recovery narrative model is perhaps most straightforwardly implemented at the training level, it could be easily adapted for practicing professionals, as the type of transformative learning provided through this approach has the potential markedly change the way health providers see and interact with patients with mental illnesses. Agrawal and Edwards,[19] for example, write about a similar model being used for psychiatric residents working in hospitals and community settings.

We thus close with a call to action. Nurses are extremely well positioned to play a meaningful leadership role in solving the problem of mental illness stigmatization. Nursing leadership begins at the outset of every nursing education program and continues throughout the practice of every nurse. It is about inspiring the practice of the profession in ways that can change individual lives and that can ultimately lead to policy and system change.[15] The organizational application of stigma reduction programs using an approach such as that demonstrated through the Narrative Recovery Assignment may be a key vehicle through which to accomplish this task and to realize much-needed quality of care improvements in mental healthcare. We thus encourage leaders and managers to explore how such a model may be adaptable or implementable for their own organizations and departments.

The specific intervention described in this article is available for sharing and adaptation for broader implementation by interested parties. Indeed, the Mental Health Commission of Canada is keen to partner with organizations and individuals interested in integrating anti-stigma programming into student and/or continuing education curricula by providing program-specific tools and implementation and evaluation resources and in partnering with organizations interested in the organizational application of the narrative recovery model. Realizing culture change requires a sustained, coordinated, and integrated commitment from healthcare leaders. Organizations and individuals interested in learning more about the Recovery Narrative program described in this article and/or in implementing other stigma-reduction programming are invited to contact the corresponding author for more information.