Collaboration and Partnership: Nursing Education and Self-Help Groups

Marsha D. Snyder and Mary E. Weyer

Nursing Connections, Spring 2000

Abstract
Development of a collaborative partnership between a mental health psychiatric nursing course and Recovery Incorporated, a self-help group, is described. Baccalaureate nursing students' reactions to their clinical experience as participant observers are examined. Through collaboration, a partnership developed that afforded students an appreciation of the role of selfhelp groups in supporting mental health, awareness of consumer responsibility for decision making. This partnership also fostered increased openness to diversity.

Baccalaureate nursing education has directed attention toward community-based care and development of partnerships with health care consumers (AACN, 1998). Professional nurses are challenged to provide sophisticated and diverse services in environments far removed from traditional inpatient settings. Effective provision of services in these various care environments requires collaborative partnerships that are built on understanding and sensitivity to consumers' perceptions and needs (Rogers & Pilgrim, 1997). As the number of patients in the traditional health system has decreased, so have student learning opportunities in such settings. These changes have challenged nurse educators looking for clinical placement experiences for students. Nurse educators must thus be prepared to work with less centralized, and often nontraditional, patient care systems (Rothert, Talarczyk, & Awbrey, 1994).

Literature Review

Health professionals have become increasingly interested in developing closer relationships and referral patterns with self-help groups. Abdellah (1990) believes that, as the focus of health care moves farther toward health promotion and maintenance, support and self-help groups may eventually evolve into another system of health care. The need for cost effective adjuncts to traditional programs of treatment is especially critical in mental health, where insurance companies have sharply limited inpatient and outpatient services. Mental health self-help groups can play an important role in providing needed information and the opportunity for members to receive and to offer help. Certain research findings, however, suggest that health and social service professionals do not properly appreciate the potential of self-help groups for helping people avoid physical and emotional isolation (Banks, Crossman, Poel, & Steward, 1997; Murray, 1996; Wilson, 1996). Murray (1996) concurs that physicians and other health professionals are often "out of the loop" when it comes to utilizing self-help groups.

Particularly in mental health, support groups offer health care providers opportunity to work as partners with consumers of services and, in doing so, to promote client empowerment. Because of their holistic approach and frequent contacts with clients, nurses are in an ideal position to empower people who need mental health services (Trivedi, 1996). To facilitate development of a partnership, nurses and health care providers should initiate collaborative alliances with self-help groups in the community. Effective partnerships evolve only when attitudes and cultural norms change on both sides, however. Service consumers must be active participants in their treatment and service providers willing to examine the use of their power in the healthcare relationship (Trivedi, 1996). Characteristic to self-help groups, Farquharson and Cardinal (1990) identified (1) respect and value for individual experience and point of view and (2) collegial relationships that convey support of individual decision making as ideal characteristics for professionals interested in partnerships.

Choosing a Partner

The demand for clinical placements and the need to shift student experiences to reflect a community focus stimulate consideration of a variety of clinical opportunities, self-help groups among them. Self-help groups offer students the opportunity to work collaboratively with consumers of health services. Especially for baccalaureate nursing students in a mental health rotation, self-help groups can heighten students' awareness of community resources, the health continuum, and alternative approaches to health care. They also offer opportunities to increase competency in relationship building and mutual goal setting between caregivers and consumers. With these objectives in mind, the faculty of a baccalaureate mental health psychiatric nursing course formed a partnership with the self-help group, Recovery International.

Recovery Inc. has about 1000 groups in the United States, Canada and other countries and is increasingly being used as a referral source by professionals. Recovery Inc. consists of a large network of a community based mental health, nonprofit, peer-based organization that supports members' efforts to assume responsibility for their mental health (Murray, 1996). Members are 18 years or older, attend meetings at least weekly, regularly read from founder Dr. Abraham Low's text Mental Health Through Will Training, and practice the Recovery method (Low, 1950). The method supports using cognitive behavioral strategies to promote and maintain personal mental health, rather than focusing on the problem of illness (Murray, 1996). Attendance does not substitute for regular physician or professional intervention, nor does Recovery offer advice, diagnosis, treatment, or counseling (Murray, 1996). Meetings are held in public venues in the community, and last two hours. Professionals and students are welcome as observers and may ask questions after the meeting. The meeting format is very structured. Meetings are opened with an excerpt reading or tape from Dr. Low's work. Members relate some "trivial" experience and their reaction to and insight into the event in the context of the Recovery "method". Other members then respond to the example presented. Refreshments and support are offered at the meetings' conclusion. Recovery Inc. meetings are led by experienced, trained volunteers who receive regular supervision. In an effort to education and promote awareness of Recovery Inc., as a support within the community for persons with mental disorders, volunteer leaders present the Recovery method through demonstration panels.

Collaboration

Establishing a partnership involved several steps; identification of mutual needs, exploration, networking establishing credibility, trust building, role clarification, decisions, and agreements. Communication was a critical element at all stages. Faculty selected learning experiences according to course objectives. After exploring advantages of collaborating with this self-help group, faculty proceeded to contact and network with the local leaders of Recovery Inc. Networking-phone calls and face-to-face dialogue with the regional director of Recovery Inc.- resulted in initiation of a demonstration panel. After clarification of roles, responsibilities, and operational issues, the decision was made to pilot a partnership for one year.

A month before their mental health clinical course was to begin, students were advised of the clinical practicum with Recovery Inc. and the need for flexible clinical scheduling. Students could select from 21 different weekly Recovery Inc. meetings, which were offered at various times at churches and schools in the large metropolitan area. The variety of meeting sites enabled students to choose one close to home or to work that was held at a time that fit their schedules.

At the beginning of the course, Recovery Inc. members presented a demonstration panel meeting during class. This interaction offered certain leaders of Recovery Inc. groups, faculty, and students opportunity for mutual goal setting and for review of channels of communication, attendance, and relationship building to promote comfort with the clinical experience. Healthcare disciplines such as psychology, social work, and nursing have long utilized the participant observer role to teach aspiring professionals and this was the role defined for students in this experience. Faculty communicated to the area director the belief that the role of participant observer enables students to increase their knowledge and awareness of (1) the mental health continuum, (2) awareness of self and impact on others, and (3) a support system for a vulnerable and often undeserved population. While the students' role during meetings was that of participant observer, students had opportunity to actively engage members to ask questions or clarify concerns about the meeting process at the meeting's conclusion.

Course Experience

The mental health psychiatric nursing course is comprised of four didactic hours and 12 clinical hours per week and is taught over sever weeks of a semester. The course utilized a stress adaptation framework and a holistic approach to the promotion, maintenance, and restoration of mental health. Students spent 10 clinical hours per week in adult and adolescent inpatient psychiatric units and two hours per week for five weeks in a single Recovery Inc. self-help group.

Students were required to produce a critical reflective journal for each Recovery Inc. meeting they attended. Through critical reflection, the students examined perceptions and assumptions that guided and directed clinical practice (Ford, 1994). Outcomes associated with journaling are critical thinking, self-awareness, and integration of professional values, standards, and knowledge (Menghella & Benson, 1995; Riley-Doucet & Wilson, 1997). Faculty provided feedback to students weekly via completed written work and clinical conferences.

To facilitate evaluation of this unique clinical experience, students were asked to provide written consent for faculty use of journal entries for outcome evaluation. Anonymity and confidentiality for each student were guaranteed. Students who agreed to submit journals for outcome evaluation did so at the end of the course and faculty read and reread all journal entries at that time. Through continuous dialogue and examination of journal entries by the two faculty on the course, several learning outcomes related to collaborative partnerships were identified.

The Partnership and Reflective Learning

A partnership with Recovery Inc. challenged students' assumptions about who is mentally ill and about the nature of mental healthcare. Students were challenged to examine the professional role of the nurse in the community and the boundaries implicit in a client partnership. Repeatedly, students were stuck with the essence of the human condition and the university of human suffering and coping with everyday stresses. In their journal writing, students were forced to examine their practice and consider their values, beliefs, and biases about the experience and to form questions about the impact of this experience on their future practice. Several themes occurred repeatedly in the students' journals: awareness of self, looking beyond the illness, challenging biases and taking the client's perspective, and professional partnerships. Following are representative expressions of these themes.

Gained Increased Awareness of Self and Respect for Others

"During the meeting, the leader seemed to give more time to those members she liked and less to those she did not care for. While all members present a common thread in their nervous disorders, each (is an) individual with their own personalities. It must be difficult to remain positive and encouraging to someone you simply don't like. This experience made me examine my own biases and interpersonal interactions with those I really don't care for. This is much easier to say than put in practice."

Another student actively used Recovery Inc. principles as she related her own coping with an incident in a meeting.

"This week I had a negative reaction to a member presenting their problem. The member couldn't seem to get to the point and kept covering her face, looking down and speaking at the table, and making long, silent pauses between sentences. I wanted to scream, "Would you just spit it out already!" I surprised myself with these thoughts because usually I am very understanding, and the member looked very distressed over the incident. Personally, I had to really "control my muscles" from fidgeting and showing my negative facial expressions. I did not understand why I was so anxious. After personally working through it I concluded that I was upset with having to come to one more of these meetings and this member's behavior fueled my negativity toward the meetings. This member was opening up, which was an accomplishment for her. Her needs were a priority, and, professionally I need to remind myself of this and put aside my issues."

Looking Beyond the Illness and Seeing a Fellow Human Being

Students identified questions and personal insights into the universality of human experience. One student reported,

"The people in my Recovery Inc. group were very real people. I could relate to those who were using the group as an aid in dealing with and preserving mental health. The experience raised questions for me...These people and their problems are not unlike me and my problems. I reflected on this and concluded that, while we may have similar problems, we do not have the same coping ability."

Another student related,

"I was surprised to see the progress over three weeks in one of the very quiet and withdrawn men attending the Recovery meeting. I asked myself, "Did I give this man enough credit? Did I believe this once silent man would be initiating feedback? Did I prejudge him?" That brought up thoughts from working with patients in the hospital. Do I give them enough credit? Do I see them as leaders? I learned from this experience that I must look beyond the mental illness and see my patients as people who function in specific roles and have daily tasks to achieve."

Challenging Biases and Accepting the Client's Perspective

"Based on the Recover Inc. panel demonstration we saw in class. I was sure that I was going to hate the meetings. This first meeting showed me that, while I may not agree with or like all the components of the group. I can see that the meetings are what helps members with their particular problems. I realized that I need to truly keep an open mind about what I hear with regards to treatment needs and options and will try to be nonjudgmental and respect people's opinions and decisions."

Another student summarized her experience this way,

"The thought of coming to the meeting every week for two hours was not appealing. Once I realized that, for the members of the group it is their life, my attitude began to change. These people suffer from a condition that seems to trivial to me, but to them it is life-hindering. I must admit, I have begun to apply some of the skills Recovery teaches. The Recovery Inc. experience was a good one. I think it allows me to put all three levels of prevention into perspective."

Professional Partnerships

"After the meeting a group member came up to me and said that some members of another Recovery Inc meeting were getting upset because they thought students were writing their stories down. This situation was very stressful for me, because I wondered what I would do if I were a student in the other group or a group member. It made me question, "How far should we take confidentiality. As a professional, how do I convey that confidentiality is being maintained? As I considered myself a part of this situation, I realized the importance of explaining what I am writing down and how it will be used."

From another student,

"This week a member who had not been at the meeting for the last 4 weeks attended. The returning member was able to pick up where he left off and even co-lead the group., Professionally, this showed me that if you educate a patient well and if they are able to apply what they learn in their lives, it doesn't matter how many times they slip away. They will always have the resources to fallback on when needed.

After being asked to assume a full member role in the group a student commented,

"I felt 'put on the spot' and became aware of the subtle ways that our boundaries can be crossed. The leader just announced to the group that the students would be taking a full role next week without even discussing it with us. I just remember the sick feeling I had after I left the meeting. I was so stunned that I didn't respond to the leader but later discussed the incident with my clinical faculty. After receiving some feedback, I felt better able to handle the situation the following week. I can see the importance of gaining skills to maintain professional boundaries. Patients will cross over boundaries, so we need to recognize what we will or will not tolerate. Each event encountered will help in dealing with next incident."

Challenges to Effective Partnerships

Initiating a partnership with a self-help group in the community presented challenges for both faculty and students. Student issues included scheduling times that would mesh with work and family responsibilities, role clarification, resistance to knowledge and language specific to the selfhelp group ideology, and opposing attitudes and beliefs about a nontraditional treatment.

Although meetings were offered at various locations and times, students' schedules, commitments, and resistance affected their regular attendance at meetings. Faculty offered weekly "hang in there" comments to encourage students to remain open to the learning experience. As one student observed, "It is important to give groups a chance. Initially I only saw any group as better than none, but by the third meeting I looked to this group differently and more positively." Trust developed over time as recognition of intent was verified through consistent action and adherence to contractual agreements.

Both students and group members had difficulty with the participant observer role. Recovery International members, in their desire to include students more in the meeting structure, attempted to engage some students into the role of full members. Students were guided to hold fast to the role of participant observer, and faculty discussed professional boundary issues with the area director to reinforce course objectives.

Although Recovery Inc. meetings offered opportunity for students to observe cognitive behavioral strategies, the uniqueness of the experience, compounded with the novel language of Recovery Inc. and its ideology made some students uncomfortable. A few students viewed the meetings as being too structured. However, several commented on a change in skepticism and the positive value of Recovery Inc. as a referral service.

Summary

In response to the challenge of educating professional nurses to practice in diverse communitybased settings and to work as partners with consumers of health care, an alliance was formed with the self help group Recovery Inc.

Benefits of Recovery International from the partnership included providing a forum for education about mental health and for increasing awareness and visibility of the program and its goals. In addition, the affiliation with a baccalaureate nursing program afforded an opportunity to increase knowledge and affect attitudes and practices of future health care professionals in relation to mental health. The partnership enhanced students' knowledge of the promotion, maintenance, and restoration of mental health and challenged their accustomed ways of knowing and of making decisions.

This collaboration and partnership produced positive outcomes for faculty and students in terms of an increase in awareness for community issues, the everyday struggles of individuals dealing with mental health issues, and the power of self care and support.

Acknowledgement

The authors acknowledge Mary Jane Spudeas, Area Director and the volunteer group leaders and members of Recovery Inc. for their commitment to student education and assistance in this project.

References

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Abdellah, F. (1990). Self-help groups offer prime areas for nurse researchers. Journal of Professional Nursing, 6, 257.

Banks, S., Crossman, D., Poel, D., & Stewart, M. (1997). Partnerships among health professionals and self-help members. Canadian Journal of Occupational Helath. 64 (5), 259-269.

Ford., J. & Profetto-McGrath, J. (1994). A model for critical thinking within the context of curriculum as praxis. Journal of Nursing Education, 33, 341-344.

Low, A. (1950). Mental Health through will-training, a system of self-help in psychotherapy as practiced by Recovery Incorporated. Boston: The Christopher Publishing House.

Minghella, E., & Benson, A. (1995). Developing reflective practice in mental health nursing through critical incident analysis. Journal of Advanced Nursing, 21. 205-213.

Murray, P. (1996). Recovery, Inc., as an adjunct to treatment in an era of managed care. Psychiatric Services, 47, 1378-1381.

Rogers, A., & Pilgrim, D. (1997). The contribution of lay knowledge to the understanding and promotion of mental health. Journal of Mental Health, 6 (1), 23-35.

Robert M. Talarczyk, G., & Awbrey, S. (1994). Partnerships in nursing education. In J. McCloskey & H. Grace (Eds.), Current issues in nursing. St Louis: Mosby-Yearbook, Inc.

Trivedi, P. (1996). Partners, not adversaries: Planning resources and care in partnership with users of mental health services. Nursing Tmes, 92, 59-60.

Wilson,J. (1996). Self Service.Community Care, 1107, 24-26.

Posted with permission of the authors.
Marsha D. Snyder, PhD, RN, CS, is Associate Professor, and Mary E. Weyer, EdD, RN, CS is Associate Professor, Concordia University & West Suburban College of Nursing, Oak Park, IL.

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