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Consumers and carers as colleagues

For each paper, identify the main argument, and provide an outline or synopsis of the content of the paper. Discuss areas of agreement or disagreement (synopsis and discussion should total approximately 500 words per paper). In addition to the synopsis and literature discussion, provide a personal reflection on your response to the papers, including your thoughts on the implications for nursing care and your opinions on how these papers may influence your future practice. Your paper should also include a brief introduction and conclusion.
* Recent in this context refers to papers published no earlier than 2001.

Description Written assessment
2000 word written assignment


Assessment Marking Grid Not Adequate Needs Improvement Meets Expectations Above average Exceptional MARK
Presentation & Style 2 4 6 8 10
Meaning unclear & / or grammar & / or spelling contain frequent errors Meaning apparent, but language not always fluent. Grammar &/or spelling contain errors Language mainly fluent. Grammar & spelling mainly accurate Language fluent. Grammar & spelling accurate Excellent writing style appropriate to document. Grammar & spelling always accurate
Content & Knowledge 2 6 8 12 15
Lacks evidence of knowledge relevant to the topic. Significantly misuses terminology. Evidence of limited knowledge of the topic & some use of appropriate terminology. Has given evidence of a factual and /or conceptual knowledge base regarding the topic & has utilised appropriate terminology. Reasonable exploration of the topic and an awareness of a variety of ideas and contexts relating to the topic. Comprehensive/detailed knowledge of topic with areas of specialisation, in- depth awareness of impacts on practice.
Argument & Evidence 2 4 8 12 15
Lacks critical thought/analysis/ reference to theory Some evidence of critical thought/critical analysis & rationale for work Demonstrates application of theory through analysis of the topic area Clear application of theory through critical analysis / critical thought of the topic area Consistently demonstrates application of critical analysis well integrated in the text.
Critical Analysis &Integration of theory 0 4 6 8 10
Either no evidence of literature being consulted or irrelevant to the topic Literature is presented uncritically in a purely descriptive way & indicates limitations of understanding Clear evidence & application of readings appropriate to the subject; use of academic sources identified Able to critically appraise the literature & theory gained from variety of academic sources, developing own ideas in the process Has developed & justified own ideas based on a wide range of academic sources which have been thoroughly analysed, applied & discussed
Referencing style 0 3 5 7 10
Referencing is absent / unsystematic Some literature cited. Some attempt at referencing. Literature cited is appropriate. Referencing is mainly accurate Literature cited is relevant yet not extensive. Referencing is accurate with minimal errors Literature cited is relevant and extensive. Referencing is consistently accurate



The facilitator will examine papers by assessing whether the student has addressed the question directly, engaged in critical analysis of the issues that has been well supported by the relevant literature and has organized and presented the assignment in a suitable manner. Sources must be cited in the text and details of them included in the reference section using Harvard style guide (refer to Harvard guide from VU library).
Essays must be typed, double spaced, page numbered and spelling, punctuation and expression checked prior to submission. The use of point form is not acceptable. The front cover must identify which scenario has been chosen and the total word count.


Article number 1.
Issues in Mental Health Nursing, 28:1065–1079, 2007
Copyright c Informa Healthcare USA, Inc.
ISSN: 0161-2840 print / 1096-4673 online
DOI: 10.1080/01612840701522069
Stephen Elsom RN. MHN, BA, MN PhD Candidate
Centre for Psychiatric Nursing, School of Nursing,
The University of Melbourne, Level 1, 723 Swanston Street,
Carlton, Victoria 3053
Brenda Happell, RN, Cert Psych Nurs, BA (Hons),
Dip Ed, BEd, MEd, PhD
Professor of Contemporary Nursing, Department of Nursing
and Health Studies, Central Queensland University, Bruce
Highway North Rockhampton, 4702 Queensland, Australia
Elizabeth Manias, RN, Cert Crit Care, B Pharm,
M Pharm, M Nurs Stud, PhD
School of Nursing, The University of Melbourne, Level 1,
723 Swanston Street, Carlton, Victoria 3010
Community-based mental health as the primary focus of
treatment has influenced more autonomous roles for mental
health nurses. A limited literature suggests that this has
resulted in the expansion of community mental health
nursing into territory usually the exclusive domain of the
medical profession. Consumers and carers are the two
groups most affected by changes to service delivery;
however, their views regarding the changing role of
community mental health nurses have not been sought. This
paper presents the findings of a qualitative study involving
indepth interviews with Australian consumers (n = 4) and
The authors wish to acknowledge the support for this research provided by the Australian
Research Council and Eli Lilly Australia.
The authors extend their thanks to the consumers and carers who gave their time, their
experiences and their opinions so freely and willingly.
Address correspondence to Brenda Happell, Department of Nursing and Health Studies,
Central Queensland University, Bruce Highway North Rockhampton, 4702 Queensland, Australia.

1066 S. Elsom et al.
carers (n = 6) designed to explore their views and opinions
about the expanded practice roles of community mental
health nurses. Four main themes were identified:
accessibility and convenience; relationship with clinicians;
beneficiaries of expanded nursing practice; and, are nurses
up to it? The findings suggest expanded practice roles are
perceived positively by consumers and carers and therefore
worthy of further investigation.
Widespread changes to mental health service delivery in Australia
now places the community as the primary focus of care and treatment
for people experiencing mental illness (Whiteford, Buckingham,&
Manderschied, 2002). This profound policy transformation has resulted
in substantial reduction in inpatient care and has significantly altered the
role of the nurse in relation to mental health care (Cleary, 2004). As a
consequence of the policy changes, community mental health nursing
has developed a greater degree of autonomy and independence than has
traditionally been associated with institutional and hospital-based care.
The relationship between mental health professionals has also altered
with a tendency for consumer care to be provided according to individual
needs with less emphasis on the traditional roles associated with
each professional group (Cleary, 2004; McCann & Baker, 2002; Rosen
& Callaly, 2005).
The provision of community care means that medical resources are
not so readily available as in the hospital setting. A limited literature
proposed that the combination of increased autonomy and decreased
access to medical resources has led to community nursing roles expanding
beyond those customarily associated with the nursing role (McCann
& Baker, 2002). Such expanded practice has been been described by
Dunphy, Younking & Smith (2004) and Schober (2004) as consistent
with the tendency for nursing practice to move beyond legal and
other regulatory authorities in response to the health-care needs of
As a consequence of the significant growth in community mental
health care and the breadth of the changes to the system, responsibility
for the care of people experiencing mental illness cannot totally be
met by mental health professionals. Informal carers (defined as people
who provide unpaid care for people using mental health services, usually
relatives or friends of services users) have been estimated to devote
approximately 104 hours per week to this role (Mental Health Council
of Australia and Carers Association of Australia, 2000) and have
Expanded Practice Roles for Community Mental Health Nurses 1067
subsequently become crucial for the effective delivery of mental health
By virtue of constituting the largest professional group within mental
health services, nursing plays an integral role in providing care for
consumers of mental health services and support for those who provide
informal care for them. In this respect consumers and carers represent
the groups ultimately affected by expanded practice roles in nursing.
A review of the literature, however, reveals a paucity of research exploring
the opinions of consumers and carers towards expanded roles
for community mental health nurses. In light of the rapid increase in
community-based mental health care and the concerns raised by consumers
and carers about the quality and standards of services available
(Mental Health Council of Australia, 2005), the expanded practice roles
of community mental health nurses warrant further investigation. The
aim of this paper is to articulate the views and opinions of consumers of
mental health services and their informal carers towards the expanded
practice roles of community mental health nurses.
For the purposes of this paper, the term community mental health
nurse refers to nurses who work in community settings rather than
inpatient services. They provide care to service users either in their own
homes or within a community-based clinic or through a combination of
the two. Community mental health nurses frequently undertake a case
management role in the provision of mental health care. Although there
are no specifically determined qualifications for community practice,
nurses generally undertake these roles after several years of experience
in an inpatient setting.
A qualitative exploratory approach was selected for this study in order
to elicit an in-depth understanding of an area where there a paucity
of relevant literature (Aranda & Street, 2001). As the review of the literature
demonstrates, the perspectives of consumers and carers regarding
expanded practice roles for nurses within mental health care have not
been the subject of investigation, particularly in the mental health area.
Four consumers and six informal carers participated in this stage of
the study. The recruitment of participants was facilitated by three senior
psychiatric nurses who delivered information about the project to consumer
and carer consultants employed by their respective mental health
1068 S. Elsom et al.
services. These consultants, in turn, sought expressions of interest from
consumers and carers with whom they had meetings in the course of
their employment. Interested participants were invited to contact the
principal researcher directly to arrange a mutually convenient time for
the interview. In an attempt to increase the number of participants, consumer
and carer organisations were also contacted and fliers distributed
through their email networks. The principal researcher also presented
information sessions about the project at meetings of consumer and carer
groups. The recruitment phase extended for approximately two months
in the attempt to secure additional participants. Payments to cover travel
costs were offered. No additional incentives could be provided as this
would contravene the provisions of the ethical approval. Unfortunately
these efforts realised only small recruitment numbers. It is beyond the
scope of this paper to consider the reasons for difficulty in recruiting
participants. It might be speculated that consumers and carers have little
understanding of, or interest in, expanded roles for community mental
health nurses.
Two of the consumers were employed as consumer consultants by
mental health services. Consumer consultants are people who have
previously received treatment for a mental health problem or disorder
and who are employed by mental health services to facilitate
consumer input into various aspects of mental health care. The
two consumer consultants were interviewed individually and the remaining
two consumers were interviewed together. The researcher
(a qualified and experienced psychiatric nurse) judged these participants
competent to provide informed consent for the interview.
The six carers participated in a single focus group. All six were
parents of people currently receiving mental health care. Three of
the consumers were male and one was female while equal numbers
of male and female carers made up the focus group. The age range of
the consumers was from 25 to 45 years and the carers were all aged
between 45 and 60 years.
Ethical approval for the study was obtained from the relevant institutional
ethics committees. A full explanation of the procedure was
provided to all participants, including their right not to participate or to
withdraw from the study at any stage. Informed consent was obtained
in writing prior to commencement.
The intention was to conduct focus groups with both consumers and
carers to provide an environment to encourage discussion and interaction
between participants (Grbich, 1999; Happell, 1996). A focus group
Expanded Practice Roles for Community Mental Health Nurses 1069
TABLE 1. Interview Guide
1. Can you give examples of any instances where mental health nurses’ practice
has moved beyond the usual boundaries of nursing practice? I am particularly
interested in those areas traditionally regarded as the exclusive domain of
medical practitioners. Some examples might include suggesting changes in
medication, admission to hospital, recommending referral to other services or
for tests.
2. Can you please describe the circumstances in which this occurred?
3. Is this regular occurrence or an isolated example?
4. How do you feel about this sort of expanded practice?
5. Are there any areas into which you think community mental health nursing
practice could or should be expanded?
6. What do you think the advantages of this expansion would be? For example,
would it be advantageous if the nurse case manager was able to prescribe
7. Disadvantages?
8. Who (if anyone) do you think would most benefit from any expansion of
nurses’ roles?
9. Who (if anyone) would be most disadvantaged?
10. What are the main barriers to an expansion of the role of community mental
health nurses? How could these be overcome?
11. What do you think would be required of nurses in order to fulfil any future
expanded practice roles?
was successfully arranged with a carer group, however difficulties in
recruiting consumers meant that obtaining enough participants to conduct
a group interview at one site would be unlikely, thus individual
interviews were conducted, and on one occasion two individuals participated
in the one interview.
The duration of the interviews was between 30 minutes and one hour;
this time frame was guided by the participants themselves rather than a
pre-determined schedule. A semi-structured format was adopted for the
interviews. An interviewguidewas developed to provide some focus and
direction for discussion (Table 1). The interview guide was developed
by the research team and based on the information derived from the
literature review. However, this was intended only as a loose framework
to provide some structure and commonality to the interviews. The overall
aim was to consider the issue from the perspective of the participants
To preserve confidentiality and facilitate analysis each participantwas
allocated a code prior to analysis of the transcripts. These codes were
allocated sequentially according to whether the person was a consumer
or a carer. For example ICFG1 refers to the first member of the carer
1070 S. Elsom et al.
focus group. CIV3 refers to the third consumer interview. This meant
that the identity of each participant was known only to the researcher
who conducted the interviews.
Data Analysis
All interviews were audiotaped and transcribed verbatim in order
to supply a complete and accurate account of participant contributions
(Grbich, 1999). Data analysis was based on the approach developed
by Ritchie and Spencer (1994). This method comprises five key stages:
familiarization with content; identifying a thematic framework; indexing
themes; charting themes; and, the mapping and interpretation of themes.
To enhance research rigour, the three researchers conducted data analysis
separately. Subsequently they came together to compare themes and
interpretations. Consensus was readily achieved following discussions
of minor discrepancies.
There were four main themes evident in the expressed views of the
consumers and carers. The first theme was that the expansion of nurses’
practice would be beneficial because of the accessibility of community
mental health nurses compared to doctors. A second theme to emerge
was that the relationships that consumers and carers have with doctors
are both quantitatively and qualitatively different than the relationships
they have with community mental health nurses. A further theme concerned
the consumers’ and carers’ perceptions of benefits to clinicians
of expanded nursing practice. Finally, a less prominent but nonetheless
noteworthy theme was the consumers’ concern about whether nurses
have appropriate education and training to prescribe medication. These
themes are presented in more detail below with illustrative quotations
from the consumer and carer participants.
Accessibility and Convenience
In their discussions regarding expanded nursing practice all of the
consumers and carers referred to the relative accessibility of community
mental health nurses compared to doctors, including both general practitioners
(GPs) and psychiatrists. This greater accessibility was seen as an
important factor in enabling the consumer to receive treatment in a timely
manner as is seen in the following extract from the carers’ focus group.
Expanded Practice Roles for Community Mental Health Nurses 1071
Our daughter was unwell now and she couldn’t get in to see the psychiatrist
untilWednesday but her case worker [community mental health
nurse] rang her and she talks to her and that helps her. (ICFG2)
One of the consumers had a similar view.
Sometimes it’s really hard to get to see a doctor so it would be good. I
think things would happen faster if nurses could do it instead of waiting
for the doctor. (CIV3)
The need for medications to be prescribed in a timely mannerwas seen
by one of the consumer consultants as a reason to extend prescriptive
authority to nurses. He thought that such prescriptions could be reviewed
afterwards by a doctor.
My view is that it should be possible [for nurses to prescribe] on a temporary
basis and then reviewed by a specialist doctor. Sometimes it’s
essential that it’s done then and there. (CIV2)
This same consumer believed that the expansion of mental health
nurses’ scope of practice was a logical response to a shortage of medical
resources. His viewis illustrated in the following quotation regarding the
expansion of the nurses’ role to include hospital admission and discharge
If they [doctors] are not available, its only common sense that you’d
initiate a concept like that to allow mental health nurses to be able to
control the ins and outs of the hospital. (CIV2)
Two of the consumers spoke of the benefits of expanded nursing
practice in terms of reducing the need for consumers to be seen by
multiple clinicians.
It would save a lot of time. It would avoid reviewing the consumer once
again through the doctor. I think it would also be helpful for the consumer
and the family member because the consumer wouldn’t have to see the
doctor as well as the nurse when they’re feeling not the best as well and it’s
stressful on the family too. When a decision [regarding treatment] needs
to be made it is important that it’s made promptly and very accurately
rather than going from person to person for a decision to be made. (CIV2)
The following extract from an interview with a consumer highlights
an unfortunate experience that she had had in visiting a GP to seek a
prescription. She explained that she had been experiencing acute anxiety
whilst eating her meals in the stressful environment of a women’s refuge
and she had hoped that a GP would prescribe some diazepam to help
her with this problem.
1072 S. Elsom et al.
I went to the GP for an appointment and I said, “I can’t eat at the moment,”
and, you know, he thought I was a bit of a nutcase and he didn’t have
much experience with psychiatric patients, and then he found out I was a
psychiatric patient he had to ring the clinic. He had to get authorisation
from my doctor that I was a psych [sic] patient and that maybe I did have,
you know, a nervous condition at that time, and that it could be legitimate,
that I wasn’t just doctor-shopping for Valium [diazepam] or something
like that. (CIV1)
Relationships with Clinicians
This theme emerged in several different contexts and included comments
concerning howwell the consumer and their family members were
known to the clinicians and also some differing perspectives about the
inherent nature of interactions between professional clinicians and consumers.
Most of the consumers and carers noted that community mental
health nurses have greater contact and therefore know consumers better
than either GPs or psychiatrists.
I think nurses know you better on a one-to-one basis and they would be
able to decide whether there is something wrong with you because they
know you better. They would be able to see if you’re having a relapse or
something. (CIV3)
One of the carers reported relying on a community mental health
nurse to report information that he had experienced some difficulty in
obtaining from his daughter’s doctor.
We never actually found out an awful lot from the psychiatrist about
what was happening with our daughter. We had to find out from her
case manager [community mental health nurse] who’s very very good.
Another carer attributed this difficulty in obtaining information from
the psychiatrist to something inherent in the psychiatrist’s professional
What’s the point of trying to talk to a psychiatrist? It’s just the fact that
he’s doing a professional job but at the same time, he’s detached from the
family whereas they’re not, I mean the case worker [community mental
health nurse], they have a more common touch, I don’t know whether
it’s their background but they [community mental health nurses] seem to
come across better and understand the families better. It’s like, as I said,
Expanded Practice Roles for Community Mental Health Nurses 1073
he’s [psychiatrist] professionally distant in his job. I think the psych nurse
comes across far better. (ICFG4)
A slightly different perspective was advanced by one of the consumer
consultants who spoke about howshe behaved differently in the presence
of a doctor than she did when interacting with her case manager who
was a community mental health nurse. She explained that this difference
stemmed from her own expectations of the traditional roles of doctors
and nurses.
In a way, you know, maybe I’m old-fashioned or something, but I would
find it almost a bit confusing if the nurse was authorised to prescribe me
with medication because I get in a different mindset for the appointment
I have with my doctor than what I have with my case manager. And for
me, if the case manager was able to say, “Oh look, it looks like you’re
doing really well, we can reduce your anti-psychotics or something like
that,” I don’t know, . . . it just seems to me like there could be a conflict of
interests or something. . . Probably I’m a bit more respectful when I go
to the doctor. Like, if I’m feeling tired or something or I’m in a crappy
mood or something like that, I’m likely to let the case manager know, and
be perhaps a bit belligerent or something like that, but if I’m feeling the
same symptoms and I’m seeing the doctor, I’ll try and pull it together, just
to, you know, at least be respectable. Does that make sense?. . . As if he
won’t tolerate it if I am less than business-like or responsible, something
like that. But I don’t know, I feel like a – that’s just my upbringing about
how you are meant to respond around a doctor, or something like that.
The Beneficiaries of Expanded Mental Health Nursing Practice
As outlined earlier, the consumers and carers identified some benefits
to themselves from community mental health nurses expanding
their roles to include some aspects of medical treatment. These benefits
were primarily related to ease of access to mental health nurses and the
perception that the nurses were more familiar with the patients’ needs.
When asked directly who they believed would benefit most from any
expansion of the mental health nurse’s role, all of the consumers identified
the nurses themselves. They believed that role expansion would
add to the nurses’ responsibility and also save the nurses time in so far
as they would not need to chase doctors for any changes to medication,
requests for investigations, or referrals to specialists.
1074 S. Elsom et al.
It would expand the nature of their [nurses’] role, it would give them
more say in how their client’s going, it would give them more control
over outcomes. (CIV1)
One of the consumer consultants expressed concern that extra responsibility
could be seen as both a benefit and a potential source of extra
unwanted stress for nurses. He also thought that there should be a redistribution
of financial remuneration between the medical and nursing
professions commensurate with the redistribution of responsibility.
The only gain the doctors will get out of this is less chance of
negligence. . .. Nurses are already complaining that they’re doing too
much, too much paperwork. So I think that doing more work like this
will probably burden their stress levels in their jobs. I personally think
if a move like that is to happen, wages or funding for wages need to be
restructured so that nurses earn more and doctors earn less. . .. If you’re
going to put more work on nurses then they should be respected for that
work and they should be paid for it. And if doctors are going to take less
responsibility then they should be paid for that less responsibility. That’s
my view from a consumer’s perspective. (CIV2)
When asked directly if they saw any potential disadvantages associated
with mental health nursing role expansion the carers focus group
could only see advantages to themselves and to nurses.
It’s more to their [mental health nurses] gain really in a way, they’re
more knowledgeable and maybe it’s more easily accessible for us to get
somebody if we need them. I mean if we’re in a crisis point and we need
something, they’d come out to you. (ICFG3)
Are Nurses Up to It?
Both of the consumer consultants expressed some concern about the
current capacity of mental health nurses to undertake some aspects of
expanded practice. One of these consultants held her own reservations.
I know this sounds horrible, but I would not feel confident in the nurse’s
ability to assess as to whether I need a reduction in that medication.
The other consumer consultant held a different view but noted that he
was aware of some concerns from fellow consumers.
One consumer in a hospital told me that he thought it wouldn’t be safe. It
would be negligent. It would not be respecting the doctor’s training and
so he was strongly against the notion about making mental health nurses
Expanded Practice Roles for Community Mental Health Nurses 1075
eligible to prescribe or to refer to specialists. That was his viewpoint. But
in my view, as long as there are protocols in place to protect the consumer
and also to protect the mental health worker I don’t mind it. If it’s going
to make work a lot easier for the mental health service, for the mental
health system, for everybody, its worthwhile progressing it. (CIV2)
The first consumer consultant (CIV1) also noted that she was aware
of some widespread negative views amongst mental health consumers
about doctors and she thought that it was possible that these consumers
would prefer their mental health nurse case managers to be able to undertake
medical tasks.
I knowa lot of people who have a lot of reservations about doctors, they’ve
got really bad attitudes about them, and they think they’re all monsters or
whatever, and so maybe for those people to have their case manager in a
more – you know, have more licence to do stuff would be beneficial. But
then again – I mean, the general consensus from what I can gather from
a lot of consumers tends to be, you know, doctors are pompous idiots
who just reel off decisions without even taking into mind your wellbeing.
All of the consumers and the carers stated views that nurses would
require appropriate education and training in order to be able to undertake
expanded practice roles. This view is captured in the following quote
from one of the consumers who also placed value on clinical experience.
They [nurses] should have experience to start off with, a lot of experience,
particularly with the current medications. They should be provided
with information like doctors get regarding the medications and the newer
medications, journals and whatever. They should read up on them [medications].
They should also be offered professional development courses
to be current with current practices. That should also not be done through
the school of nursing. It should be done through the faculty of medicine.
The findings of this study address an important gap in the literature
pertaining to the perspectives of consumers and carers about expanded
practice roles of community mental health nurses. In general, consumers
and carers supported the development of the expanded practice role, and
perceived that nurses in these roles function in ways that complement
and possibly improve the quality of care currently received by consumers.
Four major themes were identified in the study: accessibility and
1076 S. Elsom et al.
convenience, relationship with clinicians, beneficiaries of expanded
nursing practice and the current capacity of mental health nurses to
undertake expanded practice.
Consumers and carers perceived community mental health nurses
were relatively accessible compared to doctors. These perceptions support
the evidence provided in past research carried out in primary care
settings. In an examination of case records of 120 random medication
charts, Fisher and Vaughan-Cole (2003) found that while nurses and
psychiatrists prescribed the same number of different types of antidepressant
medications, nurses spent more time with patients compared to
a psychiatrist during medication evaluation session. Shum et al. (2000)
who examined consumers’ level of satisfaction of the management of
minor illnesses in general practice found that appointments with nurse
practitioners averaged approximately 10 minutes while those conducted
with general practitioners were about 8 minutes. Aside from time spent
in consultation, previous studies have identified that consumers reported
receiving more information about their illnesses from nurses compared
with doctors (Byrne, Richardson, Brundson, & Patel, 2000; Kinnersley
et al., 2000; Horrocks et al., 2002).
While past studies involving perceptions and experiences of expanded
practice are somewhat limited because they were conducted in primary
care settings (Byrne et al., 2000; Kinnersley et al., 2000), they draw out
parallels with the mental health context. Ultimately, consumers were satisfied
about the standard of care provided by nursesworking in expanded
practice roles. In relation to the specific needs of consumers with mental
health problems, such individuals are likely to require enormous levels
of care because they are more likely to experience life-threatening problems
relating to co-morbidities such as cardiac and respiratory diseases
(Davidson, Judd, Jolley, Hocking,&Thompson, 2000). Consumers with
mental illness are also more likely to practise risky behaviours including
smoking, and substance and alcohol abuse, which increases the need for
additional support. As demonstrated by consumers in this study, additional
support was easily accessible through community mental health
Consumers and carers identified with the closeness of the therapeutic
relationship between nurses and themselves. They related empathically
with the positive nature of the interactions with nurses, which enabled
participants to be receptive in communicating about managing health
problems. Mental illness is a condition that not only affects the consumer,
but it also has an important impact on family dynamics. In the study,
consumers and carers stated that the nature of the psychiatrists’ role
meant that psychiatrists were professionally distant and detached. Luker,
Expanded Practice Roles for Community Mental Health Nurses 1077
Austin, Hogg, Ferguson and Smith (1998) proposed that nurses have a
unique social position through their ability to comprehensively examine
consumers and the way they interact in their natural environment.
Consumers and carers acknowledged the beneficiaries of expanded
nursing practice were nurses and themselves. Two main reasons were
provided for the benefits of expanded practice included: increased
nurses’ responsibility and improved efficiency of nurse access to doctors
for the purpose of obtaining changes to medication, request for investigations
and referrals to specialists. Interestingly none of the participants
mentioned that psychiatrists or the medical profession would benefit
from initiation of expanded practice. Unfortunately no randomised
controlled trials have been conducted to confirm if the quality of care and
clinical outcomes are enhanced through the use of an expanded practice
role for mental health nurses.
In this study, there was some concern raised by consumers and carers
about the current capacity of mental health nurses to undertake expanded
practice roles. These sentiments confirmed the views raised in the literature
about the need for training programs to support mental health
nurses’ development in expanded practice (Elsom, Happell, & Manias,
2005; Jones, & Jones 2005). Jones and Jones highlighted a problem of
currently available prescribing programs in the UK since they are available
to nurses of all disciplines and the uptake by mental health nurses
into an individual course is small. Furthermore, these programs follow
a generic framework, adding very little to nursing knowledge in the
management of complex mental health conditions. It is advisable that
currently available and future programs detail the assessment and treatment
of specified mental health conditions, including schizophrenia,
anxiety, depression and dementia. Without adequate training in mental
health conditions, mental health nurses may not be in a position to
competently fulfil their responsibilities of expanded practice.
The small sample size of this study means that the findings may not
be directly transferable to the views held by consumers and carers in
various contexts. Consumers and carers were recruited from the community
and therefore the perspectives of those individuals in inpatient
settings, may be very different. Despite the acknowledged limitations,
the study findings confirm the importance of consumers and carers as key
stakeholders in consideration of the practice roles of community mental
health nurses. In light of this, further research to explore their views on a
larger scale is warranted. However, given the difficulties experienced in
recruiting participants for this study, alternative methods of recruitment
need to be explored. A more active involvement of consumers and carers
in the design and execution of this research may secure a greater sense
1078 S. Elsom et al.
of ownership in the aims and outcomes, and hence lead to increased
rates of participation. The formation of a reference group comprising
consumers and carers was found to be valuable in conducting research
with these target groups in a study by Lammers and Happell (2004).
In summary, the consumers and informal carers interviewed held
generally positive views regarding the expansion of community mental
health nursing practice into areas that have traditionally been the sole
domain of doctors. They sawadvantages deriving from the relative accessibility
of nurses compared to doctors and also from the perception that
the nurses develop closer relationships with mental health consumers
than is possible for doctors. These participants thought that there would
be benefits to consumers, carers, and also to the nurses themselves, provided
that the nurses had the appropriate education and training.
The authors wish to acknowledge the support for this research provided
by the Australian Research Council and Eli Lilly Australia.
The authors extend their thanks to the consumers and carers who gave
their time, their experiences and their opinions so freely and willingly.

Article number 2

Issues in Mental Health Nursing, 29:131–143, 2008
Copyright c Informa Healthcare USA, Inc.
ISSN: 0161-2840 print / 1096-4673 online
DOI: 10.1080/01612840701792340
Michelle Cleary, RN, BHlthSc (Nurs), MHlth Sc
(Nurs), PhD
Clinical Associate Professor Mental Health, Faculty of
Nursing and Midwifery, University of Sydney, and Clinical
Nurse Consultant, Research Unit, Sydney South West Area
Mental Health Service (Eastern Zone), Australia
Sandra Matheson, BSc (Hons, Psych)
Research Officer, Research Unit, Sydney South West Area
Mental Health Service (Eastern Zone), Australia
Garry Walter, MB BS, BMedSc, PhD, FRANZCP
Professor of Child and Adolescent Psychiatry, Discipline of
Psychological Medicine, University of Sydney, and Area
Clinical Director, Child and Adolescent Mental Health
Services, Northern Sydney Central Coast Health, Australia
Gillian Malins, BA (Hons, Psych), PhD
Executive Officer, NSW Consumer Advisory Group – Mental
Health Inc., Sydney, Australia
Glenn E. Hunt, BA, MSc, PhD
Senior Research Fellow, Discipline of Psychological
Medicine, University of Sydney and Research Unit, Sydney
South West Area Health Service (Eastern Zone), Australia
Increasingly, consumers and carers are involving
themselves in many aspects and levels of mental health
services. However, one area in which active involvement
has been less prominent is research. This paper describes
an educational initiative that sought to increase consumers’
and carers’ understanding of the way research is conducted
Address correspondence to Michelle Cleary, Research Unit, Sydney SouthWest Area Mental
Health Service P. O. Box 1, Rozelle, New South Wales Australia 2039. Tel: +61 2 9556 9493;
Fax: +61 2 9818 5712. E-mail:
132 M. Cleary et al.
and its role in evidence-based practice. Information
regarding participants’ attitudes towards research,
knowledge about research practice and participation was
also examined. The findings provide evidence that workshop
attendance increases knowledge and encourages
participation in future research projects, particularly when
participants have confidence in the researcher.
There is an increasing expectation that consumers of mental health
services participate in all aspects of their care (e.g.; Cleary, Walter, &
Escott, 2006; Cleary, Freeman, & Walter, 2006; Crawford, 2001;
Crawford et al., 2002; Lammers & Happell, 2003; Linhorst, Eckert, &
Hamilton, 2005; Malins et al., 2006; Meehan et al., 2002). This means
that consumers are no longer passive recipients of care and treatment,
but are actively involved in the delivery and evaluation of mental health
services. This is generally seen as worthwhile, with benefits to healthcare
including users bringing “expert” opinion, refined and more pertinent
research questions, and differing and novel perspectives and approaches
(Hanley et al., 2001; Tait & Lester, 2005). This involvement
also contributes to de-stigmatising mental disorders (Griffiths, Jorm, &
Christensen, 2004).
Greater consumer participation may also be therapeutic to the user
by raising self-esteem and assisting mental health professionals to overcome
negative attitudes towards consumers through enhanced understanding
(Roper & Happell, 2007; Tait & Lester, 2005). However, the
effects are yet to be thoroughly evaluated (Crawford et al., 2002; Simpson&
House, 2002), and there is little literature regarding the training of
consumers for active involvement (Meehan et al., 2002). In a systematic
review of RCTs and other comparative studies, it was found that involving
consumers as employees, trainers or researchers resulted in positive
effects on care (Simpson & House, 2002).
Although consumers and carers are involving themselves in many
aspects and levels of modern mental health services, one area in which
active consumer and carer participation has been less prominent is research.
This topic is, however, attracting increasing attention (Goodare&
Lockwood, 1999; Horsfall et al., 2007; Rose, 2003; Telford & Faulkner,
2004; Wykes, 2003). The reluctance of many consumers and carers to
participate in research, elicited in a variety of studies (e.g. Cleary et al.,
Demystifying Research and Evidence-Based Practice 133
2005; Cleary, Freeman, Hunt, & Walter, 2006; Cleary, Hunt, Walter, &
Freeman, 2006), presents service providers with an enormous challenge
in improving health outcomes. Nevertheless, in a previous study that examined
the experience, knowledge and attitudes of consumers and staff
regarding research, we found that most consumers expressed an interest
in research and were keen to learn more about research methods and
processes (Cleary et al., 2007). Gaps in their knowledge base and some
of the reasons for declining to participate in research were also identified.
As consumers and carers are important beneficiaries of research
findings, it is imperative to keep them informed of research processes
and how to access results (Griffiths et al., 2002).
It is against this background that we undertook the project of developing
a workshop for the purposes of increasing attendees’ (consumers
and carers) understanding of the way research is conducted in mental
health settings. Further, we aimed to provide consumers and carers with
a basic knowledge of the role of research in evidence-based practice
(EBP). In an attempt to ascertain the effectiveness of the workshop,
participants’ knowledge and attitudes towards research was sought preand
post-workshop to determine factors contributing to participation and
whether attendance at the workshop changed their views and increased
Expressions of interest were circulated through consumer and carer
government and non-government organizations, inviting people to register
to attend a half-day workshop. Five workshops were conducted
with a convenience sample of consumers and carers in metropolitan
area health services in New South Wales, Australia over a period of
three months.
The workshop content was developed in collaboration with health
staff, as well as consumer and carer government and non-government
organizations. Content covered the following areas: 1) What is research
and EBP? 2) Why is research important and how does it help best practice?
3) How do you conduct research and what factors contribute to
the ongoing success of research projects? 4) What are the common
barriers to and reasons for participation? and, 5) How do you access
research findings? Handouts from the program were made available after
the workshops and some individuals and organisations subsequently
requested further assistance from the presenters (e.g., review of documents,
development of protocols).
134 M. Cleary et al.
Facilitated exercises were conducted during the workshops to stimulate
discussion amongst the group. Exercises focused on: the meaning
of research and EBP to participants; difficulties of, and challenges to,
conducting research; barriers to participation; accessing and assessing
results; and how research helps guide practice. An overview of the feedback,
in the form of notes taken during the discussion session, is included
in the results.
In addition, participants’ attitudes were obtained by surveys conducted
prior to commencement of the workshop and immediately afterwards.
Survey questions were adapted from a similar instrument (Cleary
et al., 2007; Siegfried et al., 2003). The internal consistency was high
for both patients (α = 0.84) and staff (α = 0.80) on these items (Cleary
et al., 2007). The purpose of the initial survey was to establish baseline
data regarding the views and experiences of participants in relation
to research and EBP. Attitude questions provided an opportunity
for consumers and carers to rate their agreement with statements about
evidence-based mental health care. Items in the second survey pertained
to respondents’ rating of knowledge about a range of subjects listed on
the initial survey and to the perceived usefulness of information provided
in the workshop. Respondents were given a variety of answer
options ranging from a standard Likert scale (e.g., “strongly agree” to
“strongly disagree”) to “yes,” “no,” or “unsure” responses. No validity
or reliability measures are currently available for this survey.
Data Analysis
Descriptive data are presented as simple frequencies, percentages and
means. Displayed lists in tables are rank ordered to assist interpretation.
Categorical variables were analysed using the Pearson χ2 test for independence.
Some categories were merged in order to avoid low expected
frequencies. Responses for some of the items were recoded to positive
and negative categories (Yes/No, Agree/Disagree) to assess change over
time. The pre- and post-workshop data were analysed using the χ2 statistic
for paired samples (McNemar’s test) with a probability level set at
p < 0.05. This test does not consider the pairs with the same outcome; it is based on discordant pairs (e.g., those who differ in their responses). RESULTS Forty-five people attended the workshops and 44 completed the survey (98% response rate). Out of these, 37 (84%) surveys were usable, Demystifying Research and Evidence-Based Practice 135 as seven had a high level of incomplete data. This was probably due to considerable literacy difficulty in one group (flagged by the organiser), which was too large to individually assist participants to complete their survey. The sample consisted of 25 consumers (67.6%), 4 carers (10.8%) and 8 people who were both a consumer and a carer (21.6%). There were 11 males (30%) and 26 females (70%). The mean age was 48.7 years (SD 12.56, range 25–77 years) and 15 people (40.5%) had participated previously in healthcare research. Attitudes Towards Research, Pre and Post Workshop The vast majority of participants said they were fairly or very interested in research pre- and post-workshop (pre: 81%, post: 92%) and reported being interested in research results (fairly or very interested pre: 87%, post: 81%). Differences were not significant between pre- and post-workshop. Table 1 outlines participants’ attitudes about evidence-based care. There were no statistically significant changes in the number of participants rating attitudes differently pre- to post-workshop. Furthermore, there were no significant differences between patients who had, and patients who had not previously participated in healthcare research in terms of attitudes towards evidence-based practice (items on Table 1). Factors that Influence Research Participation, Pre and PostWorkshop Table 2 shows the percentage of affirmative or endorsed responses preand post-workshop to 12 factors regarding their decision to be involved in research.Only one factor showed a significant difference pre versus postworkshop: the characteristics of the researcher (p = 0.031), with six participants changing their response from “no” to “yes” post-workshop, and none changing their response from “yes” to “no.” In response to the question, whether I’ll be able to answer the questions shows the same percentage change pre- and post test; however, the difference did not reach statistical significance as 9 subjects changed their response from “no” to “yes” and 3 subjects responded in the opposite direction. There were no significant differences between patients who had or had not previously participated in healthcare research on any of the factors contributing to their decision to be involved in research (items listed in Table 2). 136 M. Cleary et al. TABLE 1. Attitudes about EBP Sorted by Rank Pre-workshop Post-workshop (N = 37) (N = 37) % Agree or % Agree or p-value2 Item strongly agree1 strongly agree1 (pre/post) Research is as important to my mental health care as it is to my physical health care 78% 81% 1.00 Research findings may help my day to day care 76% 81% 0.727 Research that is proven to work will help me receive the best mental health care 70% 81% 0.289 Most staff are not able to use mental health research in my everyday health care 41% 43% 1.00 Treatment of mental illness is not usually based on research 30% 30% 1.00 A focus on mental health research will over-burden staff and impact on my care 24% 14% 0.219 It is not possible to assess the effectiveness of mental health interventions 16% 16% 1.00 1The remainder of respondents rated the question either “neutral,” “disagree,” or “strongly disagree.” 2McNemar test for paired samples. Comments from Group Discussions Participants deemed research to be essential: “if we didn’t have research, we’d have the same treatment as we had in the 60s,” “research avoids assuming that something that appears obviously right is right when it may not be.” Other comments were that research was stated to involve “investigation,” “finding answers,” “fact finding,” “exploring,” “developing knowledge,” “using scientific methods,” also that “theoretical and practical viewpoints are formed as a result of research,” “proves/disproves other research,” “explores ground not previously mapped or where there is inadequate information,” “finds solutions to problems,” “formulates policies and education,” and “initiates change through findings.” Demystifying Research and Evidence-Based Practice 137 TABLE 2. Factors that Influence Research Participation Sorted by Rank Pre-workshop Post-workshop (N = 37) (N = 37) Item % Yes1 %Yes1 p-value2 Whether the research will benefit others like me in the future 89% 92% 1.00 The purpose of the research 76% 73% 1.00 The research method (survey, interview, discussion group) 73% 65% 0.453 Whether I have the time to do it 68% 78% 0.388 If there are any risks involved (e.g., if the study requires me to take a new medication on the market which could cause side effects) 62% 68% 0.754 Whether I believe my responses will be confidential 57% 57% 1.00 Whether I will receive an incentive to participate (e.g., morning tea) 49% 35% 0.125 Whether the research will be of direct benefit to me (e.g., trial of new medication when no others have worked) 46% 49% 1.00 The researcher (e.g., whether known to me, doctor nurse, their age, etc) 38% 54% 0.031† Whether I’ll be able to answer the questions 38% 54% 0.146 Whether the researcher will help me (e.g., to fill in a survey) 38% 46% 0.549 Whether I will be paid for my time 35% 46% 0.219 1The remainder of respondents answered “no” or “unsure.” 2McNemar test for paired samples. †p < 0.05, df = 1. Good research was perceived to be “objective” and conducted by qualified research staff. Participants remarked that researchers needed to be “inquisitive” and “enthusiastic” about their topic. It was also considered important that results were disseminated in easy to understand language. Some participants did not know how to access or have access to the Internet, while others who did have access (eg health centre or employment) reported no interest in using the Internet to access results. Participants raised a number of points about EBP, including: “staff experience and training should focus on latest evidence,” “settings must be comfortable with change and not be based on tradition,” “findings 138 M. Cleary et al. must be replicable, not anecdotal, measured/published,” “evidence from research is used to provide quality, tailored care,” “whose evidence is it? Does it actually prove/disprove previous evidence,” and “can the new knowledge be evaluated and incorporated into practice?” Research Challenges Participants identified a range of barriers to their participation in research, which related to “relevance of research topic,” “not hearing about it,” wanting “money or other incentives to participate,” “transport difficulties,” “time constraints,” “responsibilities associated with caring,” “enough notice/advance warning,” “fear of the unknown,” “education— being able to engage and understand,” “being used as ‘guinea pigs’ by drug companies,” “privacy and confidentiality - what will happen to the findings?” and whether taking part would be good for self-esteem and confidence. Participants identified a range of challenges in furthering research. These included adequate staffing for projects, acquiring funding, recruiting participants, participant motivation, achieving consensus, ensuring confidentiality, knowing the needs of the community, and managing results (i.e., too much information, too long and unwieldy). Other comments included: “Recommendations look great but often don’t actually happen – too idealistic.” “Outcomes of research should be something substantial that mainstream health services can pick up and utilize.” Research can be “a negative experience”; “too many researchers, not enough people helping,” often research is conducted into areas that are “purely common sense.” “We need to be realistic—there is no time to read everything that crosses your desk!” (comment made by consumer working in an Area Mental Health Service). The following topics were suggested for further research: illness prevention, onset and development of mental issues, outcomes for different diagnoses with and without drug and alcohol issues, interventions, links between childhood and adult depression, recovery, stigma, nutrition and mental health, medication and side effects, subacute care, relapse, monitoring mental state, impact of negative body image, friendships and support networks, consumer led support groups, and, needs (e.g., accommodation, financial and social). Feedback and Usefulness of Program Seventy percent of participants said they would be moderately or a lot more willing to participate in research in the future. Eighty-four percent Demystifying Research and Evidence-Based Practice 139 found the program interesting or very interesting, and 70% found the program increased their knowledge and understanding moderately or a lot. Seventy three percent of participants said this knowledge/insight would influence future participation in research moderately or a lot. Eighty-six percent of participants rated the organization of the program (e.g., facilitation) well or very well organised and 89% were satisfied or very satisfied with it. Ninety-seven percent of participants said they would recommend the program to others, and 91% indicated that they would like to attend future programs on research. Eighteen people made comments regarding the workshop at the end of the survey and these were overwhelmingly positive. In addition to thanking presenter(s), comments included: “I thoroughly enjoyed this opportunity to look at how research is formulated and understand the process,” “very efficient and well presented,” “found the program interesting and exhilarating,” “worthwhile and informative,” “a lot to consider but a very good overview” and “a great refresher.” DISCUSSION This study examined the attitudes and expectations of participants towards research and the impact of an educational intervention on these attitudes. Prior to the workshop, most participants were already interested in research and, not surprisingly, concerned with areas that were most relevant to them. The number of participants reporting interest in results from research was also high. Most agreed that research is influential and central to improved mental health care, which was supported by the large number of positive comments. This high level of interest and support appears characteristic of the group, as one would assume an interest in research was their primary reason for attending. Nevertheless, many participants highlighted their concerns regarding confidentiality when deciding to participate in research projects. Previous research has found participants are confused around the issue of confidentiality, in particular about who has access to the data (Cleary et al., 2007). Thus, the challenge for researchers is to reinforce the rules governing confidentiality to appease concerns and encourage greater participation and collaboration in the future. After the workshop, it was encouraging that most attendees indicated they would be more willing to participate in future research and reported that the knowledge gained from the workshop was an influential factor in their decision. These positive responses show that attending research workshops may enhance future participation rates and might 140 M. Cleary et al. also encourage collaboratively organised education initiatives (Roper & Happell, 2007). Identifying factors which influence research participation is also important as these can be addressed in the planning of projects and when recruiting participants. In this study, the majority of participants reported being influenced by: benefits to others; research purpose and method; time constraints; potential risks; confidentiality issues; their ability to answer the questions; and the characteristics of the researcher (postworkshop only). It is therefore important that these facets of research are communicated clearly at the outset of any project. Characteristics of the researcher was the only item showing a significant increase in “yes” responses regarding influences on participation pre- to post-workshop. Perhaps the familiarity and characteristics (eg confidence, professionalism) of the researcher became more important to attendees during the workshop. This reflects the importance of the way researchers present themselves to potential participants. The factors identified in this study that most influenced research participation were those same factors identified in our previous research, which involved 160 consumers with no educational intervention (Cleary et al., 2007). Interestingly, whether the participants will be paid was endorsed by the least amount of participants in both studies, although providing monetary incentives has been found by other investigators to be an effective and appealing method for obtaining strong response rates (Erwin & Wheelright, 2002). Attitude ratings pre-workshop were again similar to our previous survey (Cleary et al., 2007), with the most consistently endorsed attitudes being research deemed as important to mental healthcare as physical healthcare, and proven research deemed helpful to providing the best, day to day care. The fact that there were no significant changes in the number of participants rating attitudes differently pre- to post-workshop may be due to a ceiling effect of most participants already viewing research as generally positive prior to the workshops, or that attitudes are difficult to shift over only one brief session. The finding that less participants agreed with the statements, most staff are not able to use mental health research in my everyday health care, (41% pre- and 43% post-workshop in this study, 33% previous study) and treatment of mental illnesses is not usually based on research (30% pre- and post-workshop in this study, 54% previous study), indicates a need to clarify healthcare in practice and how research influences EBP in future workshops. Consumer input when designing research projects has been found to be an important factor contributing to the concept of “evidence” in Demystifying Research and Evidence-Based Practice 141 EBP (Faulkner & Thomas, 2002) while providing fresh insights (Rose, 2003), better focussed research (Trivedi & Wykes, 2002) and increased quality and relevance of the evaluation (NSW Department of Health, 2006). Although participants readily suggested a wide range of research topics relevant to their needs, grouping suggestions in a yes/no format in future workshops may allow areas of consumer/carer priority to be identified. Overall, the programwas well received, with most participants reporting that they found it interesting and that it increased their knowledge. Most said they would recommend the program to others and would attend future programs. It was encouraging to see consumers and carers involved in the planning and recruitment. Establishing networks of consumers and carers who have made themselves available to be involved in further workshops and research projects ensures the program has the capacity to be self-sustaining. The program is not without its limitations. The positive evaluation may reflect response bias as the groups included participants who already had some interest in research and may not be representative of consumers and carers in general (Happell & Roper, 2006). This can be a problem for much mental health research as participants may be quite well and motivated to be involved. However, one study in the United Kingdom found that involved consumers’ priority ratings for mental health service development were very similar to those of a broader patient group (Crawford & Rutter, 2004). Further, as it has been found previously that a wider variety of topics is beneficial to consumers when undertaking training to participate in mental health services (Meehan et al., 2002), incorporating broader topics in future workshops may maximize their effectiveness and uptake. CONCLUSION In conclusion, this project was built upon previous initiatives to facilitate clinical research and EBP and sought to communicate effectively with consumers and carers to enhance their participation and understanding of the research process. It was envisaged that consumers’ and carers’ knowledge of and skills in accessing and reviewing evidence may lead to a greater sense of autonomy, more interest in research, and a greater ability to make informed choices regarding both treatment and participation in research. Improved understanding regarding the impact of research and the importance of participation may in part address unmet needs for information (Cleary et al., 2005), which may, in turn, improve consumers’ and carers’ quality of life. Article 3 Journal of Mental Health, October 2008; 17(5): 498 – 508 ISSN 0963-8237 print/ISSN 1360-0567 online Shadowfax Publishing and Informa UK Ltd. DOI: 10.1080/09638230701530242 (Copeland 2006; Deegan 2006; Glover, 2005). Evidence suggests that consumer providers are as effective as non-consumer delivered services and, when partnered with non-consumer providers, actually produce better outcomes (Felton, Stasny, Shern et al., 1995; Paulson et al., 1999). Solomon (2004) art


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