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Cultural Issues in Pre-Registered Mental Health Student Nurses' Clinical Placements

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Cultural Issues in Pre-Registered Mental Health Student Nurses' Clinical Placements Cultural Issues in Pre-Registered Mental Health Student Nurses’ Clinical Placements: An Anthropologically Informed Critical Incident Study Andrew Mark Bassett A Thesis Submitted in Partial Fulfilment of the Requirements of Nottingham Trent University for the Degree of Doctor of Philosophy May 2013 1 “This work is the intellectual property of the author. You may copy up to 5% of this work for private study, or personal, non-commercial research. Any re-use of the information contained within this document should be fully referenced, quoting the author, title, university, degree level and pagination. Queries or requests for any other use, or if a more substantial copy is required, should be directed in the owner of the Intellectual Property Rights”. 2 Table of Contents Table of Contents……………………………………………….3 Abstract…………………………………………………………..10 Acknowledgements…………………………………………….11 Introduction to the Thesis…………………………………….12 Introduction.......................................................................................... 12 The Impetus for the Study………………………………………………. 12 Research Purpose and Questions………………………………………. 13 Significance of Study……………………………………………………... 14 Structure of the Thesis..........................................................................15 Foundations (Setting the Scene)………………………………………………15 The Methodological Direction………………………………………………… 17 Findings………………………………………………………………………… 18 Summary………………………………………………………………....... 20 Chapter 1: Philosophical, Theoretical and Conceptual Foundations……………………………………………………. 22 Introduction………………………………………………………………… 22 A Cultural Constructionist Philosophical Perspective…………………. 23 A Meaning Centred Approach…………………………………………… 24 The Meaning of ‘Culture’…………………………………………………. 25 Clinical Placement………………………………………………………….29 3 ‘Multicultural Clinical Interactions’: The Intersection of ‘Popular’, ‘Folk’ and ‘Professional’ Health Care System Sectors………………………. 30 ‘Multicultural Clinical Interactions’ and ‘Culture General Competency’….................................................................................... 34 The ‘Family’ and ‘Multicultural Clinical Interactions’…………………... 35 Summary……………………………………………………………………38 Chapter 2: ‘Disease’-‘Illness’ Perspectives, ‘Explanatory Model’ (EM) Transactions, Conceptions of ‘Self’, and ‘Multicultural Clinical Interactions’………………………….40 Introduction………………………………………………………………… 40 ‘Etic’ and ‘Emic’ Perspectives……………………………………………. 42 The Anthropological Distinction between ‘Disease’ and ‘Illness’................................................................................................ 42 Conceptions of the ‘Self’ and their Relevancy to Understanding Pre- Registered Mental Health Student Nurses’ ‘Multicultural Clinical Interactions’…………………………………………………………………45 ‘Multicultural Clinical Interactions’ as ‘Explanatory Model’ (EM) Transactions………………………………………………………………. 49 Introduction……………………………………………………………………… 49 The Meaning of the ‘Explanatory Model’ (EM) Concept……………………. 51 ‘Cultural Theories of Illness’ and ‘Explanatory Models’…………………….. 55 The Meaning of Lay and Practitioner ‘Explanatory Models’………………... 57 ‘Insight’ and ‘Explanatory Models’………………………………………62 Traditional Definitions of ‘Insight’ and its Clinical Implications…………….. 62 ‘Multidimensional’ Definitions of ‘Insight’…………………………………….. 63 4 ‘Insight’ and the Influence of Culture………………………………………… 64 Critiques of the ‘Explanatory Model’ (EM) Framework…………………68 Summary……………………………………………………………………69 Chapter 3: ‘Abnormality’ or ‘Normality’: The ‘Normative Uncertainty’ Evaluation Dilemma and ‘Multicultural Clinical Interactions’……………………………………………………...70 Introduction………………………………………………………………….70 Religion and Spirituality: Similar, but Distinct Concepts……………….72 The ‘Culture’ or ‘Psychopathology’ Clinical Dilemma…………………..74 The Pathologisation of Religion and Spirituality in Clinical Practice……………………………………………………………………. 77 ‘Normative Uncertainty’: Religion, Spirituality, Culture, and the Differential Diagnosis Dilemma…………………………………………. 80 The ‘Category Fallacy’ Error………………………………………………84 Religion, Spirituality and Psychopathology: Matters of Diagnostic ‘Concern’…………………………………………………………………… 85 ‘Normality’ or ‘Abnormality’………………………………………………..90 ‘Absolutism’ and ‘Universalism’…………………………………………...91 The ‘Standard Diagnostic Method’…………………………………………….92 The ‘Psychoanalytic’ Model…………………………………………………….93 ‘Statistical’ Approach…………………………………………………………… 94 Assessment of ‘Function’……………………………………………………… 94 The Multidisciplinary Mental Health Team and the Hegemony of the ‘Standard Diagnostic Method’…………………………………………… 94 5 Evaluating ‘Absolutism’ and ‘Universalism’ from the ‘Meaning Centred’ Perspective………………………………………………………………… 95 Cultural Relativist Perspectives…………………………………………. 97 Summary……………………………………………………………………98 Chapter 4: Methodology…………………………………….. 100 Introduction………………………………………………………………… 100 An Anthropologically Informed Research Design……………………… 101 A Qualitative Strategy……………………………………………………...104 The Meaning of ‘Critical Incidents’: Contextualising the Narratives of Student Nurses’ ‘Multicultural Clinical Interactions’…………………… 104 The Generation of ‘Critical Incident Data’: Considering the Alternatives………………………………………………………………….108 Introduction………………………………………………………………………. 108 The ‘Critical Incident’ Approach and the Health Sciences…………………...108 Collecting ‘Critical Incidents’…………………………………………………….110 The ‘Critical Incident’ Focused Ethnographic Interview………………………114 Sampling Process………………………………………………………….116 Selecting the Participants……………………………………………………….116 Participants……………………………………………………………………….119 Data Collection Process…………………………………………………...120 Location and Arrangement of Interviews………………………………………120 Ethical Procedures and Recording Interviews………………………………...121 Conducting Interviews……………………………………………………………122 6 Transcription and Member Checks……………………………………… 123 Data Analysis……………………………………………………………… 126 Introduction……………………………………………………………………… 127 Unitizing the Data……………………………………………………………….. 127 Categorizing………………………………………………………………………129 Summary…………………………………………………………………….130 Chapter 5: The ‘Normative Uncertainty’ Evaluation Dilemma: A Key Concern of Clinical Placement…………………………………………………… 132 Introduction………………………………………………………………….132 Delusions or Religious Beliefs…………………………………………... 134 Normative Uncertainty and the Clinical Concept of ‘Insight’…………..137 Religious Experience or Psychotic Hallucination……………………….139 A Three Way Dilemma…………………………………………………… 141 ‘Normative Uncertainty’ and Culture Specific Knowledge……………..143 Summary……………………………………………………………………150 Chapter 6: Clinical Evaluation Errors and the Decontextualisation of the Service User’s Experience…….....................................................................152 Introduction………………………………………………………………….152 The Clinical Implications of Assessment Errors………………………...152 Language Discordance and the ‘Culture Blind’ Approach……………..159 Summary…………………………………………………………………….168 7 Chapter 7: ‘Dealing’ with the ‘Normative Uncertainty’ Evaluation Dilemma: Outcome Criteria and Other Strategies………………………………………………………. 169 Introduction………………………………………………………………….169 The Criterion of ‘Outcomes’……………………………………………….169 ‘Criterion of Function’……………………………………………………………170 The Assessment of ‘Risk’ ………………………………………………………178 Emotional Valence……………………………………………………………….181 Other Strategies…………………………………………………………….183 ‘Relying on Intuition’……………………………………………………………..183 Religious Coping and Psychopathology……………………………………….185 Summary…………………………………………………………………….188 Chapter 8: ‘Dealing’ with the ‘Normative Uncertainty’ Evaluation Dilemma: The ‘Importance’ of Context………………………………………………………… 189 Introduction………………………………………………………………….189 Cultural Knowledge……………………………………………………… 189 Cultural Brokers…………………………………………………………… 194 Consulting with Family…………………………………………………………..196 Bicultural and Culturally Informed Staff Members…………………………… 200 Religious Group Spokespersons……………………………………………… 201 Summary…………………………………………………………………….205 Conclusion………………………………………………………207 Introduction………………………………………………………………….207 8 Strengths and Limitations………………………………………………….208 Reflecting on the Findings…………………………………………………209 Recommendations for Educational Practice…………………………….213 Future Research Suggestions…………………………………………….216 Summary…………………………………………………………………….217 Bibliography…………………………………………………….219 Appendix A: Written Critical Incident Guidance Sheet……..............................................................................285 Appendix B: Participant Information and Consent Form for Pre-Registered Mental Health Student Nurses................ 286 Appendix C: Participant Information and Consent Form for Mental Health Nursing Branch Educators…………………289 Appendix D: Focus Group Participant Information and Consent Form…………………………………………………..292 9 Abstract The aim of this anthropologically informed qualitative study was to explore the primary cultural issues in mental health student nurses’ clinical placements and to explore how these issues in placements were dealt with, from the perspectives of years two and three mental health student nurses and their undergraduate university nursing educators. ‘Critical incident’ (Fitzgerald, 2000) focused ethnographic interviews (Spradley, 1979) were undertaken with a self-selected and purposive sample of 36 second and third year mental health nursing branch students, and 7 undergraduate mental health nursing branch educators across four nursing education centres in northern England. Member checking at descriptive and analytical levels was carried out, and these checks allowed for
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