Learning about mental health nursing: Linking threshold concepts to practice

Article information

J Probl Based Learn. 2018;5(1):21-28
Publication date (electronic) : 2018 April 30
doi : https://doi.org/10.24313/jpbl.2018.5.1.21
1School of Nursing and Midwifery, University of Newcastle, Australia
2University of Newcastle, Australia, and University of New England, Australia
3School of Nursing and Midwifery, University of Newcastle, Australia
Address reprint requests to: Dr. Anna Treloar School of Nursing and Midwifery, University of Newcastle, Callaghan NSW 2308 Australia Tel: 02 4921 6303, Fax: 02 4921 6301, E-mail: Anna.treloar@newcastle.edu.au



To examine how a story involving threshold concepts can be used as stimulus material for student nurses involved in mental health care.


Case study research conducted in Australia collected 100 stories told by nurses working in mental health settings which were written down and then analysed to determine their clinical and educational purpose. This paper focuses on one of these stories because its complexities offer an introduction to the role of the therapeutic relationship in mental health nursing care.


This single story provides many insights into the role of the clinical mental health nurse and when used as stimulus material for nursing students combined with a framework for enquiry it also an example of how a story may be used to illuminate a threshold concept such as the therapeutic relationship.


When choosing learning materials, it is important to i) identify an actual situation that the student might encounter, then ii) identify the knowledge, skills and behaviours that are required by the practitioner in this situation before iii) outlining the appropriate level of objective expected for students investigating this situation to achieve and then iv) listing the threshold concepts from the various disciplines that will be developed from exploring this situation.


Given the incidence of mental health disorders and the need for mental health promotion in the community (Whiteford, Degenhardt, Rehm, Baxter, Ferrari et al., 2013), finding ways to encourage better appreciation of the nursing response to those in need of effective mental and physical health care is critical if new graduates are to enter and thrive in this specialist context of practice as well as be involved in the client’s recovery processes. Our understandings about, and expectations of, nursing in the context of mental health and illness demand further exploration given the complexity of people’s experiences of mental disorders

Some of the more difficult aspects of mental health nursing can be classed as threshold concepts. A threshold concept is like a portal in that it opens up a new way of thinking about something (Meyer & Land, 2006); it is transformative because it changes the way the student views the discipline, troublesome because of the inherent challenges, irreversible because the student cannot return to the previous way of thinking, integrative because it can bring together ideas which were previously seen as unrelated, and bounded because it delineates a particular understanding (Meyer & Land, 2003). Therapeutic engagement and establishing a therapeutic relationship may be seen as examples. A study of the clinical and educational purposes of stories told by nurses working in mental health to undergraduates and new recruits highlighted many aspects of the profession which may seem arcane or puzzling (Treloar, McMillan & Stone, 2016), and many aspects which can be viewed as threshold concepts, such as therapeutic engagement and the therapeutic relationship. This study involved collecting one hundred stories and then analysing them using a template based on the work of Tripp (1994) and McCormack (2000). Ethics approval was gained from the Human Research Ethics Committee at the University of Newcastle. Students can be guided in their exploration of these with the use of a framework in the form of a series of questions to lead discussion (Treloar, McMillan & Stone, 2015).


To begin the process of developing stimulus material for nurses, it is useful to differentiate between three considerations; namely,

  • what contemporary mental health nursing is,

  • what experienced mental health nurses and their clientele do in partnership in pursuit of recovery or how they work in partnership in pursuit of recovery

  • the characteristics of optimal practice and education which might be used to inform curricula that prepare professional nurses for contemporary nursing practice.

Three threads emerge from the use of this framework for learning: The first of these interacting themes is ‘thinking about’ the threshold concepts (conceptualising practice), the second is ‘doing in a collaborative way’ (with therapeutic intent) and the third, ‘becoming and evolving’ as a mental health nurse imbued with certain principles and values.

Thinking about the threshold concepts, as part of conceptualising practice, provides a theoretical perspective (including identifying principles and values) against which mental health nurses can examine and evaluate their own expectations and understandings. For example Stacey and Stickley (2012) conceptualise recovery as a threshold concept in mental health and mental health has in itself been seen as a threshold concept in inter-professional learning activities (Nambiar-Greenwood, 2010).

As an educator, one needs to begin by identifying a situation that involves a teachable moment that stimulates critical thinking and the honing of knowledge, skills and behaviours that are required by the practitioner in this situation. The nature and level of objectives should inform the learning outcomes and finally it is important to list the threshold concepts from the various disciplines that will have been developed from exploring this situation. Where additional questions are posed by educators at the design stage, these can be included in a facilitator guide, keeping in mind the nature of the learning objectives: What points are you going to encourage the students to draw from the story? How might consideration about responses to the client be carefully tailored to the client’s current mental state and likely reaction and not be about the nurse’s needs? How might the novice weigh up alternatives? Who might they turn to as a resource person for their ongoing learning?

The Story

The need for authenticity of clinical stories as resource material for learning is paramount (Treloar et al., 2015). However, the stories need to reflect the right level of challenge but not be overwhelming. Given the stories were taken from clinical practice, this very authenticity may contribute to liminality. Liminality is seen as a “place of incoherence and confusion for students” (Savin-Baden 2016, p. 6) which links to the notion of threshold concepts being “troublesome knowledge” (Nambiar-Greenwood, 2010).

The following story from the collection of 100 stories was unusual in that the teller (an academic and experienced educator who also worked clinically) adds a caveat at the beginning, advising that students should not be told about the dangerousness of the man described in the story. No other story in the collection came with a caveat, but with this one the teller saw the focus as being on therapeutic engagement and building of a therapeutic relationship, rather than on any threat the patient may have posed, and the outcome of the story demonstrates that the focus on the relationship also managed any potential threat.

  • [*I nursed a man who had recently punched a co-worker and threw him on to a low verandah roof. The patient was huge and very paranoid].

  • When I met the man as I came on to my 12-hour night duty shift, he looked at me with affection and, smiling, said, “You’re not Carl-you are Paul-yes-Paul-long time no see-I haven’t seen you since school”. He then put his arm around me and patted me repeatedly.

  • I didn’t know how to deal with this. Should I tell him that I wasn’t Paul and that I was 20 years under the man’s age? In the end I just allowed him to call me whatever he wanted to, but addressed myself as Carl, and all that is associated with my life was discussed as appropriate.

Land, Rattray and Vivian (2014) caution that even when students enter liminality, it can be a suspended state where they can still be diverted into mimicry and a lack of authenticity. Making sense of a complex phenomenon such as mental health nursing can seem a daunting task. The goal of education is to make the essence of the role of the professional explicit within conceptual frameworks; it facilitates transformation, new ways of thinking and alignment of unrelated ideas such as delusions and therapeutic engagement. Frameworks enable practitioners not only to understand what they do and why they do it but also what the consequences are of doing this and not that and how to evaluate and to know when and how to change and why.

Students are taught not to reinforce delusions, and to lead the person experiencing them back to reality on all occasions (Bardwell & Taylor, 2013). However sometimes the need to engage the client effectively over-rides the requirement not to reinforce delusions. In this story the teller’s knowledge that the patient had previously been violent colours attitudes and responses, though the teller specifically advises students should not be aware of this violence when they come to discuss the story. The issues as highlighted by the teller (in his own words) become “parallel realities” but also “honesty in the face of potential adversity” as he allowed the patient to continue to call him by the wrong name and did not challenge the patient’s belief that they had known each other for a long time while in all other respects basing their interactions in reality. This comment (about honesty in the face of personal adversity) alone may suggest to students that there was some risk involved in challenging the patient’s mistake about the nurse’s identity. The story embraces the establishment of a therapeutic relationship, the nurse’s work to anchor the patient in reality apart from one small detail, and the management of risk. All three things are “juggled” to provide a satisfactory outcome. But what would have happened if the storyteller insisted that he was not Paul? What would have happened if he “went along with” the patient’s other misconceptions and misunderstandings? What credibility would he then have had as a professional mental health nurse? How did he manage to avoid risk and injury and yet maintain a therapeutic relationship with this “huge and very paranoid” man? In this story is therapeutic engagement the most important factor? Or is it management of risk? It cannot be the “textbook advice” about not reinforcing a delusion. Evans and Kevern (2015, p. 6) find liminality in both the practice of mental health nursing “where it is not possible to limit all uncertainties and risks” and in its philosophy of refusal to accept nursing care as “a series of remote functions and instrumental interventions”.


The starting place for developing stimulus material for learning events, and this includes learning events related to threshold concepts, has been clearly identified as practice with the intention of discovering the nature and scope of that practice and what is entailed in being a practitioner in order that the insights gained will enhance the delivery of care. As is so often the case when confronted with the unknown, one needs to encourage the students to start by asking questions. This sounds like a simple enough process and on the surface it is, but if one is to proceed with the minimum amount of difficulty, it is helpful to coach the students to ask the right questions and preferably in the right order. It is sometimes difficult for both the teacher and the students to know initially what are the right questions and in what order to ask them. This difficulty should not however become a deterrent. It is important to make the first question address the heart of the issue under investigation and therefore to open up the subject and to allow the development of relevant and related issues to flow in a sequential fashion. Thus this first question becomes the organiser or super-ordinate organiser around which all the following questions develop. A simple question arises from the scenario “What is the nature of Mental Health Nursing”? This seems the most obvious starting place and one ideally suited for the task of super-ordinate organiser for thinking about what to do in the situation presented. The question is simple but understandably there is neither a single nor a simple answer. In the first instance, to avoid the learner being diverted down too many alternative pathways, an examination of mental health nursing as an activity or practice might be required, and after that, other key landmarks in investigating the special nature of mental health clientele can be allowed to emerge – those landmarks which amplify our understanding and help make explicit the nature of practice and all matters with which it is concerned, especially for our relationship and interactions with the client.

Threshold concepts in any discipline need to be both epistemologically transformative and ontologically transformative as noted by Quinlan et al. (2013) (based on a personal communication from Meyer). However, threshold concepts in mental health nursing have not been much explored. Gould et al. (2015) have remarked on the paucity of research even in the use of Problem Based Learning (PBL) and mental health nursing. To embrace irreversibility which is one component of the process view of threshold concepts, stories which are used to highlight threshold concepts would need to show practice which is skill-based, tacit and taken-for granted (Walker, 2013) as the nurse’s way of managing the situation in the story above shows. The establishment of the therapeutic relationship and how the nurse went about this highlight the difficulties inherent in the process, particularly if the students were to be told after discussion of the story about the patient’s dangerousness.

Anything central to the mastery of a subject is often difficult to grasp (Stacey & Stickley, 2012). The threshold concepts in the story are very different from one of the threshold concepts in nursing, social justice, identified by Levett-Jones, Bowen & Morris (2015), although other concepts identified in this paper such as person-centred care and patient safety are more relevant to this particular story. McAllister et al. (2015) also identify threshold concepts in nursing such as boundary transgression, dehumanisation, adversity and the burden of care, as well as engaging with the ‘Other’, and overcoming stigma. The story above could be said to touch on all of these even though briefly or superficially.

A characteristic of threshold concepts in nursing is that they are abstract, rather than concrete. So while undergraduates can follow an acronym like SURETY (Stickley, 2011) which teaches them to “Sit at an angle, Un-cross legs and arms, Relax, Eye contact, Touch, Your intuition”, as a means to listen effectively while interacting with a patient, there is no similar acronym to help them with therapeutic engagement and the development of a therapeutic relationship. SURETY is easily grasped; the subtleties of a true therapeutic relationship are not so easily grasped, and can see some students lost on the threshold.

Many of the situations encountered in mental health nursing are fluid and unpredictable making it impossible to mandate a single management plan or style; instead a focus on threshold concepts could make the specialty more comprehensible and more appealing to undergraduates. Sometimes what is needed is inspired creativity which is based in a sound understanding of the particular diagnosis and how it might manifest in an individual but also in the ability to adapt communication style and ways of therapeutic engagement to take into account the particular person who is being cared for. In this “proactive knowledge” Perkins (2008) looks for the ability to apply the knowledge with understanding, serious energetic engagement and alertness to where it applies. For students “Mastery of a threshold concept often involves messy journeys back, forth and across conceptual terrain” (Cousin 2006, p. 5). For their teachers, as Barradell (2013) points out, a number of important questions about threshold concepts remain unanswered, and while they remain unanswered, full development of threshold concepts particularly in mental health nurse education will be difficult. In the case of therapeutic engagement and the therapeutic relationship, and the efforts of mental health nurses to define them, these efforts have been described as “digging a deeper hole”, and mental health nursing as having been “derailed” by the focus on the therapeutic relationship at the expense of what actually occurs for the patient within that relationship (Browne, Cashin & Graham, 2012). If the practitioners themselves cannot explain what it is they do when they engage and work with a patient, how can undergraduates be expected to understand all that is involved?


Depending on the learning goal related to the stimulus material, the more challenging or troublesome concepts within any authentic storyline can be explored using frameworks developed from recent research into what mental health nurses perceive they do. The imperative is to provide a ‘frame of reference’ for those wanting to learn how to provide better mental health nursing care and how to prepare nurses for the complexities of practice in the real world.

This is where authentic clinical anecdotes from practice can help with a greater understanding of what is involved; similarly, a well-constructed PBL scenario can also assist even if it cannot bring complete and instantaneous understanding. A framework for discussion and exploration can help students direct their thinking towards understanding the more difficult aspects of these threshold concepts.

Conceptualising is akin to developing a mind map: a map in which the parameters of the area to be considered are clearly outlined, the key landmarks are identifiable and the relationships or links between the landmarks can be understood. The map becomes the conceptual framework (or theoretical basis) of the practice but is the end product of a number of processes. These processes can be described and learners encouraged to engage in a task, bearing in mind that the processes are characteristics of the health professional and will enhance that aspect of their development in becoming a mental health nurse. The product which results from participation will grow in terms of quality as professional development occurs and the specialist nurse in the field of mental health becomes more of an expert and less of a novice.

If we accept that health professionals, because of the nature of practice, are action-based thinkers who confront the problematic in client situations, circumstances, health status and practice protocols, then making sense of the practice must be the starting point for the creation of conceptual frameworks and theory development (Andersen and McMillan, 2015).

Any conceptual framework is not simply an end in itself but a means to an end in that it informs practice by providing explanations, predictions and gives clarity and direction to practice, research and education. Significantly the outcome of such a position is that practice is not made to fit theory but rather that theory derived from practice is both relevant and dynamic. A symbiotic relationship results with each affecting and informing the other.

Figure 1.

Theory from practice: A paradigm


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Article information Continued

Figure 1.

Theory from practice: A paradigm