WORKFORCE CSIRO PUBLISHING
Australian Health Review, 2015, 39, 211–216 http://dx.doi.org/10.1071/AH14099
A better way to do this? Views of mental health nursing directors about preparation for mental health nursing practice Brenda Happell RN, RPN, BA(Hons), DipEd, BEd, MEd, PhD, Professor of Nursing and Executive Director Research Centre for Nursing and Midwifery Practice, University of Canberra, Faculty of Health and ACT Health, Woden, ACT 2606, Australia. Email: [email protected]
Abstract Objective. Nursing directors in mental health services hold important leadership positions that include responsibility for the nursing workforce. The comprehensive or generalist approach to undergraduate nursing education consistently poses significant recruitment problems. Specialisation in mental health within Bachelor of Nursing programs has been suggested as a potential solution. This paper presents the views and opinions of mental health nursing directors regarding undergraduate specialisation. Methods. A qualitative exploratory study was undertaken. Thirteen nursing directors from Queensland Mental Health Services participated in an in-depth telephone interview. The data were analysed thematically. Results. Nursing directors were very supportive of specialisation in mental health at the undergraduate level. Thematic analysis revealed four main themes: perceived advantages of the specialist stream; knowledge and experience; increased recruitment; and commitment. Conclusions. Nursing directors are important stakeholders in educational preparation for practice in mental health settings. The research participants described many potential benefits to undergraduate specialisation. Their voice provides an important contribution to this issue. What is known about the topic? The current model of nurse education in Australia aims to prepare graduates for practice in a broad range of healthcare settings with specialisation occurring at the postgraduate level. Mental health nursing is identified as one of the least popular career options for nursing graduates, and mental health services struggle to recruit sufficient graduates for their nursing workforce; this is attributed, at least in part, to the current model of education. What does this paper add? This paper gives voice to the perspectives of nursing directors from the mental health service delivery sector about the educational preparation for nursing practice in mental health. Nursing directors support the introduction of specialist preparation in mental health nursing at the undergraduate level. A more skilled and committed workforce is seen as contributing to addressing current recruitment problems. What are the implications for practitioners? The educational preparation for nursing graduates for mental health practice impacts significantly on nursing leaders, and their perspective is essential in addressing the debate. Mental health nursing directors need to be formally recognised as key stakeholders in the preparation of nursing graduates. Additional keywords: education, recruitment, specialisation. Received 27 June 2014, accepted 20 October 2014, published online 17 December 2014
Introduction The challenges in providing sufficient numbers of adequately skilled nurses for a sustainable mental health nursing workforce have been consistently articulated in government reports1–3 and the broader academic literature.4–6 Shortages within the nursing workforce are not unique to the mental health field. However, there are additional specific issues that impact negatively on this field. Mental health nursing has consistently been demonstrated through research findings to be one of the least favoured areas of practice for nursing students.4,7–10 Student choices are generally Journal compilation Ó AHHA 2015
influenced by negative attitudes towards people with mental illness, particularly a fear of their own physical and emotional well being. Furthermore, mental health nursing is not seen to be as exciting, technologically advanced and rewarding as the hightech areas of practice and those involving the care of children and babies.11 If an adequate mental health nursing workforce is to be secured and maintained, the responsibility of attracting students into mental health nursing should be focused primarily on Bachelor of Nursing programs. The research and scholarly literature provides many examples of how this can and has been achieved. Clinical experience, www.publish.csiro.au/journals/ahr
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particularly when undertaken in a positive and supportive environment, has been influential in enhancing mental health nursing as a career option,7,8,12–14 and there is some evidence to suggest that longer periods of clinical exposure are associated with increased interest in mental health nursing.7,13,15 Other positive factors identified include establishing strong collaborative relationships with clinical partners14 and the availability of appropriately qualified preceptors.16 The relationship between theory hours and interest in mental health nursing has also been observed, although to a lesser extent than for clinical experience.15,17 Although the evidence suggests a solution may be possible, the amount of clinical and theoretical content continues to differ significantly between universities.18,19 It is an ongoing concern that the under-representation of mental health nursing continues despite a plethora of reports and government inquiries highlighting the problem.5 The overcrowding of the 3-year Bachelor of Nursing programs is the reason primarily offered for not increasing mental health content,20–22 although this does not explain the fact that some universities are able to include substantially more content than others. Within the nursing profession, including the mental health speciality, many continue to espouse the value of the comprehensive model as providing a broad and inclusive education, and promoting more positive attitudes towards people with mental illness despite no evidence to suggest this philosophy has been or will be realised.23 On the contrary, there is substantial evidence suggesting nurses frequently hold strong discriminatory views towards people diagnosed with mental illness and do not feel they have the skill and confidence to provide high-quality care for them.24,25 Given limited exposure to mental health nursing within most curricula, these attitudes may further dissuade students from considering a career in mental health nursing.4,26 Therefore, although it may be argued that many nursing specialties could benefit from undergraduate specialisation, mental health nursing is uniquely impacted by the effects of stigma and discrimination. Conversely, there is renewed interest in a return to separate registrations and educational preparation for mental health nursing.23,27,28 Supports of specialist preregistration education argue on the basis that the current approach is fundamentally flawed and will not meet the needs for a specialist mental health nursing workforce.23 Although anecdotal evidence suggests that the broader mental health nursing industry is frustrated by the difficulty in recruiting graduates with the skills, knowledge and attributes required for practice in this area, the research agenda has primarily been led by academics. The aim of this paper is to explore the views of mental health nurse leaders about a specialist pathway within undergraduate Bachelor of Nursing programs. Methods Approach A qualitative exploratory design was used. According to the work of Stebbens (2001),29 qualitative exploratory research provides the opportunity to investigate topics of interest at a deeper level. This is particularly pertinent when the research and scholarly literature is limited. The most appropriate method
B. Happell
for educating the nursing workforce for mental health services into the future has been the subject of debate and discussion in Australia for decades. Despite this, very little is documented about the perspectives of nursing directors as the people charged with the primary responsibility for employing nurses into the services. Setting and participants The present study was undertaken in Queensland. At the time of data collection there were 18 nursing directors employed in public mental health services in the State. An email invitation was sent to all 18. Potential participants were also sent a plain language statement describing the research, a consent form and a copy of the project ethics approval letter. Those interested in participating were asked to reply by email. Interview times were set with those who responded. Reminders were sent to those from whom an initial response was not received. By the end of the process 15 nursing directors agreed to participate; no response was received from three. Three additional participants were not able to arrange a time for interview due to pressing workload issues. Thus, 12 interviews were conducted. Participants were nurses with specialist qualifications in mental health nursing. Six were male and six were female. No other demographic data were collected. Procedure Interviews were conducted via telephone. This was the only viable method given the vast geographical distances across Queensland. An interview guide was prepared by the research team to ensure consistency across interviews and ensure essential content was covered. Participants were asked two main questions: ‘what are your views about the potential advantages of a specialist mental health nursing stream in undergraduate bachelor of nursing programs’ and ‘what might the potential disadvantages be?’. Participants were encouraged not to be limited by the guide and to contribute other information they considered important. Interviews were of approximately 45 min duration and were audiotaped and transcribed verbatim. Interviews were conducted between April and June 2013. Ethical issues This research was approved by the Ethics Committee of the Central Queensland University. Participants were fully informed of the scope of the study and the commitment required from them. They were assured that their participation was voluntary and that no identifying information about individuals or services would be published. Participants were required to return a completed consent form before the interview commenced. Data analysis Data analysis was based on Braun and Clarke’s (2006)30 approach to thematic analysis. Initially, interviews were transcribed by an independent company to ensure an accurate record of interviews was available. The interview transcripts were read and re-read until the data became familiar. Once familiarity was attained, the data were carefully searched to identify patterns. Verbatim comments that illustrated main points in a
Preparation for mental health nursing
concise and interesting manner were identified and coded. Once all patterns had been identified and coded, the information was summarised and grouped according to commonalities. This led to the final stage of the identification and naming of themes. Results Data analysis revealed strong support for the specialist stream; participant responses reflected perceived advantages of the specialist stream, as well as perceived disadvantages. The theme advantages included two subthemes: (1) increased knowledge and experience; and (2) more employable graduates. An overview of these themes is presented below and supported by relevant quotes from the study participants. Perceived advantages of the specialist stream The interview participants were wholly supportive of the idea of an undergraduate speciality mental health nursing stream; for example: I think it’s fantastic. I can’t wait for the day that we can come back to having nurses specifically trained for the area they want to work in. It’s the same concept as midwifery really. It’ll be great for consumers and their outcomes, and it will be great for the profession of mental health nursing. Potential advantages associated with the introduction of the specialist undergraduate stream were identified by the interviewees; these were reflected in the two subthemes of increased knowledge and experience, and more employable graduates. Increased knowledge and experience Participants were confident that students of a specialist stream would graduate with much higher levels of theoretical knowledge and practical experience in mental health. It was thought that this would, in turn, translate into a greater preparation for the working reality of mental health nursing: Earlier streaming within the undergraduate would be helpful in having graduates better prepared; I think it also helps with the attrition rate. Greater focus on mental health nursing would provide the opportunity for students to be exposed to clinical placements across the continuum of mental health services (acute in-patient, out-patient and community) before graduation. Such exposure was described as highly important: The best thing that would improve on the current experience, ensuring people have a mix of experience, both inpatient and community, because in the longer term, its understanding about the complexities about people’s worlds outside of hospital that really goes into some of the more complex discharge planning and support arrangements for people who have enduring health conditions.
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More employable graduates Participants believed that an undergraduate speciality in mental health nursing may attract higher numbers of students into the field than the current postgraduate system of specialisation and thus boost recruitment potential. It would also provide a higherquality graduate better suited for immediate employment within a mental health setting: We would have a higher. . .quality of nurse coming out graduated, hitting the floor, in our area of specialty. . .they’d be of higher value than your average graduate coming out. It would also indicate to someone like me that, there’s somebody I want to invest in to develop them to their full potential. All participants indicated they would be very keen to employ graduates who had completed the undergraduate specialist mental health nursing stream, largely due to their additional experience in the field: They’re a lot more ready, at least the fundamentals are here. The basics are there to say, right, you know how to engage. You’ve seen people in a rally manic phase; you can see the potentials and the dangers around it. And it just gives them the edge. . .a big edge. It was also felt that employers would view graduates with a mental health nursing speciality favourably because of their demonstrated interest in the field: . . .it shows a commitment to mental health to me. . .and that’s the most important thing to me. Perceived disadvantages The primary perceived disadvantage of the specialist stream was the possibility that it would produce graduates who are highly skilled in mental health nursing but have limited general nursing skills; for example. If they’re going to spend more time in mental health, what other things are they going to give up? The importance of maintaining strong general nursing skills in the practice of mental health nursing was explained by several participants, particularly well expressed in the following example: [reflecting on what was gained from his own general nursing experience prior to moving into mental health nursing] I knew what other symptoms were with other issues. I knew if someone was hypoglycaemic, that’s not mental illness, that’s hypoglycaemia. I mean, if someone is having a stroke, ‘no, that’s not a side effect, that’s a stroke’. So I had a better understanding of the physical issues that can happen to somebody. Additional associated disadvantages identified by the respondents included: the restriction of career opportunities for a specialist rather than a general nursing graduate; the missed opportunity for students who are drawn to mental health later in
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their degree; and the potentially problematic outcome for students who select the specialist stream, only to discover that this field of practice is not really for them: [Universities need to] take a little bit of responsibility if someone’s doing a mental health major as part of an undergraduate [degree]. . .make sure you’re getting the right people, or give them such broad skills and complementary skills that they’d be able to work in [emergency departments]. . ..use those mental health skills from a CL [Consultation-Liaison] perspective. Discussion Nursing directors hold senior positions within mental health services and have considerable responsibility for ensuring an adequately skilled mental health nursing workforce. This positions them well to contribute to discussions about issues of recruitment and the educational preparation of nurses for mental health practice. The nursing director participants in this study all provided overwhelming support for the introduction of a specialist stream in mental health within undergraduate Bachelor of Nursing programs. Their views and opinions reflect the literature in support of a return to preregistration specialisation,23,27,28 due primarily to the failure of the current approach to nurse education to devote sufficient time to the theory and practice of mental health nursing.1,4,19 The participants were confident that preregistration specialisation would ensure a greater level of knowledge and skill. Not only would these graduates have greater theoretical and practical knowledge of mental health nursing overall, but they would also have a broader knowledge base with experience in in-patient and community settings. The current under-representation of mental health nursing within many Australian universities1 means that students will, at best, receive limited exposure to the clinical arena. Although clinical experience is essential across a broad range of healthcare settings to prepare a competent and confident graduate nurse, mental health settings pose particular issues because students need to overcome the misconceptions and stereotypes they frequently hold towards people with mental illness. Clinical experience has generally been acknowledged as the most important influencing factor in creating a more positive image of mental health nursing for students.7,10,12–14,31 Differences in attitudes towards clinical experience have been observed according to whether students attend a community-based or inpatient placement.7,13 Students undertaking a specialist preparation would be more likely to experience both settings and therefore have a more realistic view of the function of mental health services. Participants saw ‘more employable graduates’ as a positive outcome of a specialist stream and one that could help address the problems experienced in recruiting nurses into mental health. Commitment to mental health nursing was identified as a particular advantage of preregistration specialisation. Graduates would have made the choice to enter this field, most likely reflecting strong interest. It is known from research that interest in mental health nursing as a potential career option increases as a result of educational exposure, although the
B. Happell
increase in popularity is often minimal.4,7,15 What research doesn’t tell us is what influences the decision of a graduate to enter the mental health nursing field. It is not clear whether the decision is borne from genuine interest, a convenient option for a job or the last alternative. What is evident though is that before the introduction of comprehensive nursing education, students did pursue mental health nursing (more commonly referred to as psychiatric nursing) as a career.27 Victoria was the only Australian state to introduce a university-based psychiatric nursing program into the higher education sector.24 Qualitative research undertaken with graduates of one such program suggested graduates entered mental health with an enthusiasm for a career in this field.32,33 Although limited, there is clearly some evidence to support that offering students an opportunity to specialise in mental health nursing and undertake a specialist program in this field is considered an attractive option. The low level of interest in mental health nursing at the commencement of the Bachelor of Nursing program4 suggests people with these interests have not engaged with the contemporary approach to education and have therefore potentially been lost to the mental health workforce. Some concerns were identified with what may be lost through the introduction of a specialist pathway. Participants acknowledged what is described in the literature as the overcrowded curriculum,20–22 which claims the 3-year duration of the Bachelor of Nursing program is insufficient to cover the content a new nursing graduate should bring to the workforce. This is important and raises the question, should the Bachelor of Nursing program be all things to all people? The responses of the research participants suggest this is a goal that has not and probably cannot be obtained. Mental health nursing in particular has not been well served by the current educational model.5 If the healthcare system is committed to high-quality mental health services, then we cannot continue to ignore the current dilemma and a more appropriate way to educate nurses for mental health nursing practice must be sought. The nursing directors all welcomed the idea of undergraduate specialisation. At the same time, they identified potential disadvantages. Increasing mental health content would mean a decrease in other areas. The overcrowding of undergraduate programs has been identified in the literature, and presents a significant limitation to curriculum reform.20,21 Although the focus remains on providing what all nurses must know, mental health nursing content is likely to remain under threat within undergraduate programs, as it has since the introduction of comprehensive education.5 It would appear therefore that mental health nursing specialisation at the undergraduate level would require a complete reconceptualisation of preparation for mental health nursing practice, and indeed for practice across healthcare settings. Limitations Given the small number of participants representing a specific organisational role, the ability to generalise the findings of the present study to broader populations or circumstances is limited. The research was conducted in one Australian jurisdiction, so it is difficult to discern the degree to which specific locality
Preparation for mental health nursing
factors may have influenced the opinions expressed by participants. Furthermore, although nursing directors hold important leadership positions, other nursing leaders may have different positions that may also contribute to the debate about educational preparation for mental health nursing practice. Additional research is required to seek the views of nursing directors and other stakeholders from a broader range of settings to determine the degree to which these views are shared and provide additional insights regarding this issue. Conclusions The educational preparation of nursing students for mental health nursing practice has been plagued with controversy since the introduction of comprehensive nursing education in Australia. The debate about educational preparation has primarily been led by academics (at least in the published literature). The findings presented in this paper provide a rare perspective representing the service delivery sector itself. The nursing director participants in this study echo the documented concerns about the extent to which Bachelor of Nursing programs adequately prepare students for employment within this speciality. They considered the opportunity for specialist mental health nursing preparation positively. More enthusiastic graduates with a broader range of skills and experiences were seen as providing increased recruitment opportunities. The support from industry nursing leaders would be essential for such an initiative to be successful.
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Competing interests The author has no competing interests. 18
Acknowledgements Thanks to the Nursing and Midwifery Office Queensland Health for providing the funding for this work to be completed. Thanks also to the participants who willingly gave their time to provide this information.
References 1 2
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National Health Workforce Taskforce. The health workforce in Australia and factors influencing current shortages. KPMG, 2009. Australian Health Workforce Advisory Committee (AHWAC). Australian mental health nurse supply, recruitment and retention, AHWAC report 2003.2. Sydney: AHWAC; 2003. Mental Health Nurse Education Taskforce. Mental health in pre-registration nursing courses. Melbourne: Mental Health Nurse Education Taskforce; 2008. Stevens J, Browne G, Graham I. Career in mental health still an unlikely career choice for nursing graduates: a replicated longitudinal study. Int J Ment Health Nurs 2013; 22: 213–20. doi:10.1111/j.1447-0349.2012. 00860.x Happell B. Moving in circles: a brief history of reports and inquiries relating to mental health content in undergraduate nursing curricula. Nurse Educ Today 2010; 30: 643–8. doi:10.1016/j.nedt.2009.12.018 Roche M, Duffield C.. Issues and challenges in the mental health workforce development. Contemp Nurse: J Aust Nurs Prof 2007; 25: 94–103. doi:10.5172/conu.2007.25.1-2.94 Happell B. The importance of clinical experience for mental health nursing. Part 1: undergraduate nursing students’ attitudes, preparedness and satisfaction. Int J Ment Health Nurs 2008; 17: 326–32. doi:10.1111/ j.1447-0349.2008.00555.x
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Happell B, Gaskin CJ. The attitudes of undergraduate nursing students towards mental health nursing: a systematic review. J Clin Nurs 2013; 22: 148–58. doi:10.1111/jocn.12022 Whitehead E, Mason T, Ellis J. The future of nursing: career choices in potential student nurses. Br J Nurs 2007; 16: 491–6. doi:10.12968/ bjon.2007.16.8.23422 Surgenor LJ, Dunn J, Horn J. Nursing student attitudes to psychiatric nursing and psychiatric disorders in New Zealand. Int J Ment Health Nurs 2005; 14: 103–8. doi:10.1111/j.1440-0979.2005.00366.x De Brennan S. Out by more than one degree: politics and organizational change within an Australian university. Educ Res Policy Pract 2006; 5: 73–100. doi:10.1007/s10671-005-5061-7 O’Brien L, Buxton M, Gillies D. Improving the undergraduate clinical placement experience in mental health nursing. Issues Ment Health Nurs 2008; 29: 505–22. doi:10.1080/01612840801981355 Henderson S, Happell B, Martin T. So what is so good about clinical experience? A mental health nursing perspective. Nurse Educ Pract 2007; 7: 164–72. doi:10.1016/j.nepr.2006.06.003 Curtis J. Working together: a joint initiative between academics and clinicians to prepare undergraduate nursing students to work in mental health settings. Int J Ment Health Nurs 2007; 16: 285–93. doi:10.1111/ j.1447-0349.2007.00478.x Henderson S, Happell B, Martin T. Impact of theory and clinical placement on undergraduate students’ mental health nursing knowledge, skills, and attitudes. Int J Ment Health Nurs 2007; 16: 116–25. doi:10.1111/j.1447-0349.2007.00454.x Charleston R, Happell B. Psychiatric nurses and undergraduate nursing students’ perceptions of preceptorship in the mental health setting. Int J Psychiatr Nurs Res 2005; 10: 1166–78. Happell B. Influencing undergraduate nursing students’ attitudes toward mental health nursing: acknowledging the role of theory. Issues Ment Health Nurs 2009; 30: 39–46. doi:10.1080/016128408 02557113 Moxham L, McCann T, Usher K, Farrell G, Crookes P. Mental health nursing education in pre-registration nursing curricula: a national report. Int J Ment Health Nurs 2011; 20: 232–6. doi:10.1111/j.1447-0349. 2010.00735.x McCann TV, Moxham L, Usher K, Crookes PA, Farrell G. Mental health content of comprehensive pre-registration nursing curricula in Australia. J Res Nurs 2009; 14: 519–30. doi:10.1177/174498710 9347041 McAllister M, Williams LM, Gamble T, Malko-Nyhan K, Jones CM. Steps towards empowerment: an examination of colleges, health services and universities. Contemp Nurse: J Aust Nurs Prof 2011; 38: 6–17. doi:10.5172/conu.2011.38.1-2.6 McAllister M, Madsen W, Godden J, Greenhill J, Reed R. Teaching nursing’s history: a national survey of Australian Schools of Nursing, 2007–2008. Nurse Educ Today 2010; 30: 370–5. doi:10.1016/j.nedt. 2009.09.010 Ironside PM. Covering content and teaching thinking: deconstructing the additive curriculum. J Nurs Educ 2004; 43: 5–12. Happell B, Cutcliffe JR. A broken promise? Exploring the lack of evidence for the benefits of comprehensive nursing education. Int J Ment Health Nurs 2011; 20: 328–36. doi:10.1111/j.1447-0349.2011.00745.x Brunero S, Jeon Y-H, Foster K. Mental health education programmes for generalist health professionals: an integrative review. Int J Ment Health Nurs 2012; 21: 428–44. doi:10.1111/j.1447-0349.2011.00802.x Clarke D, Usick R, Sanderson A, Giles-Smith L, Baker J. Emergency department staff attitudes towards mental health consumers: A literature review and thematic content analysis. Int J Ment Health Nurs 2014; 23: 273–84. doi:10.1111/inm.12040 Happell B, Platania-Phung C. Mental health placements in a general health setting: no substitute for the real thing! J Clin Nurs 2012; 21: 2026–33. doi:10.1111/j.1365-2702.2011.04016.x
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27 Warelow P, Edward K.. Australian nursing curricula and mental health recruitment. Int J Nurs Pract 2009; 15: 250–6. doi:10.1111/j.1440172X.2009.01751.x 28 Stuhlmiller C. Rethinking mental health nursing education in Australia: a case for direct entry. Int J Ment Health Nurs 2005; 14: 156–60. doi:10.1111/j.1440-0979.2005.00374.x 29 Stebbens R. Exploratory research in the social sciences: Qualitative research methods: Volume 48. London: Sage Publications; 2001. 30 Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3: 77–101.
31 Happell B. Changing their minds: using clinical experience to ‘convert’ undergraduate nursing students to psychiatric nursing. Int J Psychiatr Nurs Res 2008; 14: 1776–84. 32 Happell B. Tertiary psychiatric nursing graduates: something different or more or the same? Aust N Z J Ment Health Nurs 1996; 5: 112–9. 33 Happell B. University-based psychiatric nursing education: a promise for the future? Aust J Adv Nurs 1998; 15: 7–13.
www.publish.csiro.au/journals/ahr
Australian Health Review, 2015, 39, 211–216 http://dx.doi.org/10.1071/AH14099
A better way to do this? Views of mental health nursing directors about preparation for mental health nursing practice Brenda Happell RN, RPN, BA(Hons), DipEd, BEd, MEd, PhD, Professor of Nursing and Executive Director Research Centre for Nursing and Midwifery Practice, University of Canberra, Faculty of Health and ACT Health, Woden, ACT 2606, Australia. Email: [email protected]
Abstract Objective. Nursing directors in mental health services hold important leadership positions that include responsibility for the nursing workforce. The comprehensive or generalist approach to undergraduate nursing education consistently poses significant recruitment problems. Specialisation in mental health within Bachelor of Nursing programs has been suggested as a potential solution. This paper presents the views and opinions of mental health nursing directors regarding undergraduate specialisation. Methods. A qualitative exploratory study was undertaken. Thirteen nursing directors from Queensland Mental Health Services participated in an in-depth telephone interview. The data were analysed thematically. Results. Nursing directors were very supportive of specialisation in mental health at the undergraduate level. Thematic analysis revealed four main themes: perceived advantages of the specialist stream; knowledge and experience; increased recruitment; and commitment. Conclusions. Nursing directors are important stakeholders in educational preparation for practice in mental health settings. The research participants described many potential benefits to undergraduate specialisation. Their voice provides an important contribution to this issue. What is known about the topic? The current model of nurse education in Australia aims to prepare graduates for practice in a broad range of healthcare settings with specialisation occurring at the postgraduate level. Mental health nursing is identified as one of the least popular career options for nursing graduates, and mental health services struggle to recruit sufficient graduates for their nursing workforce; this is attributed, at least in part, to the current model of education. What does this paper add? This paper gives voice to the perspectives of nursing directors from the mental health service delivery sector about the educational preparation for nursing practice in mental health. Nursing directors support the introduction of specialist preparation in mental health nursing at the undergraduate level. A more skilled and committed workforce is seen as contributing to addressing current recruitment problems. What are the implications for practitioners? The educational preparation for nursing graduates for mental health practice impacts significantly on nursing leaders, and their perspective is essential in addressing the debate. Mental health nursing directors need to be formally recognised as key stakeholders in the preparation of nursing graduates. Additional keywords: education, recruitment, specialisation. Received 27 June 2014, accepted 20 October 2014, published online 17 December 2014
Introduction The challenges in providing sufficient numbers of adequately skilled nurses for a sustainable mental health nursing workforce have been consistently articulated in government reports1–3 and the broader academic literature.4–6 Shortages within the nursing workforce are not unique to the mental health field. However, there are additional specific issues that impact negatively on this field. Mental health nursing has consistently been demonstrated through research findings to be one of the least favoured areas of practice for nursing students.4,7–10 Student choices are generally Journal compilation Ó AHHA 2015
influenced by negative attitudes towards people with mental illness, particularly a fear of their own physical and emotional well being. Furthermore, mental health nursing is not seen to be as exciting, technologically advanced and rewarding as the hightech areas of practice and those involving the care of children and babies.11 If an adequate mental health nursing workforce is to be secured and maintained, the responsibility of attracting students into mental health nursing should be focused primarily on Bachelor of Nursing programs. The research and scholarly literature provides many examples of how this can and has been achieved. Clinical experience, www.publish.csiro.au/journals/ahr
212
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particularly when undertaken in a positive and supportive environment, has been influential in enhancing mental health nursing as a career option,7,8,12–14 and there is some evidence to suggest that longer periods of clinical exposure are associated with increased interest in mental health nursing.7,13,15 Other positive factors identified include establishing strong collaborative relationships with clinical partners14 and the availability of appropriately qualified preceptors.16 The relationship between theory hours and interest in mental health nursing has also been observed, although to a lesser extent than for clinical experience.15,17 Although the evidence suggests a solution may be possible, the amount of clinical and theoretical content continues to differ significantly between universities.18,19 It is an ongoing concern that the under-representation of mental health nursing continues despite a plethora of reports and government inquiries highlighting the problem.5 The overcrowding of the 3-year Bachelor of Nursing programs is the reason primarily offered for not increasing mental health content,20–22 although this does not explain the fact that some universities are able to include substantially more content than others. Within the nursing profession, including the mental health speciality, many continue to espouse the value of the comprehensive model as providing a broad and inclusive education, and promoting more positive attitudes towards people with mental illness despite no evidence to suggest this philosophy has been or will be realised.23 On the contrary, there is substantial evidence suggesting nurses frequently hold strong discriminatory views towards people diagnosed with mental illness and do not feel they have the skill and confidence to provide high-quality care for them.24,25 Given limited exposure to mental health nursing within most curricula, these attitudes may further dissuade students from considering a career in mental health nursing.4,26 Therefore, although it may be argued that many nursing specialties could benefit from undergraduate specialisation, mental health nursing is uniquely impacted by the effects of stigma and discrimination. Conversely, there is renewed interest in a return to separate registrations and educational preparation for mental health nursing.23,27,28 Supports of specialist preregistration education argue on the basis that the current approach is fundamentally flawed and will not meet the needs for a specialist mental health nursing workforce.23 Although anecdotal evidence suggests that the broader mental health nursing industry is frustrated by the difficulty in recruiting graduates with the skills, knowledge and attributes required for practice in this area, the research agenda has primarily been led by academics. The aim of this paper is to explore the views of mental health nurse leaders about a specialist pathway within undergraduate Bachelor of Nursing programs. Methods Approach A qualitative exploratory design was used. According to the work of Stebbens (2001),29 qualitative exploratory research provides the opportunity to investigate topics of interest at a deeper level. This is particularly pertinent when the research and scholarly literature is limited. The most appropriate method
B. Happell
for educating the nursing workforce for mental health services into the future has been the subject of debate and discussion in Australia for decades. Despite this, very little is documented about the perspectives of nursing directors as the people charged with the primary responsibility for employing nurses into the services. Setting and participants The present study was undertaken in Queensland. At the time of data collection there were 18 nursing directors employed in public mental health services in the State. An email invitation was sent to all 18. Potential participants were also sent a plain language statement describing the research, a consent form and a copy of the project ethics approval letter. Those interested in participating were asked to reply by email. Interview times were set with those who responded. Reminders were sent to those from whom an initial response was not received. By the end of the process 15 nursing directors agreed to participate; no response was received from three. Three additional participants were not able to arrange a time for interview due to pressing workload issues. Thus, 12 interviews were conducted. Participants were nurses with specialist qualifications in mental health nursing. Six were male and six were female. No other demographic data were collected. Procedure Interviews were conducted via telephone. This was the only viable method given the vast geographical distances across Queensland. An interview guide was prepared by the research team to ensure consistency across interviews and ensure essential content was covered. Participants were asked two main questions: ‘what are your views about the potential advantages of a specialist mental health nursing stream in undergraduate bachelor of nursing programs’ and ‘what might the potential disadvantages be?’. Participants were encouraged not to be limited by the guide and to contribute other information they considered important. Interviews were of approximately 45 min duration and were audiotaped and transcribed verbatim. Interviews were conducted between April and June 2013. Ethical issues This research was approved by the Ethics Committee of the Central Queensland University. Participants were fully informed of the scope of the study and the commitment required from them. They were assured that their participation was voluntary and that no identifying information about individuals or services would be published. Participants were required to return a completed consent form before the interview commenced. Data analysis Data analysis was based on Braun and Clarke’s (2006)30 approach to thematic analysis. Initially, interviews were transcribed by an independent company to ensure an accurate record of interviews was available. The interview transcripts were read and re-read until the data became familiar. Once familiarity was attained, the data were carefully searched to identify patterns. Verbatim comments that illustrated main points in a
Preparation for mental health nursing
concise and interesting manner were identified and coded. Once all patterns had been identified and coded, the information was summarised and grouped according to commonalities. This led to the final stage of the identification and naming of themes. Results Data analysis revealed strong support for the specialist stream; participant responses reflected perceived advantages of the specialist stream, as well as perceived disadvantages. The theme advantages included two subthemes: (1) increased knowledge and experience; and (2) more employable graduates. An overview of these themes is presented below and supported by relevant quotes from the study participants. Perceived advantages of the specialist stream The interview participants were wholly supportive of the idea of an undergraduate speciality mental health nursing stream; for example: I think it’s fantastic. I can’t wait for the day that we can come back to having nurses specifically trained for the area they want to work in. It’s the same concept as midwifery really. It’ll be great for consumers and their outcomes, and it will be great for the profession of mental health nursing. Potential advantages associated with the introduction of the specialist undergraduate stream were identified by the interviewees; these were reflected in the two subthemes of increased knowledge and experience, and more employable graduates. Increased knowledge and experience Participants were confident that students of a specialist stream would graduate with much higher levels of theoretical knowledge and practical experience in mental health. It was thought that this would, in turn, translate into a greater preparation for the working reality of mental health nursing: Earlier streaming within the undergraduate would be helpful in having graduates better prepared; I think it also helps with the attrition rate. Greater focus on mental health nursing would provide the opportunity for students to be exposed to clinical placements across the continuum of mental health services (acute in-patient, out-patient and community) before graduation. Such exposure was described as highly important: The best thing that would improve on the current experience, ensuring people have a mix of experience, both inpatient and community, because in the longer term, its understanding about the complexities about people’s worlds outside of hospital that really goes into some of the more complex discharge planning and support arrangements for people who have enduring health conditions.
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More employable graduates Participants believed that an undergraduate speciality in mental health nursing may attract higher numbers of students into the field than the current postgraduate system of specialisation and thus boost recruitment potential. It would also provide a higherquality graduate better suited for immediate employment within a mental health setting: We would have a higher. . .quality of nurse coming out graduated, hitting the floor, in our area of specialty. . .they’d be of higher value than your average graduate coming out. It would also indicate to someone like me that, there’s somebody I want to invest in to develop them to their full potential. All participants indicated they would be very keen to employ graduates who had completed the undergraduate specialist mental health nursing stream, largely due to their additional experience in the field: They’re a lot more ready, at least the fundamentals are here. The basics are there to say, right, you know how to engage. You’ve seen people in a rally manic phase; you can see the potentials and the dangers around it. And it just gives them the edge. . .a big edge. It was also felt that employers would view graduates with a mental health nursing speciality favourably because of their demonstrated interest in the field: . . .it shows a commitment to mental health to me. . .and that’s the most important thing to me. Perceived disadvantages The primary perceived disadvantage of the specialist stream was the possibility that it would produce graduates who are highly skilled in mental health nursing but have limited general nursing skills; for example. If they’re going to spend more time in mental health, what other things are they going to give up? The importance of maintaining strong general nursing skills in the practice of mental health nursing was explained by several participants, particularly well expressed in the following example: [reflecting on what was gained from his own general nursing experience prior to moving into mental health nursing] I knew what other symptoms were with other issues. I knew if someone was hypoglycaemic, that’s not mental illness, that’s hypoglycaemia. I mean, if someone is having a stroke, ‘no, that’s not a side effect, that’s a stroke’. So I had a better understanding of the physical issues that can happen to somebody. Additional associated disadvantages identified by the respondents included: the restriction of career opportunities for a specialist rather than a general nursing graduate; the missed opportunity for students who are drawn to mental health later in
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their degree; and the potentially problematic outcome for students who select the specialist stream, only to discover that this field of practice is not really for them: [Universities need to] take a little bit of responsibility if someone’s doing a mental health major as part of an undergraduate [degree]. . .make sure you’re getting the right people, or give them such broad skills and complementary skills that they’d be able to work in [emergency departments]. . ..use those mental health skills from a CL [Consultation-Liaison] perspective. Discussion Nursing directors hold senior positions within mental health services and have considerable responsibility for ensuring an adequately skilled mental health nursing workforce. This positions them well to contribute to discussions about issues of recruitment and the educational preparation of nurses for mental health practice. The nursing director participants in this study all provided overwhelming support for the introduction of a specialist stream in mental health within undergraduate Bachelor of Nursing programs. Their views and opinions reflect the literature in support of a return to preregistration specialisation,23,27,28 due primarily to the failure of the current approach to nurse education to devote sufficient time to the theory and practice of mental health nursing.1,4,19 The participants were confident that preregistration specialisation would ensure a greater level of knowledge and skill. Not only would these graduates have greater theoretical and practical knowledge of mental health nursing overall, but they would also have a broader knowledge base with experience in in-patient and community settings. The current under-representation of mental health nursing within many Australian universities1 means that students will, at best, receive limited exposure to the clinical arena. Although clinical experience is essential across a broad range of healthcare settings to prepare a competent and confident graduate nurse, mental health settings pose particular issues because students need to overcome the misconceptions and stereotypes they frequently hold towards people with mental illness. Clinical experience has generally been acknowledged as the most important influencing factor in creating a more positive image of mental health nursing for students.7,10,12–14,31 Differences in attitudes towards clinical experience have been observed according to whether students attend a community-based or inpatient placement.7,13 Students undertaking a specialist preparation would be more likely to experience both settings and therefore have a more realistic view of the function of mental health services. Participants saw ‘more employable graduates’ as a positive outcome of a specialist stream and one that could help address the problems experienced in recruiting nurses into mental health. Commitment to mental health nursing was identified as a particular advantage of preregistration specialisation. Graduates would have made the choice to enter this field, most likely reflecting strong interest. It is known from research that interest in mental health nursing as a potential career option increases as a result of educational exposure, although the
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increase in popularity is often minimal.4,7,15 What research doesn’t tell us is what influences the decision of a graduate to enter the mental health nursing field. It is not clear whether the decision is borne from genuine interest, a convenient option for a job or the last alternative. What is evident though is that before the introduction of comprehensive nursing education, students did pursue mental health nursing (more commonly referred to as psychiatric nursing) as a career.27 Victoria was the only Australian state to introduce a university-based psychiatric nursing program into the higher education sector.24 Qualitative research undertaken with graduates of one such program suggested graduates entered mental health with an enthusiasm for a career in this field.32,33 Although limited, there is clearly some evidence to support that offering students an opportunity to specialise in mental health nursing and undertake a specialist program in this field is considered an attractive option. The low level of interest in mental health nursing at the commencement of the Bachelor of Nursing program4 suggests people with these interests have not engaged with the contemporary approach to education and have therefore potentially been lost to the mental health workforce. Some concerns were identified with what may be lost through the introduction of a specialist pathway. Participants acknowledged what is described in the literature as the overcrowded curriculum,20–22 which claims the 3-year duration of the Bachelor of Nursing program is insufficient to cover the content a new nursing graduate should bring to the workforce. This is important and raises the question, should the Bachelor of Nursing program be all things to all people? The responses of the research participants suggest this is a goal that has not and probably cannot be obtained. Mental health nursing in particular has not been well served by the current educational model.5 If the healthcare system is committed to high-quality mental health services, then we cannot continue to ignore the current dilemma and a more appropriate way to educate nurses for mental health nursing practice must be sought. The nursing directors all welcomed the idea of undergraduate specialisation. At the same time, they identified potential disadvantages. Increasing mental health content would mean a decrease in other areas. The overcrowding of undergraduate programs has been identified in the literature, and presents a significant limitation to curriculum reform.20,21 Although the focus remains on providing what all nurses must know, mental health nursing content is likely to remain under threat within undergraduate programs, as it has since the introduction of comprehensive education.5 It would appear therefore that mental health nursing specialisation at the undergraduate level would require a complete reconceptualisation of preparation for mental health nursing practice, and indeed for practice across healthcare settings. Limitations Given the small number of participants representing a specific organisational role, the ability to generalise the findings of the present study to broader populations or circumstances is limited. The research was conducted in one Australian jurisdiction, so it is difficult to discern the degree to which specific locality
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factors may have influenced the opinions expressed by participants. Furthermore, although nursing directors hold important leadership positions, other nursing leaders may have different positions that may also contribute to the debate about educational preparation for mental health nursing practice. Additional research is required to seek the views of nursing directors and other stakeholders from a broader range of settings to determine the degree to which these views are shared and provide additional insights regarding this issue. Conclusions The educational preparation of nursing students for mental health nursing practice has been plagued with controversy since the introduction of comprehensive nursing education in Australia. The debate about educational preparation has primarily been led by academics (at least in the published literature). The findings presented in this paper provide a rare perspective representing the service delivery sector itself. The nursing director participants in this study echo the documented concerns about the extent to which Bachelor of Nursing programs adequately prepare students for employment within this speciality. They considered the opportunity for specialist mental health nursing preparation positively. More enthusiastic graduates with a broader range of skills and experiences were seen as providing increased recruitment opportunities. The support from industry nursing leaders would be essential for such an initiative to be successful.
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Competing interests The author has no competing interests. 18
Acknowledgements Thanks to the Nursing and Midwifery Office Queensland Health for providing the funding for this work to be completed. Thanks also to the participants who willingly gave their time to provide this information.
References 1 2
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