Copyright © eContent Management Pty Ltd. Contemporary Nurse (2014) 47(1–2): 16–26.
Identifying mental health nursing research priorities: A Delphi study Dianne Wynaden, Karen Heslop*, Omar Al Omari+, Deborah Nelson!, Bernadette Osmond#, Monica Taylor** and Trevor Gee++ School of Nursing and Midwifery, Curtin Health, Innovation Research Institute, Curtin University, Perth, WA, Australia; *Department of Psychiatry, Royal Perth Hospital, Curtin University, Perth, WA, Australia; +School of Nursing and Midwifery, Jerash University, Jordan - Jerash, Amman, Jerash, Jordan; !South Metropolitan Health Service, Mental Health Strategic Leadership Unit, Mt Pleasant, WA, Australia; #Department of Psychiatry, Royal Perth Hospital, Perth, WA, Australia; **Armadale Mental Health Service, Armadale, WA, Australia; ++Bentley MHS, Perth, WA, Australia
Abstract: Engaging in research and using evidence based practice are essential for mental health nurses to provide quality nursing care to consumers and families. This paper reports on a Delphi study that identified the top 10 mental health nursing research priorities at one area health service in Australia servicing a population of 840,000 people. Initially 390 research questions were identified by nurses and these were then reduced to 56 broader questions. Finally, the top 10 questions were ranked in order of importance. The priority questions were clinically and professionally focussed and included research into the delivery and organisation of mental health services and the need to design and evaluate new practice paradigms for nurses in the primary care setting. The mental health knowledge and skill set of graduates from Australian comprehensive nursing programmes along with improved recruitment and retention of graduates in mental health were also identified priority areas for research.
Keywords: mental health nursing, research priorities, Delphi study, consumer outcomes, evidence based practice
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esearch into mental health practice is a necessary part of ongoing national mental health reform and its significance has been identified in the Australian Fourth National Mental Health Plan 2009–2014 (Australian Health Ministers, 2009a) and Australian National Mental Health Policy 2008 (Australian Health Ministers, 2009b). Nationally, there is now an expectation that clinicians will generate, review and implement evidence based practice across all areas of mental health delivery (Australian Health Ministers, 2009a, 2009b). Evidence based practice is defined by Rice (2008) ‘as an effective appraisal and use of research based evidence and clinical expertise applied to patient values and preferences in order to generate the best clinical outcomes’ (Rice, 2008) (p. 108). While research suggests that both the quality of care as well as consumer outcomes are improved when care is evidence based (Fisher & Happell, 2009; Happell, 2004), a considerable part of nursing practice remains based on tradition rather than scientific evidence (DiCenso, 2003; Parahoo, 2000; Wynaden et al., 2005).
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In meeting the expectations outlined in the Australian Fourth National Mental Health 2009–2014, there is an urgency for the mental health nursing profession to define a research strategy that fits within national and international mental health research and service priorities (Australian Health Ministers, 2009a). This will enhance the capacity of the profession to obtain substantive competitive funding and to systematically build the professional capacity of mental health nurses to engage in and generate evidence based practice. To facilitate this, improved collaborations between universities and clinical areas are needed as clinician led research which engages with the academic sector enhances the potential for research translation into policy and practice change (Curran, Grimshaw, Hayden, & Campbell, 2011; Glasgow & Emmons, 2007) and allows clinicians to address gaps to improve service delivery based on the dissemination of new knowledge (Australian Health Ministers, 2009a). Within this context, a Delphi study was completed in 2011 at the South Metropolitan Health
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Identifying mental health nursing research priorities Service (SMHS) in Western Australia to identify the mental health nursing research priorities. The SMHS includes two large tertiary and three secondary hospitals and health services, and it is the fastest growing of the three area health services in Western Australia. It delivers high quality, safe and effective hospital and health services to a population of over 840,000 people which is projected to increase to over one million by 2020 (Government of Western Australia, 2012). Method The objectives of the study were to: 1. Utilise Delphi methodology to obtain expert consensus on the top 10 nursing research priorities for mental health nurses working at SMHS. 2. Report the findings to the Mental Health Nursing Directorate to inform the development of a service wide research strategy to build the mental health nursing capacity to generate, implement and review evidence based practice into all aspects of care. Research design Adopting a classic Delphi method allowed the researchers to use a systematic approach to data collection where the views and judgements of all participants could be aggregated to identify mutual positions, establish priorities and to develop a conceptual framework to investigate the most important issues impacting on the profession of mental health nursing (Turton, Wright, White, & Killaspy, 2010). The Delphi method has been used in other nursing and midwifery areas to identify research priorities for those professional groups (Bartu, Nelson, Ng, McGowan, & Robertson, 1991; Davidson, Merritt-Gray, Buchanan, & Noel, 1997; Fenwick, Butt, Downie, Monterosso, & Wood, 2006; Neville et al., 2010; Owens, Ley, & Aitken, 2008; Skews, Meehan, Hunt, Hoot, & Armitage, 2000). In this study, the method allowed the researchers to systematically elicit the judgements of a group of mental health nurses through a series of surveys and reflective feedback to identify mutual positions and consensus (Neville et al., 2010; Owens
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et al., 2008; Turton et al., 2010). The strength of the Delphi method is that it achieves consensus while ensuring the input of each participant is equal, valued and recorded (MacNeela, Morris, Scott, Treacy, & Hyde, 2010). It also ensures the findings are achieved through a democratic process and are representative of the group being surveyed (Haines & Jones, 1994). The Delphi method traditionally utilises a series of survey rounds or focus groups allowing aggregation of the judgements of the target group (Okoli & Pawlowski, 2004). Typically, the first round asks all participants to respond to a broad question and indicate their responses to the question. These responses are analysed and grouped for the second round which is returned to participants for further ranking and consensus. This process allows the individual to consider the group’s viewpoint and, therefore, re-evaluate their own opinions within this context. This process is continued until enough information is obtained and consensus achieved on the topic which in this study occurred after the third round data was analysed. The key to trustworthy interpretation of the Delphi method hinges on several factors (Okoli & Pawlowski, 2004). These include the formulation and structure of the initial questions sent to participants, transcribing and analysis of individual responses by the researchers, response rates over successive rounds of the survey, participants’ level of knowledge in the subject area and an understanding of the meaning of consensus (Crisp, Pelletier, Duffield, Adams, & Nagy, 1997; Okoli & Pawlowski, 2004). Data collection Ethical approval was obtained from one university and the SMHS Human Research Ethics Committee. SurveyMonkey, a web-based on-line survey database was used in all three rounds of data collection (SurveyMonkey, 2012). In data collection rounds one and two; all mental health nurses received an email with an attached information sheet outlining the objectives of the study, an invitation to participate and the web link to the SurveyMonkey web-based data collection programme. In reaching expert consensus, data
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collection in round three specifically targetted senior mental health nurses (identified as Level 3 SRN or above) at all services. Demographic data was collected in each round but to maintain confidentiality no participant names were collected. Data analysis Data collected from rounds one and two surveys were transcribed verbatim and then entered into the qualitative data analysis software (©QSR NVivo 8, 2012). This database facilitated management and coding of the transcribed data facilitating the extrapolation, emergence and identification of themes in the first two rounds. Using the accepted standards of qualitative data analysis, two researchers independently conducted a thematic analysis on the data to identify the emergence of themes and categories. These were then divided into units of meaning when coded by each of the researchers and then classified into higher level concepts (Elo & Kyngs, 2008). The researchers then re-examined the data to ensure that the interpretation and description were appropriate and continued to meet the accepted standards of qualitative analysis (Sandelowski, 2000). The two researchers then looked at the data collaboratively and differences between the researchers coding and theme identification were discussed until consensus was achieved. While this took considerable time it further increased the validity and trustworthiness of data captured during round one (Graneheim & Lundman, 2004). Demographic data were analysed within the SurveyMonkey data analysis programme and descriptive statistics were obtained to describe the participant group in each round. Results Two-hundred and fifty responses were received over the three rounds of the study. In the first two rounds all mental health nurses were invited to participate. Ninety-five responded to round one and 127 to round two. Thirty-five senior nurses provided third round data. The increasing response rate in each round of the study was deemed important to the overall quality of data. Demographic data on participants in each round is detailed in Table 1. 18
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Delphi round one In this round, mental health nurses were asked to identify ‘the five most important mental health questions or issues that they believed should be the focus of research’ and they provided 390 responses. Following data analysis, 56 broader research questions were formed from the 390 identified in the first round by participants. These were themed into five categories: (1) Admission and bed availability issues, (2) Best practice, (3) Education, training and support, (4) Professional issues, and (5) Service delivery. Delphi round two In the second round, participants were asked to rate each of the 56 research questions in relation to how important they were to mental health nurses. The questions were divided within the five original categories in the following manner: Accommodation and bed availability (8); service delivery (13); best practice (5); education, training and support (5); and professional issues (25). Participants were asked to complete the rating for each question using a five point Likert-type response format with one (1) indicating the lowest priority and five (5) indicating their highest priority as a research question. Mean scores were calculated to identify the top 10 from the responses (see Table 2). Delphi round three The 10 most important research priorities identified from round two formed the basis of the third round survey given to senior nurses. The aim of round three was to obtain expert consensus regarding the priority of the 10 questions identified from the analysis of round two data. Participants were asked to rank the 10 areas in order of importance with one (1) being the most important and ten (10) being the least important. The results were further coded into two major categories: Clinical (four questions) and professional (six questions) – See Table 3. Limitation of the study The study participants were recruited from one of the three public area health services in Western Australia and therefore, the research questions
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Identifying mental health nursing research priorities Table 1: Sample N = 35)
demographics of each
Delphi
round
(Delphi 1: N = 95, Delphi 2: N = 127, Delphi 3:
Variables Age (years) 20–29 30–39 40–49 50–59 >60 Missing data Experiences in mental health nursing (years) 16 Missing data Experience in mental health nursing with SMHS (years) 16 Missing data Work area Inpatient Community Consultation and liaison Administration Missing data Rehabilitation Triage Education Management Current employment level Enrolled nurse Level 1 – registered nurse Level 2 – clinical nurse Level 3 – clinical nurse specialist/manager Level 4 and above HSU position (nurses working in generic positions) Missing data Highest professional and/or academic qualifications TAFE Hospital based MHN certificate/diploma University diploma in mental health nursing University diploma in general/comprehensive nursing Degree in nursing Postgraduate diploma Masters Missing data
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Delphi 1 N (%)
Delphi 2 N (%)
Delphi 3 N (%)
6 (6.3) 22 (23.2) 33 (34.7) 28 (29.5) 6 (6.3)
9 (7.1) 28 (22.0) 42 (33.1) 44 (34.6) 4 (3.2)
3 (8.6) 7 (20.0) 8 (22.9) 12 (34.2) 2 (5.7) 3 (8.6)
11 (11.6) 17 (17.8) 7 (7.4) 57 (60.0) 3 (3.2)
39 (41.0) 23 (24.2) 9 (9.5) 22 (23.2) 2 (2.1) 34 (35.8) 30 (31.6) 11(11.6) 6 (6.3) 6 (6.3) 4 (4.2) 2 (2.1) 2 (2.1)
6 (4.7) 10 (7.9) 19 (15.0) 22 (17.3) 70 (55.1)
12 (9.4) 47 (37.0) 28 (22.0) 22 (17.3) 18 (14.2)
2 (5.7) 4 (11.4) 8 (22.9) 18 (51.4) 3 (8.6)
9 (25.7) 5 (14.3) 12 (34.3) 6 (17.1) 3 (8.6)
44 (34.6) 35 (27.6) 18 (14.2)
7 (20.0) 4 (11.4) 8 (22.9)
5 (3.9) 4 (3.1) 8 (6.3) 3 (2.4) 10 (7.9)
5 (14.3) 3 (8.6) 4 (11.4) 2 (5.7) 2 (5.7)
4 (4.1) 8 (8.3) 33 (35) 36 (38) 5 (5.2)
3 (2.4) 20 (15.7) 40 (31.5) 55 (43.3) 4 (3.1)
9 (9.4)
5 (3.9)
1 (2.9) 12 (34.3)
3 (3.2) 25 (26.3) 5 (5.3) 4 (4.2) 35 (36.8) 14 (14.7) 4 (4.2) 5 (5.3)
1 (0.8) 38 (29.9) 10 (7.9) 6 (4.7) 42 (33.0) 14 (11.0) 10 (7.9) 6 (4.7)
6 (17.1) 1 (2.8) 1 (2.8) 12 (34.3) 8 (22.9) 4 (11.4) 3 (8.6)
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22 (62.8)
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Table 2: Fifty-six research questions in round two Delphi survey (1 = least important, 5 = most important) 1. Accommodation and bed availability issues 1.1 How can public mental health services assist consumers to secure long term supportive accommodation with trained carers? 1.2 What factors improve access, standards and choices for consumers in supported accommodation? 1.3 Does supported admission diversions, respite and early support programmes improve consumer health outcomes? 1.4 How can consumers who have a dual diagnosis be better supported to find appropriate rehabilitation and accommodation within the community? 1.5 How can the problems of homelessness in the mental health population be appropriately managed? 1.6 What is the impact of bed availability on the delivery of mental health services? 1.7 Are there alternative primary care models that can be adopted to reduce the pressure on acute inpatient mental health beds? 1.8 How does the increasing pressure on inpatient beds impact on the consumer’s ability to achieve sustainable recovery? 2. Best practice 2.1 Which mental health nursing indicators can be used to measure effective mental health outcomes? 2.2 Are MHN sensitive indicators important to the profession? 2.3 How is the cost of MHN care measured? 2.4 How do we translate research outcomes in mental health nursing to policy and practice changes? 2.5 What factors lead to effective rehabilitation and care for mental health consumers? 3. Education, training and support 3.1 How can consumers at risk of developing physical health issues such as metabolic syndrome be more readily identified? 3.2 What strategies most effectively support the physical health of consumers who do not have a general practitioner? 3.3 What factors determine positive outcomes for people who have a borderline personality disorder and/or self -harming behaviours? 3.4 Does staff training in psychosocial intervention and recovery models impact on consumer mental health outcomes? 3.5 Is mandatory training via E-learning effective? 4. Professional issues 4.1 What is the role and scope of practice of mental health nursing? 4.2 How can we expand the role and scope of practice for mental health nurses? 4.3 How do we define the skills and competencies of mental health nurses? 4.4 Do mental health nurses working in acute care services have a role in mental health promotion and prevention? 4.5 What factors impact on the level of job satisfaction for mental health nurses? 4.6 What are the factors that influence recruitment of comprehensive nursing graduates into the area of mental health nursing? 4.7 Do comprehensive nursing programmes provide sufficient skills and knowledge to allow graduates to effectively work with people who have a mental illness? 4.8 How can mental health nursing be promoted more effectively at a national level within the Nursing and Midwifery Board of Australia and the Australian Nursing Federation?
Mean
SD
3.96
0.980
3.92
0.992
4.31
0.851
4.21
919
4.17
1.023
4.43 4.55
0.891 0.743
4.34
0.931
3.82
0.909
3.71 3.60 4.00
0.971 0.970 1.019
4.12
0.898
4.07
0.893
4.03
0.916
4.25
0.870
4.37
0.783
3.35
1.166
4.02 4.15 4.18 4.30
0.911 0.822 0.822 0.780
4.46 4.49
0.743 0.793
4.36
0.816
4.13
0.922
(Continued)
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Table 2: Continued 4.9 4.10
Do uniforms promote identify and professionalism in mental health nurses? How do governance structures and strategic plans have relevance to the mental health nursing workforce? 4.11 How can we make mental health nursing more family friendly? 4.12 How can we reduce the cultural differences between mental health and general nursing? 4.13 What will be the long term effect for the profession of mental health nursing of generic positions in mental health? 4.14 What is the strategic direction for nurses working at SMHS? 4.15 How do we ensure equity for mental health nurses in SMHS nursing programmes and positions? 4.16 What is the mental health nursing role in the provision of appropriate pharmacological interventions and management? 4.17 How can we make a standardised model of clinical supervision available to all mental health nurses? 4.18 What is the optimal consumer to nurse ratio/case management load? 4.19 How do we increase the scientific merit of mental health nursing research so that it is more widely accepted by other disciplines? 4.20 How can the role of nurse practitioners be expanded in mental health? 4.21 What is the role for mental health nurses in the up skilling of non-government organisation staff? 4.22 How does the up skilling of non-government organisation staff affect mental health nursing? 4.23 Do current selection processes in SMHS select the best person for the job? 4.24 How can we develop new career pathways in education, clinical and research for mental health nurses at levels higher than SRN3? 4.25 How can we better prepare clinical nurses for management positions within the organisation? 5. Service delivery 5.1 How can we support adolescents in the transition into adult mental health services? 5.2 How do we provide better access and support to mental health care for children, adolescents and their families? 5.3 Which factors facilitate the integration of drug and alcohol services into mental health services? 5.4 How does stigma impact on help seeking behaviours? 5.5 Assistive technology: How can consumers benefit from this within the home? 5.6 How can mental health nurses reduce the number of consumers being readmitted to the service? 5.7 What factors improve the delivery of care to Aboriginal Australians? 5.8 How can Aboriginal liaison services be enhanced? 5.9 Which adjunct/alternative therapies have a place in the delivery of care in the mental health setting? 5.10 What factors decrease the use of seclusion? 5.11 How can community teams effectively utilise acuity tools to determine case management workloads? 5.12 How does the consumer’s presentation to the emergency department impact on their mental health outcomes? 5.13 What affect does the amount of paperwork that has to be completed in the mental health area have on consumer care?
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Mean
SD
2.46 3.49
1.305 1.216
3.81 3.81
1.074 1.117
3.93
0.988
3.73 3.93
1.051 0.887
3.97
0.926
3.99
0.976
4.07 3.88
0.872 0.978
4.03 3.65
1.001 0.978
3.66
0.941
3.93 3.84
1.155 1.199
4.01
1.077
3.89
1.049
4.03
0.985
4.28
0.960
4.03 3.52 4.21
0.966 1.067 0.942
4.23 4.13 3.46
0.886 0.902 1.118
4.15 4.03
0.909 0.874
4.04
0.980
4.24
0.950
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Table 3: Most important research areas identified in Delphi study (1 = most important, 5 = least important) Ranked
Research Area
Mean
SD
1.
What is the impact of bed availability on the delivery of mental health services? – clinical issue What factors impact on the level of job satisfaction for mental health nurses? – professional issue Do comprehensive nursing programmes provide sufficient skills and knowledge to allow graduates to effectively work with people who have a mental illness? – professional issue How does the increasing pressure on inpatient beds impact on the consumer’s ability to achieve sustainable recovery? – clinical issue Are there alternative primary care models that can be adopted to reduce the pressure on acute inpatient mental health beds? – clinical issue Does supported admission diversions, respite and early support programmes improve consumer health outcomes? – clinical issue What are the factors that influence recruitment of comprehensive nursing graduates into the area of mental health nursing? – professional issue Does staff training in psychosocial intervention and recovery models impact on consumer mental health outcomes? – professional issue Do mental health nurses working in acute mental health services have a role in mental health promotion and prevention? – clinical issue Which factors facilitate the integration of drug and alcohol services into mental health services? – clinical issue
3.23
2.59
3.31
2.97
3.43
3.01
3.43
2.92
3.46
2.90
3.51
2.99
3.89
3.21
3.91
3.03
4.03
2.77
4.63
3.47
2. 3a.
3b. 4. 5. 6. 7. 8. 9.
generated in this study must be viewed within this context. However, as previously stated the SMHS offers public mental health services (both inpatient and community) to a large percentage of the population of Perth and its surrounding regions. This includes authorised inpatient units under the 1996 Western Australian Mental Health Act, older adult mental health inpatient and community services and adult early intervention, community and inpatient services. Consultation and liaison services are also provided, for example, into the general hospital and to general practitioners in the community. Discussion In line with the traditional Delphi research method, data collection ceased when consensus was reached and the 10 research questions for mental health nurses working at SMHS were clearly identified. In round one, 95 nurses responded to the survey representing 19% of possible participants. This response rate in the first round of data collection was a concern for the researchers as a low response rate is often seen to limit the validity and trustworthiness of research 22
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data. To increase the response rate: (1) the survey remained open for data collection for an extended period of time; (2) senior staff actively tried to recruit participants; and, (3) paper versions of the survey were provided. After this concerted effort, it was decided to continue with the second round of the survey as it was deduced that those participants who had not responded either did not wish to or did not deem themselves sufficiently knowledgeable about mental health research to provide informed data. This decision to proceed was based on the knowledge that responses from uninformed participants may also be a threat to validity and trustworthiness of data when using Delphi methodology (Okoli & Pawlowski, 2004). According to Okoli and Pawlowski ‘The Delphi group size does not depend on statistical power, but rather on group dynamics for arriving at consensus among experts’ (2004, p. 19). In this current study, the 390 research areas from round one were able to be reduced to 56 broad research questions indicating an acceptable level of homogeneity and consensus among the group of participants. It is important to discuss that the low response rate in round one may also be interpreted to
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Identifying mental health nursing research priorities be reflective of the perceived lack of relevance of research to a number of mental health nurse clinicians. While nurses are encouraged to read and utilise evidence based practice in their clinical care they may believe that the generation of knowledge has little relevance to their daily practice (Freshwater, 2005). This may be due to a lack of research culture in the workplace and the low nursing research profile and hence the perceived inability to make differences to policy and practice changes at the service level (Gill, 2004). As there are few nurse researchers employed in the mental health setting nationally, role modelling of the importance of research to practice remains limited. Thus many mental health nurses’ may perceive that they lack of expertise in the area of research and this may have been reflected in the low response rate in round one of the survey. Despite the acknowledged limitation of the sample population being drawn from one public mental health service, the findings are important and generalisable to other settings. As the majority of mental health nurses in Australia still practice within acute public mental health services (Mental Health Workforce Advisory Council, 2011) the findings allowed participants to voice research priorities that will facilitate improvements to the delivery and quality of care in this area. Round one results allowed five categories to be developed that incorporated the broad concerns of mental health nurses. Service delivery and bed availability were a priority and reflected how nurses on a daily basis working in public mental health services, witness changes that impact on their ability to facilitate positive consumer outcomes. While much of the nursing profession presume that the nurse patient relationship first described by Peplau remains the focus of mental health nursing (Peplau, 1952) in reality clinicians are managing people with high levels of acuity and symptoms of psychopathology (Prescott, Madden, Dennis, Tisher, & Wingate, 2007) within an environment that has an ever increasing pressure on available inpatient beds (Cleary, 2004; Saxena, Thornicoft, Knapp, & Whiteford, 2007). Since 1960 inpatient beds in Australia have been cut from 30,000 to 8000 in 2006 despite
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the population doubling in that time (White & Whiteford, 2006). At the same time failed social policies and inadequate community based mental health services, has led to increased and sustainable pressure on existing inpatient beds. It has also led to an increased number of people with mental illness in the criminal justice system (Doessel, Scheurer, Chant, & Whiteford, 2005; Lamb & Weinberger, 2005). For participants in this study, the importance of the changing acute inpatient environment was evidenced by the outcome of several research questions in this area. The themes of best practice and education, training and support were identified with questions related to mental health nurses declining use of therapeutic skills within the acute inpatient environment. Questions included the need to research new models of care such as supported admission diversion and early support programmes in the community to determine their ability to decrease the pressure on inpatient beds. These community innovations could enhance mental health nurses’ capacity to work collaboratively with consumers and their family in a supportive community environment. This potential is supported by emerging evidence of the value and contributions made by mental health nurses working in primary care environments in the initial evaluations of the mental health nurse incentive programmes (Australian College of Mental Health Nurses Inc., 2011). In the future it is within this environment that nurses will make significant future contributions to the mental health outcomes of the Australian population. However, this increasingly autonomous practice role warrants an increased skill set to work with consumers and their families on an ongoing and longer term basis and a more intensive articulation with the primary health sector. Hence the request by participants for more research into the efficacy of psychosocial and recovery training programme currently available at the service. Internationally, these programmes have been seen to have positive outcomes (Sin & Scully, 2008) and these findings need to be supported in the Australian context to further facilitate practice change. Within public mental health services the contributions made by nurses from both economic
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and therapeutic perspectives remains relatively unexplored from a research perspective (Lomas, 2009; Thompson, Estabrooks, Scott-Findlay, Moore, & Wallin, 2007). This lack of evidence undermines and undervalues the contributions made by nurses. The clinical and professional categories identified in round three incorporated questions concerning nursing staff cuts, the introduction of patient care assistants and the decreasing skill set of Australian comprehensive nurses. The decreasing skill set has impacted on levels of job satisfaction, stress and burnout and recruitment and retention rates. It also impacts on the therapeutic capacity of the profession to make significant contributions to mental health care (Cottrell, 2001; Hyrkäs, 2005). Under the ‘clinical’ category the findings suggest mental health nurses place importance on caring for the consumer in a holistic manner. Research into how co-morbid drug and alcohol problems can be integrated with mental health services to benefit the consumer was a priority. The need for integrated services has been supported by other researchers (Llopis & Matytsina, 2006). Further clinical research questions highlighted the importance of health promotion and prevention strategies to mental health nursing practice to further facilitate positive physical and mental health outcomes for consumers. These too are identified within the Fourth National Mental Health Plan 2009–2014 (Australian Health Ministers, 2009a) as priority areas for further development and research. Surprisingly, while the importance of family/carer support and inclusion in the delivery of mental health care is the focus of many policy developments in the area of mental health (Australian Health Ministers, 2009a) it was not identified in this study as a priority area by nurses. Not within the top priorities for round three but relevant in the clinical category were three areas that included the administrative burden accompanying an increasing technological service delivery, how best to care for Aboriginal consumers and how to reduce the use of restrictive practices. Also of interest was the fact that clinical supervision was not mentioned as a research topic of response as this can be a tool to identify opportunities for 24
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research and/or enhancement of evidence based knowledge and practice. Professional issues was the greatest area of research concern within the second round and continued to be the most prevalent in the third round. An improved understanding of the ability of comprehensive nursing programmes to provide sufficient knowledge and skills to work with consumers is needed. How to attract more graduate into the area of mental health was also identified as a priority area for research. While this issue has long been identified at an academic level nationally (Happell, 2002; Happell & Cutcliffe, 2011; Happell, Robins, & Gough, 2008; Wynaden, 2010, 2011; Wynaden, Orb, McGowan, & Downie, 2000), the findings of this study are based on the views of clinicians and add another dimension to the ongoing debate on the current educational preparation of nurses to work with consumers of mental health care. Conclusion For the profession of mental health nursing to continue to be a key stakeholder group in the delivery of mental health care and to expand practice into new models of care delivery, research evidence that demonstrates nurses’ contributions to care is essential. The research priority areas identified in this paper are a representation of priorities identified by nurses working at one health service in Western Australia. However, as the service is representative of many across Australia, the researchers believe they provide valuable insights into the current mental health nursing environment nationally. They also highlight the importance of research to the sustainability of the mental health nursing profession within an ever changing health care environment. Acknowledgement The group would like to acknowledge the contributions made to this project by Mr Gary Colley, Ms Robina Redknap and Mr Donald Cook. All three were members of the Mental Health Nursing Research Group at South Metropolitan Health Service over the duration of the study.
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Identifying mental health nursing research priorities References Australian College of Mental Health Nurses Inc. (2011). Mental Health Nurse incentive program: Achieving through collaboration, creativity and compromise. Canberra, ACT: Author. Australian Health Ministers. (2009a). Fourth national mental health plan: An agenda for collaborative government action in mental health 2009–2014. Canberra, ACT: Commonwealth Department of Health and Ageing. Australian Health Ministers. (2009b). National mental health policy 2008. Canberra, ACT: Commonwealth Department of Health and Ageing. Bartu, A., Nelson, M., Ng, C., McGowan, S., & Robertson, J. (1991). A Delphi survey of clinical nursing research priorities in Western Australia. Australian Journal of Advanced Nursing, 8(3), 29–33. Cleary, M. (2004). The realities of mental health nursing in acute inpatient environments. International Journal of Mental Health Nursing, 13(1), 53–60. Cottrell, S. (2001). Occupational stress and job satisfaction in mental health nursing: focused interventions through evidence-based assessment. Journal of Psychiatric and Mental Health Nursing, 8(2), 157–164. Crisp, J., Pelletier, D., Duffield, C., Adams, A., & Nagy, S. (1997). The Delphi method? Nursing Research, 46(2), 116–118. Curran, J., Grimshaw, J., Hayden, J., & Campbell, B. (2011). Knowledge translation research: The science of moving research into policy and practice. Journal of Continuing Education in the Health Professions, 31(3), 174–180. Davidson, P., Merritt-Gray, M., Buchanan, J., & Noel, J. (1997). Voices from practice: Mental health nurses identify research priorities. Archives of Psychiatric Nursing, 11(6), 340–345. DiCenso, A. (2003). Research: Evidence based practice: How to get there from here. Nursing Leadership, 16(4), 20–26. Doessel, D. P., Scheurer, R. W., Chant, D. C., & Whiteford, H. A. (2005). Australia’s national mental health strategy and deinstitutionalization: Some empirical results. Australian and New Zealand Journal of Psychiatry, 39(11–12), 989–994. Elo, S., & Kyngs, H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62(1), 107–115. Fenwick, J., Butt, J., Downie, J., Monterosso, L., & Wood, J. (2006). Priorities for midwifery research
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in Perth, Western Australia: A Delphi study. International Journal of Nursing Practice, 12(2), 78–93. Fisher, J. E., & Happell, B. (2009). Implications of evidence-based practice for mental health nursing. International Journal of Mental Health Nursing, 18(3), 179–185. Freshwater, D. (2005). Researcher or handmaiden: What’s in a name? Journal of Research in Nursing, 10(6), 876–879. Gill, P. (2004). Difficulties in demonstrating a nursing research culture in the UK. British Journal of Nursing, 13(14), 879–976. Glasgow, R. E., & Emmons, K. M. (2007). How can we increase translation of research into practice? Types of evidence needed. Annual Review of Public Health, 28, 413–433. Government of Western Australia. (2012). South metropolitan health Service. Retrieved from http://www. southmetropolitan.health.wa.gov.au/ Graneheim, U. H., & Lundman, B. (2004). Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24(2), 105–112. Haines, A., & Jones, R. (1994). Implementing findings of research. British Medical Journal, 308(6942), 1488–1492. Happell, B. (2002). Mental health nursing: The need to distinguish between generic and specialist skills. Australian Electronic Journal of Nursing Education, 8(1), Article 3. Retrieved from http://scu.edu.au/schools/nhcp/aejne/ vol8-1/refereed/happell_gen.html Happell, B. (2004). The centre for psychiatric nursing research and practice: An innovative approach to enhancing clinical nursing research in the psychiatric/ mental health field. Issues in Mental Health Nursing, 25(1), 47–60. Happell, B., & Cutcliffe, J. (2011). A broken promise? Exploring the lack of evidence for the benefits of comprehensive nursing education. International Journal of Mental Health Nursing, 20(5), 328–336. Happell, B., Robins, A., & Gough, K. (2008). Developing more positive attitudes towards mental health nursing in undergraduate students: Part 1 – Does more theory help? Journal of Psychiatric and Mental Health Nursing, 15, 439–446. Hyrkäs, K. (2005). Clinical supervision, burnout, and job satisfaction among mental health and psychiatric nurses in Finland. Issues in Mental Health Nursing, 26(5), 531–556.
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Lamb, H. R., & Weinberger, L. (2005). The shift of psychiatric inpatient care from hospitals to jails and prisons. Journal of the American Academy of Psychiatry and the Law, 33(4), 529–534. Llopis, E., & Matytsina, I. (2006). Mental health and alcohol, drugs and tobacco: A review of the comorbidity between mental disorders and the use of alcohol, tobacco and illicit drugs. Drug and Alcohol Review, 25(6), 515–536. Lomas, C. (2009). Lack of robust nurse research may jeopardise metrics, warns academic. Nursing Times. Retrieved from http://www.nursingtimes.net/ whats-new-in-nursing/acute-care/lack-o[horizontal MacNeela, P., Morris, R., Scott, A., Treacy, M. P., & Hyde, A. (2010). Seen as core: A Delphi consensus study of essential elements of mental health nursing care in Ireland. Archives of Psychiatric Nursing, 24(5), 339–348. Mental Health Workforce Advisory Council. (2011). National mental health workforce committee. Melbourne, VIC: Victorian Government Department of Health. Neville, C., Hangan, C., Eley, D., Weir, J., Quinn, J., & Meehan, T. (2010). The review and revision of ‘standards of practice for mental health nurses in Australia’. Journal of Psychiatric and Mental Health Nursing, 17(1), 87–93. Okoli, C., & Pawlowski, S. D. (2004). The Delphi method as a research tool: An example, design considerations and applications. Information & Management, 42(1), 15–29. Owens, C., Ley, A., & Aitken, P. (2008). Do different stakeholder groups share mental health research priorities? A four-arm Delphi study. Health Expectations, 11(4), 418–431. Parahoo, K. (2000). Barriers to, and facilitators of, research utilization among nurses in Northern Ireland. Journal of Advanced Nursing, 31(1), 89–98. Peplau, H. E. (1952). The psychiatric nurse’s family group. The American Journal of Nursing, 52(12), 1475–1477. Prescott, D., Madden, L., Dennis, M., Tisher, P., & Wingate, C. (2007). Reducing mechanical restraints in acute psychiatric care settings using rapid response teams. Journal of Behavioural Health Services and Research, 34(1), 96–104. ©QSR NVivo 8 (2012). Retrieved from http://www. qsrinternational.com/products_nvivo.aspx Rice, M. (2008). Psychiatric mental health evidence based practice. Journal of American Psychiatric Nurses Association, 14(2), 107–111.
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Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing & Health, 23(4), 334–340. Saxena, S., Thornicoft, G., Knapp, M., & Whiteford, H. A. (2007). Resources for mental health: scarcity, inequity, and inefficiency. The Lancet, 370(9590), 878–889. Sin, J., & Scully, E. (2008). An evaluation of education and implementation of psychosocial interventions within one UK mental health care trust. Journal of Psychiatric and Mental Health Nursing, 15(2), 161–169. Skews, G., Meehan, T., Hunt, G., Hoot, S., & Armitage, P. (2000). Development and validation of clinical indicators for mental health nursing practice. Australian and New Zealand Journal of Mental Health Nursing, 9(1), 11–18. SurveyMonkey. (2012). Retrieved from http://www. surveymonkey.com Thompson, D., Estabrooks, C., Scott-Findlay, S., Moore, K., & Wallin, L. (2007). Interventions aimed at increasing research use in nursing: A systematic review. Implementation Science, 2(15). Turton, P., Wright, C., White, S., & Killaspy, H. (2010). Promoting recovery in long-term institutional mental health care: An international Delphi study. Psychiatric Services, 61(3), 293–299. White, P., & Whiteford, H. (2006). Prisons: Mental health institutions in the 21st century. Medical Journal of Australia, 185(6), 302–303. Wynaden, D. (2010). There is no health without mental health: Are we educating Australian nurses to care for the health consumer of the 21st Century? International Journal of Mental Health Nursing, 19(3), 203–209. Wynaden, D. (2011). Education issues: Always on the agenda for the profession of mental health nursing. International Journal of Mental Health Nursing, 20(3), 153–154. Wynaden, D., Landsborough, I., Chapman, R., McGowan, S., Lapsley, J., & Finn, M. (2005). Establishing best practice guidelines for the administration of intramuscular injections in the adult: A systematic review of the literature. Contemporary Nurse, 20(2), 267–277. doi: 10.5172/conu.20.2.267 Wynaden, D., Orb, A., McGowan, S., & Downie, J. (2000). Are universities preparing nurses to meet the challenges posed by the Australian mental health care system? Australian and New Zealand Journal of Mental Health Nursing, 9(3), 138–146. Received 09 November 2012
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Accepted 10 October 2013
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Identifying mental health nursing research priorities: A Delphi study Dianne Wynaden, Karen Heslop*, Omar Al Omari+, Deborah Nelson!, Bernadette Osmond#, Monica Taylor** and Trevor Gee++ School of Nursing and Midwifery, Curtin Health, Innovation Research Institute, Curtin University, Perth, WA, Australia; *Department of Psychiatry, Royal Perth Hospital, Curtin University, Perth, WA, Australia; +School of Nursing and Midwifery, Jerash University, Jordan - Jerash, Amman, Jerash, Jordan; !South Metropolitan Health Service, Mental Health Strategic Leadership Unit, Mt Pleasant, WA, Australia; #Department of Psychiatry, Royal Perth Hospital, Perth, WA, Australia; **Armadale Mental Health Service, Armadale, WA, Australia; ++Bentley MHS, Perth, WA, Australia
Abstract: Engaging in research and using evidence based practice are essential for mental health nurses to provide quality nursing care to consumers and families. This paper reports on a Delphi study that identified the top 10 mental health nursing research priorities at one area health service in Australia servicing a population of 840,000 people. Initially 390 research questions were identified by nurses and these were then reduced to 56 broader questions. Finally, the top 10 questions were ranked in order of importance. The priority questions were clinically and professionally focussed and included research into the delivery and organisation of mental health services and the need to design and evaluate new practice paradigms for nurses in the primary care setting. The mental health knowledge and skill set of graduates from Australian comprehensive nursing programmes along with improved recruitment and retention of graduates in mental health were also identified priority areas for research.
Keywords: mental health nursing, research priorities, Delphi study, consumer outcomes, evidence based practice
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esearch into mental health practice is a necessary part of ongoing national mental health reform and its significance has been identified in the Australian Fourth National Mental Health Plan 2009–2014 (Australian Health Ministers, 2009a) and Australian National Mental Health Policy 2008 (Australian Health Ministers, 2009b). Nationally, there is now an expectation that clinicians will generate, review and implement evidence based practice across all areas of mental health delivery (Australian Health Ministers, 2009a, 2009b). Evidence based practice is defined by Rice (2008) ‘as an effective appraisal and use of research based evidence and clinical expertise applied to patient values and preferences in order to generate the best clinical outcomes’ (Rice, 2008) (p. 108). While research suggests that both the quality of care as well as consumer outcomes are improved when care is evidence based (Fisher & Happell, 2009; Happell, 2004), a considerable part of nursing practice remains based on tradition rather than scientific evidence (DiCenso, 2003; Parahoo, 2000; Wynaden et al., 2005).
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In meeting the expectations outlined in the Australian Fourth National Mental Health 2009–2014, there is an urgency for the mental health nursing profession to define a research strategy that fits within national and international mental health research and service priorities (Australian Health Ministers, 2009a). This will enhance the capacity of the profession to obtain substantive competitive funding and to systematically build the professional capacity of mental health nurses to engage in and generate evidence based practice. To facilitate this, improved collaborations between universities and clinical areas are needed as clinician led research which engages with the academic sector enhances the potential for research translation into policy and practice change (Curran, Grimshaw, Hayden, & Campbell, 2011; Glasgow & Emmons, 2007) and allows clinicians to address gaps to improve service delivery based on the dissemination of new knowledge (Australian Health Ministers, 2009a). Within this context, a Delphi study was completed in 2011 at the South Metropolitan Health
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Identifying mental health nursing research priorities Service (SMHS) in Western Australia to identify the mental health nursing research priorities. The SMHS includes two large tertiary and three secondary hospitals and health services, and it is the fastest growing of the three area health services in Western Australia. It delivers high quality, safe and effective hospital and health services to a population of over 840,000 people which is projected to increase to over one million by 2020 (Government of Western Australia, 2012). Method The objectives of the study were to: 1. Utilise Delphi methodology to obtain expert consensus on the top 10 nursing research priorities for mental health nurses working at SMHS. 2. Report the findings to the Mental Health Nursing Directorate to inform the development of a service wide research strategy to build the mental health nursing capacity to generate, implement and review evidence based practice into all aspects of care. Research design Adopting a classic Delphi method allowed the researchers to use a systematic approach to data collection where the views and judgements of all participants could be aggregated to identify mutual positions, establish priorities and to develop a conceptual framework to investigate the most important issues impacting on the profession of mental health nursing (Turton, Wright, White, & Killaspy, 2010). The Delphi method has been used in other nursing and midwifery areas to identify research priorities for those professional groups (Bartu, Nelson, Ng, McGowan, & Robertson, 1991; Davidson, Merritt-Gray, Buchanan, & Noel, 1997; Fenwick, Butt, Downie, Monterosso, & Wood, 2006; Neville et al., 2010; Owens, Ley, & Aitken, 2008; Skews, Meehan, Hunt, Hoot, & Armitage, 2000). In this study, the method allowed the researchers to systematically elicit the judgements of a group of mental health nurses through a series of surveys and reflective feedback to identify mutual positions and consensus (Neville et al., 2010; Owens
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et al., 2008; Turton et al., 2010). The strength of the Delphi method is that it achieves consensus while ensuring the input of each participant is equal, valued and recorded (MacNeela, Morris, Scott, Treacy, & Hyde, 2010). It also ensures the findings are achieved through a democratic process and are representative of the group being surveyed (Haines & Jones, 1994). The Delphi method traditionally utilises a series of survey rounds or focus groups allowing aggregation of the judgements of the target group (Okoli & Pawlowski, 2004). Typically, the first round asks all participants to respond to a broad question and indicate their responses to the question. These responses are analysed and grouped for the second round which is returned to participants for further ranking and consensus. This process allows the individual to consider the group’s viewpoint and, therefore, re-evaluate their own opinions within this context. This process is continued until enough information is obtained and consensus achieved on the topic which in this study occurred after the third round data was analysed. The key to trustworthy interpretation of the Delphi method hinges on several factors (Okoli & Pawlowski, 2004). These include the formulation and structure of the initial questions sent to participants, transcribing and analysis of individual responses by the researchers, response rates over successive rounds of the survey, participants’ level of knowledge in the subject area and an understanding of the meaning of consensus (Crisp, Pelletier, Duffield, Adams, & Nagy, 1997; Okoli & Pawlowski, 2004). Data collection Ethical approval was obtained from one university and the SMHS Human Research Ethics Committee. SurveyMonkey, a web-based on-line survey database was used in all three rounds of data collection (SurveyMonkey, 2012). In data collection rounds one and two; all mental health nurses received an email with an attached information sheet outlining the objectives of the study, an invitation to participate and the web link to the SurveyMonkey web-based data collection programme. In reaching expert consensus, data
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collection in round three specifically targetted senior mental health nurses (identified as Level 3 SRN or above) at all services. Demographic data was collected in each round but to maintain confidentiality no participant names were collected. Data analysis Data collected from rounds one and two surveys were transcribed verbatim and then entered into the qualitative data analysis software (©QSR NVivo 8, 2012). This database facilitated management and coding of the transcribed data facilitating the extrapolation, emergence and identification of themes in the first two rounds. Using the accepted standards of qualitative data analysis, two researchers independently conducted a thematic analysis on the data to identify the emergence of themes and categories. These were then divided into units of meaning when coded by each of the researchers and then classified into higher level concepts (Elo & Kyngs, 2008). The researchers then re-examined the data to ensure that the interpretation and description were appropriate and continued to meet the accepted standards of qualitative analysis (Sandelowski, 2000). The two researchers then looked at the data collaboratively and differences between the researchers coding and theme identification were discussed until consensus was achieved. While this took considerable time it further increased the validity and trustworthiness of data captured during round one (Graneheim & Lundman, 2004). Demographic data were analysed within the SurveyMonkey data analysis programme and descriptive statistics were obtained to describe the participant group in each round. Results Two-hundred and fifty responses were received over the three rounds of the study. In the first two rounds all mental health nurses were invited to participate. Ninety-five responded to round one and 127 to round two. Thirty-five senior nurses provided third round data. The increasing response rate in each round of the study was deemed important to the overall quality of data. Demographic data on participants in each round is detailed in Table 1. 18
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Delphi round one In this round, mental health nurses were asked to identify ‘the five most important mental health questions or issues that they believed should be the focus of research’ and they provided 390 responses. Following data analysis, 56 broader research questions were formed from the 390 identified in the first round by participants. These were themed into five categories: (1) Admission and bed availability issues, (2) Best practice, (3) Education, training and support, (4) Professional issues, and (5) Service delivery. Delphi round two In the second round, participants were asked to rate each of the 56 research questions in relation to how important they were to mental health nurses. The questions were divided within the five original categories in the following manner: Accommodation and bed availability (8); service delivery (13); best practice (5); education, training and support (5); and professional issues (25). Participants were asked to complete the rating for each question using a five point Likert-type response format with one (1) indicating the lowest priority and five (5) indicating their highest priority as a research question. Mean scores were calculated to identify the top 10 from the responses (see Table 2). Delphi round three The 10 most important research priorities identified from round two formed the basis of the third round survey given to senior nurses. The aim of round three was to obtain expert consensus regarding the priority of the 10 questions identified from the analysis of round two data. Participants were asked to rank the 10 areas in order of importance with one (1) being the most important and ten (10) being the least important. The results were further coded into two major categories: Clinical (four questions) and professional (six questions) – See Table 3. Limitation of the study The study participants were recruited from one of the three public area health services in Western Australia and therefore, the research questions
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Identifying mental health nursing research priorities Table 1: Sample N = 35)
demographics of each
Delphi
round
(Delphi 1: N = 95, Delphi 2: N = 127, Delphi 3:
Variables Age (years) 20–29 30–39 40–49 50–59 >60 Missing data Experiences in mental health nursing (years) 16 Missing data Experience in mental health nursing with SMHS (years) 16 Missing data Work area Inpatient Community Consultation and liaison Administration Missing data Rehabilitation Triage Education Management Current employment level Enrolled nurse Level 1 – registered nurse Level 2 – clinical nurse Level 3 – clinical nurse specialist/manager Level 4 and above HSU position (nurses working in generic positions) Missing data Highest professional and/or academic qualifications TAFE Hospital based MHN certificate/diploma University diploma in mental health nursing University diploma in general/comprehensive nursing Degree in nursing Postgraduate diploma Masters Missing data
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Delphi 1 N (%)
Delphi 2 N (%)
Delphi 3 N (%)
6 (6.3) 22 (23.2) 33 (34.7) 28 (29.5) 6 (6.3)
9 (7.1) 28 (22.0) 42 (33.1) 44 (34.6) 4 (3.2)
3 (8.6) 7 (20.0) 8 (22.9) 12 (34.2) 2 (5.7) 3 (8.6)
11 (11.6) 17 (17.8) 7 (7.4) 57 (60.0) 3 (3.2)
39 (41.0) 23 (24.2) 9 (9.5) 22 (23.2) 2 (2.1) 34 (35.8) 30 (31.6) 11(11.6) 6 (6.3) 6 (6.3) 4 (4.2) 2 (2.1) 2 (2.1)
6 (4.7) 10 (7.9) 19 (15.0) 22 (17.3) 70 (55.1)
12 (9.4) 47 (37.0) 28 (22.0) 22 (17.3) 18 (14.2)
2 (5.7) 4 (11.4) 8 (22.9) 18 (51.4) 3 (8.6)
9 (25.7) 5 (14.3) 12 (34.3) 6 (17.1) 3 (8.6)
44 (34.6) 35 (27.6) 18 (14.2)
7 (20.0) 4 (11.4) 8 (22.9)
5 (3.9) 4 (3.1) 8 (6.3) 3 (2.4) 10 (7.9)
5 (14.3) 3 (8.6) 4 (11.4) 2 (5.7) 2 (5.7)
4 (4.1) 8 (8.3) 33 (35) 36 (38) 5 (5.2)
3 (2.4) 20 (15.7) 40 (31.5) 55 (43.3) 4 (3.1)
9 (9.4)
5 (3.9)
1 (2.9) 12 (34.3)
3 (3.2) 25 (26.3) 5 (5.3) 4 (4.2) 35 (36.8) 14 (14.7) 4 (4.2) 5 (5.3)
1 (0.8) 38 (29.9) 10 (7.9) 6 (4.7) 42 (33.0) 14 (11.0) 10 (7.9) 6 (4.7)
6 (17.1) 1 (2.8) 1 (2.8) 12 (34.3) 8 (22.9) 4 (11.4) 3 (8.6)
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Table 2: Fifty-six research questions in round two Delphi survey (1 = least important, 5 = most important) 1. Accommodation and bed availability issues 1.1 How can public mental health services assist consumers to secure long term supportive accommodation with trained carers? 1.2 What factors improve access, standards and choices for consumers in supported accommodation? 1.3 Does supported admission diversions, respite and early support programmes improve consumer health outcomes? 1.4 How can consumers who have a dual diagnosis be better supported to find appropriate rehabilitation and accommodation within the community? 1.5 How can the problems of homelessness in the mental health population be appropriately managed? 1.6 What is the impact of bed availability on the delivery of mental health services? 1.7 Are there alternative primary care models that can be adopted to reduce the pressure on acute inpatient mental health beds? 1.8 How does the increasing pressure on inpatient beds impact on the consumer’s ability to achieve sustainable recovery? 2. Best practice 2.1 Which mental health nursing indicators can be used to measure effective mental health outcomes? 2.2 Are MHN sensitive indicators important to the profession? 2.3 How is the cost of MHN care measured? 2.4 How do we translate research outcomes in mental health nursing to policy and practice changes? 2.5 What factors lead to effective rehabilitation and care for mental health consumers? 3. Education, training and support 3.1 How can consumers at risk of developing physical health issues such as metabolic syndrome be more readily identified? 3.2 What strategies most effectively support the physical health of consumers who do not have a general practitioner? 3.3 What factors determine positive outcomes for people who have a borderline personality disorder and/or self -harming behaviours? 3.4 Does staff training in psychosocial intervention and recovery models impact on consumer mental health outcomes? 3.5 Is mandatory training via E-learning effective? 4. Professional issues 4.1 What is the role and scope of practice of mental health nursing? 4.2 How can we expand the role and scope of practice for mental health nurses? 4.3 How do we define the skills and competencies of mental health nurses? 4.4 Do mental health nurses working in acute care services have a role in mental health promotion and prevention? 4.5 What factors impact on the level of job satisfaction for mental health nurses? 4.6 What are the factors that influence recruitment of comprehensive nursing graduates into the area of mental health nursing? 4.7 Do comprehensive nursing programmes provide sufficient skills and knowledge to allow graduates to effectively work with people who have a mental illness? 4.8 How can mental health nursing be promoted more effectively at a national level within the Nursing and Midwifery Board of Australia and the Australian Nursing Federation?
Mean
SD
3.96
0.980
3.92
0.992
4.31
0.851
4.21
919
4.17
1.023
4.43 4.55
0.891 0.743
4.34
0.931
3.82
0.909
3.71 3.60 4.00
0.971 0.970 1.019
4.12
0.898
4.07
0.893
4.03
0.916
4.25
0.870
4.37
0.783
3.35
1.166
4.02 4.15 4.18 4.30
0.911 0.822 0.822 0.780
4.46 4.49
0.743 0.793
4.36
0.816
4.13
0.922
(Continued)
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Table 2: Continued 4.9 4.10
Do uniforms promote identify and professionalism in mental health nurses? How do governance structures and strategic plans have relevance to the mental health nursing workforce? 4.11 How can we make mental health nursing more family friendly? 4.12 How can we reduce the cultural differences between mental health and general nursing? 4.13 What will be the long term effect for the profession of mental health nursing of generic positions in mental health? 4.14 What is the strategic direction for nurses working at SMHS? 4.15 How do we ensure equity for mental health nurses in SMHS nursing programmes and positions? 4.16 What is the mental health nursing role in the provision of appropriate pharmacological interventions and management? 4.17 How can we make a standardised model of clinical supervision available to all mental health nurses? 4.18 What is the optimal consumer to nurse ratio/case management load? 4.19 How do we increase the scientific merit of mental health nursing research so that it is more widely accepted by other disciplines? 4.20 How can the role of nurse practitioners be expanded in mental health? 4.21 What is the role for mental health nurses in the up skilling of non-government organisation staff? 4.22 How does the up skilling of non-government organisation staff affect mental health nursing? 4.23 Do current selection processes in SMHS select the best person for the job? 4.24 How can we develop new career pathways in education, clinical and research for mental health nurses at levels higher than SRN3? 4.25 How can we better prepare clinical nurses for management positions within the organisation? 5. Service delivery 5.1 How can we support adolescents in the transition into adult mental health services? 5.2 How do we provide better access and support to mental health care for children, adolescents and their families? 5.3 Which factors facilitate the integration of drug and alcohol services into mental health services? 5.4 How does stigma impact on help seeking behaviours? 5.5 Assistive technology: How can consumers benefit from this within the home? 5.6 How can mental health nurses reduce the number of consumers being readmitted to the service? 5.7 What factors improve the delivery of care to Aboriginal Australians? 5.8 How can Aboriginal liaison services be enhanced? 5.9 Which adjunct/alternative therapies have a place in the delivery of care in the mental health setting? 5.10 What factors decrease the use of seclusion? 5.11 How can community teams effectively utilise acuity tools to determine case management workloads? 5.12 How does the consumer’s presentation to the emergency department impact on their mental health outcomes? 5.13 What affect does the amount of paperwork that has to be completed in the mental health area have on consumer care?
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Mean
SD
2.46 3.49
1.305 1.216
3.81 3.81
1.074 1.117
3.93
0.988
3.73 3.93
1.051 0.887
3.97
0.926
3.99
0.976
4.07 3.88
0.872 0.978
4.03 3.65
1.001 0.978
3.66
0.941
3.93 3.84
1.155 1.199
4.01
1.077
3.89
1.049
4.03
0.985
4.28
0.960
4.03 3.52 4.21
0.966 1.067 0.942
4.23 4.13 3.46
0.886 0.902 1.118
4.15 4.03
0.909 0.874
4.04
0.980
4.24
0.950
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Table 3: Most important research areas identified in Delphi study (1 = most important, 5 = least important) Ranked
Research Area
Mean
SD
1.
What is the impact of bed availability on the delivery of mental health services? – clinical issue What factors impact on the level of job satisfaction for mental health nurses? – professional issue Do comprehensive nursing programmes provide sufficient skills and knowledge to allow graduates to effectively work with people who have a mental illness? – professional issue How does the increasing pressure on inpatient beds impact on the consumer’s ability to achieve sustainable recovery? – clinical issue Are there alternative primary care models that can be adopted to reduce the pressure on acute inpatient mental health beds? – clinical issue Does supported admission diversions, respite and early support programmes improve consumer health outcomes? – clinical issue What are the factors that influence recruitment of comprehensive nursing graduates into the area of mental health nursing? – professional issue Does staff training in psychosocial intervention and recovery models impact on consumer mental health outcomes? – professional issue Do mental health nurses working in acute mental health services have a role in mental health promotion and prevention? – clinical issue Which factors facilitate the integration of drug and alcohol services into mental health services? – clinical issue
3.23
2.59
3.31
2.97
3.43
3.01
3.43
2.92
3.46
2.90
3.51
2.99
3.89
3.21
3.91
3.03
4.03
2.77
4.63
3.47
2. 3a.
3b. 4. 5. 6. 7. 8. 9.
generated in this study must be viewed within this context. However, as previously stated the SMHS offers public mental health services (both inpatient and community) to a large percentage of the population of Perth and its surrounding regions. This includes authorised inpatient units under the 1996 Western Australian Mental Health Act, older adult mental health inpatient and community services and adult early intervention, community and inpatient services. Consultation and liaison services are also provided, for example, into the general hospital and to general practitioners in the community. Discussion In line with the traditional Delphi research method, data collection ceased when consensus was reached and the 10 research questions for mental health nurses working at SMHS were clearly identified. In round one, 95 nurses responded to the survey representing 19% of possible participants. This response rate in the first round of data collection was a concern for the researchers as a low response rate is often seen to limit the validity and trustworthiness of research 22
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data. To increase the response rate: (1) the survey remained open for data collection for an extended period of time; (2) senior staff actively tried to recruit participants; and, (3) paper versions of the survey were provided. After this concerted effort, it was decided to continue with the second round of the survey as it was deduced that those participants who had not responded either did not wish to or did not deem themselves sufficiently knowledgeable about mental health research to provide informed data. This decision to proceed was based on the knowledge that responses from uninformed participants may also be a threat to validity and trustworthiness of data when using Delphi methodology (Okoli & Pawlowski, 2004). According to Okoli and Pawlowski ‘The Delphi group size does not depend on statistical power, but rather on group dynamics for arriving at consensus among experts’ (2004, p. 19). In this current study, the 390 research areas from round one were able to be reduced to 56 broad research questions indicating an acceptable level of homogeneity and consensus among the group of participants. It is important to discuss that the low response rate in round one may also be interpreted to
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Identifying mental health nursing research priorities be reflective of the perceived lack of relevance of research to a number of mental health nurse clinicians. While nurses are encouraged to read and utilise evidence based practice in their clinical care they may believe that the generation of knowledge has little relevance to their daily practice (Freshwater, 2005). This may be due to a lack of research culture in the workplace and the low nursing research profile and hence the perceived inability to make differences to policy and practice changes at the service level (Gill, 2004). As there are few nurse researchers employed in the mental health setting nationally, role modelling of the importance of research to practice remains limited. Thus many mental health nurses’ may perceive that they lack of expertise in the area of research and this may have been reflected in the low response rate in round one of the survey. Despite the acknowledged limitation of the sample population being drawn from one public mental health service, the findings are important and generalisable to other settings. As the majority of mental health nurses in Australia still practice within acute public mental health services (Mental Health Workforce Advisory Council, 2011) the findings allowed participants to voice research priorities that will facilitate improvements to the delivery and quality of care in this area. Round one results allowed five categories to be developed that incorporated the broad concerns of mental health nurses. Service delivery and bed availability were a priority and reflected how nurses on a daily basis working in public mental health services, witness changes that impact on their ability to facilitate positive consumer outcomes. While much of the nursing profession presume that the nurse patient relationship first described by Peplau remains the focus of mental health nursing (Peplau, 1952) in reality clinicians are managing people with high levels of acuity and symptoms of psychopathology (Prescott, Madden, Dennis, Tisher, & Wingate, 2007) within an environment that has an ever increasing pressure on available inpatient beds (Cleary, 2004; Saxena, Thornicoft, Knapp, & Whiteford, 2007). Since 1960 inpatient beds in Australia have been cut from 30,000 to 8000 in 2006 despite
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the population doubling in that time (White & Whiteford, 2006). At the same time failed social policies and inadequate community based mental health services, has led to increased and sustainable pressure on existing inpatient beds. It has also led to an increased number of people with mental illness in the criminal justice system (Doessel, Scheurer, Chant, & Whiteford, 2005; Lamb & Weinberger, 2005). For participants in this study, the importance of the changing acute inpatient environment was evidenced by the outcome of several research questions in this area. The themes of best practice and education, training and support were identified with questions related to mental health nurses declining use of therapeutic skills within the acute inpatient environment. Questions included the need to research new models of care such as supported admission diversion and early support programmes in the community to determine their ability to decrease the pressure on inpatient beds. These community innovations could enhance mental health nurses’ capacity to work collaboratively with consumers and their family in a supportive community environment. This potential is supported by emerging evidence of the value and contributions made by mental health nurses working in primary care environments in the initial evaluations of the mental health nurse incentive programmes (Australian College of Mental Health Nurses Inc., 2011). In the future it is within this environment that nurses will make significant future contributions to the mental health outcomes of the Australian population. However, this increasingly autonomous practice role warrants an increased skill set to work with consumers and their families on an ongoing and longer term basis and a more intensive articulation with the primary health sector. Hence the request by participants for more research into the efficacy of psychosocial and recovery training programme currently available at the service. Internationally, these programmes have been seen to have positive outcomes (Sin & Scully, 2008) and these findings need to be supported in the Australian context to further facilitate practice change. Within public mental health services the contributions made by nurses from both economic
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and therapeutic perspectives remains relatively unexplored from a research perspective (Lomas, 2009; Thompson, Estabrooks, Scott-Findlay, Moore, & Wallin, 2007). This lack of evidence undermines and undervalues the contributions made by nurses. The clinical and professional categories identified in round three incorporated questions concerning nursing staff cuts, the introduction of patient care assistants and the decreasing skill set of Australian comprehensive nurses. The decreasing skill set has impacted on levels of job satisfaction, stress and burnout and recruitment and retention rates. It also impacts on the therapeutic capacity of the profession to make significant contributions to mental health care (Cottrell, 2001; Hyrkäs, 2005). Under the ‘clinical’ category the findings suggest mental health nurses place importance on caring for the consumer in a holistic manner. Research into how co-morbid drug and alcohol problems can be integrated with mental health services to benefit the consumer was a priority. The need for integrated services has been supported by other researchers (Llopis & Matytsina, 2006). Further clinical research questions highlighted the importance of health promotion and prevention strategies to mental health nursing practice to further facilitate positive physical and mental health outcomes for consumers. These too are identified within the Fourth National Mental Health Plan 2009–2014 (Australian Health Ministers, 2009a) as priority areas for further development and research. Surprisingly, while the importance of family/carer support and inclusion in the delivery of mental health care is the focus of many policy developments in the area of mental health (Australian Health Ministers, 2009a) it was not identified in this study as a priority area by nurses. Not within the top priorities for round three but relevant in the clinical category were three areas that included the administrative burden accompanying an increasing technological service delivery, how best to care for Aboriginal consumers and how to reduce the use of restrictive practices. Also of interest was the fact that clinical supervision was not mentioned as a research topic of response as this can be a tool to identify opportunities for 24
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research and/or enhancement of evidence based knowledge and practice. Professional issues was the greatest area of research concern within the second round and continued to be the most prevalent in the third round. An improved understanding of the ability of comprehensive nursing programmes to provide sufficient knowledge and skills to work with consumers is needed. How to attract more graduate into the area of mental health was also identified as a priority area for research. While this issue has long been identified at an academic level nationally (Happell, 2002; Happell & Cutcliffe, 2011; Happell, Robins, & Gough, 2008; Wynaden, 2010, 2011; Wynaden, Orb, McGowan, & Downie, 2000), the findings of this study are based on the views of clinicians and add another dimension to the ongoing debate on the current educational preparation of nurses to work with consumers of mental health care. Conclusion For the profession of mental health nursing to continue to be a key stakeholder group in the delivery of mental health care and to expand practice into new models of care delivery, research evidence that demonstrates nurses’ contributions to care is essential. The research priority areas identified in this paper are a representation of priorities identified by nurses working at one health service in Western Australia. However, as the service is representative of many across Australia, the researchers believe they provide valuable insights into the current mental health nursing environment nationally. They also highlight the importance of research to the sustainability of the mental health nursing profession within an ever changing health care environment. Acknowledgement The group would like to acknowledge the contributions made to this project by Mr Gary Colley, Ms Robina Redknap and Mr Donald Cook. All three were members of the Mental Health Nursing Research Group at South Metropolitan Health Service over the duration of the study.
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Identifying mental health nursing research priorities References Australian College of Mental Health Nurses Inc. (2011). Mental Health Nurse incentive program: Achieving through collaboration, creativity and compromise. Canberra, ACT: Author. Australian Health Ministers. (2009a). Fourth national mental health plan: An agenda for collaborative government action in mental health 2009–2014. Canberra, ACT: Commonwealth Department of Health and Ageing. Australian Health Ministers. (2009b). National mental health policy 2008. Canberra, ACT: Commonwealth Department of Health and Ageing. Bartu, A., Nelson, M., Ng, C., McGowan, S., & Robertson, J. (1991). A Delphi survey of clinical nursing research priorities in Western Australia. Australian Journal of Advanced Nursing, 8(3), 29–33. Cleary, M. (2004). The realities of mental health nursing in acute inpatient environments. International Journal of Mental Health Nursing, 13(1), 53–60. Cottrell, S. (2001). Occupational stress and job satisfaction in mental health nursing: focused interventions through evidence-based assessment. Journal of Psychiatric and Mental Health Nursing, 8(2), 157–164. Crisp, J., Pelletier, D., Duffield, C., Adams, A., & Nagy, S. (1997). The Delphi method? Nursing Research, 46(2), 116–118. Curran, J., Grimshaw, J., Hayden, J., & Campbell, B. (2011). Knowledge translation research: The science of moving research into policy and practice. Journal of Continuing Education in the Health Professions, 31(3), 174–180. Davidson, P., Merritt-Gray, M., Buchanan, J., & Noel, J. (1997). Voices from practice: Mental health nurses identify research priorities. Archives of Psychiatric Nursing, 11(6), 340–345. DiCenso, A. (2003). Research: Evidence based practice: How to get there from here. Nursing Leadership, 16(4), 20–26. Doessel, D. P., Scheurer, R. W., Chant, D. C., & Whiteford, H. A. (2005). Australia’s national mental health strategy and deinstitutionalization: Some empirical results. Australian and New Zealand Journal of Psychiatry, 39(11–12), 989–994. Elo, S., & Kyngs, H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62(1), 107–115. Fenwick, J., Butt, J., Downie, J., Monterosso, L., & Wood, J. (2006). Priorities for midwifery research
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in Perth, Western Australia: A Delphi study. International Journal of Nursing Practice, 12(2), 78–93. Fisher, J. E., & Happell, B. (2009). Implications of evidence-based practice for mental health nursing. International Journal of Mental Health Nursing, 18(3), 179–185. Freshwater, D. (2005). Researcher or handmaiden: What’s in a name? Journal of Research in Nursing, 10(6), 876–879. Gill, P. (2004). Difficulties in demonstrating a nursing research culture in the UK. British Journal of Nursing, 13(14), 879–976. Glasgow, R. E., & Emmons, K. M. (2007). How can we increase translation of research into practice? Types of evidence needed. Annual Review of Public Health, 28, 413–433. Government of Western Australia. (2012). South metropolitan health Service. Retrieved from http://www. southmetropolitan.health.wa.gov.au/ Graneheim, U. H., & Lundman, B. (2004). Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24(2), 105–112. Haines, A., & Jones, R. (1994). Implementing findings of research. British Medical Journal, 308(6942), 1488–1492. Happell, B. (2002). Mental health nursing: The need to distinguish between generic and specialist skills. Australian Electronic Journal of Nursing Education, 8(1), Article 3. Retrieved from http://scu.edu.au/schools/nhcp/aejne/ vol8-1/refereed/happell_gen.html Happell, B. (2004). The centre for psychiatric nursing research and practice: An innovative approach to enhancing clinical nursing research in the psychiatric/ mental health field. Issues in Mental Health Nursing, 25(1), 47–60. Happell, B., & Cutcliffe, J. (2011). A broken promise? Exploring the lack of evidence for the benefits of comprehensive nursing education. International Journal of Mental Health Nursing, 20(5), 328–336. Happell, B., Robins, A., & Gough, K. (2008). Developing more positive attitudes towards mental health nursing in undergraduate students: Part 1 – Does more theory help? Journal of Psychiatric and Mental Health Nursing, 15, 439–446. Hyrkäs, K. (2005). Clinical supervision, burnout, and job satisfaction among mental health and psychiatric nurses in Finland. Issues in Mental Health Nursing, 26(5), 531–556.
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25
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Lamb, H. R., & Weinberger, L. (2005). The shift of psychiatric inpatient care from hospitals to jails and prisons. Journal of the American Academy of Psychiatry and the Law, 33(4), 529–534. Llopis, E., & Matytsina, I. (2006). Mental health and alcohol, drugs and tobacco: A review of the comorbidity between mental disorders and the use of alcohol, tobacco and illicit drugs. Drug and Alcohol Review, 25(6), 515–536. Lomas, C. (2009). Lack of robust nurse research may jeopardise metrics, warns academic. Nursing Times. Retrieved from http://www.nursingtimes.net/ whats-new-in-nursing/acute-care/lack-o[horizontal MacNeela, P., Morris, R., Scott, A., Treacy, M. P., & Hyde, A. (2010). Seen as core: A Delphi consensus study of essential elements of mental health nursing care in Ireland. Archives of Psychiatric Nursing, 24(5), 339–348. Mental Health Workforce Advisory Council. (2011). National mental health workforce committee. Melbourne, VIC: Victorian Government Department of Health. Neville, C., Hangan, C., Eley, D., Weir, J., Quinn, J., & Meehan, T. (2010). The review and revision of ‘standards of practice for mental health nurses in Australia’. Journal of Psychiatric and Mental Health Nursing, 17(1), 87–93. Okoli, C., & Pawlowski, S. D. (2004). The Delphi method as a research tool: An example, design considerations and applications. Information & Management, 42(1), 15–29. Owens, C., Ley, A., & Aitken, P. (2008). Do different stakeholder groups share mental health research priorities? A four-arm Delphi study. Health Expectations, 11(4), 418–431. Parahoo, K. (2000). Barriers to, and facilitators of, research utilization among nurses in Northern Ireland. Journal of Advanced Nursing, 31(1), 89–98. Peplau, H. E. (1952). The psychiatric nurse’s family group. The American Journal of Nursing, 52(12), 1475–1477. Prescott, D., Madden, L., Dennis, M., Tisher, P., & Wingate, C. (2007). Reducing mechanical restraints in acute psychiatric care settings using rapid response teams. Journal of Behavioural Health Services and Research, 34(1), 96–104. ©QSR NVivo 8 (2012). Retrieved from http://www. qsrinternational.com/products_nvivo.aspx Rice, M. (2008). Psychiatric mental health evidence based practice. Journal of American Psychiatric Nurses Association, 14(2), 107–111.
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Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing & Health, 23(4), 334–340. Saxena, S., Thornicoft, G., Knapp, M., & Whiteford, H. A. (2007). Resources for mental health: scarcity, inequity, and inefficiency. The Lancet, 370(9590), 878–889. Sin, J., & Scully, E. (2008). An evaluation of education and implementation of psychosocial interventions within one UK mental health care trust. Journal of Psychiatric and Mental Health Nursing, 15(2), 161–169. Skews, G., Meehan, T., Hunt, G., Hoot, S., & Armitage, P. (2000). Development and validation of clinical indicators for mental health nursing practice. Australian and New Zealand Journal of Mental Health Nursing, 9(1), 11–18. SurveyMonkey. (2012). Retrieved from http://www. surveymonkey.com Thompson, D., Estabrooks, C., Scott-Findlay, S., Moore, K., & Wallin, L. (2007). Interventions aimed at increasing research use in nursing: A systematic review. Implementation Science, 2(15). Turton, P., Wright, C., White, S., & Killaspy, H. (2010). Promoting recovery in long-term institutional mental health care: An international Delphi study. Psychiatric Services, 61(3), 293–299. White, P., & Whiteford, H. (2006). Prisons: Mental health institutions in the 21st century. Medical Journal of Australia, 185(6), 302–303. Wynaden, D. (2010). There is no health without mental health: Are we educating Australian nurses to care for the health consumer of the 21st Century? International Journal of Mental Health Nursing, 19(3), 203–209. Wynaden, D. (2011). Education issues: Always on the agenda for the profession of mental health nursing. International Journal of Mental Health Nursing, 20(3), 153–154. Wynaden, D., Landsborough, I., Chapman, R., McGowan, S., Lapsley, J., & Finn, M. (2005). Establishing best practice guidelines for the administration of intramuscular injections in the adult: A systematic review of the literature. Contemporary Nurse, 20(2), 267–277. doi: 10.5172/conu.20.2.267 Wynaden, D., Orb, A., McGowan, S., & Downie, J. (2000). Are universities preparing nurses to meet the challenges posed by the Australian mental health care system? Australian and New Zealand Journal of Mental Health Nursing, 9(3), 138–146. Received 09 November 2012
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Accepted 10 October 2013
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