Issues in Mental Health Nursing, 35:940–947, 2014 Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2014.924608
Postgraduate Education in Psychiatric Nursing in Israel: Closing the Gap Yafa Haron, RN, PhD Ministry of Health, Nursing Division, Jerusalem, Israel
Monica Gun-Usishkin, RN, PhD The Jerusalem Mental Health Center, Jerusalem, Israel
Razia Shor, RN, MA Nes-Ziona Mental Health Center, Nes Ziona, Israel
Dror Tran, RN, MA Mental Health Hospital Mazrah, Akko, Israel
Shoshana Riba, RN, PhD Ministry of Health, Jerusalem, Israel
Deinstitutionalization policies are being gradually implemented in Israel. Most recently, an insurance reform has been approved, in which mental health services will be included in the HMO’s service package. As most Israeli mental health nurses are currently employed in institutional settings, the Ministry of Health’s Nursing Division seeks to estimate their scope of employment in preparation for the anticipated changes. The aim of this study is to describe present-day professional practice characteristics of qualified psychiatric nurses and identify practice areas for which advanced training may be required. The research design is cross-sectional on a national level, including all state psychiatric hospitalization services. A countrywide sample of nurses with post-basic training in state psychiatric hospitals identified areas of practice in which further training may be required: psychotherapy intervention (60% of respondents); consultation for the elderly (60%); care prescriptions (64%); community drug treatment management (69%); and referral to professionals and community resources (56%). Nurses reported gaps in continued care and community rehabilitation activities. These findings have training implications in an era of increased focus on chronic mental illness in the community.
INTRODUCTION During the last two decades, the treatment of the mentally ill in Western countries has been transformed, with increased emphasis on community rehabilitation services. In-keeping with this approach, psychiatric hospitals in Israel have undergone Address correspondence to Yafa Haron, Ministry of Health, Nursing Division, Jerusalem, Israel. E-mail: [email protected]
significant changes in the last decade. The structural reform in psychiatry and the cutback in the number of beds have revolutionized the nature of active and extended-stay wards (Levy, 2010). Hospital wards treat mainly psychotic, violent patients often also suffering from physical illnesses, and drugs and alcohol abuse. In addition, the phenomenon of patients hospitalized by subject to a court observation and hospitalization order has expanded considerably. The mental health insurance reform currently underway in Israel has raised concerns that patients experiencing the most severe symptoms would be neglected because ambulatory services will focus on persons with less serious forms of mental illness (Aviram, Ginath, & Roe, 2012). All these have meant a change in the patient mix, and an increase in the number of actions required by inpatient and community nurses to address mental health and substance abuse comorbidities, mental health and primary healthcare needs, with greatest emphasis on prevention and early intervention (Hanrahan, Delaney, & Merwin, 2010). Since the insurance reform will transfer the brunt of treatment to the community (Nirel, Ecker, Rosen, Brammli-Greenberg, & Gross, 2007), local HMOs (which are also the insurers) plan to open community clinics, including outpatient wards, rehabilitation and occupational services, and hospitalization alternatives (hostels, assisted living). As part of this reform, psychiatric nurses are expected to assume a central role in treating and rehabilitating the mentally ill in the community (Rosen, Nirel, Gross, Brammli-Greenberg, & Ecker, 2008). This would depend on their ability to act as case managers within the multidisciplinary staff (Puskar & Bernardo, 2002). On the other hand,
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in Israel, many community activities, such as family coaching, group therapy, and interventions such as CBT are currently performed less by nurses and more by other professionals, such as social workers or psychologists. The Mental Health Nursing Workforce in Israel Approximately 1,000 psychiatric nurses are currently employed in Israel, 88% of whom work in public mental health hospitals (there are no private mental health institutions in Israel). While Israeli law does not require RNs to have a specialist qualification to work in mental health, about 60% of RNs working in mental health hospitals in Israel have post-basic mental health training. This 700-hour post-generic training program is offered to RNs with a BA in nursing and includes theory and clinical practice, mainly in the following areas: special evaluations, enhancing compliance with medication therapy, case management, facilitating therapeutic groups, and coaching patients and their families. Recently, post-generic training for nurses in cognitive behavioral therapy (CBT) has been made available. At the end of this training, the nurses take a government test to obtain a post-generic psychiatric nursing diploma. The Nursing Division of the Israeli Ministry of Health (ND) is responsible, among its other roles, for updating and defining a renewed scope of nursing, which is adapted to the changes in nursing in Israel, and accordingly for setting the post-generic training policy. In recent years, the ND has been creating positions for nurse specialists (NPs) in the following areas: palliative care, geriatrics, and premature newborns. Due to shortage in nursing staff in general and in psychiatry in particular, in addition to the insurance reform, there is urgent need to reassess the Israeli RNs’ professional core in psychiatry. To the best of our knowledge, however, no studies have examined the activity of psychiatric nurses in Israel, although specific training in the area has been provided for about a decade. Therefore, the ND’s Research Unit has decided to examine more thoroughly whether specific training in psychiatry is suitable to the practice areas and functions of psychiatric nurses today and in the near future. In other Western countries, promoting nurses’ practice and expanding their role in mental health is a growing trend. Most countries in European, Asian and American industrialized countries began developing advanced practice nursing (APN) more than a decade ago (Caldwell, Piren, & Torre, 2012). Although in a number of Western countries the psychiatric nurse has extensive powers and roles as a specialist NP, mainly in the community, in Israel, post-generic training does not allow the nurse to operate independently, similar to a clinical specialist. BACKGROUND Nurses’ Role in Psychiatry In several countries, the community role of the psychiatric nurse specialist has developed within the concept of his or
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her role as a professional caregiver and member of the multidisciplinary staff. This emerging trend is motivated by budget cuts, as well as the desire to improve access to treatment, reduce waiting time, outreach to marginalized populations and provide case management within specific populations (Elsom, Happell, & Manias, 2007). Studies have shown that the APN’s role can indeed reduce costs and improve patient satisfaction. These findings have helped decision-makers to include APNs as chief partners in the therapeutic team (Sheer & Wong, 2008). Moreover, changes in the health system have positioned psychiatric nurses, where they are required to provide a wide range of professional services based on skillful mental and physical assessment/referrals to specialist consultations (Happell, Hoey & Gaskin, 2012; Happell, Palmer, & Tennent, 2011). Gilfedder, Barron, and Docherty (2010) note that the role of the clinical specialist in psychiatry includes: carrying out autonomous decisions, performing tests requiring decisionmaking and problem-solving skills, admitting and releasing patients, working in cooperation with a team of caregivers and developing a treatment plan. In their opinion, incorporating clinical mental health specialists in the General Hospitals in Scotland improved treatment thanks to the skills and knowledge of the mental health nurses working in collaboration with the multidisciplinary staff. In Belize, too, the role of the clinical specialist in the hospital and the community has been expanded and has contributed to the accessibility of mental health services in the community and to the promotion of health (Killion & Gayetano, 2009). Indeed, in most countries where psychiatric nurse specialists operate, they are authorized to prescribe medication, perform tests, and write protocols. According to Johnston and Cowman (2008), the role of liaison (consultant) in psychiatry is a sub-specialty in advanced nursing. The liaison has the autonomy to perform clinical evaluations of psychiatric patients, where the important aspects of the role are recognizing the problems, evaluating and developing a treatment plan with emphasis on promoting mental health and working in accordance with standards. An assessment by the liaison assists in empowering the patient and providing support and consultation in addition to receiving help. Elsom, Happell, and Manias (2008, 2009) present results in support of the fact that mental health nurses in the community command a high level of confidence in writing prescriptions/referral to tests and experts. Despite their support of expanding nurses’ authorities, they are aware of the formal difficulties and the public objection of the medical unions in Australia. Finally, a qualitative study conducted in Australia (Baker, 2010) examined the area of practice of the clinical specialist among adolescents with initial psychosis. It was found that the clinical specialist’s activity in the areas of case management, health promotion, advice, prescription writing, referral to tests and emergency room, led to positive treatment results among the patients in 92% of the cases. In the USA as well, the role of the psychiatric nurse in the community was found to be very
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significant in first-line detection and treatment of youth and adolescents with mental problems (Kaye, 2009). Although psychiatric nursing has made tremendous progress as a profession, it is believed that in several countries, including the USA (Oleck et al., 2011) and the UK (Laing, 2012), mental health nurses are far from exhausting their professional potential. In some cases, there is confusion regarding the scope of practice (psychotherapy, prescription medication, etc.) (Hanrahan et al., 2010; Smith & Khanlou, 2013) – both in hospital settings and in community care. As mental health care is no longer confined to institutional settings and mental health training is pertinent to all areas of health care, the need for advanced mental health education is relevant to all healthcare settings where nurses practice (Smith & Khanlou, 2013). Israel is an example where psychiatric nursing is still overwhelmingly concentrated in hospital settings, with plans to reform community services. This near-term target challenges the ND to assess and clarify psychiatric nursing practice areas on a national level, in order to develop appropriate standards and roles and even to consider the establishment of a dedicated clinical practice area. Research Aim, Questions, and Focus The overall aim of this study is to describe present-day professional practice characteristics of nurses qualified in psychiatry and identify practice areas for which advanced education is required. Accordingly, the research questions are as follows: 1. What is the current scope of performance of the various psychiatric nursing activities? Specifically, are there differences in practice between nurses without and with specific postgeneric psychiatric training? 2. What are the areas of practice for which post-generic training is required in order to expand the psychiatric nurses’ role? Although this article focuses on issues most directly relevant to the Israeli context, we believe its conclusions provide a potential way forward to developing a scope of practice for mental health nurses and enhancing their professional identity worldwide. METHOD The research design is cross-sectional on a national level, including all state psychiatric hospitalization services in Israel. Instrument The questionnaire was constructed based on descriptions in the literature of the roles of the clinical specialist in psychiatry in Western countries, as well as on discussions of the present researchers with nursing directors in the psychiatric hospitalization centers in Israel. The questionnaire covered a variety of
practice areas of psychiatric nurses in the community and in hospitals, as well as activities included in the Israeli post-basic psychiatric training program.
Validity and Reliability Three methods were used to establish the instrument’s validity. First, a panel review was conducted by seven nursing experts who evaluated the relevance of each question to the study’s aim. Second, the questionnaire was used in a pilot that included 25 RNs with post-basic psychiatric training who work in psychiatric inpatient wards. Their feedback was used to refine questionnaire items. Finally, factor analysis was performed to establish the instrument’s construct validity. Reliability was evaluated using Cronbach’s Alpha and was found to be 0.87. The questionnaire had four parts. The first referred to current nursing practice areas, including evaluation, patients’ instruction, medication treatment management, and intervention in specific situations. Responses were rated on an ordinal scale: (1) The nurse decides and acts at his or her discretion; (2) The nurse acts according to doctor’s instructions; (3) The nurse does not decide nor acts. The second part of the questionnaire included a list of selected activities in the area of psychiatry. The respondents were asked to classify them from 1 to 4, according to the required training level: (1) Every RN; (2) Post-basic training in psychiatry; (3) Any specific training required beyond the post-generic level; (4) The activity is not within current nursing practice. The third part (one question) tested nurses’ satisfaction with their current activities and responsibilities on a scale from 1 to 10. The fourth and last part of the questionnaire collected demographic and personal data: gender, age, education, place of employment, post-basic training, and professional seniority.
Sample and Data Collection The sample included all RNs with at least 1 year of professional experience in the psychiatry area, currently working, and directly treating patients in psychiatric wards in Israel. The country’s small geographical area and population of the mental health nurses allowed us to use a nationwide sample. The questionnaires were distributed in all 13 state psychiatric wards in Israel; respondents were asked to mail the completed questionnaires in sealed envelopes to the ND Research Unit’s contact persons within the various mental health settings and personal reminders helped facilitate response rates. Our data were collected during a period of 7 months (June 2012 to January 2013).
Ethical Issues The study was approved by the hospitals’ managements and the Institutional Review Board in all relevant institutions.
POSTGRADUATE EDUCATION IN PSYCHIATRIC NURSING IN ISRAEL
Statistical Analyses Data processing was performed using the SPSS software version 15. The questionnaire’s reliability was evaluated by an items analysis test for determining the Cronbach’s Alpha coefficient and its construct validity was evaluated using factor analysis. Statistical tests included χ 2 , t-test, and ANOVAs for describing the distribution and for two-variable analysis. FINDINGS Sample Characteristics The final sample included 518 RNs – a 71% response rate. The characteristics of these respondents are listed in Table 1. About 60% of these respondents had completed a post-basic course; ∼65% were aged 41–60; ∼62% had an academic education and ∼72% had professional experience of more than 10 years in psychiatry. TABLE 1 Sample characteristics of respondents (n = 518) Characteristic Gender Women Men Age 20–30 31–40 41–50 51–60 >60 Education Registered with no degree BA MA Post-basic course in psychiatry Yes No Years of experience after basic course 1–10 11–20 >21 Workplace Psychiatric hospital Psychiatric ward in general hospital Community clinics Years of experience in psychiatry 1–5 6–10 11–15 16–20 ≥21
(%) 61.7 38.3 5.2 27.3 42.0 21.7 3.8 37.6 47.8 14.6 58.8 41.2 47 46 7 89.6 9.6 0.8 14.6 12.0 17.2 22.2 34.0
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Activities According to Training Level Most respondents (80%) reported that the RNs with postbasic training decide on and perform the following actions: physical assessment; evaluation of nutritional condition; evaluation of pain; evaluation of mental status; evaluation of risk; follow-up on symptoms and impact of drug therapy; group intervention; instruction of patients and their families; administering OTC medication. Less than 50% of respondents reported that nurses with post-basic training in psychiatry decide on and perform the following actions: evaluations (Nurse Observation Scale for Inpatient Evaluation (NOSIE); Positive and Negative Syndrome Scale (PANSS); Brief Psychiatric Rating Scale (BPRS); cognitive evaluation using the Mini Mental Test; summoning or referring patients to professional consultation; interdepartmental coordination of community rehabilitation; and issuing continued care prescriptions. Approximately 75% of the respondents reported that the above actions are not performed at all by RNs with no post-basic training in psychiatry (Table 2). There are significant differences between respondents with and without post-basic training in psychiatry in assessments (PANSS, BPRS, Mini Mental Test); group interventions; developing a treatment plan from first intake; and planning care and referring to community resources to ensure continuity of care. About 70% of RNs with post-basic training report that issuing continued care prescriptions to the patient in the community is not an activity performed by nurses today. Activities classified by nurses with post-basic training as requiring further training, include: psychotherapy intervention (60%); evaluation and consultation for the elderly on mental illnesses, particularly dementia (60%); issuing continued care prescriptions (64%); management of drug treatment in the community (69%); and referral to professionals and community resources to ensure continuity of care, such as rehabilitation resources (56%) (Table 3). According to the nurses’ reports regarding the extent of actions currently performed, as well as the training required, gaps were observed in the following actions: referral to professionals – 46% perform this activity, and 56% of nurses reported the need for further training; periodic follow-up to monitor drug levels – 45% perform this activity at their discretion, and 69% report the need for further training for performing management of drug treatment in the community; and issuing continued care prescriptions – 64% reported the need for further training. Finally, all the respondents averaged 7.21 on a 1–10 satisfaction scale. Specifically, more senior nurses reported lower satisfaction. Moreover, a significant difference was found between nurses with and without post-basic training (7.38 and 6.91, respectively). DISCUSSION The goal of the study was to examine the practice and activity areas of nurses in psychiatry today, while comparing RNs with and without a post-basic course in psychiatry. The study’s
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TABLE 2 Distribution of answers regarding current scope of performance by nurses with and without post-basic psychiatric training
The nurse decides on and performs the following action at her discretion 1. Physical assessment 2. Nutritional evaluation 3. Pain evaluation 4. Mental status evaluation 5. PANSS 6. BPRS 7. NOSIE 8. Evaluates the impact of drug treatment and plan of care 9. Risk evaluation 10. Cognitive function evaluation (Mini Mental Test) 11. Identifies and intervenes in sleep disorders for in/outpatients 12. Identifies and intervenes in sexual functioning disorders for in/outpatients 13. Conducts group intervention for patients and their families 14. Manages psychiatric emergency situations 15. Develops a treatment plan from the first intake 16. Plans care and prevention services for patients in community 17. Helps family members cope with the illness 18. Refers inpatients to rehabilitation resources funded by the Ministry of Health 19. Administers OTC drugs 20. Monitors blood and urine drug levels (lab) 21. Refers to other professionals and community resources to ensure continuity of care 22. Coordinates all rehabilitative care settings in the community 23. Issuing continued care prescriptions
findings show that the practice areas of nurses with post-basic training are wider, since more activities of evaluation, instruction, intervention, and case management are attributed to nurses with post-basic training. These findings paint a clear picture of the main practice areas of RNs with post-basic psychiatric training, as well as – critically – activities currently less performed. They are similar to the findings of a study in England (Allen, 1998), in which the roles of diagnosis and drug therapy management of patients were more emphasized among the specialist nurses with post-basic training in mental health. Israeli nurses with training in psychiatry include in their practice, the following actions: physical evaluation, pain evaluation, risk evaluation, follow-up on drug therapy impact, and instruction of patients and families. In contrast, the following actions are included to a lesser degree in their current practice, despite their training: evaluation of anxiety and depression, cognitive evaluation, symptom-focused physical examinations with emphasis on mental status, and drug therapy. The need for dedicated training for nurses in the mental health area varies in scope and practice between countries (Nolan & Bradley, 2007; Cleary, 2010; Sheer, 2008). Furthermore, there
RNs with post-basic training (%)
RNs without post-basic training (%)
86 83 97 86 46 45 56 90 84 52 78 51.5 90 76 80 91 90 52 89 45 46
77 76 91 59 20 17 27.5 75 70 29 62 33 62 53 50 66 68 20 76 23 24
55 30
25 10
is a need to define the mental health nurse’s roles, scope of practice and authority, as this lack of clarity is leading the way for other health professions and care givers to adapt some of the roles and functions (Elsom et al., 2005; Holmes, 2006; Smith & Khanlou, 2013). Last but not least are the potential stresses and added weight of responsibility which often accompany the expansion of legal powers and duties (Laing, 2012). Another key finding relates to management of drug treatment for the patient in the community, including issuing continued care prescriptions. Most RNs in this study perceived this responsibility as not included in their current psychiatric practice today, thus requiring additional training. This may be explained by the fact that nurses working in a hospital setting perceive prescriptions as a technical activity with no clinical significance, and therefore do not perform it. Another possible explanation is that it is perceived as requiring further authority or competence, and they therefore still refrain from it, although it is included in the scope of their training and authority. The lack of agreement regarding prescriptions was reported also by community mental health nurses in Australia (Elsom et al., 2007, 2008) and Ireland (Wells, Bergin, Gooney, & Jones, 2009).
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TABLE 3 Activities considered by respondents to require further training Activities for which additional training is required Management of drug treatment for the patient in the community Issuing continued care prescriptions Intervention in psychotherapy Mental evaluation and consultation to the elderly in the community Liaison with caregivers Referral to professionals in the community Decisions regarding non-medicine therapy (psychotherapy or art therapy) Evaluation of depression and anxiety Case management Treatment in stress and crisis situations Group therapy
Agreement by RNs with post-basic training (%) 69 64 60 60 58.5 56 48 25 22 22 15
In another study in England (Nolan & Bradley, 2007), nurses with no training in mental health expressed more apprehension in writing prescriptions, since this activity was perceived as potentially risking their relationships with the psychiatrists. It seems that on this subject, the positions and opinions of psychiatric nurses are split: some of them describe the great responsibility and time required for this activity, since it is accompanied by evaluation and symptom assessment, adding to the already heavy workload. However, they are aware that this activity contributes to the appreciation of the nurse’s work in psychiatry and to elevating her image in the eyes of both the patients and themselves. In Israel, the question is whether this position represents the nurses in general or only nurses in psychiatry, and if so, why do nurses with specific training in psychiatry avoid performing this activity. This question is particularly relevant, since in Israel, authority to issue continued care prescriptions to chronic patients in the community by RNs with post-generic training has only recently been given by the Ministry of Health’s Nursing Division (Nursing Division Circular, 2010). A partial answer to these questions is related to the process of change in nurses’ roles and practice core. This is more than just a change in regulations and rules, but rather the result of a long-term paradigmatic shift in the perception of nurses’ autonomy (Kaplan & Brown, 2007). In fact, autonomy is considered the core of the profession and the basis for the nurse’s practice. Therefore, appropriate training prior to legislative and regulatory change is necessary for policy implementation in the field. It is not just with our actions but also in our thoughts that we create our autonomy as nurses (Kaplan & Brown, 2007).
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Santos and Amaral (2011) also point out the need to raise the level of responsibility and authority of nurses in psychiatry, particularly in an era of economic contraction and limited budget on the one hand, and the need to focus on drug treatment and its impact on the process of recovery and community rehabilitation on the other (Hogan, 2012; Caldwell et al., 2012). Although our findings point to significant differences between nurses with and without post-basic training, key areas identified by RNs with post-basic training as requiring further training, included: psychotherapy; treatment of the chronic patient within the community (with dementia or other mental problems); management of drug therapy in the community; and liaison with caregivers. The conclusion is that the post-basic training for the nurses currently working in inpatient facilities is of the utmost importance, but that training contents and post-training responsibilities, particularly those related to follow-up community work, should be expanded (advanced psychopharmacology, psychiatric assessment and diagnosis, and specific psychotherapeutic practices). This will position psychiatric nurses in Israel in the suitable role in the multidisciplinary healthcare teams.
Workforce Considerations In planning for the future of professional health providers in psychiatry, it is important to also take into account characteristics related to burnout, such as age, seniority, and satisfaction. It was found that 68% of respondents were over 40, which means that psychiatric nurses are aging, with seniority averaging more than 10 years (74%), a finding which probably indicates low turnover and high professional stability. Furthermore, the participants’ attributes represent the overall profile of psychiatric practitioners in Israel. The percentage of men in this field is relatively high (38%) in comparison with other nursing practice areas in nursing in Israel, where the men constitute about 12% (Nursing Division Annual Report, 2013). Another finding is that satisfaction was higher among nurses with post basic-training as opposed to no training. The ability to retain nurses in the profession is influenced mainly by the perception of career options and satisfaction (Hampel, Procter, & Deuter, 2010). Therefore, a policy based on examining the nurses’ positions regarding their activity, their satisfaction and areas perceived to require expanded authorities and/or additional training will be an important step in exhausting the existing potential and expanding the practice areas in psychiatry. These findings suggest the importance of recruiting and training new, younger nurses in psychiatry, as well as providing further training for the current workforce in order to align psychiatry nurses to the reformed mental health services in Israel. It is also necessary for the mental health nursing profession to develop a systematic approach to education and to lobby government and other policy-makers about the potential benefits of role expansion.
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Limitations The present study was conducted among nurses working in inpatient facilities, since they represent about 90% of psychiatric nurses in Israel. In the present situation, psychiatric services are mostly offered within these facilities, including the ambulatory services in clinics. In order to examine the nurses’ areas of activity in the community, as expected in the new framework of outpatient treatment by the insuring HMOs, we relied on reports and positions of the nurses working in hospitals, assuming they know the community patient population and its needs. In the present study, the nurses’ areas of activity and scope of practice were examined in general, without referring to specific populations, such as youths, the elderly, immigrants, and minority groups. Another limitation is that the practice areas were examined only from the viewpoint of the nurses alone. It would be interesting to examine the positions of their healthcare role partners, such as physicians, and maybe even more importantly, the patients themselves. CONCLUSIONS AND IMPLICATIONS The findings presented in this study contribute significantly to articulating the advanced nurse’s role in mental health services. Our findings identified gaps reported by nurses in the core of mental health practices in hospitals and, as well as future practice needs in community mental health settings. Immediate-term policy planning would have to take into serious consideration the profession’s development needs, as identified here in terms of the major issues it faces in the current deinstitutionalization process, in order to provide viable solutions. This study found that when planning for the community setting, mental health nurses have the confidence to undertake expanded practice roles but they require further education and practice. In Israel, our findings have already helped change the post-basic curriculum: starting from 2014, the curriculum will undergo structural and content changes, with emphasis on practice areas of psychiatric nurses in the community. One important conclusion is that mental health nursing must create programs based on a lifespan approach facilitating the nurses’ transition through a variety of practice skills and settings. Specifically, a training program for nurses in mental health was found to heighten their sense of professionalism and satisfaction and broadens their practice scope. Thus, as more options open up for specializing in mental health, and the more nurses who acquire dedicated psychiatric training, we may assume more younger nurses will be attracted to this specialty in the future, preventing a human resources shortage in this area, while better addressing the population’s mental health needs. Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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Postgraduate Education in Psychiatric Nursing in Israel: Closing the Gap Yafa Haron, RN, PhD Ministry of Health, Nursing Division, Jerusalem, Israel
Monica Gun-Usishkin, RN, PhD The Jerusalem Mental Health Center, Jerusalem, Israel
Razia Shor, RN, MA Nes-Ziona Mental Health Center, Nes Ziona, Israel
Dror Tran, RN, MA Mental Health Hospital Mazrah, Akko, Israel
Shoshana Riba, RN, PhD Ministry of Health, Jerusalem, Israel
Deinstitutionalization policies are being gradually implemented in Israel. Most recently, an insurance reform has been approved, in which mental health services will be included in the HMO’s service package. As most Israeli mental health nurses are currently employed in institutional settings, the Ministry of Health’s Nursing Division seeks to estimate their scope of employment in preparation for the anticipated changes. The aim of this study is to describe present-day professional practice characteristics of qualified psychiatric nurses and identify practice areas for which advanced training may be required. The research design is cross-sectional on a national level, including all state psychiatric hospitalization services. A countrywide sample of nurses with post-basic training in state psychiatric hospitals identified areas of practice in which further training may be required: psychotherapy intervention (60% of respondents); consultation for the elderly (60%); care prescriptions (64%); community drug treatment management (69%); and referral to professionals and community resources (56%). Nurses reported gaps in continued care and community rehabilitation activities. These findings have training implications in an era of increased focus on chronic mental illness in the community.
INTRODUCTION During the last two decades, the treatment of the mentally ill in Western countries has been transformed, with increased emphasis on community rehabilitation services. In-keeping with this approach, psychiatric hospitals in Israel have undergone Address correspondence to Yafa Haron, Ministry of Health, Nursing Division, Jerusalem, Israel. E-mail: [email protected]
significant changes in the last decade. The structural reform in psychiatry and the cutback in the number of beds have revolutionized the nature of active and extended-stay wards (Levy, 2010). Hospital wards treat mainly psychotic, violent patients often also suffering from physical illnesses, and drugs and alcohol abuse. In addition, the phenomenon of patients hospitalized by subject to a court observation and hospitalization order has expanded considerably. The mental health insurance reform currently underway in Israel has raised concerns that patients experiencing the most severe symptoms would be neglected because ambulatory services will focus on persons with less serious forms of mental illness (Aviram, Ginath, & Roe, 2012). All these have meant a change in the patient mix, and an increase in the number of actions required by inpatient and community nurses to address mental health and substance abuse comorbidities, mental health and primary healthcare needs, with greatest emphasis on prevention and early intervention (Hanrahan, Delaney, & Merwin, 2010). Since the insurance reform will transfer the brunt of treatment to the community (Nirel, Ecker, Rosen, Brammli-Greenberg, & Gross, 2007), local HMOs (which are also the insurers) plan to open community clinics, including outpatient wards, rehabilitation and occupational services, and hospitalization alternatives (hostels, assisted living). As part of this reform, psychiatric nurses are expected to assume a central role in treating and rehabilitating the mentally ill in the community (Rosen, Nirel, Gross, Brammli-Greenberg, & Ecker, 2008). This would depend on their ability to act as case managers within the multidisciplinary staff (Puskar & Bernardo, 2002). On the other hand,
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in Israel, many community activities, such as family coaching, group therapy, and interventions such as CBT are currently performed less by nurses and more by other professionals, such as social workers or psychologists. The Mental Health Nursing Workforce in Israel Approximately 1,000 psychiatric nurses are currently employed in Israel, 88% of whom work in public mental health hospitals (there are no private mental health institutions in Israel). While Israeli law does not require RNs to have a specialist qualification to work in mental health, about 60% of RNs working in mental health hospitals in Israel have post-basic mental health training. This 700-hour post-generic training program is offered to RNs with a BA in nursing and includes theory and clinical practice, mainly in the following areas: special evaluations, enhancing compliance with medication therapy, case management, facilitating therapeutic groups, and coaching patients and their families. Recently, post-generic training for nurses in cognitive behavioral therapy (CBT) has been made available. At the end of this training, the nurses take a government test to obtain a post-generic psychiatric nursing diploma. The Nursing Division of the Israeli Ministry of Health (ND) is responsible, among its other roles, for updating and defining a renewed scope of nursing, which is adapted to the changes in nursing in Israel, and accordingly for setting the post-generic training policy. In recent years, the ND has been creating positions for nurse specialists (NPs) in the following areas: palliative care, geriatrics, and premature newborns. Due to shortage in nursing staff in general and in psychiatry in particular, in addition to the insurance reform, there is urgent need to reassess the Israeli RNs’ professional core in psychiatry. To the best of our knowledge, however, no studies have examined the activity of psychiatric nurses in Israel, although specific training in the area has been provided for about a decade. Therefore, the ND’s Research Unit has decided to examine more thoroughly whether specific training in psychiatry is suitable to the practice areas and functions of psychiatric nurses today and in the near future. In other Western countries, promoting nurses’ practice and expanding their role in mental health is a growing trend. Most countries in European, Asian and American industrialized countries began developing advanced practice nursing (APN) more than a decade ago (Caldwell, Piren, & Torre, 2012). Although in a number of Western countries the psychiatric nurse has extensive powers and roles as a specialist NP, mainly in the community, in Israel, post-generic training does not allow the nurse to operate independently, similar to a clinical specialist. BACKGROUND Nurses’ Role in Psychiatry In several countries, the community role of the psychiatric nurse specialist has developed within the concept of his or
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her role as a professional caregiver and member of the multidisciplinary staff. This emerging trend is motivated by budget cuts, as well as the desire to improve access to treatment, reduce waiting time, outreach to marginalized populations and provide case management within specific populations (Elsom, Happell, & Manias, 2007). Studies have shown that the APN’s role can indeed reduce costs and improve patient satisfaction. These findings have helped decision-makers to include APNs as chief partners in the therapeutic team (Sheer & Wong, 2008). Moreover, changes in the health system have positioned psychiatric nurses, where they are required to provide a wide range of professional services based on skillful mental and physical assessment/referrals to specialist consultations (Happell, Hoey & Gaskin, 2012; Happell, Palmer, & Tennent, 2011). Gilfedder, Barron, and Docherty (2010) note that the role of the clinical specialist in psychiatry includes: carrying out autonomous decisions, performing tests requiring decisionmaking and problem-solving skills, admitting and releasing patients, working in cooperation with a team of caregivers and developing a treatment plan. In their opinion, incorporating clinical mental health specialists in the General Hospitals in Scotland improved treatment thanks to the skills and knowledge of the mental health nurses working in collaboration with the multidisciplinary staff. In Belize, too, the role of the clinical specialist in the hospital and the community has been expanded and has contributed to the accessibility of mental health services in the community and to the promotion of health (Killion & Gayetano, 2009). Indeed, in most countries where psychiatric nurse specialists operate, they are authorized to prescribe medication, perform tests, and write protocols. According to Johnston and Cowman (2008), the role of liaison (consultant) in psychiatry is a sub-specialty in advanced nursing. The liaison has the autonomy to perform clinical evaluations of psychiatric patients, where the important aspects of the role are recognizing the problems, evaluating and developing a treatment plan with emphasis on promoting mental health and working in accordance with standards. An assessment by the liaison assists in empowering the patient and providing support and consultation in addition to receiving help. Elsom, Happell, and Manias (2008, 2009) present results in support of the fact that mental health nurses in the community command a high level of confidence in writing prescriptions/referral to tests and experts. Despite their support of expanding nurses’ authorities, they are aware of the formal difficulties and the public objection of the medical unions in Australia. Finally, a qualitative study conducted in Australia (Baker, 2010) examined the area of practice of the clinical specialist among adolescents with initial psychosis. It was found that the clinical specialist’s activity in the areas of case management, health promotion, advice, prescription writing, referral to tests and emergency room, led to positive treatment results among the patients in 92% of the cases. In the USA as well, the role of the psychiatric nurse in the community was found to be very
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significant in first-line detection and treatment of youth and adolescents with mental problems (Kaye, 2009). Although psychiatric nursing has made tremendous progress as a profession, it is believed that in several countries, including the USA (Oleck et al., 2011) and the UK (Laing, 2012), mental health nurses are far from exhausting their professional potential. In some cases, there is confusion regarding the scope of practice (psychotherapy, prescription medication, etc.) (Hanrahan et al., 2010; Smith & Khanlou, 2013) – both in hospital settings and in community care. As mental health care is no longer confined to institutional settings and mental health training is pertinent to all areas of health care, the need for advanced mental health education is relevant to all healthcare settings where nurses practice (Smith & Khanlou, 2013). Israel is an example where psychiatric nursing is still overwhelmingly concentrated in hospital settings, with plans to reform community services. This near-term target challenges the ND to assess and clarify psychiatric nursing practice areas on a national level, in order to develop appropriate standards and roles and even to consider the establishment of a dedicated clinical practice area. Research Aim, Questions, and Focus The overall aim of this study is to describe present-day professional practice characteristics of nurses qualified in psychiatry and identify practice areas for which advanced education is required. Accordingly, the research questions are as follows: 1. What is the current scope of performance of the various psychiatric nursing activities? Specifically, are there differences in practice between nurses without and with specific postgeneric psychiatric training? 2. What are the areas of practice for which post-generic training is required in order to expand the psychiatric nurses’ role? Although this article focuses on issues most directly relevant to the Israeli context, we believe its conclusions provide a potential way forward to developing a scope of practice for mental health nurses and enhancing their professional identity worldwide. METHOD The research design is cross-sectional on a national level, including all state psychiatric hospitalization services in Israel. Instrument The questionnaire was constructed based on descriptions in the literature of the roles of the clinical specialist in psychiatry in Western countries, as well as on discussions of the present researchers with nursing directors in the psychiatric hospitalization centers in Israel. The questionnaire covered a variety of
practice areas of psychiatric nurses in the community and in hospitals, as well as activities included in the Israeli post-basic psychiatric training program.
Validity and Reliability Three methods were used to establish the instrument’s validity. First, a panel review was conducted by seven nursing experts who evaluated the relevance of each question to the study’s aim. Second, the questionnaire was used in a pilot that included 25 RNs with post-basic psychiatric training who work in psychiatric inpatient wards. Their feedback was used to refine questionnaire items. Finally, factor analysis was performed to establish the instrument’s construct validity. Reliability was evaluated using Cronbach’s Alpha and was found to be 0.87. The questionnaire had four parts. The first referred to current nursing practice areas, including evaluation, patients’ instruction, medication treatment management, and intervention in specific situations. Responses were rated on an ordinal scale: (1) The nurse decides and acts at his or her discretion; (2) The nurse acts according to doctor’s instructions; (3) The nurse does not decide nor acts. The second part of the questionnaire included a list of selected activities in the area of psychiatry. The respondents were asked to classify them from 1 to 4, according to the required training level: (1) Every RN; (2) Post-basic training in psychiatry; (3) Any specific training required beyond the post-generic level; (4) The activity is not within current nursing practice. The third part (one question) tested nurses’ satisfaction with their current activities and responsibilities on a scale from 1 to 10. The fourth and last part of the questionnaire collected demographic and personal data: gender, age, education, place of employment, post-basic training, and professional seniority.
Sample and Data Collection The sample included all RNs with at least 1 year of professional experience in the psychiatry area, currently working, and directly treating patients in psychiatric wards in Israel. The country’s small geographical area and population of the mental health nurses allowed us to use a nationwide sample. The questionnaires were distributed in all 13 state psychiatric wards in Israel; respondents were asked to mail the completed questionnaires in sealed envelopes to the ND Research Unit’s contact persons within the various mental health settings and personal reminders helped facilitate response rates. Our data were collected during a period of 7 months (June 2012 to January 2013).
Ethical Issues The study was approved by the hospitals’ managements and the Institutional Review Board in all relevant institutions.
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Statistical Analyses Data processing was performed using the SPSS software version 15. The questionnaire’s reliability was evaluated by an items analysis test for determining the Cronbach’s Alpha coefficient and its construct validity was evaluated using factor analysis. Statistical tests included χ 2 , t-test, and ANOVAs for describing the distribution and for two-variable analysis. FINDINGS Sample Characteristics The final sample included 518 RNs – a 71% response rate. The characteristics of these respondents are listed in Table 1. About 60% of these respondents had completed a post-basic course; ∼65% were aged 41–60; ∼62% had an academic education and ∼72% had professional experience of more than 10 years in psychiatry. TABLE 1 Sample characteristics of respondents (n = 518) Characteristic Gender Women Men Age 20–30 31–40 41–50 51–60 >60 Education Registered with no degree BA MA Post-basic course in psychiatry Yes No Years of experience after basic course 1–10 11–20 >21 Workplace Psychiatric hospital Psychiatric ward in general hospital Community clinics Years of experience in psychiatry 1–5 6–10 11–15 16–20 ≥21
(%) 61.7 38.3 5.2 27.3 42.0 21.7 3.8 37.6 47.8 14.6 58.8 41.2 47 46 7 89.6 9.6 0.8 14.6 12.0 17.2 22.2 34.0
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Activities According to Training Level Most respondents (80%) reported that the RNs with postbasic training decide on and perform the following actions: physical assessment; evaluation of nutritional condition; evaluation of pain; evaluation of mental status; evaluation of risk; follow-up on symptoms and impact of drug therapy; group intervention; instruction of patients and their families; administering OTC medication. Less than 50% of respondents reported that nurses with post-basic training in psychiatry decide on and perform the following actions: evaluations (Nurse Observation Scale for Inpatient Evaluation (NOSIE); Positive and Negative Syndrome Scale (PANSS); Brief Psychiatric Rating Scale (BPRS); cognitive evaluation using the Mini Mental Test; summoning or referring patients to professional consultation; interdepartmental coordination of community rehabilitation; and issuing continued care prescriptions. Approximately 75% of the respondents reported that the above actions are not performed at all by RNs with no post-basic training in psychiatry (Table 2). There are significant differences between respondents with and without post-basic training in psychiatry in assessments (PANSS, BPRS, Mini Mental Test); group interventions; developing a treatment plan from first intake; and planning care and referring to community resources to ensure continuity of care. About 70% of RNs with post-basic training report that issuing continued care prescriptions to the patient in the community is not an activity performed by nurses today. Activities classified by nurses with post-basic training as requiring further training, include: psychotherapy intervention (60%); evaluation and consultation for the elderly on mental illnesses, particularly dementia (60%); issuing continued care prescriptions (64%); management of drug treatment in the community (69%); and referral to professionals and community resources to ensure continuity of care, such as rehabilitation resources (56%) (Table 3). According to the nurses’ reports regarding the extent of actions currently performed, as well as the training required, gaps were observed in the following actions: referral to professionals – 46% perform this activity, and 56% of nurses reported the need for further training; periodic follow-up to monitor drug levels – 45% perform this activity at their discretion, and 69% report the need for further training for performing management of drug treatment in the community; and issuing continued care prescriptions – 64% reported the need for further training. Finally, all the respondents averaged 7.21 on a 1–10 satisfaction scale. Specifically, more senior nurses reported lower satisfaction. Moreover, a significant difference was found between nurses with and without post-basic training (7.38 and 6.91, respectively). DISCUSSION The goal of the study was to examine the practice and activity areas of nurses in psychiatry today, while comparing RNs with and without a post-basic course in psychiatry. The study’s
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TABLE 2 Distribution of answers regarding current scope of performance by nurses with and without post-basic psychiatric training
The nurse decides on and performs the following action at her discretion 1. Physical assessment 2. Nutritional evaluation 3. Pain evaluation 4. Mental status evaluation 5. PANSS 6. BPRS 7. NOSIE 8. Evaluates the impact of drug treatment and plan of care 9. Risk evaluation 10. Cognitive function evaluation (Mini Mental Test) 11. Identifies and intervenes in sleep disorders for in/outpatients 12. Identifies and intervenes in sexual functioning disorders for in/outpatients 13. Conducts group intervention for patients and their families 14. Manages psychiatric emergency situations 15. Develops a treatment plan from the first intake 16. Plans care and prevention services for patients in community 17. Helps family members cope with the illness 18. Refers inpatients to rehabilitation resources funded by the Ministry of Health 19. Administers OTC drugs 20. Monitors blood and urine drug levels (lab) 21. Refers to other professionals and community resources to ensure continuity of care 22. Coordinates all rehabilitative care settings in the community 23. Issuing continued care prescriptions
findings show that the practice areas of nurses with post-basic training are wider, since more activities of evaluation, instruction, intervention, and case management are attributed to nurses with post-basic training. These findings paint a clear picture of the main practice areas of RNs with post-basic psychiatric training, as well as – critically – activities currently less performed. They are similar to the findings of a study in England (Allen, 1998), in which the roles of diagnosis and drug therapy management of patients were more emphasized among the specialist nurses with post-basic training in mental health. Israeli nurses with training in psychiatry include in their practice, the following actions: physical evaluation, pain evaluation, risk evaluation, follow-up on drug therapy impact, and instruction of patients and families. In contrast, the following actions are included to a lesser degree in their current practice, despite their training: evaluation of anxiety and depression, cognitive evaluation, symptom-focused physical examinations with emphasis on mental status, and drug therapy. The need for dedicated training for nurses in the mental health area varies in scope and practice between countries (Nolan & Bradley, 2007; Cleary, 2010; Sheer, 2008). Furthermore, there
RNs with post-basic training (%)
RNs without post-basic training (%)
86 83 97 86 46 45 56 90 84 52 78 51.5 90 76 80 91 90 52 89 45 46
77 76 91 59 20 17 27.5 75 70 29 62 33 62 53 50 66 68 20 76 23 24
55 30
25 10
is a need to define the mental health nurse’s roles, scope of practice and authority, as this lack of clarity is leading the way for other health professions and care givers to adapt some of the roles and functions (Elsom et al., 2005; Holmes, 2006; Smith & Khanlou, 2013). Last but not least are the potential stresses and added weight of responsibility which often accompany the expansion of legal powers and duties (Laing, 2012). Another key finding relates to management of drug treatment for the patient in the community, including issuing continued care prescriptions. Most RNs in this study perceived this responsibility as not included in their current psychiatric practice today, thus requiring additional training. This may be explained by the fact that nurses working in a hospital setting perceive prescriptions as a technical activity with no clinical significance, and therefore do not perform it. Another possible explanation is that it is perceived as requiring further authority or competence, and they therefore still refrain from it, although it is included in the scope of their training and authority. The lack of agreement regarding prescriptions was reported also by community mental health nurses in Australia (Elsom et al., 2007, 2008) and Ireland (Wells, Bergin, Gooney, & Jones, 2009).
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TABLE 3 Activities considered by respondents to require further training Activities for which additional training is required Management of drug treatment for the patient in the community Issuing continued care prescriptions Intervention in psychotherapy Mental evaluation and consultation to the elderly in the community Liaison with caregivers Referral to professionals in the community Decisions regarding non-medicine therapy (psychotherapy or art therapy) Evaluation of depression and anxiety Case management Treatment in stress and crisis situations Group therapy
Agreement by RNs with post-basic training (%) 69 64 60 60 58.5 56 48 25 22 22 15
In another study in England (Nolan & Bradley, 2007), nurses with no training in mental health expressed more apprehension in writing prescriptions, since this activity was perceived as potentially risking their relationships with the psychiatrists. It seems that on this subject, the positions and opinions of psychiatric nurses are split: some of them describe the great responsibility and time required for this activity, since it is accompanied by evaluation and symptom assessment, adding to the already heavy workload. However, they are aware that this activity contributes to the appreciation of the nurse’s work in psychiatry and to elevating her image in the eyes of both the patients and themselves. In Israel, the question is whether this position represents the nurses in general or only nurses in psychiatry, and if so, why do nurses with specific training in psychiatry avoid performing this activity. This question is particularly relevant, since in Israel, authority to issue continued care prescriptions to chronic patients in the community by RNs with post-generic training has only recently been given by the Ministry of Health’s Nursing Division (Nursing Division Circular, 2010). A partial answer to these questions is related to the process of change in nurses’ roles and practice core. This is more than just a change in regulations and rules, but rather the result of a long-term paradigmatic shift in the perception of nurses’ autonomy (Kaplan & Brown, 2007). In fact, autonomy is considered the core of the profession and the basis for the nurse’s practice. Therefore, appropriate training prior to legislative and regulatory change is necessary for policy implementation in the field. It is not just with our actions but also in our thoughts that we create our autonomy as nurses (Kaplan & Brown, 2007).
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Santos and Amaral (2011) also point out the need to raise the level of responsibility and authority of nurses in psychiatry, particularly in an era of economic contraction and limited budget on the one hand, and the need to focus on drug treatment and its impact on the process of recovery and community rehabilitation on the other (Hogan, 2012; Caldwell et al., 2012). Although our findings point to significant differences between nurses with and without post-basic training, key areas identified by RNs with post-basic training as requiring further training, included: psychotherapy; treatment of the chronic patient within the community (with dementia or other mental problems); management of drug therapy in the community; and liaison with caregivers. The conclusion is that the post-basic training for the nurses currently working in inpatient facilities is of the utmost importance, but that training contents and post-training responsibilities, particularly those related to follow-up community work, should be expanded (advanced psychopharmacology, psychiatric assessment and diagnosis, and specific psychotherapeutic practices). This will position psychiatric nurses in Israel in the suitable role in the multidisciplinary healthcare teams.
Workforce Considerations In planning for the future of professional health providers in psychiatry, it is important to also take into account characteristics related to burnout, such as age, seniority, and satisfaction. It was found that 68% of respondents were over 40, which means that psychiatric nurses are aging, with seniority averaging more than 10 years (74%), a finding which probably indicates low turnover and high professional stability. Furthermore, the participants’ attributes represent the overall profile of psychiatric practitioners in Israel. The percentage of men in this field is relatively high (38%) in comparison with other nursing practice areas in nursing in Israel, where the men constitute about 12% (Nursing Division Annual Report, 2013). Another finding is that satisfaction was higher among nurses with post basic-training as opposed to no training. The ability to retain nurses in the profession is influenced mainly by the perception of career options and satisfaction (Hampel, Procter, & Deuter, 2010). Therefore, a policy based on examining the nurses’ positions regarding their activity, their satisfaction and areas perceived to require expanded authorities and/or additional training will be an important step in exhausting the existing potential and expanding the practice areas in psychiatry. These findings suggest the importance of recruiting and training new, younger nurses in psychiatry, as well as providing further training for the current workforce in order to align psychiatry nurses to the reformed mental health services in Israel. It is also necessary for the mental health nursing profession to develop a systematic approach to education and to lobby government and other policy-makers about the potential benefits of role expansion.
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Limitations The present study was conducted among nurses working in inpatient facilities, since they represent about 90% of psychiatric nurses in Israel. In the present situation, psychiatric services are mostly offered within these facilities, including the ambulatory services in clinics. In order to examine the nurses’ areas of activity in the community, as expected in the new framework of outpatient treatment by the insuring HMOs, we relied on reports and positions of the nurses working in hospitals, assuming they know the community patient population and its needs. In the present study, the nurses’ areas of activity and scope of practice were examined in general, without referring to specific populations, such as youths, the elderly, immigrants, and minority groups. Another limitation is that the practice areas were examined only from the viewpoint of the nurses alone. It would be interesting to examine the positions of their healthcare role partners, such as physicians, and maybe even more importantly, the patients themselves. CONCLUSIONS AND IMPLICATIONS The findings presented in this study contribute significantly to articulating the advanced nurse’s role in mental health services. Our findings identified gaps reported by nurses in the core of mental health practices in hospitals and, as well as future practice needs in community mental health settings. Immediate-term policy planning would have to take into serious consideration the profession’s development needs, as identified here in terms of the major issues it faces in the current deinstitutionalization process, in order to provide viable solutions. This study found that when planning for the community setting, mental health nurses have the confidence to undertake expanded practice roles but they require further education and practice. In Israel, our findings have already helped change the post-basic curriculum: starting from 2014, the curriculum will undergo structural and content changes, with emphasis on practice areas of psychiatric nurses in the community. One important conclusion is that mental health nursing must create programs based on a lifespan approach facilitating the nurses’ transition through a variety of practice skills and settings. Specifically, a training program for nurses in mental health was found to heighten their sense of professionalism and satisfaction and broadens their practice scope. Thus, as more options open up for specializing in mental health, and the more nurses who acquire dedicated psychiatric training, we may assume more younger nurses will be attracted to this specialty in the future, preventing a human resources shortage in this area, while better addressing the population’s mental health needs. Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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Puskar, K. R. & Bernardo L. (2002). Trends in health: Implication for advanced practice nurses. Clinical Practice, 14(4), 214–218. Rosen, B., Nirel, N., Gross, R., Brammli-Greenberg, S., & Ecker, N. (2008). The Israeli mental health insurance reform. Journal of Mental Health Policy and Economics, 11, 201–208. Santos, J. C. & Amaral, A. F. (2011). Effectiveness of psychiatric mental health nurses: Can we save the core of the profession in an economically constrained world? Archives of Psychiatric Nursing, 25(5), 329– 338. Smith, M. & Khanlou, N. (2013). An analysis of Canadian psychiatric mental health nursing through the junctures of history, gender, nursing education, and quality of work life in Ontario, Manitoba, Alberta, and Saskatchewan. ISRN Nursing, 2013, 184024. Sheer, B. & Wong, F. K. Y. (2008). The development of advanced nursing practice globally. Journal of Nursing Scholarship, 40(3), 204– 211. Wells, J., Bergin, M., Gooney, M., & Jones, A. (2009). Views on nurse prescribing: A survey on community mental health nurses in the Republic of Ireland. Journal of Psychiatric and Mental Health Nursing, 16, 10–17.
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