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John. A. Stevens R.N, B.A (Hons), PhD, MRCNA - Lecturer, Southern Cross University.

Geoffrey. M. Dulhunty R.N, B.Hlth.Sc, M.H.Ed, FANZCMHN, FRCNA, FCN (NSW) - Senior Nurse Manager - Staff Education and Clinical Practice, Garrawarra Centre for Aged Care, Sydney.

This paper examines whether the integrated curriculum used in the current nurse education system will produce a sustainable workforce of registered nurses to care, specifically, for mentally ill people. The analysis of the both quantitative and qualitative data gathered in a longitudinal study would suggest that caring for the mentally ill is an area of nursing practice that does not attract a sustainable supply of graduates from the current pre-registration programs. The implications of these findings indicate that nursing is likely to loose this area of health care to other occupations unless: 1) action is taken to make caring for mentally ill people a more attractive career destination; and/or 2) provision is made for a registration pathway that caters for those undergraduate students for whom a career caring for mentally ill people is a priority.

A career with mentally ill people: an unlikely destination for graduates of pre-registration nursing programs

Much research has been undertaken to suggest that society, generally, is negative towards mentally ill people. Studies from the 1950s to now regularly produce data showing that the community is ill informed about mental illness and hold many stereotypical views about those who suffer these illnesses. Studies by Cummings and Cummings (1957), Rabkin (1972), Olade (1979; 1983), Sellick and Goodyear (1985), McLoughlan and Chalmers (1991) are just a few examples from this body of literature which spans the last 40 years. These studies identified that in many communities throughout the world terms such as 'frightening', 'distrustful', 'dislikeable', 'dangerous', 'unpredictable', 'dirty and 'worthless' are regularly used to describe those suffering mental illness.

One would expect that neophyte nursing students, drawn from these communities would reflect, at least in part, these same widespread negative stereotypes. Yet one would hope, however, that with developments in the professional education that nurses now receive throughout most of the developed world, that graduates would have come to view mental illness and the mentally ill far more objectively and rationally. Haffner and Procter (1993), Procter and Haffner (1991) and McLouglhan and Chalmers (1991) suggest that education can have an affirmative effect on attitudes towards mentally ill people. However, the underlying assumption that a more positive attitude toward mentally ill people among student nurses will result in an increase in the number of nurses choosing to work in psychiatric and mental health areas has yet to be established. Indeed, the body of research involved in this discourse infers that few students emerge from pre-registration nursing programs with intentions towards a career in psychiatric/mental health nursing (for example see Stevens 1995; Stevens and Crouch 1995; Stevens and Dulhunty 1992; Caroselli-Karinja et al. 1988; Fielding 1986; Knowles and Faan 1985; Reif and Estes 1982; Delora and Moses 1971; Campbell 1971). In general the findings from the above noted studies suggest that current education programs produce nurses whose career interest lies in acute medical surgical areas. These findings are especially germane in light of changes to registration pathways in Australia following the introduction of a university based system of integrated education.

In Australia, university based pre-registration programs produce graduates who are eligible to register with each state or territories' nurses registration board. Prior to the larger movement of pre-registration education to the university sector one had to undergo a specific pre-registration psychiatric nursing course in order to register as a psychiatric nurse. Under current provisions there are no longer any specialised pre-registration courses such as psychiatric nursing. The registration boards of all states and territories now accept that graduates from university courses are eligible for registration under a generic registration umbrella allowing a beginning clinician to practice in all areas of nursing. While there are a number of courses available to graduate nurses that provide specific psychiatric/mental health education and training there is no direct entry education or training mechanism for those nurses who see, from the outset, that their career is in a psychiatric/mental health area.

In view of the continued, if not growing, need for qualified practitioners to work with mentally ill people the question must be raised: from where are they to come? If our community does not produce a sustainable mental health workforce, then we put at risk the future quality care of those clients whose needs require specialist knowledge and skills. In addition, some client groups within institutions and in the community are expected to grow significantly over the next few decades. For example, Macklin (Health Ministers Forum 1994) predicts that the population suffering dementia in Australia is expected to increase by 77.9% over the next 20 years (a figure comparable to most developed societies throughout the world ) and mental health nurses will be expected to play a significant role in the management of this group. As well, in view of current mental health care policy to expend at least 60% of mental health resources in the community by the year 2000 (Health Ministers Forum 1994), the role and number of community mental health nurses (especially) will be expected to expand. Indeed, Hoot (1996) posits that with ever-expanding community mental health services, the need for skilled mental health nurses is increasing significantly. This research poses the question, therefore: is the current education system taking an approach to ensure the sustainability and viability of psychiatric/mental health nurses?

This research represents part of a three year longitudinal study that included the investigation of pre-registration nurses' intentions towards a career in mental health areas. A questionnaire was distributed to a cohort of nurses at three stages throughout their pre-registration course; on commencement day, during the fourth semester (approximately the half way mark) and just before the completion of their course. In addition, near the completion of the nursing program a convenience sample of students was selected and agreed to be interviewed.

Five universities agreed to participate in the research. All students commencing in 1992 at each site agreed to participate and complete the questionnaires. Subsequent returns were matched with previously completed questionnaires using names and location. Only returned questionnaires that were matched for the three years were analysed in depth for this part of the study.

It was decided that more established attitude instruments, for example The Nursing Specialty Preference Instrument (Delora and Moses 1969), were too time consuming and acquired only quantitative data. It was believed that this research would be better served by obtaining a blend of quantitative and qualitative data because, after all, it is the subjective views and experiences of the students that the study was attempting to tap into. Thus a user-friendly, time-efficient questionnaire which produced a balance of qualitative and quantitative data was designed. Colleagues at the participating universities agreed to administer the questionnaire during lecture time to improve the return rate. From administration to collection the process took less than 15 minutes.

The main task posed by the questionnaire was a ranking exercise that required respondents to rank in order their career preference for a selection of ten areas of nursing practice. The ranking task was followed by a series of open ended questions asking for reasons for their choices. This included asking respondents to provide reasons for their rank order of psychiatric and mental health nursing. The questionnaire was piloted and found to be valid in ascertaining the data required. The questionnaire was identical in each of the three stages of administration thus providing a strong indicator of changes in students career intentions.

A convenience sample of students selected by lottery method from one participating university agreed to participate in a series of interviews. A semi-focused interview style was implemented in an attempt to add a further qualifying dimension to the data acquired from the analysis of the questionnaires.

The first questionnaire was completed and returned by 610 students throughout the 5 universities. However, through natural attrition, failure of students to identify themselves and some administration errors a reduced total of 156 questionnaires could be matched over the three stages. Silverman (1985; 1993) suggests this attrition of respondent numbers is to be expected in longitudinal studies. In addition, twelve students from one of the universities under study agreed to be interviewed.

Since the ranking task produced ordinal data, a non-parametric test, the Friedman Two Way Anova, was used to assess significant rank changes over the three years. The Friedman Two Way Anova specifically uses the median rank scores in calculating rank changes because the median is the appropriate measure of central tendency when analysing ordinal data (Bulmer 1984; De Vaus 1990; Sarantakos 1993). Yet the median is too gross a measurement by which to sort rank order with any visual meaning in this particular study. The mean rank, on the other hand, provides a more discernible measure of the differences between specialties. Therefore, for the purpose of meaningful presentation of effects, Table 1 below shows the rank order of student career intentions for each year according to the mean rank for each category in each year.

	Stage I		Stage II			Stage III
Type of nursing	rank	mean		rank	mean		rank	mean
*Paediatric	1	3.42		2	4.24		2	4.44
*Intensive care	2	4.06		4	4.36		4	4.73
*Op.Theatres.	3	4.20		3	4.28		6	4.90
*Surgical ward	4	4.49		1	3.85		1	3.79
Medical ward	5	4.50		5	5.00		5	4.67
*Commun' Health	6	5.50		6	4.99		3	4.35
*Gerontic	7	6.62		10	7.64		9	7.03
Develop.Disability.	8	6.93		7	6.81		10	7.42
Psychiatric	9	7.60		8	6.88		7	6.81
*Com mental health	10	7.60		9	7.00		8	6.83

For purposes of comparison, Stage II and III results are presented in relation to the rank order produced by the mean rank scores from Stage I responses (although the statistical tests applied to assess the significant changes between ranks uses median rank scores).

As can be seen in Table 1, psychiatric nursing and community mental health nursing fill the bottom two ranks for Stage I responses. Both categories improve in rank order slightly at each stage and community mental health nursing has a statistically significant rank improvement between Stage I and Stage III. While noting the minor improvements in rank order over the three stages the more important observation is that these areas of nursing are considered by students to be very unpopular career destinations overall. Figures 1 and 2 support this proposition, showing a strong skew to the left and large modes for each category situated in the 10 and 9 rank positions throughout each stage.

Table 3 : Reasons for Negative Responses Working in Community Mental Health Nursing

The open ended responses to the questionnaires were analysed thematically and the frequency of similarly occurring themes was calculated. The analysis identified five regular themes that respondents were using to explain the low ranking of each of these mental health work areas. Tables 2 and 3 show the frequencies of responses categorised by these themes for Stages I and III (Stage II responses were very similar to Stage I for both areas of nursing and thus not included in this paper). For both areas of nursing Stage I results focused either on: 1) how working with the mentally ill would make themselves feel (46% and 47% of responses respectively); or 2) how they perceived mentally ill clients (40% and 45% of responses respectively).

This category focused largely on students perceiving a threat to either their physical and/or emotional well-being. Some examples of these responses were:

This category included responses which indicated that students held negative views about those needing care for a mental illness For example:

As well, twenty percent of Stage I responses explaining the ranking of community mental health nursing as a career prospect noted that they had no or little knowledge about this area of nursing.

There were two dominant themes in Stage III used by students to explain why they did not want a career in psychiatric or community mental health nursing: 1) experiences encountered during the pre-registration course (34% and 30%); and 2) the type and place of work (30% and 20%).

As can seen in Table 2 and 3 many responses indicated that students had encountered negative experiences during their pre-registration course. Only one comment linked a low ranking of the areas working with the mentally ill to theory and work undertaken in the classroom, all other comments in this category focused on negative experiences during clinical practicum. Comments such as the following were typical:

· The staff at (name withheld) were unreceptive... they really turned me off going there;

· I want to be where the action is like I experienced in ICU. Psych just has not got it;

· After my experience on prac I decided I don't want to baby sit. I want to be able to get amongst the energy. Pysch is not technical enough for me;

I found especially in my last prac which was in psych that I need to consolidate my nursing skills in surgical before I'd consider other areas;

Many of the responses from Stage III indicated that students where actually quite concerned for the well-being of clients. This was largely portrayed in how they felt about the institutions that they were treated in and the type of work they perceived was undertaken in these institutions. Thus psychiatric nursing collected far more responses under this category than community mental health nursing (30% and 20% respectively).

While many other comments under this category appeared to indicate that the type of work experienced in other more 'technical' areas of nursing were a better more fulfilling type of work. For example:

· Who wants to work in a place like (name withheld). Its the most disgusting, depressing place I'd ever seen;

· I cannot believe that these poor people can live like this and in places like ... (name withheld). The staff appear really frustrated because nothing they do seems to make difference. I do not want a job like that.

· They (the staff) don't seem to give a dam that their patients are covered in shit all day. I would hate to become like that so I'm staying well away from it.

By Stage III some notable changes in the pattern of responses had occurred in comparison to Stage I results. Using the same thematic categorisation of responses Tables 2 and 3 show that reasons focusing on the 'effect on self' for example had diminished considerably. Even so a large proportion of responses explaining the Stage III rankings (20% and 23% respectively) were still categorised under this theme, for example:

· Psych drained me so emotionally that after a few days I'd had it. I am not emotionally strong enough to work there;

· Despite all the education I still get the creeps and feel depressed about being there.

Responses which identified the clientele as the main reason for not wanting to work in either psychiatric nursing or community mental health nursing also diminished but still represented a large proportion of responses (15% and 18% respectively). Responses categorised under this theme had moderated considerably in essence compared to the Stage I responses. Some typical examples of Stage III responses that focused on the clientele were:

· I am no longer afraid of the mentally ill but I would prefer patients who are going to get better;

· I like to see people go home and know they are cured, that does not appear to happen in psych.

Two responses remind us that not all stereotypical behaviour is changed as a result of three years of nursing education:

Data gathered through the interviews reflected accurately the responses from the questionnaires. Interviewees tended to talk about both psychiatric nursing and mental health nursing in the same themes identified in the questionnaire data. The interviewees confirmed that they gained the majority of their impressions about the mentally ill and work associated with them from practicum experiences. They suggested unanimously that early experiences during their course set in concrete for them an inextinguishable attitude to this area of work. Most, unfortunately, recalled only having negative experiences on practicum. On a more encouraging note, the interviewees were unanimous about their change in attitude towards the mentally ill per se. One interviewee actually stated that she had been ashamed of her attitude to the mentally ill and after encountering them on clinical practicum had come to understand and no longer fear them. Most interviewees were adamant they would not find satisfaction working with mentally ill people, however, much of their negative personal attitudes towards this group had changed.

By Stage III there were a total of eight respondents who ranked either psychiatric or community health nursing as their number one choice. Of the eight, four had ranked psychiatric nursing one in all three stages of the study. The qualitative responses of these four respondents indicated that they had always wanted to work in mental health areas. These four students would appear to have entered the course with a pre-determined intention to work with mentally ill people upon graduation. One would imagine that this group would have entered a psychiatric specific registration course under the previous system of nurse education.

Four students changed from a relatively negative pre-course intention towards a career in mental health (below a rank of seven) in Stage I, to regard a career in community health nursing as their number one career option by Stage III. These students all indicated that practicum experiences had effectively changed their minds. Unfortunately their qualitative responses did not provide enough information to identify specific causes of their affirmative change in response and nor, due to ethical considerations, could they be followed up.

For the purpose of comparison Figure 3 shows the most popular ranked career destination in Stages II and III.

As can be seen in Table 1 surgical ward nursing becomes the most popular career destination of nurses by Stage III. Figure 3 shows the frequency of ranks of surgical ward nursing over the three stages. When compare with Figures 1 and 2, Figure 3 highlights the difference in popularity between surgical ward nursing and those concerned with mental health/illness nursing areas. The majority of the open-ended and interview responses were positive towards surgical ward nursing. By Stage III the responses linked to surgical ward nursing could be categorised under two main themes: 1) the need to consolidate skills before specialising: and 2) the sense that working in more technically oriented areas was more rewarding and attracted a higher status.

Many of the responses in this category indicated that students perceived the need to gain experience and develop the nursing skills found in surgical wards before they moved on to other speciality areas such as intensive care or operating theatres:

· Surgical ward nursing would be useful to practise real nursing (sic) before specialising in areas such as ICU;

2) the sense that working in more technical areas was more rewarding and/or higher status work.

The students' responses indicated that areas like surgical ward nursing are where they expect to find technology and where the skills required to manipulate technological 'things' could be developed. Responses were typified by the following:

· I want the action of an acute setting. I like controlling the machines and the technology.

One must be cautious making generalisations as the sample of participants used in this study is not necessarily representative of student nurses generally. Yet these results provide a useful beginning, at least, to understanding some the attitudes and behaviours of student nurses as well as the construction of those attitudes and behaviours, regarding their choice of career destinations.

The pre-course career intentions (ie; Stage I responses) of the students shows that psychiatric /community mental health nursing are the most unpopular choices; ranked at 9 and 10 respectively. The reasons given by students for these rankings in Stage I are dominated by concerns for their own sense of well-being and by stereotypical fear of the clientele. When the interviewees were asked how they had come to this position on mentally ill people in Stage I most indicated that they had made their rankings and statements about the mentally ill based on secondary sources (sources other than personal experience) such as the mass media, movies and their own subjective view points.

As can be seen in Table 1, there was an improvement in the rank order of both categories of nursing mentally ill people by Stages II and III. This improvement corresponds with a changes in the sentiments and descriptions provided in the open ended responses and interviews. Response emphasis moved from concerns about well-being and dislike of the clientele to concerns about institutions and the type of work anticipated and experiences gained during the pre-registration course. The fewer (but still disturbing) responses that remained focused on the mentally ill client as the reason for marginalising this area appeared to have moderated in sentiment considerably by Stage III. The data shown in Tables 1, 2 and 3, as well as from the exerts from the open ended responses and the interviews, suggests that attitudes towards the mentally ill per se had improved throughout the duration of the pre-registration program. However, this apparent improved attitude towards mentally ill people does not appear to translate into an improved desire to work in areas where mentally ill people are generally cared for.

By comparison, the category of surgical ward nursing advanced in rank over the three stages to become the most popular career intention of respondents. When Figure 3 is compared to Figures 1 and 2 a striking difference can be seen between the desire to work in these areas of nursing practice. Students are indicating throughout this research that they would rather work in areas where medical technology has infiltrated. It would appear that throughout the pre-registration course that the profession of nursing is somehow transmitting to students that work in areas associated with the manipulation of technology is high status and rewarding nursing. Indeed if Table 1 is re-examined a pattern begins to emerge. The table can almost be divided in two halves. The top ranked (with the exception of community nursing) categories are generally considered areas that owe their existence to medical and technical advances in the treatment of clients. Yet the lower ranked half of Table 1 is a list of nursing practice areas where medical technology has not infiltrated and indeed is often seen as areas neglected by the medical profession such as working with old and/or mentally ill people. It would appear that the pre-registration programs are not promoting areas of nursing practice where nursing practice alone makes the biggest impact on client care such working with mentally ill people.

Stevens (1995) and Stevens and Crouch (1995) write at some length of this conceptual division of labour amongst nurses and the implications for the profession of nursing more generally. However, the direct implication of these data is that they suggest the continuation of psychiatric/mental health care as an area of nursing practice is under threat. It would appear that the pre-registration programs fail to encourage nurses to consider, positively, the prospect of a career in either psychiatric or community mental health nursing. As an integrated university education is the only mechanism by which nurses are produced to care for mentally ill people in Australia, then the profession as a whole should be deeply concerned for the future of its role in this area of practice as well as for the continuation of quality care for people who have mental illness. This area of practice will become the responsibility of other occupational groups unless much more thought and resource, than is currently allocated, is provided to making a career with mentally ill people more appealing to graduates. As well, these data would suggest that an alternate pathway to registration for those wanting a career specifically caring for mentally ill people should be re-considered.

Thus it would appear from this data that the current pre-registration nurse education system is unlikely to produce a sustainable workforce of registered nurses to care, specifically, for mentally ill people. Further study is warranted inquiring as to whether with experience as a registered nurse this attitude towards a career in mental health changes. Nonetheless, these data indicate that working with the mentally ill is one of the least desired career destinations of student nurses. It would appear that attitudes towards those with a mental illness improves throughout the duration of the pre-registration program, however, this change does not translate into increased desire to make a career in this area of nursing practice. In addition, these results suggest that integrated pre-registration programs tend to serve the production of nurses who can work in acute medical care environments. The suitability of the integrated curricula within nurse education programs, in their current form, would appear to require some further investigation. Indeed, this study indicates that the few graduands who identify psychiatric or community mental health nursing as a career destination have held such a view from the start and despite the socialisation processes encountered throughout their pre-registration program. These are indeed deviant nurses.

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