A pilot study Of rural mental health/psychiatric nurses' Educational Needs Towards The Year 2005.
AEJNE Volume 3 - No.2 March,1998.
RN RPN RgerN DNE BEd(N) Med FCN(NSW) FANZCMHN
RN A.C.T.L A.Mus BA Msc PhD MCN(NSW)
This paper describes a pilot study which was carried out to ascertain the educational requirements of rural mental health/psychiatric nurses towards the year 2005. Fifteen senior mental health/psychiatric nurse specialists employed in the clinical field of mental health services on the Far North Coast of New South Wales participated. The respondents were requested to complete a questionnaire that itemised three criteria: (1) content and knowledge; (2) foundations of practice; and (3) special populations and unique settings. The questionaire further required the respondents to link these three criteria with the educational needs of: (a) a Professional Nurse with a Post Graduate Certificate; (b) a Specialty Nurse with Post Graduate Diploma; and (c) a Consultant Nurse with a Higher Degree education. The respondents' answers were mathematically scored and results ranked for each of the identified answers, and from each of the three criteria. Results from the analyses appear traditional however showed a newer trend or pattern emerging in the Knowledge/Content and Skills that differentiate the three levels of Professional, Specialist, and Consultant nurse.
The service changes for both nurse and patient in the last 20 years have been dynamic. These include, massive deinstitutionalization of clients from the larger State hospitals (formally known as 5th schedule); the growth of smaller (4-30 beds) acute psychiatric units within general hospital settings; living skill centres; residential hostels; community mental health services; crisis teams, and so on. The changes in the 1990/1994 Mental Health Acts, and the recent 1997 Amendments, as well as the humanistic, social, cultural, political, ethical, economic, and pharmacological advancements in the psychosocial and biological sciences have impacted on the traditional educational requirements of mental health/psychiatric nurses.
The restructuring of nursing personnel within services, both in hospitals and community settings has led to nurses having increased responsibilities within the therapeutic team. A team which is more multi-disciplinary based and collaborative. These services include crisis teams where nurses are deployed to work on the streets among the homeless and mentally ill. The recent State and National policies and reports outlining expanded community services imply the need for clients to have more involvement (and their significant others) in care planning, and care contracts. People are being educated into new ways of living and coping with chronicity (Lubkin, 1990:5). Further clients and their significant others require educational knowledge concerned with their illness or disorder, including reasons for pharmacological compliance and known drug side effects. The changing Australian society which has brought about unemployment; increased use of alcohol and other substances; increased youth suicide; homelessness; increases in petty crime, and assaults; and, an increasing elderly population, has expanded the educational requirements of mental health/psychiatric nurses.
In addition the changing roles of both men and women, the influence of holistic health care and alternative therapies, are challenging the biopsychosocial model and leading to more emphasis on preventative and wellness models. These factors are also influencing mental health and aligned services.
Rationale for pilot study
Both current and future changes reflecting on mental health nurses include: mainstreaming of mental health services; research findings; psychiatric classifications DSM-IV and the 5 Axis; nursing diagnosis; nursing case loads; team leadership roles; case mix; human rights issues including multicultural Australia, and the mental health of Indigenous Australians. All these many changes indicate a need for nursing curricular to be congruent of current happenings and the implications for client care, and the education and clinical skills of the mental health/psychiatric nurse specialist. The undergraduate courses in nursing have demystified mental illness for the 'generalist' student nurse graduate, and have provided the knowledge and skills required for the first level practitioner or novice (Benner, 1984:20). There is a need for those psychiatric nurses currently employed in the various fields of mental health service to identify what additional essential knowledge, skills and experience are necessary for: (I) professional mental health/psychiatric nursing practice; (2) advancement to specialty status; and (3) consultant status in the practice, of mental health/psychiatric nursing.
Aim of study
The aim of the pilot study was to seek and analyse the perceived educational requirements of rural mental health/psychiatric nurses towards the year 2005. This information was gathered from specialist registered nurses currently working at the "coal face" within the Mental Health Services on the Far North Coast of New South Wales.
Whilst there are many text books, journal articles, and anecdotal information concerned with mental health/ psychiatric nurse education, a literature search could not find any actual information of the educational requirements, or needs, from those actual working within the mental health settings that allows advancement to higher positions.
Williams (1995), whilst discussing the mainstreaming of mental health services has made strong arguments suggesting: 'Nurses consciousness must be raised to the need for political activity in the determination, establishment and administration of adequate funding for mental health services' (p.5). She recommended that current and future 'generalist' nurse education programs must ensure that mental health disturbances of varying severity and duration are explored in sufficient depth. Williams reasoned that '...education should be at both preparatory and continuing levels, to enable nurses to be therapeutic' (Williams, 1995:5).
In assessing the quality and quantity of current offerings in post registration specialist nurse education in Australia, Russell, Gething and Convery (1997) in their Executive summary stated that over the past few decades there has been a rapid proliferation of nursing specialties and it is likely that this will continue into the foreseeable future. Reasons include:
Andrews saw education initiatives to be necessary for successful restructuring of mental health services in Australia. Andrews contended, 'If university level education is being provided to all professional staff then it will become possible to accredit staff as to the levels of patient care they are competent to carry out' (Andrews,1991; cited in Tolkien Report,:24). He further argues that '...if there is to be accountability in diagnosis and in treatment it must be clear that staff are only allocated to diagnostic or treatment roles that are consistent with their levels of training and therefore accreditation' (Andrews, 1991:24). Applying these views of Andrews within the context of mental health/psychiatric nursing, the question may be asked: What level of knowledge and skill is required for a professional mental health/psychiatric nurse, a specialist mental health/psychiatric nurse, a leader or consultant in the field of mental health/ psychiatric nursing, being allocated to diagnostic or treatment roles?
The Australian & New Zealand College Of Mental Health Nurses (ANZCMHN) Inc, has recently introduced Standards Of Mental Health Nursing In Australia (May, 1995). Further, the ANZCMHN are currently researching the Definitions, Descriptions and Classification of Mental Health Nursing. Both of these projects will give direction and guidance as to the roles and functions of the mental health nurse. The ANZCMHN, in consultation with its Board of Education and members, together with Registration Authorities, Nursing Unions, and Professional Organisations is advancing inquiry in regards to credentialling and accreditation of mental health/psychiatric nursing specialty.
The 'Report of the National Inquiry into the Human Rights of People With Mental Illness' (known as the Burdekin Report), made the following statements on educational requirements and needs to the Commonwealth Government:
The report further outlined the need for major universities to be encouraged to make academic appointments in rehabilitation psychiatry and psychiatric nursing, and additional appointments in child and adolescent psychiatry, psycho geriatrics, co-morbidity, family intervention, and forensic psychiatry (Burdekin, 1993:912). Burdekin recommended that training courses should be as accessible as possible with particular attention given to the needs of rural and isolated professionals, and that tertiary based education programs must accord higher priority to mental health training (Burdekin, 1993:912).
Parkes (1995) has also outlined a blueprint for the future of nurse education and training in Australia. When commenting on post graduate nursing education, she suggested 'Recognition of universities self-accreditation responsibility has to be balanced with the profession's desire for active participation in the courses which, in particular, meet its advanced practice and skills development needs' (p.25). She further recommended improved articulation arrangements for specialists and post graduate courses (Parkes,1995:25).
In a contemporary society, care of the mentally ill and mentally disordered people involves a variety of professional and supportive groups and individuals including nurses, social workers, lawyers, occupational therapists, medical practitioners, psychiatrists, psychologists, welfare officers, parole officers, police, prison officers, chaplains, religious groups, natural therapists, Alcoholics Anonymous, concerned citizens, clients, relatives and friends. The nurse is often the pivotal person in this collaborative effort.
Major principles and issues reported within the Australian National Mental Health Policy (1992) are also significant for educational planning. The report states, ''Mental health is the product of biological, psychological and social factors.' Further, '...no single service or intervention is likely to achieve good outcomes for every person with a mental health problem or a mental disorder'. The report recommended that 'It is therefore essential that services are provided in a multifaceted and multi disciplinary manner. Mental health services are important, as are carers and non -government support agencies, general health services, and services provided outside the mental health sector such as housing, disability support, domiciliary care, income support, employment and training programs' (National Mental Health Policy, 1992:11).
According to Williams (1995:6), the costing of such services is not restricted to what is eaily identifiable within institutions, it must, she claims also account for the homeless, hostels, inadequate community facilities, and families who have assumed carer roles. Owen and Sweeney (cited in Williams,1995), have described the problem of the untreated severely mentally ill that are homeless, as being 40% of the homeless population in America. Williams (1995:9) argued that 'Deinstitutionalization has contributed to homelessness. The assumption that this scenario does not have currency within the Australian context is ill informed'.
There has been a shift from hospital focused care to community orientated care. In New South Wales alone, there are now (39) Gazetted Public Hospital Units within the Mental Health Act 1990 guidelines (Government Gazette of 10.1.97). From each of these Units, mental health workers have links with the many community agencies and resources. Within all such settings, the New South Wales Mental Health Acts, 1990 and 1997 Amendments (and the other Australian States' Mental Health Acts) have influenced mental health care providers to take into account human rights and freedom. The Act recommends that persons who are mentally ill or who are mentally disordered receive the best possible care and treatment in the least restrictive environment enabling the care and treatment to be effectively given, '...and any interference with their rights, dignity and self respect are kept to the minimum necessary in the circumstance' (Mental Health Act: 3-4).
The role of the Magistrate and Mental Health Review Tribunal has been extended. Community treatment, and counselling orders, and patient consent are all examples of changes in delivery of services.
The questionnaire was designed after a literature review, which examined the various aspects of mental health/ psychiatric nursing. These aspects of nursing included what was considered essential knowledge, practice, and skills, within the roles and functions of mental health/psychiatric nurses as currently understood. Three areas evolved which equate with knowledge, practice, and special population groups.
The three areas of content criteria were outlined as:
1. Content/Knowledge where eleven (11) broad options were identified and listed (ranked by respondent 1-11, number 1 being highest priority).
2. Foundations of Practice (assessment, planning, intervention, and evaluation), where seventeen (17) areas of knowledge and practice skills were identified (ranked by respondent 1-17, number 1 being highest priority) and:
3. Special Populations and Unique Settings where seventeen (17) areas of knowledge, experience and skills were outlined (ranked by respondent 1-17, number 1 being highest priority).
The survey instrument consisted of a four-page questionnaire, which included a covering letter and a letter of introduction. The first page of the questionnaire consisted of biographical data, including gender, age, present qualifications, clinical experience and the present status of the respondents were also obtained. The questionnaire was designed to elicit information about the educational requirements for professional mental health/psychiatric nurses who wish to advance to specialty and consultation status in mental health care.
The questionnaire also inquired if the respondent viewed a need for further progression in nurse education from novice to an expert nurse. Therefore, the questionnaire was designed to elicit educational requirements for employment advancement at the post graduate certificate, post graduate diploma, and higher degree levels. Three columns were added to the questionnaire adjacent to the listed content to elicit this information. The three columns were identified as level A, B, C, where;
One Unit equivalent to 150 hours of study.
The questionnaire asked the participants to provide responses within the three columns by ranking in numbers one (1) as highest priority and so on down the list. The respondents were requested to do the ranking, and to number what was important at post graduate certificate level in column A, at post graduate diploma level in column B, and at higher degree level in column C.
The pilot target group were mental health/psychiatric nurses employed on the Far North Coast of New South Wales in both acute hospital and community nursing positions. This health sector serves a population of approximately 500,000, within are populations of Indigenous peoples, elderly , and people wishing for alternative life style. There are three small Psychiatric Units associated with the General Hospital in the three larger cities. There is also one large Corrective Institution. Both the hospital based nurses, and the community nurses, network, and collaborate in various mental health teams, within these health districts.
A total of fifty mental health/psychiatric nurses employed from Tweed Heads to Port Macquarie were identified. Questionnaires were dispatched with self-addressed envelopes, which included the researcher's name and the name address of the institution. There was a follow-up on two occasion's with phone calls to encourage participation.
The results of the survey were scored mathematically and each of the questions were identified and ranked. Results were obtained from the ranking of the highest priority to the lowest priority for each of the three categories identified.
Return Rates of Questionnaires
Out of the fifty questionnaires distributed, there was a response rate of 30% (N=15). Polit, & Hungler, have argued researchers should make decisions about sample size and design with the following in mind: the ultimate criterion for assessing a sample is its representativeness, not the quantity of data it produces (Polit, & Hungler, 1983:427). The researcher examined the representativeness of the returned questionnaires and decided to go ahead with the final analysis.
Biographical characteristics of the fifteen respondents are shown in Table 1. There were nine males and six female respondents working within psychiatric nursing. Among the fifteen respondents, there was one aged between 20-30 years, five aged between 30- 40 years, six aged between 40-50 years, and three aged between 50-65 years.
Table 1: Distribution of sex and age of subjects (N=15)
There were three team leaders, two clinical nurse specialists, one community project officer, one community nurse unit manager, and one welfare officer among the respondents. Ten of the respondents were hospital based and five of the respondents were community based.
Their qualifications included a master degree, five with degree level education, two with diploma's, and all were registered mental health/psychiatric nurses, with many other undergraduate certificates and qualifications. This would therefore be representative of leaders in the field of psychiatric nursing between Tweed Heads, Lismore, Coffs Harbour, and Port Macquarie, and not a cluster from one centre.
The psychiatric nursing experienced ranged from 3-30 years, averaging 14.9 years for the participants. It was therefore reasoned an analysis of the data was worthwhile, as it is representative sampling of a rural context.
Analysis of Data as Ranked by Respondents
Table 2 shows the rank in order of priority in the areas of knowledge and content.
Table 2: Knowledge /Content Ranked Requirements for (A) Professional nurse with postgraduate certificate, (B) Specialty nurse with postgraduate diploma, and (C) Consultant nurse with Masters degree.
Results in Table 2 show that the highest priority given by group (A) Professional nurse with postgraduate certificate to content/knowledge include items 3,5,8,11 and 2 and items 9,6,1,7 and 4 were ranked as least priority. For group (B) Specialty nurse with postgraduate diploma, the highest priority given to content/knowledge include items 3,11,5,6 and 8 and items 9,7,10,1 and 2 were ranked as least priority. For group (C) Consultant nurse with Masters degree, the highest priority given to content/knowledge include items 5,7,8,4 and 3 and the lowest priority were given to items 1,2,6,9 and 10.
Table 3 shows the rank in order of priority in the areas of foundations of practice - assessment, planning, interventions and evaluation.
Table 3: Foundations of Practice Ranked Requirements for (A) Professional nurse with postgraduate certificate, (B) Specialty nurse with postgraduate diploma, and (C) Consultant nurse with Masters degree.
Results in Table 3 show that the highest priority given by group (A) Professional nurse with postgraduate certificate to foundations of practice include items 8,12,17,6 and 9 and items 16,15,4,10 and 14 were ranked as least priority. For group (B) Specialty nurse with postgraduate diploma, the highest priority given to foundation of practice include items 9,8,5,6 and 17 and items 15,14,16,1 and 13 were ranked as least priority. For group (C) Consultant nurse with Masters degree, the highest priority given to foundations of practice include items 17,5,4,10 and 11 and the lowest priority were given to items 15,16,14,7 and 3.
Table 4 shows the rank in order of priority in the areas of special populations and unique settings.
Table 4: Special Populations and Unique Settings Ranked Requirements for (A) Professional nurse with postgraduate certificate, (B) Specialty nurse with postgraduate diploma, and (C) Consultant nurse with Masters degree.
Results in Table 4 show that the highest priority given by group (A) Professional nurse with postgraduate certificate to special populations and unique settings include items 12,11,8,13 and 9 and items 1,2,6,4 and 5 were ranked as least priority. For group (B) Specialty nurse with postgraduate diploma, the highest priority given to special populations and unique settings include items 11,12,14,8 and 9 and items 2,3,15,1 and 6 were ranked as least priority. For group (C) Consultant nurse with Masters degree, the highest priority given special populations and unique settings include items 11,4,12,8 and 13 and the lowest priority were given to items 2,3,15,17 and 5.
DISCUSSION AND CONCLUSION
The respondents of the pilot study actually working at the "coal face" in the field of mental health/ psychiatric nursing ranked as highest priority for the Professional Nurse in the criteria A; 'Knowledge/ Content' areas: mental illness, mental disorder, psycho-pharmacology, legal and ethical issues, nursing process and diagnoses in psychiatric settings and mental health. Priorities for the Specialty Nurse included somatic therapies as well as the above, Priority ranking for the Consultant Nurse included the addition of knowledge related to contemporary issues and policies, and predominant therapies.
Highly ranked in criteria under 'Foundations of Practice' for the Professional Nurse included: nursing people with; schizophrenia, mood disorder, those who contemplate suicide, people with personality disorder, and communication and counselling skills. Both the Specialist and Consultant nurse were ranked high for these areas also. Post traumatic stress disorder(or crisis) was required of both the specialist and consultant nurses. Self destructive defences, was highly ranked for the consultant nurse.
Within the category area of 'Special Populations and Unique Settings' the Professional Nurse was ranked high for : community crisis teams, acute psychiatric settings, community settings, the homeless and chronic mental illness. The Specialist Nurse was identically ranked. The psychophysiological diseases, and community settings, living skills, hostels, and home care was added as a high priority for the Consultant nurse, suggesting the importance of chronicity for this focus group.
The lowest priority areas ranked by respondents may be considered educational background that is basic to know (this knowledge may have been adequately covered in undergraduate course). The lowest ranked items varied within each category, however, cultural diversity, and major theories of personality, were the lowest ranked in 'the areas of Knowledge/Content'. People with eating disorders, alcohol dependence, signs of panic, and people with aggression and violence, were ranked lowest in the areas under 'Foundations of Practice '. The respondents may have assumed these latter areas are perhaps adequately covered through Inservice and undergraduate courses.
The category of questions dealing with 'Special Populations and Unique Settings' were ranked lowest in areas of; chronic pain, HIV+ AIDS, adult relationships and sexuality, and infant, childhood, and adolescence disorders. These were ranked low by respondents in all three categories Professional Nurse, Speciality Nurse, and Consultant nurse educational needs.
These latter areas of study may be considered or viewed as less traditional work areas in the professional roles of mental health psychiatric nursing, or adequately covered in under graduate courses.
The other areas ranked above and below the five items discussed as highest and lowest priorities in 'Knowledge and Content', 'Foundations for Practice' and 'Special Populations and Unique Settings' may be considered areas of study that are essential knowledge and skills by the respondents of the Far North Coast of New South Wales but were not ranked as highly.
Subjective comments made by a few respondents are included within the discussion as they are meaningful to the future educational research. One respondent listed; " Alternative therapies and sociological dimensions" as important study areas. Another respondent commented; " I found it very difficult to rank some areas as many deserve equal priority. Another respondent stated that; "Assuming that Masters level students have the grounding of a post graduate diploma, I would assume students could choose the area of study that they wanted to specialise in to develop consultancy skills". Other comments listed as educational needs included ,"Case mix and outcomes"; "Aboriginal and ethnic groups, with special needs and understanding of culture"; "Community mental health"; "Family Therapy"; "Rehabilitation"; and "People indoctrinated by Western Individualism".
Reser (1991) whilst examining Aboriginal mental health and conflicting cultural perspectives described social problems such as substance abuse, youth suicide, domestic violence, as being high on health agenda's both State and Federal. Reser argued that understanding of these phenomena is impoverished or politically driven, and even 'straightjacketed' by inadequate frameworks for understanding the other culture realities of Aboriginal Mental Health (Reser,1991 in Reid and Trompf:221). It is suggested that more consideration should be given to the Australian Aboriginal culture/Indigenous mental health, and people from other cultures in the educational requirements of mental health nurses.
Interestingly no reference was made by the respondents for research skills in the areas of mental health or mental disorder; however the survey questionnaire had not included research as an item. The areas of management, finance, and leadership were not specifically included within the questionnaire either.
Having stated this the analysis does show that the respondent mental health/ psychiatric nurses see that mental illness and mental disorders are their major expertise in both hospital and community settings. Early intervention, crisis, and effective communication being paramount in prevention and care. The rehabilitation of the chronically mentally ill and homeless people were major educational priorities.
The "big picture" approach used within the questionnaire to capture as much information as possible may have been a deterrent for some of the respondents. In further research column C the masters level requirements would be excluded for the following reasons;
(a) few mental health/ psychiatric nurses presently in the clinical settings have a masters qualification therefor found it difficult to advance an opinion and;
(b) masters degree by course work allows for more focused projects, and field work assessments.
The mature age of the respondents may reflect the closure of the psychiatric nurse Register in New South Wales in 1988.
The mental health/psychiatric nurses who responded to the questionnaire confirm a need for further education of mental health/ psychiatric nurses at the post graduate levels. The researchers would recommend to the nursing profession, that further education of nurses following 'generalist' graduation is essential especially for those nurses who wish to specialise and advance in the field and care of the mentally ill, and mentally disorder individuals in the hospital, and/ or various community settings.
Whilst analysing and describing the changes in mental health services Williams argued;
"The translation of the philosophy, process and policy directions of mainstreaming compels a review of Graduate programs in nursing in the higher education sector to reflect the shift from acute care hospital delivery to community based services" (Williams, 1995:28).
The results of the survey show guidelines for the future educational requirements for professional, specialty, and consultant mental health nurses. The analysis of results reveal changing trends or patterns in the Knowledge/Content and skills that differentiate the Professional, Specialist, and Consultant nurse.
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