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Comprehensive Nursing Education: Mission Incomplete?
AEJNE Volume 4 - No.1 October, 1998.
Dr. Brenda Happell
The strength of psychiatric nursing as a recognised specialty of nursing practice is dependent upon an adequate supply of nurses with the skills, knowledge and interest required by the field. A review of the literature suggests that within a comprehensive or generic model of nursing education, psychiatric nursing is not highly regarded by students as an area for future employment. This paper describes the preliminary findings of a research project in which the attitudes of undergraduate nursing students in the state of Victoria, Australia were examined. The results indicate that unless nursing education can affect the orientation of students towards psychiatric nursing, the profession will face a serious predicament in attracting graduates into its workforce.
The Nurses Act of Victoria introduced in 1993 signalled the introduction of comprehensive nursing education throughout Australia. Specialist undergraduate psychiatric nursing degree programs immediately ceased new intakes of students. This legislation reflected the long standing and enduring pressure exerted primarily by the nursing profession itself, to relocate specialisation of practice solely within the postgraduate arena. The wisdom or otherwise of this decision will not be debated in this paper, rather the focus of discussion will concern the implications of comprehensive education for the formerly recognised specialty of psychiatric nursing.
The aim of comprehensive education was to prepare graduates "... for general practice with beginning level of competence in primary, secondary and tertiary health care in all settings where nursing care is required" (Royal College of Nursing Australia, et al, 1989, p.2). Comprehensively prepared graduates would presumably be equipped with skills, which would readily be transferred across a variety of health care settings. Further postgraduate education and experience could build upon these basic skills. The degree to which comprehensive education has been successful in this aim is subject to debate. Even if one was to accept that it had been successful, there appears to be a further underlying assumption that has not been sufficiently considered. The survival of specialist areas of nursing practice requires not only the ability of graduates to commence practice in a specific area, but first and foremost it depends upon students being genuinely interested in doing so.
It may be assumed that the type of students who were previously attracted to psychiatric nursing programs would now enter comprehensive programs with a view to specialising in psychiatric nursing after graduation. This assumption is not supported by research findings, such an assumption would appear to be unfounded. Psychiatric/mental health nursing has consistently emerged as an unpopular career choice within comprehensive programs (Arnswald 1987; Carter 1986; Peplau). Studies conducted by Reif & Estes (1982); Knowles & Faan (1985); Fielding (1986) and Caroselli-Karinja, et al (1988) suggest that acute medical-surgical nursing is the most popular area of practice for nurses.
Research conducted by Stevens and Dulhunty (1992) in New South Wales, suggests the Australian experience of comprehensive education has not been substantially different. A survey of undergraduate nursing students from five Schools of Nursing indicated that psychiatric and community mental health nursing were ranked ninth and tenth respectively from a total of ten possible career choices presented to the students. Stevens and Dulhunty found that undergraduate nursing students tend to share the negative disposition toward the mentally ill held by wider society. Fear, mistrust and dislike of the mentally ill were frequently cited by students as the reason for ranking psychiatric/ community mental health nursing as their least favoured preference.
If comprehensive education claims to prepare graduates for beginning level practice in all health care settings, how can educators not be concerned by, and take responsibility for such a disturbing situation? Does nursing education have a role not just in preparing students for practice in the psychiatric/mental health field, but in influencing their attitudes to the mentally ill towards a more positive orientation? The research addressing this issue is relatively scarce. Available results do however suggest that through experiencing the theory and practice of psychiatric/ mental health nursing, the attitudes of undergraduate nursing students are likely to become more positive. An Australian study demonstrated a small but significant increase in positive attitudes towards psychiatric nursing as the result of education (Proctor & Hafner 1991; Hafner & Proctor 1993). Results obtained by McLoughlin and Chalmers (1991) were similar. It is important to note however that this study was conducted with post-basic psychiatric nursing students. In view of the fact that these students have chosen to undertake a course in psychiatric nursing it is likely that their attitudes towards the mentally ill are more positive than those of undergraduate nursing students. Collister (1983) found that although theoretical and clinical experience with psychiatric nursing led to a more favourable attitude toward the mentally ill, four months after this experience the attitudinal changes had reversed almost completely.
In the final phase of their longitudinal study, conducted immediately prior to the completion of the course, Stevens and Dulhunty (1994) found the popularity of psychiatric/mental health nursing had increased marginally to become the seventh and eighth most popular choice. Of the one hundred and fifty six students involved in the study in this final stage, only eight had chosen psychiatric or community mental health nursing as their most preferred career option. Of the eight, four had identified their interest in the area of psychiatric/mental health nursing from the commencement of the study and had maintained their interest throughout the course. Although it might be argued that a 100% increase in the popularity of psychiatric nursing had been attained through the years of undergraduate nursing education, the eight students represent only 5% of the total students participating in this study. That such a small number of students look upon a career in psychiatric/mental health nursing in a positive light is disturbing for the future of this specialist area of nursing practice and must cast serious doubts on the degree to which comprehensive nursing education is preparing graduates for beginning practice in all health care settings.
BACKGROUND TO THE CURRENT RESEARCH.
The purpose of this study is to ascertain the popularity of psychiatric/mental health nursing in relation to other areas of nursing specialty in Victoria. The study, based upon that conducted by Stevens and Dulhunty (1992;1994) is longitudinal. The attitudes of students towards psychiatric/mental health nursing will be measured, initially at the commencement, and later, immediately prior to the completion of the undergraduate nursing program.
The primary purpose of this study is two-fold. Firstly to ascertain the extent to which the results obtained by Stevens and Dulhunty (1992;1994) are representative of the Victorian situation; and secondly, to ascertain the influence of education upon the career preferences of undergraduate nursing students. Emphasis will be placed upon differences in attitudinal changes towards psychiatric nursing observed between institutions. The identification of universities where positive shifts are found to occur (if at all) will enable investigation of the techniques, practices or other factors which might be responsible for improving the desirability of psychiatric nursing as a viable future career option. This will potentially provide the opportunity for the development of best practice models. Further research and the publication of results will enable successful strategies to be shared amongst the profession, with the ultimate being the building of a more positive profile for psychiatric nursing.
Permission was sought from all of the Victorian Universities conducting undergraduate nursing courses to administer the questionnaire at their institution. Favourable responses were received from eleven of the fourteen campuses. Although not all campuses participated in this research, a wide diversity of geographic locations was able to be included. The questionnaire was administered at Universities located in Central, Western, North Eastern, Eastern and Outer Eastern Melbourne, plus campuses from rural and regional Victoria. It is anticipated that such a geographic spread facilitates the degree to which these responses are representative of undergraduate student nurses throughout Victoria. A total of 793 students completed the questionnaire. This number represents approximately 48% of first year undergraduate nursing students in Victoria.
The questionnaire used in this research was a modified version of the tool developed by Stevens and Dulhunty (1992). The questionnaire was designed to be self-administered and able to be completed in a short period of time (approximately 10 - 15 minutes). Information about the career preferences of nursing students was sought through a combination of closed and open-ended questions. Students were asked to rank nine areas of nursing practice in order from their most preferred (ranked no. 1) to least preferred option (ranked no. 9). In the open ended questions students were asked to give reasons for choosing their most preferred and least preferred options and for their ranking of psychiatric nursing (if it were other than their first or last preference). The students were asked to include their mother's maiden name and their date of birth to enable changes in the career options of individual students to be monitored over the three years of the course. Students were informed that participation in this study was voluntary and they were free to withdraw from the study at any stage.
The questionnaire was administered to first year students within the first three to four weeks of Semester 1. This time frame was chosen for two reasons. Firstly, to minimise the impact of the nursing course itself on the attitudes of students towards their future career choices; and secondly, as attendance at lectures and tutorials tends to be higher in the early stages of the semester, access to a larger number of students was more likely. The questionnaire was administered during class time to facilitate a high return rate.
The data was analysed using SPSS for Windows. Information was obtained regarding the relative popularity of all nine options. The open-ended questions were coded. The influence of other factors such as age and prior nursing experience was also analysed. The relative popularity of each career choice was measured by the mean, median and mode. The mean was calculated from the frequencies of each ranking 1 - 9. The higher the mean therefore the less popular the particular career choice.
Analysis of the results clearly indicates that psychiatric nursing does not present itself as a popular career choice for undergraduate nursing students at the commencement of their course. These results are indicated in Table 1.
The unpopularity of psychiatric nursing as a career choice for undergraduate nursing students is clearly demonstrated in table 1. Only 24% of students have ranked psychiatric nursing within their first five choices. For 55% of students psychiatric nursing is either the least or second least popular career choice.
In order to establish the popularity of psychiatric nursing relative to other career choices the mean, median and mode for each career option were calculated and are represented in Table 2.
These results demonstrate a tendency for undergraduate nursing students to favour those areas of nursing practice associated with children and babies and the highly technical areas of nursing practice such as intensive/critical care and operating theatre nursing. At this stage of their nursing course students are significantly less interested in other areas of practice, most notably community health, psychiatric nursing and working with the elderly. Further analysis revealed no statistically significant relationship between the variables of age, sex, and prior nursing experience and institution of study, upon the career preferences of students. These findings support the available literature, which suggests that undergraduate nursing students favour the highly technical areas of nursing practice at the expense of areas such as psychiatric nursing and care of the elderly.
A total of 28 students ranked psychiatric nursing as their most preferred career option. Their open-ended responses were analysed to ascertain the attraction held by this area of practice. A total of 47 responses were elicited (more than one responses was possible). An interest in psychology and/or the care of the mentally ill was the most common response, accounting for 47%. This area was perceived as rewarding and challenging for 19% of students. Twenty-six percent of students consider they have the necessary characteristics and motivations to be suited to a career in this area. Personal or family involvement with mental illness or positive feedback regarding this area was an influencing factor in 8% of responses.
The open-ended responses of the 298 students who ranked psychiatric nursing as their last preference were similarly analysed in order to ascertain why this area of nursing practice is so unpopular. It is clear from these results that undergraduate students tend to enter their nursing course with a preconceived notion or a significant lack of knowledge of psychiatric nursing. Fear of the clientele with whom they would be working accounted for 11% of the responses. Twenty eight percent of students did not consider they would be able to cope working in this area. These students described the working environment as depressing, sad or stressful. For 27% of the students, psychiatric nursing was considered to be boring, uninteresting or unrewarding. Nineteen percent of students did not consider themselves to have the knowledge, experience or personal attributes to perform the role adequately. The influence of negative feedback from family or friends or their own prior unfavourable experiences with the mentally ill accounted for 7% of responses. Eight percent indicated that they were more interested in working in other areas of nursing specialty.
Students who ranked psychiatric nursing neither as their first nor last preference, were asked to explain their ranking of this career choice. A total of 347 students responded to this question (n=20 did not respond), providing 593 answers (responses could be coded into more than one category). Overall the views of students were divided into 3 main divisions, positive views of psychiatric nursing, negative views of psychiatric nursing, and responses which could not clearly be identified as either positive or negative.
Of the 593 responses, 19% demonstrated a positive opinion of psychiatric nursing. This area of practice was commonly described as interesting, with many students indicating a specific interest in the study of psychology and the human mind (accounting for 89% of the favourable responses). Seven percent of the favourable responses referred to positive experiences with the mentally ill in either personal or work-related situations, or feedback from friends and family which depicted the profession favourably. A further 4% of students described themselves as possessing the personal characteristics necessary to be successful in psychiatric nursing.
Eighteen percent of students indicated their preference for other areas of practice over psychiatric nursing. Approximately 15% of these students suggested the possibility of employment in psychiatric nursing at some future stage of their careers, but they felt a need to work in other areas of practice before doing so.
The remaining 64% of responses indicated a negative view of psychiatric nursing. The most common explanation reflected the students' image of the working environment (accounting for 38% of the negative responses). The working environment was frequently described as stressful, depressing, boring, and providing limited experience. There was a strong perception of futility because the clientele do not recover. Fear of the mentally was frequently provided as the reason for not regarding psychiatric nursing favourably. Thirty three percent of students expressed fear of their physical or psychological safety if they were to work with the mentally ill. Thirteen percent of responses acknowledged their limited understanding of psychiatric nursing. Negative feedback or experiences of the mentally ill were described by 10% of students. The feedback originated from a number of sources including friends, family and the media. Finally, 5% of the students did not believe themselves to possess the personal characteristics required for employment in this area.
The results of this study support the findings of Stevens and Dulhunty (1992) that the majority of undergraduate nursing students does not enter their nursing program with a favourable attitude towards psychiatric nursing as a future career option. That this situation has serious implications for the future workforce requirements of psychiatric nursing is obvious. More than that, these results demand immediate acknowledgment that while such attitudes continue to exist, comprehensive education has failed in its mission to prepare graduates for practice at a beginning level in all health care settings.
The final stage of Stevens and Dulhunty's research (1994) suggests any increase in the popularity of psychiatric nursing is likely to be only minor, and unlikely to have any substantial impact on workforce demands. It may be argued that this situation has its own solutions. Even if negative attitudes towards psychiatric nursing are not altered during the undergraduate program, not all graduates will be able to secure employment in their area of choice. Workforce dynamics will dictate that some graduates will be forced to seek employment in the area of psychiatric nursing. Not all solutions however, are satisfactory. The issue at hand requires more than developing strategies to fill job vacancies. Nurses who work in an area purely because it is a job are hardly likely to provide the skills, motivation and interest required in order that a high standard of nursing care is delivered.
The supporters of comprehensive education may argue that the role of undergraduate nursing education is purely to equip students with the skills required for practice in a variety of specialties. The degree to which students indicate their interest or otherwise in specific areas such as psychiatric nursing is a matter of individual preference and therefore hardly the responsibility of course design. Anecdotal evidence would suggest there to be significant support for such a view. The author however, strongly disagrees. The transfer of nursing education from hospital-based Schools of Nursing into the tertiary sector, was in part the result of acknowledgment that nursing education should encompass more than simply the acquisition of skills (Duffy, et al 1989; D'Cruz & Bottorff 1986; Millen 1989). In order to be truly educative, nursing programs must be broad based, and they must challenge the attitudes of students, particularly where certain areas of nursing practice are viewed as inherently more desirable than others.
The degree to which these results are indicative of a cause for concern is difficult to ascertain at this stage of the study. The impact of undergraduate nursing education will need to be determined before such conclusions can be drawn. Nevertheless, the fact that students enter nursing courses with such preconceived notions of the relative desirability of certain areas of practice and the undesirability of others must be noted. It is only through awareness of this situation that curricula can be altered in terms of both its structure and its implementation to address this situation.
The results of this study confirm the findings of similar research within Australia and overseas. It is evident that undergraduate nursing students do not hold a favourable image towards psychiatric nursing as a potential area for future employment. As the state of Victoria has recently abolished specialist undergraduate nursing courses it is envisaged that similar problems will be encountered to those described in the literature. The philosophy, which underpins comprehensive nursing education, must be revisited. Nursing academics must become aware of the attitudes towards their future careers that accompany students into their nursing programs. The challenge concerns how nursing education can be used to alter the image of nursing held by undergraduate students. This is not to suggest that all students would or should choose to become psychiatric nurses, but merely that negative attitudes are able to be set aside in order that realistic and informed choices can be made concerning career options for the future.
List of References.
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