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The educational needs of nurses' in the area of mental health AEJNE Volume 6 - No.1 June, 2000. Dianne Wynaden, RN, RMHN, MSc
(HSc) Bev O'Connell, RN, PhD Sunita McGowan, RN, M App Sc. Auora Popescu, B.Sc (Psychology)
Abstract Nurses in all health care settings have frequent contact with mentally ill clients and their families. To support the national strategies for mental health care, educational programs that increase the knowledge and skills of nurses to care for this client group need to be implemented. To date, there is limited understanding of nurses' knowledge base in regard to caring for mentally ill clients, and hence, it is difficult to develop appropriate courses and educational materials. This paper, the first of three on the educational needs of nurses in the area of mental health, reports the findings of a survey of 241 nurses from 43 health services throughout Western Australia. The results revealed that nurses throughout Western Australia have regular contact with mentally ill clients and have similar educational needs in the area of mental health. Alcohol and drug issues, psychopharmacology, crisis counselling and managing aggressive and violent clients were identified by nurses in this study as the priority educational needs.
One in five Australians will at some stage in their life experience the burden of a major mental illness (National Mental Health Report 1996, 1997). The impact of the mental illness affects the individual, their family, friends, and the community at large. Caring for and supporting the mentally ill in the community is a major focus of the Australian mental health care policy (National Mental Health Policy, 1992). This policy aims to change not only the treatment of the mentally ill, but also community attitudes towards mental illness. Increasing the knowledge and skills of nurses in the area of mental health care is a significant step in the process of demystifying and normalising mental illness in our society. The National Mental Health Policy (1992) adopted by all Health Ministers outlined future directions of mental health reform in Australia over a six-year period to July, 1998. As a result, large mental institutions throughout Australia are in the process of downsizing, while at the same time community services are being developed or expanded in each health region (Kelly & Stephens, 1999). The National Mental Health Report (1997) indicated that when compared with the baseline year 1992-93, by 1995-96 spending on community care had grown by 55%. The number of beds in psychiatric hospitals have decreased by 31% and the proportion of the national mental health budget directed to these hospitals had fallen from 51% to 35%. This process, known as deinstitutionalisation, aims to maintain the consumer in the community by providing treatment, rehabilitation, and support services at a local level (Kelly & Stephens, 1999). The current directions in mental health care in Australia will ensure that all nurses will have regular contact with, and be responsible for, providing care and support to mentally ill clients and their families as the delivery of care occurs in more mainstream settings. While this is the case, what remains unclear is the nurses' perceptions of working with mentally ill clients, particularly in regards to their confidence, knowledge and skills. Brown and Lo (1998) in a pilot study of rural mental health/psychiatric nurses' educational needs towards the year 2005, confirmed the need for further educational preparation in the area of mental health following "generalist graduation" (Brown & Lo, 1998 p.13). This issue regarding the lack of education of nurses to deal with mental health problems in clients was of concern and instrumental to the development of this study. Study objectives The objectives of the current study were to: 1. Identify the educational needs of nurses in the area of mental health care and; 2. Assess nurses' perceptions of their knowledge, skills and confidence in caring for mentally ill clients. Method Sample and setting This survey was conducted in Western Australia. Four hundred and seventy three questionnaires were distributed to the forty-three health services that agreed to participate in the study. Two hundred and forty one registered nurses returned the questionnaires giving a response rate of 50.9%. One hundred and thirty two questionnaires were returned from rural and remote areas and 104 from the metropolitan area. Five questionnaires were returned where the respondents did not indicate their location. Questionnaire The questionnaire was developed based on expert opinion. It was piloted with a group of registered nurses that did not take part in the larger study. Feedback regarding the questionnaire from the group and an expert panel led to the refinement of the items in the questionnaire. The questionnaire was divided into three sections. Section one contained questions to ascertain nurses' perceptions of caring for mentally ill clients. Nurses were asked to indicate their response on a Likert scale with 1 = "strongly disagree" and 7 = "strongly agree". Section two contained questions related to the mental health educational needs of nurses, including their ability to define mental illness. The decision as to whether the respondent gave a comprehensive definition was determined at a workshop by a panel of three mental health nurse academics. The group used the definition outlined in the 1996 Western Australian Mental Health Act, as a reference point for their decision making process. Each response to the question was read, and following discussion, categorised into either a comprehensive or non-comprehensive definition. A comprehensive definition was viewed by all three nurse academics as one that covered the majority of points outlined in the 1996 Western Australian Mental Health Act. Section three of the questionnaire contained questions concerning demographic information. Procedure A letter was sent to the Directors of Nursing at health services throughout Western Australia, explaining the purpose of the study and inviting staff participation. Participation in the study was voluntary and each participant was informed that their decision to participate or not, would in no way not affect his or her employment status. All responses to the questionnaire remained confidential and a code was used so participants could not be identified from their responses. Data analysis Data analysis was undertaken using the Statistical Package for Social Sciences (SPSS) version 8.0 for Windows. Descriptive statistics were used to analyse the data. Results For the 226 (93.8%) nurses that gave their age, the mean age reported was 40 (SD = 10.34). The minimum age was 21 and the maximum age was 64. A majority of 207 (87.3%) of the nurses were female and 30 (12.7%) were male. A majority of 147(62.1%) nurses in this study were general, comprehensive or mental health nurses, with the remainder being midwives or enrolled nurses. One hundred and thirty two (55.7%) of the nurses were either level one or clinical nurses. Seventy-four (35.9%) nurses worked in the medical/surgical area and 44 (21.4%) worked in mental health/psychiatry. A majority of 175 (73.5%) nurses in this study worked in an in--patient hospital setting. Section one of the questionnaire contained items related to nurses' perceptions of their knowledge, skills and confidence in caring for mentally ill clients. The results indicated that, in regard to caring for a person who has a mental illness, approximately 42% of the nurses felt confident, whilst 58% did not; nearly 38% felt they had the knowledge and skills, whereas 62% did not; and approximately 15% felt uncomfortable dealing with a person's emotional problems, compared to the 85% of nurses that did not. Of note is that approximately 40% of the nurses felt professionals trained in mental health were available if needed, whereas 60% did not; and approximately 17% reported they received regular in-service/education, compared to 83% that did not. See table 1 for more details.
Table 1: Nurses perceived level of confidence to work with mentally ill clients Question Disagree 1, 2, 3 Neutral 4 Agree 5, 6, 7 Mean (SD) Mental health/illness issues are occurring more
frequently in the people I care for (n=241) 62 (25.7%) 33 (13.7%) 146 (60.6%) 4.66 (1.74) I feel confident to care for a person who has a
mental illness (n=240) 90 (37.5%) 50 (20.8%) 100 (41.8%) 4.16 (1.83) I have the knowledge and skills to care for a
person who has a mental illness (n=241) 175 (47.8%) 35 (14.5%) 91(37.8%) 3.84 (1.96) Professionals who are educated to work with a
person who is mentally ill are always available if
I need them (n=241) 122 (50.7%) 28 (11.6%) 91 (37.7%) 3.71 (2.03) I do not often care for a person who is mentally
ill (n=241) 119 (49.5%) 36 (14.9%) 86 (35.7%) 3.61 (2.00) There is little support where I work to help me
to care effectively for a person who is mentally
ill (n=238) 123 (51.7%) 37 (15.5%) 78 (32.8%) 3.59 (1.80) Many of the people I work with have a mental
illness (n=240) 136 (56.8) 43 (17.9%) 61(25.4%) 3.26 (1.96) The mentally ill people I care for are usually
aggressive (n=241) 156 (64.7%) 52 (21.6%) 33 (13.7%) 2.95 (1.49) I receive regular in-service/education on mental
health /illness issues (n=241) 182 (75.5%) 17 (7.1%) 42 (17.4%) 2.50 (1.84) A person who presents in a crisis state is
always mentally ill (n=240) 219 (91.2%) 9 (3.8%) 12 (5.1%) 1.71 (1.31) I find it hard to know if a person is
mentally ill or if she/he is just acting out
(n=239)*
124 (51.9%) 50 (20.9%) 65 (27.2%) 3.46 (1.68) I am frightened to care for a mentally ill
person (n=240) * 158 (66.1%) 41 (17.1%) 41 (17.1%) 2.75 (1.62) I feel uncomfortable dealing with a person's
emotional problems (n=241)* 174 (72.3%) 30(12.4%) 37 (15.4%) 2.72 (1.59) If I care for a person with a mental illness
I only provide for his/her physical needs (n=241)*
187 (77.5%) 25 (10.4%) 29 (12%) 2.37 (1.58) *Negatively worded questions Section two of the questionnaire required the nurse to define mental illness and to identify a number of mental health educational topics. The topics were divided into three areas: knowledge, skills, and management. Each nurse was required to select five items from each list that they would like to receive further education on (see tables 2. 3 & 4). Space was also provided on the questionnaire for the nurse to write additional areas not identified on the list. Two hundred and thirty nine respondents provided 1170 responses on topics they required additional knowledge on. Alcohol & drug issues and psychopharmacology were the most popular with 92 (7.9%) responses each (see table 2). Table 2. Multiple responses of nurses choosing knowledge area they would like to have further education on.
Two hundred and thirty eight respondents provided 1157 responses to topics on further skill development. Crisis counselling was the most popular with 88 (7.6%) responses (see table 3). Table 3. Multiple responses of nurses in skills area that they would like further education Skill area Frequency Percent 1. Crisis counselling 88 7.6 2. Assessing aggression 84 7.3 3. Risk assessment 83 7.2 4. Stress management 81 7.0 5. Mental status examination 80 6.9 6. counselling skills 72 6.2 7. Mental health triage 71 6.1 8. Behavioural therapies 63 5.4 9. Critical incident debriefing 60 5.2 10. Cultural awareness 44 3.8 11. Working with families 43 3.7 12. Assessing the elderly 42 3.6 13. Child and adolescent 40 3.5 14. Trans-cultural psychiatry 38 3.3 15. Cognitive behavioural therapy 37 3.2 16. Community mental health 32 2.8 17. Family assessment 29 2.5 18. Working with forensic clients 29 2.5 19. Rehabilitation principles 27 2.3 20. Family education 22 1.9 21. Rating scales 18 1.6 22. Discharge planning 14 1.2 23. Social skills training 13 1.1 24. Group work 13 1.1 25. Liaison skills 12 1.0 26. Working with couples 12 1.0 27. Research 10 0.9 Total responses 1157 11.0 In the management area, two hundred and thirty seven respondents provided 1147 responses. Managing aggressive /violent and suicidal clients both rated highly, accounting for 232 (20.2%) of the responses (see table 4).
Table 4. Multiple responses in management area nurses would like to receive further education on. Management area
Frequency Percent 1.
Aggressive/violent 117 10.2 2. Suicidal 115 10.0 3. A difficult
patient 87 7.6 4. Alcohol and drug
problem 79 6.9 5. Psychotic 75 6.5 6. Personality
disorder 65 5.7 7. Socially disruptive
behaviour 64 5.6 8. Self
harming 63 5.5 9. Confused/disorientated
61 5.3 10. History of
physical/sexual abuse 59 5.1 11. Managing critical
incidents 56 4.9 12. Self concept/esteem
issues 52 4.5 13. Acting out 49 4.3 14. Eating
disorders 48 4.2 15. Alcohol and drug
detoxification 41 3.6 16. History of mental
illness 30 2.6 17. Body image
problems 27 2.4 18. 1996 Mental Health
Act 24 2.1 19. Delirious 19 1.7 20.
Hyperactive 16 1.4 Total
Responses 1147 100.0
Respondents were then asked to define mental illness. Twenty nurses (8.3%) did not answer this question, 74 (30.7%) gave a comprehensive definition and 147 (61.0%) gave a definition of mental illness that did not include the major components required for a comprehensive definition. Several examples of definitions that fell into the non-comprehensive category are provided below: 1. When a person does not cope with the pressures of what is termed 'normal' 2. When a person has an imbalance and is unable to function in 'normal' society due to their psychological state 3. A state of unwellness of the mind The last section of the questionnaire asked respondents to select which health professionals were available on a daily, weekly, monthly, or other basis to provide support and assistance with clients. The mental health nurse was available on a daily basis more often than other professionals, followed by the occupational therapist, social worker, psychiatrist, and clinical psychologist.
Discussion This study adds significantly to the body of knowledge regarding Australian nurses' educational needs in the mental health area. The sample population is very representative of nurses in health care practice settings, with the majority of nurses in this study being level one or clinical nurses. The results indicate that the educational needs of nurses in the area of mental health are similar throughout Western Australia. Generally, nurses perceptions of being able to work with mentally ill clients were positive. Specifically while the survey illustrated that most nurses feel comfortable dealing with a person's emotional problems, the majority of nurses do not actually feel confident, or feel that they have the necessary knowledge and skills, to care for a person who has a mental illness. What is also worth noting is that approximately 76% of the nurses stated that they do not receive regular in service/education on mental health/illness issues. This lack of on-going education could be one explanation for nurses' perceived lack of confidence in dealing with this client group. Of the two hundred and forty one nurses that completed the questionnaire, only 74 (30.7%) were able to provide a comprehensive definition of mental illness. These results suggest that many nurses in Western Australia are unable to fully determine the scope and range of behaviours and cognitive processes associated with mental illness. It may therefore be assumed, that their ability to assess and intervene with this client group may in many instances be limited. Education in mental health/illness issues is therefore a priority for nurses working in all areas, in order to meet the objectives of current mental health care policies and directions. Nurses throughout Western Australia identified similar educational needs in the mental health area. The most common topics identified across all registration categories and geographical locations were, alcohol and drug issues, anger and aggression management, psychopharmacology, counselling skills to intervene with clients particularly in crisis, managing suicidal, psychotic, and difficult patients. A comparison of educational needs across all registration categories and geographical locations will be presented in another article. Universities and health services need to develop and support innovative approaches to education in the area of mental illness to facilitate increased knowledge and skill development in nurses.
Limitations of the study As there was no instrument found in the literature that addressed the study objectives, a suitable questionnaire was developed by an expert panel. This questionnaire was further pilot tested with a group of registered nurses. All issues identified during the pilot test were addressed prior to the questionnaire being administered. While a concerted effort was made to establish face validity, some limitations in relation to the instruments' reliability are acknowledged. Conclusion The care of mentally ill clients in Australia is viewed as one of the major challenges to the health care system and in particular, to nurses as the new millennium approaches. The changing focus of care from the hospital to the community highlights the need for health services and universities to be cognisant with the changing educational needs of nurses posed by the challenges of their new practice environment (Koch, 1999). This article, the first of three on the educational needs of nurses in the area of mental health, highlights significant issues and needs. This information will facilitate the development and implemention of educational programs based on nurses and industry needs. Acknowledgment The authors acknowledge the support of the Mental Health Division of the Health Department of Western Australia for funding this research.
References Brown R., & Lo, R. (1998). A pilot study of rural mental health/psychiatric nurses' educational needs towards the year 2005. The Australian Electronic Journal of Nursing Education.3(2):no pagination. Hegney, D. (1996). The status of rural nursing in Australia: a review. Australian Journal of Rural Health, 4(1):1-10. Human Rights and Equal Opportunity Commission. (1993). Human Rights and mental illness: Report of the national inquiry into the human rights of people with mental illness (Vol 1). Canberra, Australia: Australian Government Publishing Services. Kelly, J., & Stephens, I., (1999). Community case management for mental illness Australian Nurses Journal, 6 (10): 24-26. Koch, S. (1999). A better prepared nurse for the future. Nursing Review. July, p15. Mental Health Branch. National Mental Health Report 1996: Fourth Annual Report, Changes in Australia's Mental Health Services under the National Mental Health Strategy 1995-96. (1997). Canberra: Commonwealth Department of Health and Family Services. National Mental Health Policy: Australian Health Ministers (1992). Canberra: Australian Government Publishing Services. Report of the Ministerial Taskforce on Mental Health Vol I & II.(1996). Mental Health Taskforce, Perth: Government Printers.
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© 1997 Peter Cleasby | pcleasby@csu.edu.au | ISSN 1322-8676 |