Vol.7, No.2 July 2001
Editorial | Contents
Between The Lines – Maximising Nursing Students’ Exposures To Mental Health Concepts in a Comprehensive Curriculum
Refereed Article
Authors
Mr Greg Miller
Lecturer
Centre for Psychiatric Nursing Research and Practice (CPNRP)
School of Postgraduate Nursing, The University of Melbourne
Phone: (03) 8344 0783; Fax: (03): 9347 4172; Mob: 0411 704 993
Email: g.miller@nursing.unimelb.edu.au
Associate Professor Brenda Happell
Director, Centre for Psychiatric Nursing Research and Practice
Associate Head of School (Research)
School of Postgraduate Nursing, The University of Melbourne
Level 1, 723 Swanston Street
Carlton Victoria 3010
Email: b.happell@nursing.unimelb.edu.au
Abstract
The position of mental health nursing within undergraduate curricula has been and continues to be a much debated topic. Concern has been raised at a number of levels including the amount of mental health content within undergraduate curricula, the quality of teaching of mental health nursing and the popularity of mental health nursing amongst undergraduate students. It can be construed from these chronicles that the working life of the mental health nurse as academic is far from easy. This paper provides an account of the encumbrances experienced and strategies employed by mental health nurse academics in the quest to advocate for mental health nursing within the higher education sector. These strategies include ways to increase the profile of mental health nursing within a "comprehensive" curriculum when efforts to increase the legitimate hours of content allocated specifically to mental health have been unsuccessful. The maneuvering that is required to bring mental health nursing concepts into the school agenda borders on "curriculum delivery by stealth". This account of the experiences of teaching mental health nursing in academia aims to illustrate an important message about the shortcomings of contemporary undergraduate nursing education.
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Introduction
The mental health content of undergraduate nursing curricula has occupied the attention of mental health nurses for many years. This issue has been highly profiled at mental health nursing conferences over the last decade. Research projects have been undertaken at both state and national levels (Farrell 1996; Happell 1998) to develop an accurate understanding of the size of the mental health component within undergraduate programs. More recently the Scoping Study of the mental health nursing workforce highlighted the under-representation of mental health content in nursing curricula (Clinton and Hazelton 2000).
Few mental health nurses within academia, management or practice would be likely to argue that the current status of mental health nursing within undergraduate nursing curricula is adequate. Few students receive more than two weeks of clinical practicum (Farrell 1996), and the theoretical component rarely exceeds 30 hours.
The consequences of this situation have been examined through Australian research (Happell 1999b; Stevens and Dulhunty 1992; 1997). There is little doubt that the vast majority of students who commence a nursing course do not plan to pursue a career in the mental health field (Happell, 1999a; Stevens & Dulhunty, 1992). Moreover, there is considerable evidence to suggest that many students are deterred from considering this area of practice. Misconceptions they hold about the mentally ill as scary, threatening and intimidating, and of mental health nursing as a boring, unsatisfying area of practice which lacks the rewards of recovery and improvement presents an unattractive view of mental health nursing to students considering their future career aspirations.
There is justification in expecting that three years of university study will influence the attitudes of student nurses towards the mentally ill and mental health nursing. This view receives some support from the Australian research literature (Hafner & Proctor 1993; Bell, Horsfall & Goodin 1996; Proctor & Hafner 1991; Rushworth & Happell 1998) insofar as improved attitudes toward the mentally-ill and to mental health nursing were observed following the completion of theoretical and clinical education in mental health nursing.
Such improvement in attitudes is clearly desirable irrespective of the practice settings in which students choose to pursue their nursing career. However, the strength and quality of mental health services provided to the Australian public depend, in no small part, on the ability of the profession to attract and maintain a skilled and motivated workforce. While the percentage of students planning to seek employment in the mental health field increased by the end of the course, the numbers were not nearly sufficient to meet workforce demands (Stevens & Dulhunty, 1997).
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Mental health nursing academics, clinicians and managers alike are acutely aware of the recruitment difficulties faced at a local level. Academics continually see students who have the characteristics and attributes to become excellent mental health nurses, head off to a general (medical-surgical) nursing graduate year. These students, despite the potential they demonstrate do not believe they know enough about mental health to seriously consider this area. Alternatively they are advised or hold the belief that they must "consolidate" their skills before making further career decisions. Clinicians are constantly exposed to students in the field for clinical experience who may not automatically see the relevance of mental health nursing to a planned career in intensive care or midwifery. Lastly, managers’ time and time again muse at the poor response to their advertisements for clinicians and know that in many cases when they do recruit they are creating yet another vacancy in a neighboring service.
The Scoping Study of the mental health nursing workforce (Clinton & Hazelton, 2000) dispels any doubts we might have had that this is a local problem. The issues we face are now clearly national in scope. While such information may be reassuring to some degree it is also potentially overwhelming. The problem is huge and appears almost insurmountable. The temptation to give up and accept the inevitable is enormous.
A number of recommendations were made in the scoping study (Clinton & Hazelton, 2000). The extent to which these will be adopted and the degree to which they would be successful in overcoming current difficulties are not yet known. What has become clear is that action needs to be taken as a matter of urgency. The profession can no longer wait for the present difficulties to be addressed at a government, regulatory or university level.
Academics throughout Australia are well aware of the frustrations that accompany the attempts to increase the profile of mental health in undergraduate nursing curricula. Despite some individual gains, mental health nursing remains a small component of curricula across the board. The publication of research findings has seemingly done little to change the status quo, which clearly favours acute medical-surgical nursing. In this paper some strategies which may be used to influence the situation at a local level will be presented. This is not to suggest that any one strategy will solve the problem or even reduce it significantly. However, if any one, or combination, of these solutions produces one more motivated and committed mental health nurse in the future, a positive outcome would have been attained.
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Infiltration of mental health content into other units
Mental health nursing academics frequently find themselves teaching into other units in the undergraduate curriculum. This experience may be frustrating for many who have the passion for teaching mental health and recognise their limited opportunity to do so. Herein lies the challenge. There is no single area of nursing we can think of that does not by definition have a strong mental health nursing component. The teaching of basic nursing skills should rely heavily on communication skills and the assessment of the mental health needs of the client. This is not to suggest that psychosocial skills equate to mental health content, however increasing the focus on the interpersonal relationship will encourage students to think beyond the technical skills that have become so highly valued by nursing students. By influencing the mindset of students in this way, they may become more receptive to the ideals inherent in mental health nursing when they undertake this component of the curriculum.
The teaching of nursing research presents another excellent opportunity. As students are taught the process of identifying a research problem and developing a research proposal, mental health nursing examples can be presented. Mental health related articles could be used when teaching critical appraisal skills. Mental health nursing researchers and nurses undertaking higher degree studies can be brought in as guest speakers to present their findings or to discuss various approaches to the research process. Such a principle can apply just as easily to professional issues, medical-surgical nursing, aged care and community nursing subjects to name but a few.
Less subtle approaches can also be taken. Where subjects are taught using a problem-based learning (PBL) or case study approach the opportunity can be more easily taken. A case study of a man undergoing a hip replacement operation can be developed to include a diagnosis of schizophrenia or depression, which students are required to investigate and deal with as part of the total care of the client. The teaching of assessment skills in nursing subjects can include mental status assessment, including the assessment of risk factors such as suicidality.
When all else seems hopeless, the assessment of student work provides an excellent opportunity. Nothing peeks a students’ interest more than that which will be asked in the final exam or what is required for written assignments. Mental health issues can be included as part of assignments, presentations and examinations and will force students to focus on a specific area, where they might otherwise not have afforded it much consideration.
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The nursing conference
The tendency to move away from more didactic methods of teaching to incorporating more flexible and creative techniques provides an opportunity for further infiltration. The experience of one of the authors provides an excellent example of this. In the final semester of the undergraduate program the students were required to complete a professional issues in nursing unit entitled "Professional Practice and Processes". It was decided to conduct this unit as a conference. Students were required to work in small groups, to submit an abstract and ultimately to present a paper. In order to enhance the authenticity of the process and hopefully encourage students to recognise the academic and professional development benefit of conference presentation and attendance, a small number of keynote speakers were also included in the program.
Perhaps it was fortunate that one of the academic staff involved in the teaching of this subject was a mental health nurse. Nevertheless, the opportunity was clearly taken. Mental health nurses were included as keynote speakers and the benefits were many. Through the presentation itself, students were exposed to additional mental health nursing input. Furthermore, the mere fact that mental health nurses were paid the respect of being keynote speakers sent a valuable and valuing message to students. Mental health nursing was portrayed as important, that exponents of this area of practice are worthy speakers with useful, relevant information to impart to students about to embark upon their nursing career.
The input of the mental health academic also extended to the students themselves. Students were encouraged to submit papers addressing mental health nursing issues. Encouragement in this instance meant a great deal more than merely identifying mental health as a theme and suggesting to students that it would be a good idea. In particular, students who had addressed interesting and relevant issues in their mental health assignments were encouraged to develop their ideas for a presentation format and submit to the conference. This strategy proved successful, with a large number of mental health focused papers being presented at this conference, thereby further increasing the mental health nursing content to which all the students were exposed.
Of course such an option is not readily available to us all. Conferences take a lot of time and effort to organise and would require a great deal of support and enthusiasm at Faculty/School level. Nevertheless this is a strategy to be considered with perhaps some potential for being utilised on a smaller scale as formal assessment of mental health nursing units.
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Assessment of mental health nursing units
One unfortunate consequence of the under representation of mental health nursing in comprehensive curricula has lead to an overemphasis on the teaching of content. "There is so much to teach in so little time" can easily lead to cramming the curriculum with content. This is perfectly understandable -we are passionate about what we teach and feel strongly that students should know it all. This desire to "over teach" is often fueled by the complaints from the clinical field that nursing graduates are totally unprepared to work in mental health. Again the criticism is totally justified, but perhaps in the pressure to teach more we are failing to take sufficient advantage of the opportunities available to influence attitudes and encourage students to at least consider a career in mental health nursing.
This does not in any way diminish the importance of theoretical knowledge in mental health nursing, but questions the extent to which this is considered relevant and is retained by nursing students. If students have little respect for the legitimacy of mental health nursing knowledge, and do not believe it will assist them in any way in their future nursing career, no amount of theoretical knowledge will make any significant impact on their learning. By adopting creative means of assessment, which focus less on a concern with content and more on approaches which profile mental health nursing, we may encourage a more positive image of this specialty.
Such approaches could include:
1. Setting an assessment task which requires students to present mental health material to students in early stages of the course, for example Third Year students presenting to First or Second Year students in a lecture or tutorial format. Presentations are often considered a valuable means to assess understanding. In this instance the added advantage would be the introduction of mental health content to students in the first and second years of their course. This is a particularly useful strategy when the mental health component is placed in the third of the program when students have often developed firm ideas of what nursing is and where they want to pursue their future careers. The types of materials they could present are diverse and could be readily adapted to a number of nursing subjects in which newer students are enrolled.
2. Students could be encouraged to submit an abstract and a write a paper to present at a conference in lieu of a written assignment. Many conferences now encourage student presentations. Such a strategy would encourage students to view mental health knowledge within its wider context. It means more than what they have to do to pass the subject but can make a significant contribution to the wider profession of psychiatric nursing. The benefits do not end there, in attending the conference they then become exposed to large numbers of mental health nurses. They come in contact with role models, clinicians, managers and academics who feel passionate about their profession. Perhaps mental health nursing may appear as a realistic choice after all. The messages they constantly receive from the university environment that they should consolidate their skills before considering a career in mental health may become that bit less powerful and persuasive.
3. Assignments can be tailored to encourage students to further explore the real world of mental health nursing. Conducting interviews with mental health nurses from different practice settings and specialties such as the community, forensic, child and adolescent, aged care and independent practice may broaden the perspectives that tend to be limited by short clinical placements usually undertaken in one specific area. Exploring the role of non-Government organisations, self help groups and consumer groups will all give students additional valuable exposure to the field.
Such approaches may not produce graduates with any more knowledge and skills specifically related to mental health nursing, but it may get more graduates into the field. Exploring strategies to equip comprehensive graduates for practice in mental health nursing becomes somewhat futile if we can’t even encourage them to realistically consider working in this field. The current situation is critical and we must do something urgently to turn the tide towards mental health. While we should never stop the fight for an increase of mental health content within undergraduate curricula, we should direct at least some of our energies and creativity towards what we as individuals or as members of a minority mental health nursing academic team can do to make some inroads.
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Conclusion
In concluding this paper it is important to reinforce that the aim was not to provide definitive solutions and teach the less knowledgeable how it can or should be done. The aim was present ideas based on the authors’ experiences as academics facing the constant battle to increase the profile of mental health nursing within undergraduate courses. Academics throughout Australia have grappled with similar issues and undoubtedly have developed creative and unique strategies of their own, some of which could readily be adopted by others. This wealth of information needs to be shared, through conference presentations, journal publications and other less formal means of communication. The aim of this paper was to stimulate and contribute to what we hope becomes a lively debate and discussion in the future.
Readers of this paper may be justifiably cynical about the effectiveness of such a strategy. How much impact can one mental health nursing member of an academic team have on their general nursing colleagues? Maybe none, but that does not prevent each of us as an individual from subtly influencing the attitudes of the students with whom you have the greatest contact. Will this be effective in producing more mental health nurses in the future? That would be the ultimate aim but any number of new recruits however small must be considered worthwhile. At the very least, enhanced exposure to mental health content and process will help undergraduate students to become ‘better’ nurses, with more sensitivity and awareness of mental health issues for when they inevitably come into contact with mentally clients in whatever area of practice they choose to enter. Over time our capacity to influence the thinking and attitudes of our non-mental health nursing colleagues will hopefully increase. Any signs of receptivity should be embraced through encouraging them to appreciate and learn more about mental health issues and how they impact across the full range of health care settings.
The relevance of this paper is not restricted to mental health. Academics and practitioners from other less popular specialty areas face these very same issues. No more so than aged care which faces the dilemma of increasing demand as a consequence of an aging population and a very poor image which has not benefited as the result of undergraduate nursing education (Happell, 1999b; Stevens & Crouch, 1995).
The reasons underlying the lack of popularity may differ but the lack of exposure to the area provided through the medical-surgical dominated program is likely to be similar. Strategies to increase exposure, portray a more positive image and encourage consideration as a viable career option are likely to have applicability across settings. By emphasising the common issues we face as nursing academics in promoting our particular specialty area in the plight of academics to profile their own specialty area, we can facilitate the exchange of ideas and strategies to help overcome the barriers in front of us.
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List of References
Bell A, Horsfall J & Goodin B 1997 A multi-centre comparative investigation of the impact of undergraduate mental health nursing curricula and clinical experience on attitudes, skills and clinical confidence. Report to the Department of Employment, Education, Training and Youth Affairs. Faculty of Nursing, University of Sydney.
Clinton M & Hazelton M 2000 Scoping mental health nursing education. The Australian and New Zealand Journal of Mental Health Nursing, 9, 1, 2-10.
Farrell G & Carr JM 1996 Who cares for the mentally ill? Theory and practice hours with a "mental illness" focus in nursing curricula in Australian universities, the Australian and New Zealand Journal of Mental Health Nursing, 5, 2, 77-83.
Hafner J & Proctor N 1993 Student nurse's specialty choices: The influence of personality and education, Contemporary Nurse, 2, 1, 38-43.
Happell B 1998 The implications of legislative change on the future of psychiatric nursing in Victoria, Australian and New Zealand Journal of Psychiatry, 32(2), 229-234.
Happell B 1999a Who wants to be a psychiatric nurse? Novice student nurses’ interest in psychiatric nursing, Journal of Psychiatric and Mental Health Nursing, 6,6, 479-484.
Happell B 1999b "When I grow up I want to be a ….?" Where undergraduate student nurses want to work after graduation, Journal of Advanced Nursing, 29,2, 499-505.
Proctor N & Hafner J 1991 Student nurses' attitudes to psychiatry: the influence of training and personality, Journal of Advanced Nursing, 16:854-849.
Rushworth L & Happell B 1998 Psychiatric nursing education: doing the impossible? Archives of Psychiatric Nursing, 12, 6, 319-325.
Stevens JA & Crouch M 1998 Frankenstein’s nurse! What are schools of nursing creating? Collegian: Journal of the Royal College of Nursing Australia, 5, 1, 10-15.
Stevens, JA & Dulhunty GM 1992 New South Wales Nursing Students' attitudes towards a career in mental health, Australian Journal of Mental Health Nursing. 2(2):59-64.
Stevens, JA & Dulhunty GM 1997 A career with mentally-ill people: An unlikely destination for graduates of pre-registration nursing programs. The Australian Electronic Journal of Nursing Education, 3,1, http://www.scu.edu.au/schools/nhcp/aejne.
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Last modified on: Monday, 23-Jul-2007 10:56:02 EST
