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Vol.7, No.2 July 2001
Editorial | Contents

Are Australian nurses professionally prepared to meet the challenges of working with mentally ill clients?

Refereed Article

Authors

Angelica Orb, RN, PhD
Senior Lecturer
School of Nursing, Curtin University of Technology
GPO Box U 1987
Perth WA 6845
email: orba@nursing.curtin.edu.au

Diana Wynaden, RN, RMHN(HSc)
Lecturer
School of Nursing, Curtin University of Technology
GPO Box U 1987
Perth WA 6845
Clinical Nurse Consultant
Directorate of Mental Health Services
Fremantle Hospital and Health Services

Sunita McGowan, RN, MApp.Sc
Co-ordinator of Nursing Research and Evaluation
Fremantle Hospital and Health Services.

Key words: educational needs, perceived level of preparedness mentally ill clients; comprehensive nursing

Abstract

One hundred and forty seven registered general, mental health and comprehensive nurses were asked questions related to their level of preparedness to care for mentally ill clients. The results demonstrate that there are statistically significant differences in nurses' perceived confidence to work with the mentally ill based on nursing registration categories. Comprehensive and general nurses are less confident and perceive that they are less prepared to care for mentally ill clients, than mental health nurses. These findings are particularly important for nurse academics throughout Australia who are responsible for the educational preparation of comprehensive nurses.

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Introduction

During the 1990s comprehensive nursing education programs were introduced in Western Australia, replacing the existing general and mental health nursing registration programs. The Nurses Board of Western Australia's position paper on Comprehensive Nursing Education (1998), outlines that comprehensive nursing education prepares a nurse as a beginning practitioner in a variety of health care settings. Comprehensive nursing is supportive of the key philosophical processes underpinning mental health care: normalisation and deinstitutionalisation, processes that seek to treat, support and facilitate the ability of the consumer to remain in his/her community (National Mental Health Report, 1997). Educating nurses to work with consumers of mental health care involves not only the teaching of knowledge and skills but also addressing their attitudes towards this consumer group. The theoretical and clinical components of comprehensive nurse curricula facilitate the development of knowledge and skills that will enable the future graduates to care for the mentally ill. However, research on Australian undergraduate curricula suggests that many programs provide limited exposure to this practice area (Lam, McMaster & Troup, 1993; Wynaden & Popescu, 1999), and that mental health nursing is often perceived by students to be less important than other specialty areas of nursing (O'Brien,1994).

The preparation of nurses to care for the mentally ill is a major issue of concern for nurse academics and health authorities. Traditionally, nursing care of the mentally ill was provided in psychiatric hospitals. However, the integration of psychiatric services to the main stream forced psychiatric services to evolve in different ways. The mentally ill can be cared for in general hospitals, in out patient clinics, in day care facilities or at home. These changes have implications for the preparation of nurses when caring for the mentally ill. The purpose of this article is to present the results of a quantitative study that explored Western Australian nurses’ perceived level of preparedness to work with the mentally ill and to ascertain their educational needs for mental health care. Although registered nurses from all registration categories as well as enrolled nurses participated in this study, the focus of this article is on general, comprehensive and mental health nurses.

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Method

Sample: The samples consisted of 147 registered general, mental health and comprehensive nurses working in 43 health services throughout Western Australia. Of the 147 participants, 124 were female and 22 were male with one participant not indicating his or her gender. The subjects’ age ranged from 22 to 63 with a mean age of 39 years (SD= 10.70).

One hundred and nine nurses were either level one (registered nurses) or level two (clinical nurses). These levels indicate the administrative classification used for all nurses in Western Australia.

All nurses worked in the in-patient setting. Fifty five nurses worked in the medical or surgical area, while 32 worked in mental health or psychiatry. Seventy -one worked in rural or remote locations in Western Australia, with a further 75 working in the metropolitan area. One participant did not indicate his or her geographical location.

Data collection

Data collection involved the used of a questionnaire that was designed based on expert opinion and literature searches. It was piloted with a group of nurses who did not take part in the larger study to establish face validity of the tool. The questionnaire with an explanatory cover letter was mailed to 43 Western Australian health agencies that were willing to participate in the study.

The questionnaire gathered demographic information, and contained 14 items related to the nurses perceived level of preparedness to work with the mentally ill. Subjects were asked to use a seven point Likert scale, with 1 = 'strongly disagree' and 7 = 'strongly agree.' In addition, the questionnaire asked nurses to identify their top five educational needs in three areas: knowledge, skills and management of nursing care.

Participation in the study was voluntary. Participants were asked to sign a consent form and they were informed that completing the questionnaire would not affect their employment status. All responses to the questionnaire remained confidential. A code was used so subjects could not be identified from their responses.

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Data analysis

Data analysis was undertaken using the Statistical Package for Social Sciences (Version 9.0 for Windows). Descriptive statistics were used in data analysis. A Kruskal-Wallis test was performed on the 14 items pertaining to the nurses perceived level of preparedness to work with the mentally ill in order to determine if there was a significant difference between registration groups. A Mann-Whitney U test was then utilised to ascertain where these differences lay.

Results

Four hundred and seventy three questionnaires were distributed, of which 147 (60.9%) of the returned questionnaires were completed by registered general, comprehensive or mental health nurses. The results reported in this article are based on the 147 responses from general, comprehensive and mental health nurses.

A Kruskal-Wallis test was performed on the 14 statements related to nurses’ perceived level of confidence to work with mentally ill clients to ascertain if there were significant differences based on registration divisions (see Table 1). Eleven of the 14 statements demonstrated significant differences and therefore a Mann-Whitney U test was utilised on the eleven statements to determine between which groups the differences lay. As three groups were being compared, an adjustment was undertaking to overcome the problem of multiple comparisons. Using the Bonferroni adjustment the significant level for each Mann-Witney U test was set at 0.003 =0.017.

The majority of differences lay between mental health nurses with both comprehensive and general nurses, with mental health nurses having the highest perceived level of preparedness followed by comprehensive nurses and then general nurses. Two statements involved significant differences between all groups of nurses. Mental health nurses were more confident to care for a person with a mental illness than comprehensive nurses (Mann-Whitney U, Z= -5.014, p=.000) or general nurses (Mann-Whitney U, Z= -7.770, p=.000). Comprehensive nurses were however, significantly more confident to care for a mentally ill client than general nurses (Mann-Whitney U, Z= -2.598, p=.000). In response to the statement regarding nurses perceived level of knowledge and skills to care for a person who has a mental illness significant differences were noted between mental health nurses and both comprehensive nurses (Mann-Whitney U, Z= -5.376, p=.000) and general nurses (Mann-Whitney U, Z=-7.959, p=.000). A significant difference was also however, recorded between comprehensive nurses and general nurses (Mann-Whitney U, Z=-3.534, p=.000).

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Table 1: Results of the Kruskal-Wallis test for comparisons between general, comprehensive & Mental health nurses

Negatively worded statements E Significant ( p= <..05)

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Six statements reported significant differences between two groups of nurses: mental health and general and mental health and comprehensive nurses. Mental health nurses were less frightened to care for a mentally ill client than general nurses ((Mann-Whitney U, Z= -5.936, p=.000) or comprehensive nurses (Mann-Whitney U, Z= -4.521, p=.000). They perceived that they cared for a mentally ill person more often than comprehensive (Mann-Whitney U, Z= -3.614, p=.000) or general nurses (Mann-Whitney U, Z= -5.754, p=.000). Mental health nurses also perceived that they were more able to determine if a person was mentally ill or just acting out than comprehensive nurses (Mann-Whitney U, Z= -3.453, p=.001) or general nurses (Mann-Whitney U, Z= -4.737, p=.000). They felt less uncomfortable dealing with a person's emotional problems than comprehensive nurses (Mann-Whitney U, Z= -3.312, p=.001) or general nurses (Mann-Whitney U, Z= -4.074, p=.000). Mental health nurses also received more in-service education on mental health/illness issues than comprehensive nurses (Mann-Whitney U, Z= -3.359, p=.001) or general nurses (Mann-Whitney U, Z= -5.090, p=.000). When caring for a mentally ill client, comprehensive (Mann-Whitney U, Z= -4.133, p=.000) and general nurses (Mann-Whitney U, Z= -5.939, p=.000) were more likely to only care for the clients physical needs than mental health nurses.

Three statements recorded significant difference between mental health and general nurses. Mental health nurses indicated that the mentally ill clients they cared for were less likely to become aggressive than general nurses (Mann-Whitney U, Z= -3.183, p=.001). They also perceived that they worked with mentally ill clients more often than general nurses (Mann-Whitney U, Z= -3.331, p=.001). Mental health nurses also perceived that they had more support to effectively care for a mentally ill client than general nurses (Mann-Whitney U, Z= -3.874, p=.000).

Participants also were asked to indicate their top five educational needs in three areas: knowledge, skills and management of nursing care of the mentally ill. In the knowledge area, alcohol and drugs was a key issue with all three groups identifying alcohol and drugs as a top educational priority. In the skills area mental status assessments, stress management and aggression were key areas for comprehensive and general nurses while mental health nurses highlighted child and adolescent issues, working with families and child and cognitive behavioural therapy as key areas. Management areas were also similar for general and comprehensive nurses with managing aggression, suicidal and difficult clients identified as educational needs of both groups. Mental health nurses identified educational needs in the area of managing clients who have been physical/sexual abused, managing socially disruptive clients and alcohol and drug problems as key areas (see Table 2 for more details).

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Table 2: Summary of findings of educational needs survey

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Discussion

This study makes a substantial contribution to the existing body of knowledge regarding the perceived level of preparedness of general, comprehensive and mental health nurses to work with the mentally ill. Significant differences according to registration categories were recorded on. Whilst all the differences existed between mental health nurses and general nurses, eight of the 11 items also demonstrated significant differences between mental health and comprehensive nurses. These results suggest that the difference in the perceived level of confidence to work with the mentally ill between mental health and comprehensive nurses is almost as large as the differences between mental health and general nurses.

These findings have several implications for consumers of mental health care. The comprehensive nurse is expected to provide the ongoing staffing needs to care for the mentally ill person. In the future large numbers of comprehensive nurses will be required to provide expert mental health care. Although statistically significant differences were recorded between all groups, comprehensive nurses perceived themselves as having less ability, knowledge, and skills and were more frightened to work with the mentally ill, than mental health nurses.

Australian nurse academics need to evaluate continually the preparedness of students to work as a first level practitioner in the mental health setting. Wynaden and Popescu (1999) note that students perceive that undergraduate programs prepare them as a first level practitioner to work in general area but not to work in mental health care settings. They also indicate that this may be a factor in the lack of attraction to and retention of comprehensive nurses in the mental health setting. Findings that are also supported by Happell and Rushworth (1999) and by Stevens and Dulhunty (1997). However, the profile of the health consumer as well as the practice domain is changing. Nurses need to understand and deliver care in a variety of health care settings. Kock (1999) claims that the need to provide mental health and palliative care are seen as major challenges to the education of nurses.

The majority of nurses in this study identified similar educational needs in the mental health area. Alcohol and drugs issues, anger and aggression management appear to be a priority. Followed by psychopharmacology, and counselling skills to intervene with clients particularly in crisis. Managing suicidal, psychotic, and difficult patients also were identified across registration categories. One possible explanation for this finding is that nurses are experiencing new challenges in their daily practice. The need for further education on mental health issues relevant to clinical practice is essential. Nurses cannot longer maintain the standard of care when there are gaps in their preparedness to care for the mentally ill.

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Stress management was identified as one of the top five educational needs in the skill area for general and comprehensive nurses. It would appear from this finding that for many nurses, nursing is perceived as a stressful profession. Davies (1995) concurs, claiming that putting emotions on hold leads to burnout, physical illness and even resignation from a job. Nurses need to be aware of the impact of stress in their clinical practice role and on their personal lives. Further investigation is warranted to identify factors that increase stress for nurses, and in particular why mental health nurses were the only group in this study that did not identify stress management as an area of educational need. The findings indicated that mental health care issues are present in all health care environments and that the perceived level of confidence, skill and knowledge to work with these consumers on a regular basis may account for some of the stress experienced by general and comprehensive nurses.

It is worth noting that the key educational needs of mental health nurses were alcohol and drugs issues and working with consumers who have a dual diagnosis or a personality disorder. However, family care, child and adolescent, family and transcultural issues have a high priority. Moreover, physical sexual abuse issues, and training in cognitive behavioural therapy, were highly rated by this group of nurses. Mental health nurses also expressed the need for further education on areas such as legal and ethical issues, as well as psychopharmacology. The need for support in the changing focus of nursing to the community, was also identified. One possible explanation for this finding is that the fabric of society is changing and that these changes are manifested in the health needs of the consumer. Education programs addressing these issues may have positive outcomes on customers’ mental health needs.

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Conclusion

This study demonstrates that nurses in all health care settings have regular contact with mental health consumers. To facilitate better outcomes for this consumer group, educational programs that provide nurses with advanced knowledge and skills are required. The educational preparation of nurses to work with mentally ill consumers must be seen as a high priority area. This is particularly true of undergraduate nursing curricula that currently do not appear to prepare a nurse who has the confidence, knowledge or skills to work as a beginning practitioner in the mental health setting.

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. Health services offering graduate nurse programs need to enhance the development of beginning practitioners to work with the mentally ill.

Administrators of health services also need to be made aware that for a nurse to work effectively with the mentally ill, time and the use of skills that have more covert outcome measures are required. If nurses in the workforce are already requiring education to help them manage stress, it is highly unlikely that unless the importance of nurses to health care outcomes is recognised, little will change in the level of care for mental health consumers. Increasingly, the roles of nursing appear to be negated by the Australian health care system and unless this group of health professionals is supported, rather than targeted in health cost rationalisation, the quality of health care in Australia will continue to be of concern.Acknowledgment

The authors wish to acknowledge the Mental Health Division of the Health Department of Western Australia for funding this research.

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List of References

Davies, E. (1995). Emotions. In P. French (Ed). The nurses, self and society. An introduction to applied behavioral sciences for nurses and health care professionals. pp. 61-68.Hong Kong: Waverly Info-Med Ltd.

Koch, S. (1999). A better prepared nurse for the future. Nursing Review. July, p15.

Lam, A., McMaster, R., & Troup, C. (1993). A pilot study: nursing students’ attitudes, interest, and concerns in the mental health field. The Australian Journal of Mental Health Nursing, 2(6): 281-286.

Happell, B & Rushworth, L. (1999). Psychiatric nursing: Can education help it become more popular? The Australian Electronic Journal of Nursing Education, 5(1), no pagination.

Mental Health Branch. National Mental Health Report 1996: Fourth Annual Report, Changesin Australia's Mental Health Services under the National Mental Health Strategy 1995-6. (1997). Canberra, Australia: Commonwealth Department of Health & Family Services.

Nurses Board of Western Australia. Position Paper: Comprehensive Nursing Education. (1998). Perth: Nurses Board of Western Australia Publication.

O’Brien, A. (1994). A review of the problems and prospects in mental health nursing education - A qualitative review. Australian & New Zealand Journal of Mental Health Nursing, 3(3):95 106.

Stevens, J.A & Dulhunty, G.M. (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), no pagination.

Wynaden, D. & Popescu, A. (1999). Graduate nurse study. Perth: Health Department of Western Australia Publication.

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Last modified on: Monday, 23-Jul-2007 10:56:02 EST