Mental health Nursing:
The Need to Distinguish between Generic and Specialist Skills
Associate Professor Brenda Happell
RN., B.A. (Hons), Dip Ed., Ph.D.
Centre for Psychiatric Nursing Research and Practice
School of Postgraduate Nursing
University of Melbourne
Level 1, 723 Swanston Street
Carlton VIC 3010 Australia
Phone (03) 8344 0769 | Fax (03) 9347 4172
The mental health content of undergraduate comprehensive nursing curricula
has been extensively criticised in recent years. The current situation
is not considered adequate to prepare graduate nurses for beginning level
practice in this area. The failure to increase mental health content is
frequently attributed to the overcrowding of the current three year program,
and mental health nursing is generally viewed as yet another specialty
area vying for limited space. The aim of this paper is to present a different
perspective on this debate. While there is clearly a basis for arguing
for specialty status, mental health nursing contains many generic skills
and knowledge which are essential to registered nurses irrespective of
the practice settings they work in.
The call for undergraduate nursing education to increase in duration
from three to four years has been made frequently and extensively. Although
some universities have increased the length of the course through a reallocation
of funded places, nursing predominantly remains a three-year course. Effectively
this means there is insufficient time available to cover all areas considered
important in the preparation of the graduate nurse. When various groups
representing areas of specialist nursing practice complain that insufficient
exposure to their area is available in current undergraduate education
they are generally meet with the response that the curriculum is already
over-crowded. "We couldnt possibly fit another thing in"
becomes the catch cry to fend off the staunch and disgruntled supporters
of specific specialist areas.
Those who support an increase in mental health content tend to meet similar
responses. The available literature clearly demonstrates that the current
clinical and theoretical content devoted to mental health is minimal and
unsatisfactory (Clinton & Hazelton 2000; Farrell 1996; Happell 1998;
Lam, McMaster & Troup, 1993; Wynaden & Popescu, 1999). In spite
of the introduction of comprehensive education, intended to prepare nurses
for beginning practice in all areas of nursing including mental health,
there is some evidence to suggest that at least in one state of Australia,
the mental health content did not increase in most universities from that
which existed in the previous general nursing courses (Happell, 1998).
While many nurse academics may have listened sympathetically to the plight
of mental health nursing, the: "couldnt possibly fit another
thing in" argument continues to be mounted as the justification for
not increasing the content. Indeed the argument has been made in some
cases that mental health nursing is a specialty area of practice that
should be preserved for post-graduate study, leaving undergraduate programs
to concentrate on the preparation of the generalist nurse.
By fiercely defending the status of mental health nursing as a specialty
area, mental health nurses may have unknowingly contributed to their own
position of weakness in relation to undergraduate nursing education. The
aim of this paper is to argue that while mental health nursing is a clear
and defined area of nursing specialty this does not negate the need for
generalist skills in this area for all graduate nurses, irrespective of
the field in which they choose to practice in the future.
Defining Specialist Practice
Arriving at a consistent and widely accept definition of specialist nursing
practice has proved difficult to achieve (Price et al 1994, Russell 1997).
In response to these difficulties the International Council of Nurses
(ICN) offered the following definition:
The nurse specialist is a nurse prepared beyond the level of a nurse
generalist and authorised to practice as a specialist with advanced expertise
in a branch of the nursing field
Post-basic nursing education for
specialty practice is a formally recognized programme of study built upon
the general education for the nurse and providing the content and experience
to ensure competency in specialty practice (International Council of Nurses
Mental Health Nursing as Specialist
Articulating clearly what does and does not constitute a specialist area
of practice has proved a complex task (Whyte, 2000) and further exploration
of this issue is beyond the scope of this paper. From an educational perspective,
mental health nursing has traditionally been regarded as a specialty with
its own dedicated pre-registration education. Since the introduction of
comprehensive education the implementation of postgraduate mental health
nursing programs has been introduced throughout Australia as a replacement
for the previous specialist preparation within hospital-based programs
and, in Victoria through the tertiary system.
The claim to specialist status is further strengthened by the existence
of the professional body, the Australian and New Zealand College of Mental
Health Nurses (ANZCMHN). This organisation (originally the Australian
Congress of Mental Health Nurses) was established in 1974, and addresses
professional issues for mental health nurses through a number of approaches
(Martyr, 1999). An annual convention is held in a different state each
year (New Zealand is also included since it joined the College in 1993).
Through its association with Blackwell Science Asia, the ANZCMHN produces
a quarterly refereed journal, the Australian and New Zealand Journal of
Mental Health Nursing (to be renamed the International Journal of Mental
Health Nursing). The ANZCMHN has produced a set of professional standards
(ANZCMHN, 1995), which clearly defines the specialist focus of this area
of practice and provides the philosophical parameters within which this
practice should occur.
The specialist nature of mental health nursing practice was succinctly
described in a recently published article from New Zealand (Prebble, 2001).
While acknowledging "
the complex interrelationship of the
physical, psychological and emotional aspects of health
Prebble argues "
that the focus of each nursing discipline
remains fundamentally different (p.140). Mental health nursing draws primarily
on the knowledge of sociology, psychology and anthropology in developing
skills to deal with the behavioural and psychological factors affecting
the consumers of the care, and in the area of interpersonal relationships
that has proven central to mental health nursing practice. This she argues
is in contrast to the more biological and physical orientation of the
general nurse (Prebble, 2001).
Prebble (2001) advocates for the implementation of a specialist mental
health stream within comprehensive undergraduate courses. This is not
a return to direct entry preparation but rather the opportunity for those
students with an interest in pursuing a career in the mental health field
to specialise in this area of practice and to graduate from their educational
preparation with the skills and knowledge to practice in this area with
a beginning level of competence. A core component of mental health nurse
should be mandatory for all students for two primary reasons: "
to break down the ignorance and stigma about mental illness and exposing
nurses to the possibility of psychiatric-mental health nursing as a career
choice (p. 142).
One of the strongest arguments mounted in response to the "couldnt
possibly fit another thing in" argument, is based on the lack of
popularity of mental health nursing as a future career option as the subsequent
implications for sustaining an adequate nursing workforce in this field
(Happell 1998; Stevens & Dulhunty 1999; Clinton & Hazelton, 2000).
The strength of this argument is however severely weakened in light of
the current widespread nursing shortage in Australia that affects most
if not all branches of nursing. Although few nurse academics would argue
against the notion that mental health nursing is not popularly regarded
by nursing students, in view of the current nursing crisis it is considered
difficult to single mental health nursing as a case for special attention
within the undergraduate curriculum.
Mental Health Nursing as Generalist Practice
We return to the notion that the undergraduate curricula is designed
to educate nurses for beginning practice in a range of health care settings.
The three-year limitation has necessitated a restriction to predominantly
generic skills. It is on this basis I would argue that mental health nursing
needs to focus its argument for an increased slice of the curricula pie.
Although there is a danger in generalising, the available literature supports
the view that undergraduate nursing preparation remains predominantly
medical-surgical dominated (Clinton & Hazelton 2000; Farrell 1996;
Happell 1998; Lam, McMaster & Troup, 1993; Stevens & Dulhunty,
1999, Wynaden & Popescu, 1999). In view of the argument made for generic
skills, the current composition of undergraduate curricula might be assumed
to be based on the assumption that medical-surgical are indeed the primary
generic skills required to prepare the graduate nurse.
It is this assumption that needs to be strongly challenged. While there
is no intention to suggest that medical-surgical skills are not essential,
it is the relative privilege of these areas over others that must be contested.
In order to do so it is necessary to clearly articulate mental health
nursing as encompassing a broad range of generic skills and knowledge
which are essential for all graduate nurses irrespective of the area in
which they choose to practice in the future.
Following the publication of the National Mental Health Plan (1992) increased
attention has been focused on the incidence and subsequent burden of mental
illness within the Australian population. It has been estimated that 18%
of Australians experience a mental health problem at some stage in their
life. The available research suggests that this figure rises significantly
within the general hospital population. Within the general hospital population
it is estimated that the incidence is even higher (Clark 1996; Gelder
1996; Mayou & Sharpe, 1991). The reason for this primarily attributed
to three main factors. Firstly mental illness and physical illness occur
simultaneously either due to a common cause or by chance; secondly, mental
illness may occur secondarily to a physical disorder; or thirdly, the
mental illness may be the cause of a physical illness.
Over the last decade in Australia mental health services have increasingly
become integrated within the general health care system through a process
known as mainstreaming (Whiteford, 1998). As a result of these changes,
nurses employed within the health care sector are finding themselves in
increased contact with patients experiencing mental health problems (Sharrock
& Happell, 2000). It is not a matter of whether graduate nurses wish
to work with the patients experiencing mental health problems, but rather
a matter of where.
This high level of contact is in fact what distinguishes mental health
from many other nursing specialities. In most instances at least within
metropolitan settings nurses can avoid the need for the skills pertaining
to other nursing specialities. Although not absolute the practice of critical
care and perioperative nursing and midwifery for example, occur within
defined practice settings that graduate nurses are able to avoid if they
do not consider themselves to have the skills, knowledge, confidence or
indeed the interest to do so. Clearly this is not the case with mental
A significant body of literature suggests that non-specialist mental
health nurses find the care of patients experiencing mental health problems
to be difficult (Bailey, 1998; Crowley, 2000; Gillette & Bucknell,
1996; Heslop et al, 2000; Smart et al, 1999). Their attitudes towards
these patients tends to be negative, reflecting popular stereotypes and
a lack of knowledge about mental illness (Bailey, 1998). Consequently,
nurses within the general hospital setting tend to consider themselves
inadequately prepared for this aspect of their role (Gillette & Bucknell,
Mental health nursing skills must therefore been viewed as generic skills,
essential for all graduate nurses in order that they are prepared to and
confident in providing a high standard of care to all patients including
those experiencing mental health problems.
Mental health nursing is broadly considered to be a specialist area of
nursing practice. Factors such as postgraduate education and the existence
of a strong professional body support the right to such a claim. However,
the high incidence of mental health problems within the general hospital
population give rise to the need to view many aspects of mental health
nursing as generic skills which are crucial to all mental health nurses
irrespective of the areas in which they choose to practice in the future.
This presents an urgent need to review current undergraduate nursing curricula
with a view to increasing the mental health content to enable nurses to
meet the needs of patients experiencing mental health problems.
The argument that curricula are so full they "couldnt possibly
fit another thing in" must be abandoned immediately. While the constraints
of a three year curriculum continue to exist, a more systematic approach
to what is and what is not included needs to occur. Curriculum content
must reflect and be responsive to current health care needs, rather than
reflect the individual interests of the nursing academics who influence
the shape of nursing programs.
List of references
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