Vol.8, No.1 April 2002
Contents
Mental health Nursing:
The Need to Distinguish between Generic and Specialist Skills
Refereed Article
Author
Associate Professor Brenda Happell
RN., B.A. (Hons), Dip Ed., Ph.D.
Director
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
Email: b.happell@nursing.unimelb.edu.au
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Abstract
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.
Introduction
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 couldn’t 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: "couldn’t 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.
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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 1992, p.12).
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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 …" (p.140) 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).
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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 "couldn’t 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.
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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.
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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 health nursing.
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, 1996).
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.
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Conclusion
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 "couldn’t 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.
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List of references
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