PsychiatricMental Health Nursing Education in Vict

Brenda Happell

The introduction of undergraduate comprehensive nursing education in Victoria,Australia,during the1990s has resulted in significant changes in undergraduate preparation for psychiatric/mental health nursing.

Comprehensive programs became charged with the responsibility of preparing graduates to provide care for people experiencing a mental illness across a broad range of health-care settings,as well as providing

a pathway for graduates with an interest in specialist practice in this

field.The aim of this article is to clearly articulate the issues assoc-iated with psychiatric/mental health nursing education at the under-graduate level,including prevalence of mental illness,the inadequacy of psychiatric/mental health nursing theory and practice at undergraduate level,the negative attitudes of students toward this field of practice,and the subsequent failure of nursing education and practice initiatives to provide a clear mechanism for specialization in this important area of nursing practice.Throughout the article,the distinction between general-ist and specialist preparation is argued and accompanied by a call for nursing education to recognize and address the issues associated with both domains.

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U NDERGRADUATE COMPREHENSIVE NURSING education was officially intro-duced into Victoria,Australia,after the proclama-tion of a new Nurses Act(Victorian Government, 1993).This new approach meant that there would no longer be a direct educational pathway for persons seeking qualifications to practice as psychiatric/mental health nurses.Comprehensive education was based on two main principles:first, that undergraduate education would prepare nurses for beginning level practice in multiple health-care settings,including mental health;second,that it would provide a pathway for nurses wishing to specialize in psychiatric/mental health nursing (Royal Australian Nursing Federation,the College of Nursing Australia,the National Florence Night-ingale Commission of Australia&the New South Wales College of Nursing,1976). Undergraduate nursing education was therefore charged with the responsibility of meeting two needs:to prepare graduates for generalist practice, including an adequate grounding in the skills and knowledge required when caring for people with mental health needs in any health-care setting and to provide a pathway for those graduates who choose to specialize in practice in the mental health field(Happell,2002).

The aim of this article is to demonstrate that comprehensive nursing education in Victoria,

From the Centre for Psychiatric Nursing Research

and Practice,School of Nursing,The University of

Melbourne,Carlton,Australia.

Address reprint requests to Brenda Happell,RN,RPN,

BA(Hons),Dip Ed,BEd,MEd,PhD,Associate Profes-

sor/Director,Centre for Psychiatric Nursing Research

and Practice,School of Nursing,The University of

Melbourne,Level1,723Swanston Street,Carlton

3010,Australia.

E-mail address:bhappell@unimelb.edu.au

B2006Elsevier Inc.All rights reserved.

0883-9417/1801-0005$30.00/0

doi:10.1016/j.apnu.2005.08.011

Archives of Psychiatric Nursing,Vol.20,No.2(April),2006:pp76–81 76Australia,has not met the needs of the psychiatric/ mental health nursing from either a generalist or specialist perspective.In terms of generalist edu-cation,the content of undergraduate courses does not reflect the prevalence of mental health prob-lems within the general health-care system.Fur-thermore,the educational and clinical pathways designed as a conduit for specialist practice in the field have been diluted to address the identified content deficiencies of undergraduate education. As a consequence,these initiatives have become de facto programs for beginning level practice in psychiatric/mental health nursing,denying the profession a clear educational pathway for special-ist preparation.

THE IMPACT OF MENTAL ILLNESS IN THE GENERAL HEALTH-CARE SYSTEM

Since the early1990s,national and state policy has focused increasing attention the prevalence and subsequent burden of mental illness within the Australian population.The findings of an Aus-tralia-wide,large-scale survey estimated that approximately18%of Australians had experi-enced a mental illness or disorder during the pre-vious12months(Andrews,Hall,Teesson,& Henderson,1999;Dear,Henderson,&Korten, 2002;Henderson,Andrews,&Hall,2000;Korten &Henderson,2000).It has been estimated that mental illness accounts for approximately13%of total disease burden(death and disability)and approximately30%of nonfatal disease burden. Within the general hospital population,it is estimated that the prevalence is even higher (Clarke,Minas,&Stuart,1991;Gelder,Gath, Mayou,&Cowen,1996;Mayou&Sharpe,1991). The reason for this primarily attributed to three main factors:First,mental illness and physical illness occur simultaneously either due to a common cause or by chance;second,mental illness may occur secondarily to a physical disorder;or third,the mental illness may be the cause of a physical illness(Mayou&Sharpe,1991). Despite the high prevalence of mental illness, nurses employed within the general health-care sector tend to consider themselves inadequately prepared for this aspect of their role(Gillette& Bucknell,1996).The available Australian literature suggests these nurses consider providing care for patients experiencing mental health problems to be difficult(Bailey,1998;Crowley,2000;Gillette&Bucknell,1996;Heslop,Elsom,&Parker,2000; Smart,Pollard,&Walpole,1999).Their attitudes toward these patients tend to be negative,reflecting popular stereotypes and a lack of knowledge about mental illness(Bailey,1998).

PSYCHIATRIC/MENTAL HEALTH NURSING

WITHIN UNDERGRADUATE CURRICULA Despite the rhetoric that comprehensive educa-tion would prepare graduates for beginning level practice in a broad range of settings(Royal Australian Nursing Federation,the College of Nursing Australia,the National Florence Night-ingale Commission of Australia&the New South Wales College of Nursing,1976),the majority of undergraduate nursing programs operating in Victoria did not revise their content following the introduction of the new Nurses Act(Happell, 1998).Indeed,this was consistent with the broader Australian literature that identified so-called com-prehensive nursing education as maintaining a primary focus on medical–surgical nursing (Clinton&Hazelton,2000;Farrell&Carr, 1996;Happell,1998;Stevens&Dulhunty,1997; Wynaden,Orb,McGowan,&Downie,2000). Increases of varying degrees,in the psychiatric/ mental health content,occurred during the fol-lowing7years.However,the widespread recog-nition that the problem had not been resolved,led to an extensive review of undergraduate curricula in Victoria(Nurses Board of Victoria[NBV], 2002).The review was overseen by a subcommit-tee of the board,comprising representation from key professional and industrial organizations and government departments.

The review highlighted the enormous variation in psychiatric/mental health nursing content between universities.The variation was between 3.6%and17.6%within the nine nursing pro-grams operating in Victoria(NBV,2002).The subcommittee made a number of recommenda-tions to the NBV,including a minimum core theoretical content of15%plus at least20days of clinical experience.These recommenda-tions were accepted and are currently in the process of implementation.

It is important to emphasize that the recommen-dations were based on the premise of generalist education.That is,they reflected the skills and knowledge required for graduate nurses to care effectively for people experiencing a mental illness

PSYCHIATRIC/MENTAL HEALTH NURSING EDUCATION IN VICTORIA,AUSTRALIA77in any health-care setting.They did not purport to address the problem of providing a specialist psychiatric/mental health nursing workforce.In recognition of the ongoing issue of specialization, the subcommittee recommended that the work of this group continue by undertaking a review of postgraduate programs specializing in psychiatric/ mental health nursing(NBV,2002).

PREPARATION FOR SPECIALIST PRACTICE Postgraduate Programs

The introduction of comprehensive undergradu-ate nursing education meant that specialization in psychiatric/mental health nursing would now occur exclusively at the postgraduate level(Happell, 1998).This model was based on the assumption that graduate nurses with an interest in this area of practice would undertake further studies to special-ize(Happell,1998).

The review undertaken on behalf of the NBV considered the existing content of postgraduate pro-grams was generalist rather than specialist in focus (NBV,2004).Although considerable variation in the depth and breadth of theoretical and clinical content was evident,it was believed that the courses had been structured to redress the deficiencies in content previously identified in the undergraduate program,meaning that by default postgraduate programs were preparing graduates for beginning level practice in psychiatric/mental health nursing, rather than the desired specialist preparation.

The consequences of this situation are far reaching and significant.The ongoing problems associated with recruiting newly graduated nurses to the psychiatric/mental health nursing field in Australia have been extensively documented (Auditor General Victoria,2002;Australian Insti-tute of Health and Welfare,1997,1998, 1999, 2001 , 2003a, 2003b ;Clinton & Haze l ton, 2000a, 2000b;Depa r tment of Heal t h and Aged Care,2000;Happell,1998;Stevens&Dulhunty, 1992,1997).This fundamental recruitment prob-lem is believed to reflect the negative attitudes undergraduate nursing students hold toward this area of practice(Davidson&Connery,2003; Emrich,Thompson,&Moore,2003;Happell, 2001;Stevens&Dulhunty,1997;Tsang,Tam, Chan,&Chang,2003)and the fact that students report feeling significantly less prepared for psychiatric/mental health practice than other prac-tice areas(Happell&Hayman-White,2004; Wynaden et al.,2000).

Specialist Psychiatric/Mental Health Graduate Nurse Programs

In2000,the Mental Health Branch of the Department of Human Services,Victoria,provided funding for the development of specialist graduate nurse programs(GNPs)to provide an avenue for new graduates to enter psychiatric/mental health nursing directly following graduation.GNPs have been identified as an important recruitment strat-egy,by providing graduates with an environment in which they can consolidate their existing skills and knowledge and commence the process of developing the competencies they require for future practice(Clare,White,Edwards,&van Loon,2002;Department of Human Services, 2003).GNPs has been identified as an important approach in supporting graduates through the anxieties often associated with their transition to professional practice(Clare et al.,2002). Although the difficulties associated with this transitional phase are considered characteristic of nursing graduates overall,it has been suggested that additional issues effect those graduates who choose to specialize in psychiatric/mental health nursing(McCabe,2000;Prebble&McDonald, 1997),largely reflecting their inadequate exposure to the theory and practice of this field during their undergraduate preparation as argued above(Aus-tralian Health Workforce Advisory Committee, 2003;Clinton&Hazelton,2000;Happell,2001; Stevens&Dulhunty,1997;Wynaden et al.,2000), which may effect the type of transition support they require.

An extensive evaluation of the newly imple-mented GNPs conducted in2003suggests that this initiative has proved a useful recruitment strat-egy,increasing the number of new graduates entering the psychiatric/mental health nursing field (Happell,Charleston,Ryan,&Hayman-White, 2004).However,the stakeholders interviewed as part of the evaluation specified that these programs to date were not providing the numbers of new entrants to the profession required to develop and maintain a high-quality nursing workforce.They also articulated their view that the skill and knowl-edge level of new graduates was highly variable;the majority of graduates had limited understanding

BRENDA HAPPELL

78regarding mental health issues,attributed to the inadequacy of mental health content.It was there-fore concluded that GNP theory content needed to be aimed at a fairly basic level,providing rather than consolidating skills and knowledge,and that new graduates required intensive support,particularly in the earlier stages of the programs.

DISCUSSION AND CONCLUSIONS

The fundamental argument of this article is that to date undergraduate comprehensive nursing programs in Victoria,Australia,have failed to meet either the generalist or specialist intentions of psychiatric/mental health nursing.Not only have existing courses not provided a clear pathway for specialization,they have not provided sufficient exposure to this field of nursing to enable graduate nurses to effectively address the mental health needs of the patients they care for in whatever practice setting they choose to work follow-ing graduation.

The issues associated with psychiatric/mental health within undergraduate comprehensive nursing education are significantly more complex than simply the proportion of the content devoted to the theory and practice of psychiatric/mental health nursing.Should this be the case,Victoria would only need to wait for the implementation of the recom-mendations of the NBV(2002)and consider the problem well on its way to being resolved.Indeed,it is hoped that these recommendations will go some way toward preparing nurses for generalist practice in psychiatric/mental health nursing across a broad range of health-care settings.

The problem of securing a specialist nursing workforce in this field is much greater than simply increasing the content to improve knowledge and skill.The fact that psychiatric/mental health nurs-ing is not viewed positively by nursing students (Davidson&Connery,2003;Emrich et al.,2003; Happell2001,Stevens&Dulhunty,1997;Tsang et al.,2003)must be acknowledged and addressed in order that more favorable attitudes can be affected,with a subsequent increase in the number of nursing graduates who consider a career in psychiatric/mental health nursing as desirable.

It is therefore imperative that the progress of the current comprehensive undergraduate programs be carefully monitored through their implementation of the NBV recommendations(2002),not only to determine their impacts on the outcomes for the undergraduate programs themselves,but to estab-lish the extent to which improvements to the undergraduate base,lead to the increase in gradu-ates choosing to specialize in psychiatric/mental health nursing.Given the arguments advanced throughout this article,it is entirely possible that on their own these recommendations will not be sufficient to achieve this aim.It is only through an increase in the desire to specialize in this field that GNP and postgraduate education can begin to realize their stated objectives in terms of pre-paring graduates for specialist,rather than gen-eralist,preparation.

In conclusion,nursing education in Victoria must recognize its responsibility for the preparation of graduates for both generalist and specialist psychiatric/mental health nursing practice.To do so,it must investigate possible strategies to attract more students into undergraduate courses with the intention to pursue a career in psychiatric/mental health nursing from the outset,must portray psychiatric/mental health nursing as a legitimate field of nursing,and provide the opportunity for students who display some interest with the opportunity to further develop their skills and knowledge in this area prior to graduation.

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