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Guest Editorial
Reflections on Mental Health Nursing Education
Dianne Wynaden
School of Nursing, Curtin University of Technology, Perth; Directorate of Mental Health, Fremantle Hospital and Health Service, WA
Article Text
For 33 years I have been involved in the profession of mental health nursing as a clinician, academic, nurse educator and researcher. When asked to write an editorial on mental health nursing education, I reflected on the issues that have influenced and impacted the profession's evolving practice. The reflection went back to the 1970s when I graduated as a mental health nurse and psychiatric patients were treated and largely confined within mental institutions. This confinement perpetuated the belief that they were dangerous, unpredictable and should be isolated from the general community (Kelly & Stephens, 1999). As the institution was my practice environment, my role and contribution as a nurse was also hidden.
In Australia, deinstitutionalisation, or the movement of psychiatric patients into the community, began in the 1960s; it resulted in the closure of most psychiatric institutions and the integration of mental health care into the general health care system by the 1990s (Savy, 2005). Deinstitutionalisation also changed the mental health nursing practice environment. As the number of inpatient psychiatric beds was dramatically reduced only acutely ill patients were admitted to inpatient care. This resulted in a significant increase in acuity levels in hospitals and a decrease in the number of nurses working in the inpatient mental health setting. Large numbers of mental health nurses now work in the community within the new care delivery framework (Zeeman et al 2002). Throughout Australia, State and Territory Mental Health Acts were revised to facilitate the delivery of care within the least restrictive environment. General hospitals, in particular emergency departments, became major gateways for mental health consumers, so the nursing practice environment was further extended. For example, in some States psychiatric liaison nurses, emergency department specialist mental health nurses, and general practitioner liaison nurse roles have been established. Having recently completed faculty practice with psychiatric liaison nurses at Fremantle Hospital, I can report how fulfilling it was to work with these professionals. They assess patients and provide guidance, mentorship, support and management strategies to other health professionals in the hospital. The nurses move freely between medical wards and intensive care units, confident in their practice domain and the knowledge and contribution that they make to patient care.
Since deinstitutionalisation began, nursing education programs have also changed. Hospital based programs ceased and in most States of Australia, nursing registration changed from 'general' and 'mental health' to a comprehensive graduate prepared at university level. Debate about the move to comprehensive nursing has continued for the last 20 years and has centred on the level of preparedness of these nurses to work with mental health consumers. As there are no national curricula content requirements in the area of mental health, each university prepares students differently. Several studies have reported the lack of mental health content in many university programs (Farrell & Carr, 1996; Happell, 1998; O'Brien, 1994, 1995; Wynaden et al 2000).
Although many changes have occurred since deinstitutionalisation began, the economic and social burden associated with mental illness remains high:
- One person in five will experience a major mental disorder (Australian Bureau of Statistics, 1997; SANE, 2004).
- Mental illness impacts on every aspect of family life (Wynaden, 2003).
- Mental and neurological conditions account for 30.8% of all years lived with disability (YLDs). Furthermore, depression accounts for almost 12% of all disability (World Health Organisation, 2001).
- People with a mental illness demonstrate the lowest percentage of recovery to full-time working and social capacity.
What of the future? A well-prepared registered nurse has the ability to reduce dramatically the level of burden on each encounter with a mental health consumer and their family. These encounters can occur in any health care setting. Therefore, more rigorous efforts are required at a national level by nurses, policy makers, governments and academics to ensure that nursing curricula have sufficient, similar and meaningful mental health nursing content. Increased collaboration is also needed between universities and clinical areas to ensure the sound preparation of the graduate. The number of academics with specialised mental health nursing qualifications also requires monitoring as the mental health nursing content is reduced from curricula when academic numbers decrease and mental health content becomes redefined or confused with psychosocial care. Postgraduate courses in the areas of mental health must be supported by governments to prepare specialist nurses who are able to further expand the practice role of the profession.
In the continuing debate, it is important that mental health nursing is not isolated from the general health care system where it has and will continue to make valuable contributions to patient care outcomes. Much has changed since mental health nursing stepped out of the practice environment of the mental institution. We need to reflect on that change in order to move forward. The community can now clearly articulate the contribution nurses make to the lives of mental health consumers (Wynaden et al 2003).
Legislature changes and the implementation of advanced practice roles, such as the Nurse Practitioner program continue to expand the practice environment. These advanced practice roles allow nurses to focus on many of the social and interpersonal issues that confront mental health consumers and their families and assist in decreasing the burden associated with mental illness.
Advanced practice roles also encompass active engagement in research to ensure best practice and produce evidence based outcomes. The four articles presented in this Mental Health Nursing Education section of this Contemporary Nurse special issue demonstrate that mental health nurses are well suited to new innovations in care delivery. The article by Hazelton, Rossiter and Milner describes how dialectical behaviour therapy can facilitate better treatment outcomes for consumers who have a borderline personality disorder. The article by Barkway explores how employees mental well being is important in the workplace environment. The article by O'Brien, Hughes and Kidd demonstrates how mental health nurses continue to expand and develop the nursing role within the primary health care sector in New Zealand. This article also highlights the similarities of issues that face mental health nurses in Australia and New Zealand. The concluding article by Cleary and Walter outlines several strategies to meet the on-going challenge of mental health nurse education.
References
Australian Bureau of Statistics (1997) Mental Health and Well-Being Profile of Adults, Canberra: Commonwealth Department of Health and Family Services.
Farrell G and Carr J (1996) Who cares for the mentally ill? Theory and practice hours with a 'mental illness' focus in nursing curricula in Australian universities. Australian and New Zealand Journal of Mental Health Nursing 5: 77-83.
Happell B (1998) The implications of legislative change on the future of psychiatric nursing in Victoria. Australian and New Zealand Journal of Psychiatry 32: 229-234.
O'Brien A (1994) A review of the problems and prospects in mental health nursing education: a qualitative review. Australian and New Zealand Journal of Mental Health Nursing 3: 95-106.
O'Brien A (1995) Measuring graduate attitudes to educational preparation in mental health nursing. Australian Journal of Mental Health Nursing 4: 132-142.
Kelly J and Stephens I (1999) Community case management for mental illness. Australian Nurses Journal 6(10): 24-26.
SANE Australia (2004) Dare to Care: SANE Mental Health Report. Retrieved 1 February 2006; http://www.sane.org/images/assets/Research_reports_and_images/MHR2004text.pdf
Savy P (ed) (2005) Closing Asylums for the mentally ill: Social consequences, Health Sociology Review (Special issue) 14(3): 205-214.
World Health Organisation (2001) World Health Report - Mental Health: New understanding, new hope. Retrieved 1 February 2006 http://www.who.int/whr/2001/chapter2/en/index3.html
Wynaden D, Chapman R, McGowan S, McDonough S, Finn M and Hood S (2003) Emergency department mental health triage consultancy service: A qualitative evaluation, Accident and Emergency Nursing 11: 158-165.
Wynaden D (2003) The primary carer's experience of caring for a person with a mental disorder: A grounded theory study, PhD thesis, Curtin University of Technology. Retrieved from the World Wide Web 29 January 2006; http://adt.curtin.edu.au/theses/available/adt-WCU20050620.155303/
Zeeman Z, Chapman R, Wynaden D, McGowan S, Lewis M and Austin J (2002) Community mental health nursing: Documenting the role of the nurse. Contemporary Nurse 12(2): 112-123.
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