Educating Mental Health Nurses in Clinical Settings: Tackling the challenge

Michelle Cleary
Faculty of Nursing and Midwifery, University of Sydney; Clinical Nurse Consultant, Research Unit, Sydney South West Area Mental Health Service (Eastern Zone), Rozelle NSW

Garry Walter
Chair of Child and Adolescent Psychiatry, University of Sydney; Area Clinical Director, Child & Adolescent Mental Health Services, Northern Sydney Central Coast Health, North Ryde NSW

PP: 153 - 157

Article Text

Education for mental health nurses, in particular undergraduate and postgraduate learning programs, is a hot topic. Whilst transition programs are generally believed to be helpful for attracting new graduate nurses to the specialty of mental health nursing, the reality is that many nurses already in clinical settings are grappling to meet the various demands encountered in the workplace. Their struggle is compounded by serious shortcomings in mental health service delivery, as highlighted in the Not for Service report compiled by The Mental Health Council of Australia (2005). Thus, education becomes crucial to enable staff to tailor and develop their professional practice to meet the current challenging circumstances. In this paper, we outline a few key pragmatic education issues for consideration and identify ways in which the profession may better address the education needs of clinicians.

The global nursing shortage is well recognised; it has implications beyond service delivery. The shortage demands that innovative approaches to education be sought to make the profession more attractive to those already working in mental health and to those keen to pursue further education (Cleary & Freeman, in press). However, facilitating nurse education is far from straightforward and numerous factors influence participation; for example, access, previous experiences, whether work environments are flexible and supportive, having opportunities to develop skills and expertise, and the presence or absence of career pathways and positive role models. Furthermore, the healthcare environment is complex and environments can change rapidly, creating new challenges. In particular, the downsizing and closure of psychiatric hospitals and the movement towards community-based care has resulted in numerous challenges within the mental health system (Callaly & Arya, 2005). In this new organisational structure, demand for inpatient beds has continued in tandem with increased patient acuity and shorter lengths of stay, testing traditional roles and responsibilities as nurses endeavour to work in rapidly shifting, increasingly complex and ambiguous environments (Anthony et al, 2005; Fourie et al, 2005). Resources are often inadequate and nurses thus face the further hurdle of attempting to provide the best care possible with dwindling physical means. Unsurprisingly, this has implications for workloads and staffing and areas such as nurse education and support become vulnerable, yet at once all the more important. Given the above context, and the need to align education and clinical practice initiatives, it is timely to reflect on a few key factors and potential support strategies.

Most clinicians will readily acknowledge the difficulty of finding adequate numbers of clinical placements for student nurses, compromising the capacity to provide quality placements to support student clinical learning (Cleary et al., in press: a). For those in rural and remote areas, the issue of access to clinical placements becomes even more difficult to organise! Poor clinical placements in which students are dissatisfied not only effects the quality of learning, but may also influence future recruitment and retention (and therefore, in turn, educational opportunities down the track) (Cleary & Happell, 2005a; Hutchings et al, 2005). To facilitate positive clinical placements, a greater availability and presence of university staff to support clinicians and students has been suggested as a possible way forward, in conjunction with designated ward-based education facilitators (Cleary et al, in press: a). The collection of timely and accurate data to determine a realistic student capacity for healthcare providers is also recommended (Hutchings et al, 2005). There is certainly opportunity to improve the quality of learning and improve communication and partnerships between education settings and healthcare providers.

In order to attract nurses to the speciality of mental health and reduce attrition rates, effective nursing education programs with the provision of adequate clinical supports are vital. For those nurses contemplating mental health nursing, supported transition programs are available and these have been found to be helpful for new graduates in the workplace (Cleary & Happell, 2005b; Fourie et al, 2005). The education needs of staff are, however, diverse and ongoing, and continuous learning in the workplace is necessary to ensure contemporary and quality service delivery. In the current climate, for example, education programmes that challenge established attitudes towards 'difficult' mental health consumers are recommended (Bee et al, 2005). It is therefore encouraging to witness the emergence of training programmes in evidence-based interventions, such as dialectical behaviour therapy for borderline personality disorder described in this issue's Mental Health Nursing Education section by Hazelton, Rossiter and Milner. Mental health priorities should be guided by evidence (eg, clinical interventions such as medication management, family work) and these interventions should be empirically supported, and the efficacy of education initiatives such as skills training evaluated (Gournay, 2001; Gray et al, 2004; Hoge et al, 2003; Lambert & Gournay, 1999).

Nursing education nowadays must make liberal reference to evidence-based practice (EBP). There is potential for greater involvement of clinicians in a range of EBP initiatives, such as the development and review of guidelines and treatment protocols. Whilst not a panacea, they can facilitate access to the best available evidence and can be adapted to local circumstances for quality improvement, structured practice improvement and continuous learning (Boyce et al, 2003; Lehman et al, 2003; Tobin et al, 2003). Although EBP has been introduced into nursing education and promoted widely in healthcare settings, the reality is that some staff lack the necessary skills and time to incorporate evidence (Cleary et al, 2005a). Increasingly, a number of helpful websites and education resources for evidence-based learning are becoming available to support education.

Inevitably, workplace learning will place pressures on managers; additional resources and the opportunity to leave and be relieved in the workplace are not always readily available. Managers are also hard pressed dealing with mandatory education requirements; eg, occupational health and safety, aggression management, first aid, child protection, suicide awareness and outcome measures. A change of culture is required, so that workplace learning and further education are [rightfully] regarded as core aspects of the role of all mental health professionals. There are also practical ways to facilitate workplace education initiatives, which are being considered by Health Services. Examples include, reward and recognition of staff who perform additional educational activities, flexible working hours to accommodate education commitments and the opportunity to take time in lieu, and financial support for conference attendance when presenting papers.

It follows that, although the mental health workforce includes a group of well-educated nurses with a repertoire of interventions at their disposal, organizational changes may be necessary to maximise opportunities for newly skilled nurses who are positive about their work (Bee et al, 2005). Education models that do not reflect the realities of the nursing role can be frustrating and may eventually lead to job dissatisfaction and high nursing turnover (Takase et al, 2005). Alternatively, those models that provide realistic expectations may enable the nurse to acknowledge and value their existing role (Fourie et al, 2005) and build upon it. The articles presented by O'Brien, Hughes and Kidd in this Education section show possibilities for the expansion and development of specialist mental health nursing roles within the primary health care sector to respond to mental health issues.

In order to successfully develop specialist roles and retain mental health nurses, education programs with a clinical leadership focus are pivotal. A range of programs to develop leaders and role models is necessary for maintaining positive work environments that are conducive to the provision of high quality care. Ensuring a stable nursing workforce is important as staff turnover is costly and may impact on the quality and continuity of care delivery (Anthony et al, 2005). Other important aspects include professional recognition, a clinical pathway for career development, appropriate remuneration, workplace incentives and succession planning to encourage nurses to pursue an array of education activities. The article by Barkway in this Education section highlights the importance of creating supportive environments for mental health promotion programs in the workplace.

In the majority of modern mental health settings, nurses are members of multidisciplinary (or 'interdisciplinary') teams (Grigg, 2001). The implications, and potential advantages, for nurse education are considerable. Such settings allow for the sharing of knowledge and experiences between professionals who come from a variety of backgrounds. Thus, nurses can contribute to the knowledge base and skills of psychiatrists, psychologists, social workers and occupational therapists, among others, and in turn can learn from these groups. As professional relationships develop further, opportunities will arise for collaborative projects with non-nursing colleagues (see for example: Cleary et al, 2005a; Cleary et al, 2005b; Cleary & Freeman, 2005; Cleary et al, in press: b). Increasingly, too, consumer and carer consultant roles are expanding to include input into health professional education programs and involvement as researchers. Again, the benefits for nurse education are significant (Cleary et al, in press: c; Cleary et al, in press: d).

It follows from the above discussion that there are several strategies to better meet the challenge of mental health nurse education:

• Continue to consult with stakeholders to ensure participation in education and support activities, to share information, experiences and opinions, to increase awareness of the complex educational issues challenging mental health nursing and provide a forum for the development of partnerships.
• Undertake a proactive approach to the establishment of learning and development environments in order to support the development of effective clinical leadership skills, succession planning opportunities and career development (Cleary & Freeman, in press).
• Ensure adequate support strategies are available to deal with the challenging nature of mental health care.
• Create opportunities for partnership between clinical and academic settings.
• Facilitate the collection of data regarding the capacity of health services to provide quality student placements.
• Participate in the full range of educational activities of multidisciplinary teams, learning from and contributing to the skills and experiences of other mental health professionals.

Changes in the organization and delivery of mental health services have impacted on the nursing role, creating special challenges in the area of education. This is a challenge that must be won. Increasingly, learning and development opportunities are becoming available in the workplace to ensure staff are appropriately supported. These programs need to not only examine the role of mental health in the context of contemporary health care trends, but also to be accessible, flexible, relevant and linked to succession planning and career development pathways. It is also important to draw upon key staff to facilitate organizational support and, if necessary, change so that the skills and knowledge that are acquired can be utilized in practice in order to achieve better outcomes for consumers, carers and the broader community.

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