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Archives of Psychiatric Nursing 27 (2013) 161–165
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Archives of Psychiatric Nursing
j ourna l homepage: www.e lsev ie r .com/ locate /apnu
Keeping the Flame Alight: Understanding and Enhancing Interest in Mental HealthNursing as a Career
Brenda Happell a,⁎, Tony Welch b, Lorna Moxham c,d, Louise Byrne e
a Central Queensland University, Institute for Health and Social Science Research, and Centre for Mental Health Nursing Innovation, Rockhampton, Queensland, Australiab Central Queensland University, Noosa Campus, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation,and School of Nursing and Midwifery, Australiac University of Wollongong, School of Nursing, Midwifery and Indigenous Health, Wollongong, Australiad Institute for Health and Social Science Research, Central Queensland University, Australiae Central Queensland University, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, School of Nursing & Midwifery, Australia
a b s t r a c t
Mental health nursing is not regarded favourably by most Bachelor of Nursing (BN) students as a desirablecareer option. However, little is known about what attracts those students who do become interested. Theprimary aim of the current study was to explore BN students' reasons for choosing to undertake the major inmental health nursing and the degree to which completing the subject: “Recovery for mental health nursingpractice”, confirmed that interest or otherwise. A secondary aim was to examine their perceptions about theattitudes of others to their expressed interest in mental health nursing. A qualitative exploratory study wasundertaken with undergraduate nursing students (BN) (n = 12) enrolled in a major stream in mental healthnursing. In-depth individual interviews were conducted primarily by telephone. Data were analysed usingColaizzi's steps to explicate the main themes. Two main themes emerged: Swimming against the tide – that'snot real nursing, captures participants' experience of the negative attitudes of others to their interest in mentalhealth nursing; and, creating and confirming an interest in mental health nursing, where participants discusshow their interest emerged and how it had been enhanced after completing the subject: Recovery for MentalHealth Nursing Practice.Mental health nursing continues to be a stigmatised and undervalued profession bothwithin nursing and the general public. Despite this, participants of this research were attracted to thespecialty, and their interest was generally strengthened after completing the Recovery subject. Furtherresearch is required to examine the impact of being taught by an academic with lived experience on interest inmental health nursing as a career.
© 2013 Elsevier Inc. All rights reserved.
PREFACE
In this paper the term “significant mental health challenge” is usedin reference to people who access mental health services, have beendiagnosed with a “mental illness” and who are recovering or haverecovered from disorientation and severe mental and emotionaldistress. “Significantmental health challenge” includes the experienceof self and social stigma frequently characteristic of mental healthservice use. It does not include the relatively common experiences ofmental distress that do not cause severe disruption to everyday life foran extended period. This term is used in preference to “mentalillness”, particularly in relation to the lived experience academic role
⁎ Corresponding Author: Brenda Happell, RN, RPN, BA (Hons), Dip Ed, B Ed, M Ed,PhD, Professor and Director, Central Queensland University, Engaged Research Chairin Mental Health Nursing, Director, Institute for Health and Social Science Research,and Centre for Mental Health Nursing Innovation, Bruce Hwy, Rockhampton,Queensland, 4702, Australia.
E-mail addresses: [email protected] (B. Happell), [email protected](T. Welch), [email protected] (L. Moxham), [email protected] (L. Byrne).
0883-9417/1801-0005$34.00/0 – see front matter © 2013 Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.apnu.2013.04.002
as it more appropriately reflects the philosophy and purpose of thatrole. The term mental illness is used when referred to by BN studentparticipants to reflect their language.
The literature has consistently shown over several decades thatundergraduate nursing students who commence their program with adesire to pursue a career in mental health nursing are a small minority(Bell, Horsfall, & Goodin, 1998; Curtis, 2007; Evangelou, 2010; Goodwin& Happell, 2007; Gough & Happell, 2009; Happell, 1998; Hoekstra, vanMeijel, & Tg, 2010; Stevens & Dulhunty, 1997; Surgenor, Dunn, & Horn,2005; Wynaden, Orb, McGowan, & Downie, 2000). Fear of peopleexperiencing significant mental health challenges (Happell, 2008b;Hoekstra et al., 2010; Stevens & Dulhunty, 1997; Surgenor et al., 2005)and the view thatworking inmental health settings is not “real nursing”(Happell, 2000; Rushworth &Happell, 2000; Stevens &Dulhunty, 1997)have been identified as two main reasons for this lack of popularity.Anecdotal evidence suggests that students with an interest in mentalhealth nursing are often dissuaded by academics, clinicians and evensignificant others from pursuing this option. However, to date there isno evidence in the literature to support or refute this.
162 B. Happell et al. / Archives of Psychiatric Nursing 27 (2013) 161–165
Research examining BN students' attitudes to mental healthnursing as a career, has generally credited a positive clinicalexperience as the major strategy for promoting mental health nursingas a worthwhile area of specialty practice (Curtis, 2007; Happell,Robins, & Gough, 2008b; Henderson, Happell, & Martin, 2007b;Mullen & Murray, 2002). This has led to a tendency to identify andimplement strategies to increase and improve clinical experiences toenhance the popularity of mental health nursing (Arnold, Deans, &Munday, 2004; Curtis, 2007; Happell, 2008a; Mullen &Murray, 2002).
There is some albeit limited evidence, that the quality and quantityof the theoretical component can also be effective in promoting morepositive attitudes to mental health nursing as a career choice.Research in this area has focused on the size of the theoreticalcomponent (Happell, 2009; Happell, Robins, & Gough, 2008a;Henderson et al., 2007b) and on learning and teaching approachesthat might present mental health nursing in a more attractive light(Rushworth & Happell, 1998; Happell & Rushworth, 2000).
The involvement of consumers of mental health services has alsobeen identified as an educational strategy with the capacity toinfluence the development of more positive attitudes of healthprofessionals to people with significant mental health challenges(Happell, Pinikahana, & Roper, 2003; Happell & Roper, 2003; Meehan& Glover, 2007; O' Donnell & Gormley, 2013; Petersen, Hounsgaard, &Nielsen, 2008; Schneebeli, O'Brien, Lampshire, & Hamer, 2010; Simonset al., 2007; Terry, 2012). To date the research has not addressed theextent to which this experience has influenced BN students' attitudestowards mental health nursing or whether it has increased itsdesirability as a career choice.
Generally the literature has concentrated more on identifying theproblem than on finding solutions (Happell, 1998; Happell, 2010). Oneattempt toprovideanopportunity for BNstudents interested inpursuinga specialist pathway inmental healthnursing at undergraduate level andaddress identifiedworkforce issues inAustraliawas the introduction of amajor in mental health nursing (Happell, Moxham, & Clarke, 2011;Kenny, McConnachie, Petrie, & Farrell, 2009). Sixteen Australianuniversities sought Commonwealth, Jurisdictional or internal universityfunding for projects to develop and implement a major. To date there islittle documented evaluation of the outcomes of these projects. A surveyof the universities involved demonstrated considerable variation in thestructure, composition and popularity of these programs and suggeststhat long-term sustainability is in doubt, even in universities where themajor was found to be popular (Happell et al., 2011).
Whilewe canconfidentially assume thatmental health nursing is notregarded favourably by BN nursing students, at least not at thecommencement of their program, we know considerably less aboutwhat attracts those students who do express an interest in, andultimately chose to work in, this specialty. Furthermore, there is nopublished qualitative or quantitative data about the extent to which themajor in mental health nursing has produced the desired outcomes:encouraging more students to undertake a career in this specialist field.
Aim
The primary aim of the current study was to explore BN students'reasons for undertaking the major in mental health nursing and thedegree to which completing the subject: “Recovery for mental healthnursing practice” confirmed that interest or otherwise. A secondaryaim was to examine their perceptions about the attitudes of others tothis choice.
METHODS
Approach
A qualitative exploratory design was utilised for this researchbased on the work of Stebbins (2001). This approach is appropriate
where little research has been undertaken and detailed exploration iswarranted as the first step to increase understanding of the issue inquestion (Stebbins, 2001). Such an approach provides an opportunityfor the opinions and experiences of participants to guide the quest forinformation and understanding.
Setting
The target participants were BN nursing students undertaking aspecialty stream in mental health nursing at a university inQueensland, Australia. These students had completed the core mentalhealth nursing subject in the previous semester and made the choiceto enter the specialty stream. This involved two extra mental healthnursing subjects. At the time of interview students had completed thefirst subject: “Recovery for mental health nursing practice”. Thissubject was led and coordinated by a personwith a lived experience ofmental health service use (also known as a consumer or livedexperience academic) in an autonomous capacity.
The content of the course includes:
• Critical examination of factors that promote recovery for peopleexperiencing serious mental health challenges
• Critical examination of the recovery focus in contemporarymental health services from a nursing perspective
• Exploration of the importance of consumer participation andconsumer perspective as drivers of the recovery paradigm
• Critical analysis of the effectiveness of the recovery model inpromoting wellness
• Using a recovery approach to assess, plan, implement, evaluate,accurately document and communicate evidence based nursingcare for people experiencing mental health challenges.
Sample
After ethics approval a brief overview of the study was sent to thestudent participants by email. Fifteen students responded and wereconsequently sent a copy of the plain language statement and consentform. Twelve students subsequently participated in an interview. Onestudent did not make further contact and due to personal reasons theremaining two were not available during the data collection period.
Procedure
In-depth interviews telephone interviewswere conductedwith 11students. One student lived close to the university campus and wasable to attend for a face to face interview. As most students livedconsiderable distances from the researcher's location, a face to faceinterview was not a viable option for participation.
The structure of the interviews was conversational and informal.Students were asked about their interest in mental health nursingand reasons for choosing to undertake the specialty stream; howpeople reacted to their interest in this field, and their degree ofinterest or otherwise in pursuing a career in mental healthnursing after graduation. These questions formed a guide only andstudents were encouraged to broaden their contribution beyond thequestions asked.
Ethical Considerations
The study was approved by the Human Research Ethics Committee(HREC) from the researchers' university. Students were informedboth verbally and in writing of the voluntary nature of the study andtheir right not to be involved. Interview times were not scheduleduntil the signed consent form was received and were subsequentlydoing so at the convenience of the participant. Interviews and data
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analyses were conducted by researchers who had not had a role inteaching or assessing the participating students.
Data Analysis
Interviews were audiotaped, with consent from the participantsand transcribed verbatim to provide an accurate and complete recordof each interview. Analysis was conducted in four main stagesaccording to the steps outlined by Colaizzi (Colaizzi, 1978). Firstly thetranscripts were read and re-read a number of times to familiarise theresearcher with an understanding of the participants' opinions andexperiences. Secondly, the transcripts were re-reviewed and signif-icant statements were extracted. These significant statements weregrouped together as relevant to construct formulated meanings orconstructs (Colaizzi, 1978). They were subsequently listed andnumbered for easy reference and theme clustering.
During the third phase the significant statements were combinedinto theme clusters (Colaizzi, 1978). In the final stage significantstatements from each participant were synthesised and furtherinformation added where available. This allows different elements ordimensions of the one experience to be articulated and adds bothbreadth and depth to the participants' descriptions of their experiences.
FINDINGS
The analysis of participant transcripts revealed two main themes:Swimming against the tide – that's not real nursing; and Creating andconfirming an interest in a career in mental health.
Swimming Against The Tide – That's Not Real Nursing
Sharing aspirations with colleagues and friends about a career inmental health was often met with bewilderment and disbelief thatsuch a career path would be considered given the alternative choice ofbeing “a real nurse” as described by participant 3:
A lot of them [peers] have said why would you want to workthere? Sometimes they go, oh, you work with the crazy people.[Often] they don't know what to say. I think their response ispartly out of ignorance.
Similar sentiments were expressed by participant 2:
When I [mention] my interest in mental health I get, oh, my gosh.What are you doing that for? I couldn't do that. I pretty well getthe same reaction from everyone.
The intensity of some people's reactions when informed thatmental health nursing was a preferred career pathway was vividlydescribed by participants 11:
People, even nurses I've told just literally reel back. You can justsee it. It was like you hit them with an elephant…I even had onenurse turn around and say I suppose you're going to psycho-analyse me now, aren't you? (Participant 11).
And:
They laugh in your face, they really do [and] say, what do youwant to go there for? Don't you like nursing? (Participant 2).
A number of participants perceived that the negative response offellow students and nurse colleagues to mental health nursing had itsorigins in a perception that mental health nurses are not “real nurses”as articulated by participant 7:
There is this preconceived idea that mental health nurses, becausethey don't run around the ward putting up IVs…that they are
actually not nursing. I tried to explain to them that they actuallywork hard and that it's actually a hard job…They don't see theskills involved, they certainly don't understand.
As a result of reactions like those described above, participantsoften avoided engaging in such conversations where possible.However, amid the negativity, there were occasions where partici-pants felt affirmed and supported in their choice of a career in mentalhealth as described by participant 2:
Occasionally I've had nurses say, ‘Oh, yeah, that will be interestingand challenging’…but mostly they say ‘I couldn't do that’.
Creating and Confirming an Interest in a Career inMental Health Nursing
Participants who chose to undertake the major in mentalhealth nursing said that the experience either created orconfirmed their interest in pursuing a career in this field. Someparticipants had not considered a career in mental health nursing.However, initial attitudes changed and they now consideredthemselves more likely to pursue this option for their futurecareer. Participant 6 describes:
When I started my degree I definitely didn't want to be a mentalhealth nurse… I [initially] thought it was too close to the bone, toodifficult. The recovery course changed that because it is moresupportive of people and I felt that is where mental health is goingand therefore, that is where I'd feel comfortable working. It [thecourse] changed my attitude quite a lot.
Participant 2 described an initial reluctance to consider mentalhealth, based on fear, that was dispelled after they completed the coremental health nursing subject:
I found it fascinating. It wasn't so scary…throughout the first yearI found…mental health quite scary and unknown but as I learnedmore about it I…became more accepting of it and – myself…I hadpost-natal depression and post-traumatic stress…I think once Iaccepted I had that it was easier for me to accept mental health.
Participant 7 also shared their experience of choosing mentalhealth as a career pathway:
Coming into the course I felt that a career in mental health was forme…after spending time with the lecturer, hearing her stories,her honesty, her openness, telling the truth, this is my experience,but only my experience, it doesn't relate to all. She had ourattention. Since then my nursing practice has improved…andmental health is where I will be heading..
For other participants, the desire to work in the area of mentalhealth was only strengthened by undertaking this course as stated byparticipant 1:
Because it is something I've always wanted to do, all it's done ismade me want to do it more.
On the other hand, a number of participants did not require anyencouragement as they already knew that mental health nursing wasfor them:
I kind of knew I didn't want to be a nurse on the general ward. Ienrolled in to the course, the psychiatric consumer [name ofsubject]. After hearing the lecturers I thought, oh, that's what I'mdoing. What attracted me was the focus on being with the person.Enrolling in the Recovery course [and listening] to the lecture'sexperiences of what it is like to be mentally ill [sic] – what
164 B. Happell et al. / Archives of Psychiatric Nursing 27 (2013) 161–165
she said – I definitely kn[e]w I was heading in the direction of[mental health]…
For two participants, the motivation to work in mental health atthe completion of their degree program was the desire to be true toself. The recovery subject provided that impetus as described byparticipant 9:
I can say [with a] hand on my heart that this has been the bestcourse I've done. The lecturer gave so much of herself and I tookmy lead from her. The more she gave the more I wanted to sharewithout being too personal. It has changed me as a person and the[way] I approach every person. It had a profound impact [on me].It confirmed for me what I was feeling that [mental healthnursing] is the right thing [for me].
In the case of participant 11, the motivation was a desire to makea change: I really, really want to make a difference in mental healthand really want to immerse myself into it [but] I am not sure nursing[being a general nurse] will give me that, if that makes sense.
DISCUSSION
As the literature suggests, most participants in this research hadnot commenced their BN program with an interest in mental healthnursing as a future career (Bell et al., 1998; Curtis, 2007; Evangelou,2010; Goodwin & Happell, 2007; Gough & Happell, 2009; Hoekstraet al., 2010; Stevens & Dulhunty, 1997; Surgenor et al., 2005;Wynaden et al., 2000). Fear of people experiencing significant mentalhealth challenges was a factor for some, again supporting the broaderliterature (Happell, 2008b; Hoekstra et al., 2010; Stevens & Dulhunty,1997; Surgenor et al., 2005).
While the participants themselves did not describe mental healthnursing as that which is not “real nursing”, they did report thisreaction from others who learned of their interest in this specialty.Questioning their choice and actual discouragement from working inthis field, came from nurses in the clinical arena and from their familyand significant others.
It was pleasing to note that this response had not come fromuniversity academics in this instance. The negative attitudes ofgeneral nurses toward mental health nursing as a career is concern-ing, particularly given the significant proportion of the populationpeople who have a mental health issue. This would appear to beunderpinned by unfavourable views about people experiencingsignificant mental health challenges.
A review of the literature over time consistently demonstratesthat nurses consider they lack the skill and knowledge to providequality mental health care in the general health environment(Linden & Kavanagh, 2012;Maria Johanna & Goossens, 2011; Sharrock& Happell, 2006). Worse still, they frequently expressed fear,held stigmatised even hostile views, and in some circumstancesblaming people with significant mental health challenges for theirhealth status (Happell & Cutcliffe, 2011; Ross & Goldner, 2009;Zolnierek, 2009).
Such attitudes, whatever the underlying reason, impact upon thequality of care provided to people experiencing significant mentalhealth challenges (Sharrock & Happell, 2006; Zolnierek, 2009). Giventhe high prevalence of mental health issues within the general healthcare sector (Happell & Platania-Phung, 2005; Zolnierek, 2009) this is amajor health concern that must be addressed as a matter of urgency,to ensure that equitable and quality health care is provided to all.
Furthermore, positive attitudes toward people with significantmental health challenges provide a positive learning environment,where mental health care is seen by students as a legitimate aspect ofnursing in any practice setting. Within an environment where BNnursing students see mental health nursing as valued, they are more
likely to consider it as a legitimate and valuable career option (Cooper& Carver, 2012; Hayman-White & Happell, 2005; Henderson, Happell,& Martin, 2007a; Surgenor et al., 2005) and be supported andnurtured in this decision rather than actively deterred. General nursesand educators therefore have not only the opportunity, but theresponsibility to model inclusive and non-judgmental practice toencourage the development of similar values amongst registerednurses of the future.
For the participants, their interest in mental health nursinggenerally resulted from the theoretical component of the programas very few had undertaken a clinical placement in mental health atthis stage. This confirms the limited research findings suggesting thatmental health nursing theory delivered by educators with a passionformental health nursing can influence the popularity of this specialty(Happell, 2009; Happell et al., 2008a; Henderson et al., 2007b;Rushworth & Happell, 1998). While this does not diminish theimportance of clinical experience, it does call for the need for greateremphasis on ensuring a quality theoretical program with sufficientbreadth and depth to increase students' familiarity with andconfidence in themental health environment. Such a positive learningenvironment that bridges theory and practice can challenge negativestereotypes and engender more positive experiences.
The inclusion of people with lived experience of significant mentalhealth challenges has been identified as an important strategy inengendering more positive attitudes to this component of nursingcare (Byrne & Happell, 2012; Byrne, Happell,Welch, &Moxham, 2012;Happell et al., 2003; Happell & Roper, 2003; Meehan & Glover, 2007;O' Donnell & Gormley, 2013; Petersen et al., 2008; Schneebeli et al.,2010; Simons et al., 2007; Terry, 2012). The responses of participantsin the current study frequently referred to the focus on humanness inthe Recovery subject. For most participants it confirmed the interestthey had developed from other aspects of the program including thecore mental health nursing subject. Although the relationshipbetween lived experience and attitudinal change has been exploredthrough research, this is the first known study to consider therelationship between involving lived experience and fostering aninterest in mental health nursing as a career option.
Limitations
This study was undertaken with only 12 participants studying atone University in Australia. In addition, these students had chosen toenter the specialty in mental health nursing. For these reasons theresponses provided may not be typical of a broader cohort of nursingstudents nationally and internationally and should not be generalised.
CONCLUSIONS
Mental health theory nested within a BN curriculum has thecapacity to positively influence students to choose mental healthnursing following graduation. These findings support the importanceof including the lived experience perspective into the undergraduatepreparation of nurses, not only to engender more positive attitudes inregistered nurses wherever they choose to practice in the future butas a possible recruitment strategy into the field. Additional researchwould be needed to determine whether similar findings are evidentacross larger numbers of students and cohorts. However, findingsfrom the current study suggest this is an area worthy of furtherexploration. In any theoretical development and when researchinglived experience roles, it is important to consider the level and scopeof involvement. The lived experience academic in this study had anautonomous role in the coordination and delivery of the subject.Tokenistic involvement runs the danger of reinforcing the powerdifferentials between service providers and service users (Cutcliffe &Happell, 2009) adding further stigma to the latter.
165B. Happell et al. / Archives of Psychiatric Nursing 27 (2013) 161–165
Acknowledgment
The authors thank the participants for giving so freely of their timeand providing such wonderful insights.
Our thanks to the Institute for Health and Social Science Researchfor providing financial support for this project.
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