CURRENT ISSUES IN MENTAL HEALTH NURSING

Introduction
Mental health nursing as a branch in nursing field has an essential role in providing mental health services. Mental health nurses under take several tasks including mental health promotion, prevention of mental illness and mitigation of mental illnesses negative effects. Among all mental health professionals, the length of time devoted by mental health nurses for interaction with their clients is the highest (Elsom, 2007). Over a number years, the shortage of mental health nursing workforce has become the most important mental health professional issue worldwide (Cowin and Jacobsson, 2003a; Holmes, 2006). To prevent the exacerbation of the mental health nurses shortage, it is necessary to discover the causes of this problem. Several factors are considered as the causes. The two factors have been generally decided as the main causes are the difficulties in recruiting and retaining mental health nurses (Cowin and Jacobsson, 2003a). If this condition does not resolve in the next few years, there will be a dangerous of lack of experts in mental health nurses and the worst impact would be a crisis in clients care (Kindy, Petersen and Parkhust, 2005) which means clients and their relatives would be the greatest victims of this problem. In order to prevent the continuation of this problem, the authorities and mental health nurse specialists have to create some strategies, either to retain the nurses who have stayed in their position or to attract the fresh graduate and other nurses to come. To meet

this aims, national practice standards for mental health workforce have been developed by Australian Health Ministers Advisory Council National Mental Health Working group (AHMAC NMHWG) (National Practice Standards 2002). It is expected that the use of these standards will increase the number of qualified mental health nurses, particularly in Australia and reduce the shortage of mental health nurses. In this essay, the current issues related to recruitment and retention in mental health nursing will be discussed with its correlation to retention of the experts of mental health nursing. Finally, standards practice and credentialing issue in mental health workforce also will be reflected in these issues.

Current issues in mental health nursing

The following are several issues that have experienced by mental health nurses in the clinical practice. These issues as suggested by a number of authors have contributed to the two factors which are widely considered to be causing the nursing shortage: the difficulties in recruitment and retention (Buchan as cited in Cowin and Jacobsson, 2003a). Cowin and Jacobsson (2003a) define recruitment as attracting a new person into an organization while retention is an organizations ability to keep those persons who are a part of an organization(p.3).

1.1 Age of nurses

The aging of mental health nurses is a significant factor that causes the shortage of mental health nurses (Roche and Duffield, 2007). According to Chief Nursing Officers Review of Mental Health Nursing (as cited in Holmes, 2006), 60 percent of nurses who

are registered in Nursing and Midwifery in United Kingdom are older than 40 years with more than one quarter older than 50. Specifically, for mental health nurse, 22 percent of nurses who work in community mental health service are older than 50. Similarly, data from Australian Institute of Health and Welfare 2005a (as cited in Roche and Duffifeld, 2007) reveal that the number of mental health nurses aged between 34 and 54 are 67 % of the total mental health nurses population. In United State, Department of Health and Human Services 2004 (as cited in Holmes, 2006) demonstrates that on average, the age of registered nurses in the USA is more than 40 years while 40% will reach over 50 by 2010. It can be predicted that in the next few years, these registered nurses would be retired and if the problems were still unresolved, there would be insufficient number of qualified nurses in mental health service.

Burnout in the workplace

A conducive work environment is considered as an important factor to attract and retain the employee. Some issues related to the mental health care settings have created uncomfortable feelings in working there. It is considered that these influence the decrease in mental health nursing staff. Barling (2001) concludes that mental health nursing always has relationship with stress and burnout. According to Sadovich (2005), burnout is a syndrome consisting of emotional exhaustion, depersonalization, and reduced personal accomplishment. The rise of burnout levels can result in increasing job stress, declining job satisfaction, and reducing job performance (Sadovich, 2005). The high level of stress is one of precipitation factors of retention issue (Aiken,et.al, 2000; Marshall, 2001).

Some factors that contribute to increase burnout among mental health nurses are an insecure situation in workplace, overload of tasks (Angermeyer, et.al, 2006; Melchior,et.al, 1997), lack of autonomy and role ambiguity (Sullivan as cited in Melchior,et.al, 1997), role conflict (Angermeyer, et.al, 2006), insufficient social support (Angermeyer, et.al, 2006), unrealistic hope of clients remedy and leader with low social leadership (Melchior,et.al, 1997).

Safety Issues
Mental health care facilities have become less safe for both nurses and clients (Roche and Duffield, 2007), whereas a therapeutic environment is an important aspect to support patients remedy. A study conducted by Barlow, Grenyer and Ilkiw-Lavalle (2000) in several psychiatric wards in New South Wales founded that 13.7% of patients who stay in mental health services have showed violence in wards and 47.4% of staff have suffered injuries. The Georgia Nurses Association (as cited in Kindy, Petersen and Parkhurst, 2005) claimed that a mental health staff in Florida has been killed by a psychiatric patient who was being admitted to a mental health service. Further, American Nursing Association (ANA) conducted an online survey about health and safety with 4,826 nurses. This survey revealed that 17% of respondents have experienced physical abuse and 57% have had verbal assault by their clients (ISNA Bulletin, 2002). Moreover, Mohamed (2002) found that 84.3% of nurses who work in psychiatric units in Riyadh have also suffered violence from their clients. Kindy, Petersen and Parkhurst (2005) discovered that nurses who have been assaulted by patients result in feeling fear,

traumatize and create emotional burden of the next violence. Some of them even think to withdraw from their work. The safety issue has led to feeling insecure, creates emotional burden to staff, and have influenced staff in making decision to leave their profession and choose other nursing fields that are more appropriate for them (ISNA Bulletin, 2002). Therefore, this issue is measured as one serious cause of the problems in recruiting and retaining mental health nurses (Kindy, Petersen and Parkhurst (2005); Roche and Duffield (2007). On the other hand, the risk of violence in mental health facilities has been suffered by patients as well. The most common intervention that is employed by mental health nurses is physical restraint. As described in Physical Restraint-Part 1 (2002), the number of patients in acute psychiatric units who have experienced physical restraints is calculated at 10% in average during long stay in hospital. The limited number of staff and insufficient observation procedure are claimed as the causes of the frequently use of physical restraint (JCAHO as cited in Gerolamo, 2006). Consequently, it would be difficult to create a therapeutic atmosphere as support for the rehabilitation of clients and to obtain comfortable feeling for nurses in their workplace. According to standards 1 of National Practice Standards of Mental Health Workforce (2002), mental health professionals have to protect clients privacy, dignity, confidentiality and privacy. However, with the nursing shortage this standard is difficult to employ. As was mentioned formerly, the ratio nurses-clients is not adequate while nurses have to maintain therapeutic environment and keep their own safety as well.

Consequently, nurses will use treatments such as restraints to counter aggressive situation, which will bother the rights, privacy and dignity of clients.

Workload
The shift of focus of mental health service from institution into community care has brought significant changes to mental health nurses, specifically to their roles and responsibilities (Roche and Duffield, 2007). The closure of psychiatric hospitals, reduction of beds in psychiatric units and the increase mental health services in community have caused the complexity of mental health nurses tasks. It is considered as the effect of the increase of the number of admission as well as more complex tasks to manage patients admitted, limited time to stay and the acuity of symptoms (Thomas as cited in Barling, 2001). Furthermore, other aspects that contribute to workload are the age of nurses that causes many qualified nurses to retire and increase the nursing shortage. Then for economic reason and the limited staff, outsourcing (Ceci and Mclntyre, 2001) and parttime and casual work of nurses (Creegan,et.al as cited in Cowin and Jacobsson, 2003a) rose dramatically. As a result, part-time staff have to fulfill the work roles that should be done by full time staff. It causes overload tasks even overtime among nurses and it brings increasing turnover and departure of staff (Cowin and Jacobsson, 2003b; Alexander,et.al, 1998). On the other hand, casual and part-time work has caused a substitution in stability of career of mental health nurses which is considered reducing working hours to a mean of 34.4 hours per week. It is claimed as the cause of declining the number of nurses who work in mental health services (Roche and Duffield, 2007).

Relationship among Multidisciplinary Mental Health Workforce

The transfer of emphasize mental health service also influence relationship between nurses and other mental health professional. In mental health field, skills and staff competencies are almost similar. It may lead to role conflict and clashes of culture and cause ineffective communication (Roche and Duffield, 2007). The relationship with colleagues as well as support from the manager is important to obtain job satisfaction and it determines quality of care. Overload of tasks without adequate support from colleagues can make nurses begin thinking to quit their work (Alexander, et.al, 1998). Moreover, Cowin and Jacobsson (2003a) argue that low appreciation from management and doctors affects the retention of mental health nurses. In standard 3 and 8 of National Practice Standards for the Mental Health Workforce (2002), mental health workforce have to create teamwork in mental health services. Yet, low respect from other profession and conflict of role will hinder the efforts to apply these standards.

1.1.1 Role of mental health nurses

The growth of new roles in mental health nursing including nurse practitioners, practice nurses, emergency case managers and the chances to employ private practice has affected the workforce shortage. This is because these roles need a number of nurses while only small quantity of new staff who can fill this requirement (Roche and Duffield, 2007). On the other hand, in community care there is an obscure role among multidisciplinary team. The role of mental health nurse usually as a case manager that is

considered as generic role (Elsom, 2007). Role that is lack of clarity can stimulate stress and burnout of nurses (Angermeyer, et.al, 2006). Roche and Duffield (2007) point out that the current trend is for most of qualified nurses to move from inpatient services to community care. It would be a risk because of the lack of experts in institutions, whereas experienced staff should be balanced either in wards or in community care.

1.2 Lack of career development

Clinton and Hazelton (2000) found that one factor that have participated in reducing the number of nurses in mental health care is because they do not feel have career pathway. This is because economic conditions tighten which lessens the number of experienced nurses who could achieve higher level than clinical nurse. Therefore, most of nurses believe that career prospect in mental health nurses is not attractive. Further, Clinton and Hazelton (2000) explain that as the effect of deinstitutionalization, the position of director for mental health nursing has been omitted except in the rest of large mental health institution. In addition, besides of lack of career pathway, lack of provision for conference leave and poor of career structure have also influenced retention of mental health nurses and decreases the desires of new graduates to choose mental health environments as their workplace (Clinton and Hazelton , 2000). Within standards 4 about the needs of mental health staff to be knowledgeable of mental health problems, standard 9 of service planning, development and management and standard 11 of evaluation and research, mental health nurses have opportunity to increase

their knowledge, continue their study and have relevant trainings to mental health services. It will develop career path of mental health nurses as well. However, these standards need sufficient funding to support its. In developing countries, budget still become a problem. For example, In Indonesia, budget to develop mental institution is arranged by the government and it is very limited. Therefore, it is difficult for mental health nurses to continue their study or conduct some research.

1.3 Disproportion between take-home pay and responsibility

Although pay rate is assumed not to influence the shortage in mental health nursing directly (Cowin and Jacobsson, 2003b), however, Robinson, Murrells and Smith, (2005) found that it contributes to job dissatisfaction when it is associated with level of responsibility. It is known that job dissatisfaction is an aspect that causes nurses to leave their profession. In addition, Cowin and Jacobsson (2003b) state that payment rate will become a significant factor when it is linked to organizational and career path factors. In contrast, Robinson, et.al (as cited in Holmes, 2006) claim that the payment is an essential factor of job dissatisfaction and the main cause of moving. Cowin and Jacobsson (2003b) explain that currently in most places in Australia, the salary of a graduate of master degree in nursing or a nurse who has more than 10 years experiences is not much more than salary for other co-workers from certificate level. This fact has also created an image that nursing is not awell-paid profession (Nowak and Preston as cited in Cowin and Jacobsson, 2003b).

1.4 The various skills and knowledge of mental health nurses

Elsom (2007) explains that the procedure to become a mental health nurse specialist is by taking postgraduate study and clinical practice of mental health nursing. However, many registered nurses who work in mental health settings came from a wide range educational background and do not have specialisation in mental health. According to Elsom (2007), this happens because of the shortage of nurses and the requirement of admission is not governed by the nurse registration authority. Similarly, in Indonesia, only a few of nurses who work in mental health facilities have specialty in mental health nursing. Mostly, they came from general nursing in diploma level, which means they study general nursing in three years after graduating from senior high school. There are only three mental health-nursing academics in Indonesia (Pusdiknakes, 2008) among hundreds of nursing academy and only one university that provide mental health nursing education in master degree. It means, in average nurses in mental institutions in Indonesia do not have mental health nursing skills, which will impact the quality of care to consumers. As a result, mental health nursing will lack qualified mental health nurses if this continues. Based on Standard Practice point 4 in National Mental Health Strategy (2002), mental health staff have to comprehend about the whole mental health problems. The diverse knowledge and skills among mental health nurses make this standard difficult to achieve. To overcome this problem, the use of credentialing is important. Credentialing is one strategy to maintain professional quality that lead to increase the quality of care.

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According to Elsom (2007), The Australian and New Zealand College of Mental Health Nurses (ANZCMHN) has created procedure for accreditation mental health nurses and has initiated the Credential for Practice Program (CPP) in 2003. Being credentialed means that a mental health nurse has achieved certain qualification in mental health nursing, has undertaken certain amount of the latest clinical practice and has retained an active portfolio of professional development. In the situation where the crisis of expert nurse arises, I think this program would very useful to retain and recruit qualified mental health nurses. Maybe initially there would be limited number of nurses who can meet the requirement to be credentialed. However, it could be increase as long as it is undertaken consistently and evaluated frequently.

1.5 Constraints in Promoting Recruitment of Mental Health Nurses

Recruitment is one of the main factors causing mental health nursing shortage. Holmes (2006) reports the unsuccessful nursing efforts to attract high-level education achievers, particularly in Australia. Several factors which influence the recruitment include perception of mental health nursing, poor educational preparation and complexity of tasks to work in mental health nursing (New South Wales Parliament legislative Council Select Committee on Mental Health as cited in Roche and Duffield, 2007).

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Perception of mental health nursing

There are some perceptions that have emerged regarding mental health nursing. Firstly, there is a description of nurses in media in United States that view nurses as poor ability, lack of academic capability and more irrational compared to doctor (Harvey as cited in Wells and McElwee, 2000). Similarly, Holmes (2006) acknowledges that the media broadcast create the thought that mental health care is a poor-skill activity, involving domination, a high level of interpersonal unpleasantness and risk to personal safety. Moreover, negative topic related to mental health nursing was published by media that mental health staff often receive at the hands of the print media (Wells as cited in Wells and McElwee, 2000). Perception itself is not a significant factor that influences the decline of nursing workforce (Wells and McElwee, 2000), however, it could create negative effects of recruitment and retention into mental health nurses (Holmes, 2006).

Insufficient educational preparation

Many writers consider that nurse education play an important role in nursing shortage issue. Department of Human Services; Select Committee on Mental Health as cited in Cleary and Happell (2005) state that inadequate theoretical and practical focus on mental health nursing impact crisis in recruitment and retention for mental health staff. This is because nurse education influences preparation and motivation of students to enter particular field of nursing.

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Elsom (2007) explains that nursing students carry out only no more than two weeks of clinical practice in mental health settings during three years undergraduate program while for the theory it is varied depends on the course. It can be seen that the preparation for first-degree nursing students is inadequate and it may influence students to put mental health nursing as the last preference of their career. Within the limited number of school leavers who enter mental health nursing, experienced nurses leaving the profession gradually will result in devastation of the nursing shortage.

Conclusion
Issues of difficulties in retaining and recruiting mental health nurses have become worldwide and has lead to the crisis in nursing shortage. Mental health nursing is struggling to maintain the high quality of care with the limited sources. Some precursor factors have been identified. These factors arise from age of nurses, work environment, misperception and educational background. By analyzing possible causes of this problem, it is hoped that the solution to overcome this difficulties would be developed. The launching of National Practice Standards for Mental Health Workforce 2002 and the initiating Credential for Practice Program as a guide for determining qualified mental health nurses are hoped could resolve the disastrous of experts nursing shortage. However, it needs the collaborative work between mental health nurses and other professions. Supports from government and communities are very important to promote the development of mental health nursing service standards and improve image of mental health nursing as well.

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