VOL: 101, ISSUE: 41, PAGE NO: 34
Tony Bush, CertEd, RMN, DipN, is staff nurse; Donna Meadows-Smith, RMN, is staff nurse
Vanessa Snowdon-Carr, BSc, D. Clin Psy, is clinical psychologist; V. Bapuji Rao, MD, SRC (Psych), MBBS, is consultant psychologist; Helen Collishaw, BSc, is trainee psychologist; all at Ty Siriol Unit, County Hospital, PontypoolTony Bush, CertEd, RMN, DipN, is staff nurse; Donna Meadows-Smith, RMN, is staff nurse
Aim: To investigate how mental health nurses working with older adults perceive the benefits and realities of developing the outcomes of current continuing professional development training into actual clinical practice.
Method: A structured questionnaire was used with a convenience sample of nursing staff. Qualitative analysis was performed using a grounded theory approach in order to identify emergent themes, concepts and categories of data. Four randomly selected nurses were subjected to a voluntary semistructured interview using the questionnaire as a basis for information gathering.
Results: The main reason for attending courses was developing skills. Of those attending courses, 42 per cent of qualified and 35 per cent of unqualified staff had a personal development plan (PDP) or individual performance review (IPR). Significantly, all unqualified staff who had not been on a course had no PDP or IPR. Learning was described as applicable to practice by 85 per cent of unqualified and 70 per cent of qualified staff. However, 28 per cent of unqualified staff and 20 per cent of qualified staff felt their practice had not changed as a result of their learning.
Conclusion: CPD can be a positive experience, providing nurses with the opportunity to direct their professional development.
Underpinning the concepts of clinical governance and clinical effectiveness in modern nursing is the essential core principle of nurse education. There is little dispute that the ideal of clinical effectiveness enabled through evidence-based practice in order to attain a quality service is a theoretically achievable aspiration in the clinical setting. However, in many environments barriers such as time constraints and increased workloads make this difficult to achieve. Furthermore, and possibly of greater relevance and implication in the long-term (Buller and Butterworth, 2000), is an apparent failure among qualified members of staff to apply theory to practice.
Progress in the nursing care of older adults with mental illness and the ways in which nurses administer that care can often appear notoriously slow and fractional.
This study aimed to investigate how nurses working in older adult mental health care perceive the benefits and implementation of the outcomes of current continuing professional development (CPD) and research in practice, and to clarify the barriers to change implementation and the needs of the nursing workforce in terms of educational ambitions and realities.
Nurse education is undoubtedly one of the foundations supporting the desirably progressive ethos of a modern NHS. The rapid changes towards a more responsive service will require nurses to adapt quickly to new knowledge and skills to take a more central role in leading these initiatives, creating the more highly developed workforce required (Department of Health, 1999a). However, in the arena of older adult mental health care these concepts may raise controversial and contentious issues.
In general, clinical nursing care decisions tend to be based on factors identified by Rees (1997):
- Tradition (always done it that way);
- Authority/policy (told to do it that way);
- Education/training (taught/learnt to do it that way);
- Personal experience (found it usually works);
- Trial and error (tried several other ways first);
- Role modelling (seen others do it this way);
- Intuition (feels right this way);
- Research (the research I have read suggests this is the best method).
Meleis (1997) argued that in order for nurses to translate academic theory into clinical practice they need to be effective at reflecting and questioning and able to perceive themselves as capable of developing their knowledge. They must also be able to move away from the traditional 'handmaiden' role that has prevailed in nursing, in which unthinking subservience to the medical profession or organisation is the custom. Boling (2003) observed that the care of people with mental illness began to reflect this shift with the increasing 'professionalisation' of mental health nurses.
Further consideration has been given to the way in which rewards in nursing tended in the past to be bestowed upon 'doers' rather than 'thinkers' or conceptualists and it has been suggested that in order to narrow the theory-practice gap a practitioner embodying both these characteristics - a thinker who is also a doer - is more desirable than a nurse who is one or the other (Meleis, 1997).
More recently there has been a suspicion that nurses may not have travelled as far as expected or required in their efforts to ensure that older people receive the high quality of care they require and deserve (Nazarko, 2004). This has been directly attributed to a lack of knowledge and a failure fully to consider the consequences of nursing action or inaction in a reflective and critical way.
It is reasonable to suggest that nurses can only truly learn the practice of nursing through direct involvement in patient care (Martin, 1989). However, this fails to acknowledge the value of CPD and lifelong learning in extending the scope of nursing practice and improving the overall quality of care administered to patients.
Dolphin and Holtzclaw (1983) prophetically concluded that nurses who wish to keep pace with their profession - keeping ahead of the 'tide of obsolescence' - have no alternative but to commit to lifelong learning. Likewise, Bowman (1986) affirmed that the educating and updating of knowledge and skills - keeping in step with, if not in advance of new developments - is a prerequisite of any professional in order to enhance the quality of care through improved understanding and practice. As Lowry (1992) pointed out, it is essential for mental health nursing to review its practice, education and research if it is to successfully prepare for changes in the care of people with mental illness.
Cutcliffe (2000) prioritised more training in psychotherapeutic interventions for mental health nurses and suggested that mental health nurse education in general is impeded by an emphasis on neurobiology and 'masculine' approaches to care, which inadequately prepare nurses for modern humanitarian interventions. In earlier qualitative research, Brooker and Dinshaw (1998) found that older adult psychiatric patients felt the nursing care they received lacked privacy, social interaction and empowerment. Nursing care of older people appears to be defined by an emphasis on physical factors and symptoms (Bush, 2003). More recently, Gournay (2000) discussed the rationale for an increase in skills-based nurse training and advocated more interdisciplinary courses, nursing approaches based on sound experimental evidence, more robust training in research methods and closer links between university departments and clinical areas.
It also has been suggested that CPD has a role to play in the recruitment and retention of staff in the care of older people. Dewing (1999) acknowledged that historically few mental health nurses have been attracted to older adult nursing, yet seemed to feel that things were changing in a positive way. However, the tide has not yet visibly turned in many areas where staff are often in post due to having more or less 'fallen' into those circumstances as a result of service need rather than vocational or career aspirations or choice.
Rushworth and Happell (1998) suggested that education can significantly increase the popularity of psychiatric nursing as a profession. It is therefore reasonable to imagine that this would hold true for psychiatric nurses engaged in the care of older people, especially taking into account that continuing scientific advances tend to drive rapid changes in the knowledge base required of these nurses (Hannelly and Inouye, 1998).
A study by Baillon et al (1999) explored the perceptions of job satisfaction and stress levels of staff working in a psychiatric unit for older people. It concluded that routine audits of staff stress could be useful in identifying the potential for staff training and individual professional development plans. They also highlighted the importance of this in the light of both national and local difficulties in the recruitment and retention of staff. Ultimately, there is a strong indication that progressive educational opportunities and development programmes should increase the attractiveness of careers in areas caring for older adults with mental health problems to both new and existing staff. However, it is debatable whether suitable programmes of this nature are currently in place fully, and if they are, whether or not they are effectively fulfilling this function on a significant or meaningful level.
A structured questionnaire was developed and piloted with a random sample of six nursing staff from an area not included in the final study. No problems were reported. A convenience sample of all nursing staff - qualified and unqualified (140 in total) - employed in three geographical boroughs of psychiatric care of older people (Torfaen, Monmouth and Blaenau Gwent) were sent questionnaires via the internal mail service. The questionnaire was anonymous - participants were only required to specify whether they were qualified or unqualified and how many years they had worked in their current positions. It was stressed that participation in the study was voluntary, but a request was made that those who did not wish to complete the questionnaire return it blank via the trust internal mail service in the preaddressed envelope provided.
The study was given ethical approval by the local research ethics committee and was passed for scientific validity by the local research scrutiny committee. In addition to this, the psychology department made an adjunct to the original study that was submitted to the chairperson of the ethics committee for the appropriate NHS trust. Four randomly selected nurses were subjected to a voluntary semistructured interview using the questionnaire as a basis for information gathering. The findings of this additional process were incorporated as a complementary aid to formulating discussion and reaching conclusions.
The numeric value results were input into an SPSS database then translated into percentage values. The accompanying comments given by the respondents were analysed qualitatively.
This involved using a grounded theory approach, as described by Glaser and Strauss (1967) in order to identify emergent themes, concepts and categories of data.
A total of 76 (54 per cent) non-respondents out of 140 represent a large deficit. However, the completed returns represented over 40 per cent of the sample group, the target figure set to enable the study to proceed.
The average number of years of working service for both unqualified and qualified staff were similar (16 for unqualified; 17 for qualified). This in turn suggests that there is a predominantly ageing, yet experienced, workforce in these boroughs and that there are few new or younger staff in the system.
Course providers and duration
A total of 33 courses were attended by qualified and unqualified staff: 63 per cent of these courses were provided by the NHS trust; nine per cent by an independent college of further education; six per cent by drug companies and two per cent by the University of Wales College of Medicine (higher degree-level study for qualified staff).
In terms of course duration, one-day courses predominated (42 per cent), while in the provision of advanced academic qualifications eight per cent of unqualified staff attending courses were undertaking NVQs and two per cent of qualified staff attending courses were studying for a degree.
Only three per cent of all courses focused specifically on the care of older people (a course entitled Dementia Update) and this was attended by five per cent of the total number of staff who had undertaken courses.
Reasons for attending
Ninety-two per cent of unqualified staff said they had attended courses to develop their skills, as did 67 per cent of qualified staff, making that the main reason for attending courses. The second most commonly cited reason among qualified staff was to keep updated (58 per cent), while 35 per cent said maintaining their professional registration was their rationale for course attendance.
Personal development plan/individual performance review
A total of 42 per cent of the unqualified staff who had attended courses had a personal development plan (PDP) or individual performance review (IPR). Of these, 35 per cent said they attended the courses as a part of their PDP/IPR. The other 58 per cent of unqualified staff who attended courses had neither PDP nor IPR. Significantly, none of the unqualified staff who did not attend any of the courses had a PDP or IPR.
Some 58 per cent of qualified staff attending courses had PDP/IPR, and 32 per cent of these said they had attended as part of their PDP/IPR. Of those who did not attend courses, 62 per cent had no PDP/IPR. Again, a direct link between the existence of a PDP or IPR and attendance on courses became apparent.
Applicability to practice
A total of 85 per cent of unqualified staff felt that the courses they attended had provided information they could apply to practice. The same number also felt they had provided both skills and theoretical knowledge that could be applied to working practice.
Of the qualified staff who had attended courses, 70 per cent felt that they received both information and theoretical knowledge that could be applied to practice and 61 per cent that the experience had taught them actual skills.
Return to work
Upon returning to the working environment, the majority of unqualified staff (85 per cent) talked to colleagues about the course - as did 52 per cent of qualified staff (colleagues were defined as peers in the workplace, at or below the same level or status as the respondent). Fifty-two per cent of qualified staff tried to incorporate what they had learnt into their current practice, as did 64 per cent of unqualified staff.
Some 35 per cent of unqualified staff actually started to pilot change and 21 per cent incorporated changes into their personal working practice. None of the unqualified staff admitted to doing nothing as a result of the courses they had attended. However, only five per cent of qualified staff confirmed that they had started to pilot change, with 29 per cent changing their own practice, while eight per cent said they had done nothing and 17 per cent involved themselves in an unspecified 'other' activity.
Of probable significance is the finding that 57 per cent of unqualified respondents and a comparatively small 17 per cent of qualified respondents actually discussed the courses they had attended with the individuals who could reasonably be considered the main change agents in the workplace - their managers.
Changes in working practice
A total of 50 per cent of unqualified and 35 per cent of qualified staff felt their working practice had changed only a little as a result of the courses they had attended, while 20 per cent of qualified and 28 per cent of unqualified staff felt nothing at all had changed. Seven per cent of unqualified staff felt their working practice had changed dramatically as a result, and 14 per cent 'a fair amount'. The same is true of five per cent and 14 per cent of qualified staff, respectively.
Practical skills acquisition
Courses were described by 71 per cent of unqualified staff as having taught them new skills and raising their awareness of skills. A smaller proportion of qualified staff (41 per cent) felt they had been taught new skills but more (55 per cent) felt their awareness of skills had increased. Some 47 per cent of qualified staff reported that their confidence had increased and 29 per cent said their awareness of other training needs had increased. Only five per cent of qualified staff felt their practical skills had not been enhanced by training.
Fifty per cent of unqualified staff reported increased confidence and 35 per cent increased awareness of other learning needs. All felt their practical skills had been enhanced.
In terms of the acquisition of theoretical knowledge, 50 per cent of unqualified staff felt informed of new theory and 71 per cent had increased awareness of new theory, while 42 per cent felt an increase in confidence in theoretical knowledge and 14 per cent experienced an increased awareness of other academic training needs. Only seven per cent felt their theoretical knowledge had not been enhanced in any way.
Of the qualified staff, 35 per cent felt informed of new theory, 44 per cent felt their awareness of new theory had increased, 41 per cent had increased confidence regarding theoretical knowledge and 29 per cent had increased awareness of other academic training needs. Only eight per cent reported no enhancement of their theoretical knowledge.
Qualified staff who attended courses made specific comments about what aspects would have helped them facilitate changes to working practice as well as the challenges they encountered in implementing change (Box 1, p35). However, only one qualified staff member who had not attended any courses made any comment - explaining that this was due to having been on sick leave throughout the past year. Many more unqualified staff who did not attend courses made comments on the questionnaire than who did attend courses - they seemed to feel the need to explain their lack of attendance (Box 2, p36).
It is a reasonable expectation in studies of this type that the response rate will be significantly lower than 100 per cent. However, guidelines by Oppenheim (1998) on increasing response rates were adhered to. The mode of returning the data via the trust's internal mail system was considered generally effective and efficient, with a less than two per cent estimated fail rate. Nurses not wishing to participate were asked to return the blank questionnaire in the envelope provided. There was a 54 per cent non-response rate and only nine per cent of questionnaires were returned blank.
Nursing staff are naturally busy and often involved in complex and time-consuming work. Their time at work is therefore both precious and limited and their domestic and social lives have additional impact on how they manage that time. Filling in questionnaires is perhaps an easy activity to forget or simply ignore as being a waste of time.
The trust in-service training department provided the majority of courses attended, and one-day courses predominated. Their brevity and their concise and direct method of providing information without eating into too much nursing time make them an attractive educational proposition for nurses and managers. Within the confines of this study it is not possible to comment on how significant the method of teaching might be - or the quality and effectiveness of that teaching. However, the Department of Health (1998) has proposed that evidence suggests that teaching and training methods are less important than many other factors.
Qualified staff are reported to be increasingly burdened by requirements to comply with standards and charters (Smith, 2000). They are also involved in clinical and managerial duties, which inevitably erode the time available for them to spend on traditional nursing tasks. The idea of training junior staff to a higher clinical standard in order to fill this gap therefore seems reasonable. However, in this study only eight per cent of unqualified staff were undergoing NVQ training or its equivalent, while two per cent of qualified staff were undertaking degree-level training and none were undertaking diploma-level study. This suggests there is little higher or further education activity being undertaken in older adult mental health care in the study area.
Clearly, not all staff could or should undertake such ventures at one time, and some may not wish to do so or be deterred by the personal sacrifices that can be caused by combining work, home activities and new learning (Dowswell et al, 1998; Pym, 1992). However, ultimately, the overall figures do seem relatively low.
Within continuing professional development there appear to be clear links between the existence of PDP and/or IPR and staff's attendance on courses and involvement in educational pursuits. This was even more apparent in the case of unqualified staff, as all those respondents who had not attended any courses also had neither a PDP nor an IPR.
Although many of the courses undertaken by both qualified and unqualified staff were not specific components of PDP or IPR, it could be suggested that these systems may encourage staff to be more self-directed in their choice of educational pathways and more informed and influenced by the structure and guidance that PDP/IPR are designed to provide.
The evidence suggests that the absence of PDP/IPR is consistent with non-participation in in-service training, or equivalent activities, in this sample group. This is perhaps a solid argument for all nursing staff in mental health care for older people being provided with the opportunity for PDP/IPR as part of their CPD.
Alternatively, Ryles (1999), writing on the empowerment of nurses, suggested that CPD is not conducive to empowerment and proposed the view that the process of nursing continually attempting to professionalise itself is beginning to erode the profession's perceived advantages - strength in numbers and proximity to the patients. Yet the positive benefits of acquiring practical skills and theoretical knowledge juxtaposed with increasing clinical confidence demonstrated by this trial, hopefully signal small-scale advances towards the creation of a more capable and self-aware workforce.
In general agreement, some theorists have suggested that the primary antecedents to the promotion of empowerment involve relationships based on mutual trust and respect, participation and commitment, education and support (Malby, 1992; Keiffer, 1984). These factors combine to form the theoretical basis of CPD.
The question of what happens when staff return to the working environment is a critical one. The broad aim of CPD in nursing is to advance and improve the quality of care and clinical practice. Most staff talked to their colleagues or peers in the workplace and most attempted to incorporate what they had learnt into existing practice. Yet whereas 57 per cent of unqualified staff approached and discussed the courses they had attended with their managers, the same was true of only 17 per cent of qualified staff.
This outcome is likely to be significant if nurse managers are considered to be the primary catalysts for change in the workplace. It is possible that this finding concurs with those of Greenwood (2000), who reviewed the barriers to nursing clinical development and training in Sydney, Australia.
It has been suggested that nursing staff often regard their working environments as unchangeable, and that the rationale for training in terms of having the potential to promote improvements in clinical practice and departmental procedures, as well as to improve the staff members' career prospects, are not made apparent. Training programmes, may, therefore, be perceived by nurses as unnecessary or a waste of time in terms of their practical application or ability to effect real change. This theory may shed some light on the relatively limited response rate this study elicited.
Of further consideration is the issue suggested by Greenwood (2000), that nurses who undergo training in clinical development units often minimise their training or fail to report on such training to other nursing staff or professionals in other disciplines - the reasons for this being a lack of appreciation of the importance of the training as well as a possible fear of being perceived as different from or superior to their colleagues. Although advanced theoretical knowledge and more effective clinical and managerial skills should improve the promotion prospects of qualified staff, is this actually the case in older adult mental health care?
Nurse managers - on wards, in nursing teams and elsewhere - occupy the positions they do in part because of their special capacity to be receptive to, active within, and progressive towards the processes of change management in the face of new developments. They are considered to be the facilitating force driving initiatives forwards that result in improvements in the quality of new and existing services.
It would therefore appear to be essential that mechanisms for debriefing, discussion, selective dissemination of information and action strategies exist to capitalise upon the outcomes of learning activity, or else the activity is simply nullified beyond the theoretical. This requirement is perhaps further illustrated by the finding that most staff felt upon returning to work that general practice changed only a little or not at all. If this is considered in conjunction with the finding that acquiring practical skills and theoretical knowledge was viewed in a generally positive light by respondents in this study, the lack of changes to practice may represent a problem in need of attention.
Qualitative analysis of the comments provided by respondents revealed that they unreservedly fell into two distinct thematic categories. Unqualified staff made comments that sought to explain their reasons for not attending courses. These centred on:
- Lack of opportunity and encouragement;
- Lack of support;
- Lack of information and awareness of what was available to them.
The fact that all unqualified respondents who did not attend courses also did not have a PDP or IPR is surely significant and should be addressed.
All qualified respondents who attended courses provided comments that focused on the challenges of implementing change as a result of the courses and the interventions that could have helped to meet those challenges. Recurrent themes such as time constraints, lack of resources, lack of interest and support from colleagues and managers and ritualistic, institutionalised patterns of working might indicate that some change in nursing culture in care of older adults with mental health problems might provide a welcome evolution.
In the changing face of health care, the proliferation of continuing education will continue as a strategy that supports the modernisation of the health service (Tennant and Field, 2004). The questions being addressed by this study in broad terms were, 'How do older adult mental health nurses use CPD training in clinical practice, and what are their attitudes towards its use and utility?'
The results strongly suggest that CPD can be a positive experience, providing nurses with the opportunity to direct their professional development. The themes emerging from current data also inform our ideas about what might aid or obstruct staff members' access to CPD and the effectiveness or utility of CPD.
The suggestion that nursing culture (within the geographical landscape of this study) may require some degree of refocusing in order to be made more accepting of and more adaptable to changes resulting from educational advances in nursing, is of major importance.
If the care of older people is to be perceived as a dynamic and career-fulfilling proposition to younger members of staff, it needs to provide attractive opportunities in terms of education and career advancement. Otherwise, such staff will continue to gravitate towards the areas that appear most fashionable and glamorous to them.
With Agenda for Change (DoH, 2004) becoming a major influence in the nursing community and qualified nursing changing to an all-degree profession, it may be wise to begin considering and reflecting on just how educationally aware and well-equipped the clinical practitioners, managers and leaders in older adult mental health care services are themselves to manage the changes and challenges that inevitably lie ahead.
- This article has been double-blind peer-reviewed.
For related articles on this subject and links to relevant websites see www.nursingtimes.net