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Undergraduate mental health nursing education in Australia: More than Mental Health First Aid
Collegian (2015) 22, 433—438
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/coll
Undergraduate mental health nursing education in Australia: More than Mental Health First Aid Brenda Happell, RN, BA (Hons), PhD a,∗, Rhonda Wilson, RN, BNc, MNurs (Hons) b,1, Paul McNamara, FACMHN, RN, BN, MMHN c,2 a
Central Queensland University, Institute for Health and Social Science Research and the Centre for Mental Health Nursing Innovation, Australia b School of Health, University of New England, Australia c Perinatal Mental Health, Cairns & Hinterland Mental Health Service, Australia Received 27 September 2013; received in revised form 21 May 2014; accepted 1 July 2014
KEYWORDS Attitudes to mental illness; Mental Health First Aid; Mental health nursing; Nursing students; Undergraduate nursing
Abstract Mental Health First Aid training is designed to equip people with the skills to help others who may be developing mental health problems or experiencing mental health crises. This training has consistently been shown to increase: (1) the recognition of mental health problems; (2) the extent to which course trainees’ beliefs about treatment align with those of mental health professionals; (3) their intentions to help others; and (4) their confidence in their abilities to assist others. This paper presents a discussion of the potential role of Mental Health First Aid training in undergraduate mental health nursing education. Three databases (CINAHL, Medline, and PsycINFO) were searched to identify literature on Mental Health First Aid. Although Mental Health First Aid training has strong benefits, this first responder level of education is insufficient for nurses, from whom people expect to receive professional care. It is recommended that: (1) Mental Health First Aid training be made a pre-requisite of pre-registration nurse education, (2) registered nurses make a larger contribution to addressing the mental health needs of Australians requiring care, and (3) current registered nurses take responsibility for ensuring that they can provided basic mental health care, including undertaking training to rectify gaps in their knowledge. © 2014 Australian College of Nursing Ltd. Published by Elsevier Ltd.
∗ Corresponding author at: Central Queensland University, Engaged Research Chair in Mental Health Nursing, Director of Institute for Health and Social Science Research, Director of Centre for Mental Health Nursing Innovation, Professor of School of Nursing and Midwifery, Building 18, Bruce Hwy, Rockhampton, Queensland 4702, Australia. Tel.: +61 07 49232164; fax: +61 07 49306402. E-mail addresses: [email protected] (B. Happell), [email protected] (R. Wilson), [email protected] (P. McNamara). 1 Tel.: +61 0267733952. 2 Tel.: +61 07 4226 3411/04 5980 0267; fax: +61 07 4226 6674.
http://dx.doi.org/10.1016/j.colegn.2014.07.003 1322-7696/© 2014 Australian College of Nursing Ltd. Published by Elsevier Ltd.
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Introduction In 2013, Mental Health First Aid (MHFA) were successful in gaining funding from the Australian Department of Health and Aging grant with the aim of training at least one nursing academic from every Australian University (Department of Health & Ageing, 2013) to become a Mental Health First Aid trainer. Upon successful completion of the programme nurse academics are then able and expected to provide this training to undergraduate nursing students. Under this arrangement nursing academics are required to attend a five-day training workshop and complete a supplementary online module. The training workshop largely consists of basic mental health knowledge, well below the level one should expect from nurses appointed as nursing academics. The rationale for requiring academic nurses to attend the MHFA training is to ensure their compliance with instructor materials because the programme is trademark and copyright protected. The infiltration of such rigid compliance to material in the higher education sector is however, cause for concern, because the peer review process that teaching materials are usually subjected to in University processes is circumvented by a trademark organisation. Nurse academics who have undertaken the training are bound by their agreement to comply with administering the MHFA course without changing any of the materials, and by ensuring that it is conducted across a 13 h training period (Mental Health First Aid, 2013). While the intention may be actuarial and risk aversive to protect the MHFA organisation from litigation, it serves to constrict the actions of nursing academics and is restrictive for universities who have their own quality frameworks to adhere to. The regulation of nursing education in this way, and with significant curriculum time requirements amount to a significant proportion of teaching time, and without the flexibility to adapt materials to include relevant regional, international or new research-based evidence is a limitation that needs to be considered carefully. The educational pedagogy of the MHFA may also be poorly aligned to some new and future nursing curriculums. The value or otherwise of MHFA in facilitating the mental health knowledge of nursing students above and beyond the core mental health nursing components would in itself be worthy of further debate. However the focus of this paper is consideration of the potential implications of introducing MHFA into undergraduate nursing curricula. The potential introduction of MHFA must be considered within the broader context of mental health within undergraduate nursing curricula in Australia. An extensive literature now documents the underrepresentation of mental health nursing content in pre-registration nursing in Australia (Brunero, Jeon, & Foster, 2012; Happell & Gaskin, 2013; Moxham, McCann, Usher, Farrell, & Crookes, 2011; Stevens, Browne, & Graham, 2013; Wynaden, 2010, 2012). Mental health nursing content has been the subject of numerous reports and inquiries emphasising the prevalence and severity of mental illness and mental distress within our community and therefore highly relevant for nursing students. However, the underrepresentation of mental health content continues (Happell, 2010). These ongoing issues were acknowledged by the Mental Health Nurse Education Taskforce and informed the development of a framework
B. Happell et al. for mental health nursing in undergraduate nursing curricula (MHNET, 2008). If MHFA is to be offered to all nursing students at the participating university, it is quite likely this will become included as part of core curriculum, to ensure as many students as possible complete it. In light of already crowded curricula (McAllister, Williams, Gamble, Malko-Nyhan, & Jones, 2011), this would need to occur at the expense of other content. The precarious position mental health often occupies that MHFA might be seen as a viable alternative at least in part to the mental health nursing component of undergraduate nursing education in Australia. The authors have all heard statements suggesting that registered nurses and nursing students learned more from MHFA than from their undergraduate mental health nursing component. This appears to reflect a view that the programme is of sufficient quality and more relevant to their educational needs. In an extreme example, an on-line article from the US (Thayer, 2008) describes the MHFA programme as teaching nurses how to respond to mental illness, crediting the programme with the capacity to avert mass killings if sufficient nurses are trained in its use. Clearly this article is an opinion piece rather than research based, and it is not clear how similar or different the content is to that used in the Australian context. Nevertheless, the idea that MHFA might be as good as, or better than mental health nursing education is an issue of concern. The evidence to date is largely anecdotal and we are not intending to present it as definitive. Notwithstanding these limitations, the aim of this paper is to commence the debate about MHFA and its relationship to mental health nursing education. The paper will include: an overview of MHFA, its intended purpose and the evaluation of its effectiveness. This will be discussed in light of a broader focus on undergraduate mental health nursing education; the inherent limitations of MHFA for the education of health professionals; and, the potential implications should MHFA be used as a substitute for all or part of a core mental health component.
Background MHFA is similar to the familiar, established concept of first aid, whereby lay people render assistance to other injured members of their community until professional help is available (Jorm & Kitchener, 2011). It is important to note that MHFA is defined as the help provided to a person developing a mental health problem or in a mental health crisis. The first aid is given until appropriate professional treatment is received or until the crisis resolves (Kitchener, Jorm, & Kelly, 2010). There are five steps to guide the implementation of MHFA and these are: (1) assess risk of suicide or harm, (2) listen non-judgementally, (3) give support and information, (4) encourage person to get appropriate professional help, and (5) encourage self-help strategies (Kitchener et al., 2010). It is anticipated that any person, regardless of vocation, once they have undertaken a 12 h MHFA training programme could render this type of assistance, in much the same way as a traditional first-aider could render basic life support assistance, until such time as professional help is available.
Undergraduate mental health nursing education in Australia: More than Mental Health First Aid Many Australian adults and young people may have limited knowledge about how to respond if someone close to them is developing mental health problems or experiences a mental health crisis (Jorm, Blewitt, Griffiths, Kitchener, & Parslow, 2005; Jorm, Wright, & Morgan, 2007; Yap, Reavley, & Jorm, 2012; Yap, Wright, & Jorm, 2011). As a result MHFA was developed to improve the general communities knowledge about mental health problems, with the intention of overcoming the fear and stigma of mental illness, and to provide skills for people to initiate a response to promote the safety of individuals until professional help can be obtained. MHFA has been a successful international and national initiative, yet despite this success, only 1% of the Australian adult population have been able to complete the Mental Health First Aid training programme over the past 10-year period (Jorm & Kitchener, 2011). MHFA is targeted towards the general population and was not designed for use as a training tool to educate health care professionals.
Literature review Mental health is a priority for future health budgets to continue to address and to plan improvements on a national scale (Lourey, Holland, & Green, 2012). The recent national mental health report card (2012) highlights that every year 3.2 million Australians experience a mental health problem. In addition, annually there are 31.1 million mental health prescriptions filled, yet there are only 900,000 mental health individual consumers who are provided with mental health services (Lourey et al., 2012). There are thought to be about 65,000 suicide attempts every year, but despite this only somewhere between 6% and 8% of the population are budgeted for in regard to mental health care (the report card calls for a budget increase to 12%) (Lourey et al., 2012). It is clearly evident that the Australian population will require an increase in the capacity of mental health service delivery in the near future, and that this circumstance will require a population of skilled nurses, and other health professionals, who have an above basic knowledge of mental health. Three databases (CINAHL, Medline, PsycINFO) were searched to identify literature on MHFA between December 2012 and February 2013. The search was limited to 2002 onwards (being the year when MHFA first appeared in the peer-reviewed literature). Evaluations of the effects of MHFA training have produced positive findings (e.g., Kelly et al., 2011; Kitchener & Jorm, 2002). Evidence from randomised controlled trials have consistently demonstrated that MHFA increases: (1) recognition of mental health problems (except when course attendees are able to identify problems, such as depression, prior to training); (2) the extent to which course participants’ beliefs about treatment align with those of mental health professionals; (3) their intentions to help others; and (4) confidence in their abilities to assist others. MHFA training also reduces the stigma associated with mental health conditions. Generally, the changes evident at post-test are maintained at 6 months (e.g., Jorm, Kitchener, Sawyer, Scales, & Cvetkovski, 2010). These outcomes have been demonstrated with a diverse range of audiences, including members of the Chinese and Vietnamese communities in Melbourne (Lam, Jorm, & Wong,
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2010; Minas, Colucci, & Jorm, 2009), people who advise and support farmers (Hossain, Gorman, & Eley, 2009; Hossain, Gorman, Eley, & Coutts, 2009; Hossain, Gorman, Eley, & Coutts, 2010), rural support workers and community volunteers (Sartore et al., 2008), and pharmacy students (O’Reilly, Bell, Kelly, & Chen, 2011). MHFA is effective when taught by one of its developers (e.g., Kitchener & Jorm, 2004) or by trained members of the public (Jorm, Kitchener, O‘Kearney, & Dear, 2004). It is evident that MHFA has been useful in increasing mental health awareness amongst the general public, and that there are some benefits which include a stronger bilateral public and professional conversation about mental health. MHFA trainees and some people requiring mental health care have been able to learn some of the language and vocabulary of the mental health professional. However it is important that health professionals do not rely on this improvement for effective bilateral communication and understanding. Despite strong efforts to improve mental health awareness, there are still many people who will not be able to easily articulate the emergence of mental health problems, and who will require the particular help of skilled health professionals who are able to interpret their problems in a mental health framework (Aisbett, Boyd, Francis, Newnham, & Newnham, 2007).
Discussion It is particularly important that health professionals are able to interpret the mental health needs of a person seeking help, particularly as the language of mental health may present a major barrier (Wilson, Cruickshank, & Lea, 2012). Therefore it is necessary that nurses and nurse academics continue to strengthen the development of vital mental health specific communication and assessment skills of new nursing graduates (Mental Health Nurse Education Taskforce (MHNET), 2008). Nurses are the most numerous professionals in mental health services (Australian Institute of Health and Welfare, 2012) and therefore have a disciplinary responsibility to influence the mental health status of the people they care for across all health settings. Nurses are a rich source of social and health capital in the communities in which they live and work, and they represent the bulk of health service delivery across the 24 h period (Boyd, Hayes, Wilson, & Bearsley-Smith, 2008; Wilson, 2009). The capacity to respond to people experiencing significant mental health challenges is as essential skill that all nursing graduates require. However, the professional level mental health care skills expected at this level exceed the mental health awareness outcomes of MHFA, in a similar way that the more physical health focused areas of nursing exceed the content of the traditional first aid programme. Nursing requires a broader range of interventions to be provided over a longer time period than that associated with a first aid response. The MHNET report clearly articulated the minimum mental health content that graduates of undergraduate nursing programmes should be exposed to (MHNET, 2008). It is clearly evident from this work that the content expected to be covered in a Mental Health First Aid programme represents only a small portion of that required for working
436 with people experiencing mental distress. Essential skills include an understanding of the therapeutic relationship, the biopsychosocial model of mental health, social determinants of health, risk assessment and management, physical and psychological treatment modalities, professional, legal and ethical issues and mental health service structures. Furthermore, MHFA takes a predominantly medical-model approach with a focus on signs and symptoms of mental illness. It does not encapsulate the Recovery approach that is now enshrined in mental health policy (Commonwealth of Australia, 2009). The public should have the confidence to anticipate a level of knowledge and subsequent mental health care by professional registered nurses that is of a calibre which exceeds that of a mental health first-aider, or of general members of the public (Wynaden, 2010). Clearly the educational preparation that nurses receive to carry out this type of work requires specific training, and this training needs to be beyond the limits of MHFA (Mental Health Nurse Education Taskforce (MHNET), 2008; Wynaden, 2010). While we are not suggesting MHFA would replace mental health nursing content in its entirety, its inclusion as core would come at the exclusion of other content, potentially other mental health nursing content. This is not generally an expectation with the traditional first aid programme despite acknowledgement of its relevance and importance for nurse. Many pre-registration nursing programmes include first aid certification prior to enrolment or clinical placement. It could be argued that, given the prevalence of mental health problems in Australia, and the likelihood of encountering people with mental health problems in any health setting, that a similar pre-requisite requirement for MHFA certification prior to course enrolment or clinical placement be implemented for all pre-registration nursing programmes in Australia. If this were to be adopted, it would enhance the pre-programme general knowledge of nursing students and would position them towards early adoption of mental health nursing concepts and nursing practice in their programme of study. In so doing, the nursing curriculum would be able to develop stronger mental health nursing features and at an earlier point in the programme. Pre-registration nursing students should expect to study specific and discreet mental health nursing unit/s of study within pre-registration nursing programmes. Mental health nursing curriculum in Australia should be strengthened further, and that additional mental health, social and psychological learning objectives should also be integrated throughout out all nursing curricula, clearly demonstrating the importance of mental health skills and knowledge across all practice settings, in addition to the specialist skills required for practice in mental health settings (Happell, 2006). In addition, the content of specific mental health nursing components of study should be taught by qualified mental health nurses. This view concurs with the recommendations of the Mental Health Nurse Education Taskforce’s Final Report (2008) and with other national nursing scholarship about this issue (Wynaden, 2010). To ensure there is a clear understanding of the differing purposes of MHFA and undergraduate mental health nursing education, the authors pose the following suggestions for further consideration:
B. Happell et al. • MHFA could be considered a prerequisite platform from which pre-registration nursing students come to the commencement of their programme of study. This is consistent with the requirement of many universities that students complete the St John’s Ambulance First Aid Course before undertaking clinical placements. Students would then be equipped with a general knowledge about how to render first assistance to a person with a mental health problem or crisis. This would reduce the burden on already crowded curricula and avoid the substitution of mental health nursing concepts within the programme with content from MHFA, and enhance the development of more effective mental health nursing learning outcomes to meet the broad range of mental health needs across health care settings. • The contributions of Registered Nurses towards meeting the challenges of Australia’s current and future burden of mental ill health needs to be considered carefully. Planning should ensure that the most plentiful health professional group in Australia is influentially positioned to address this important health matter. Nurses should be a prominent national asset in the alleviation of the mental health care burden within Australia. • The responsibility is placed with individual nurses. Where current Registered Nurses consider that they are unequipped, or inadequately educated, to provide initial mental health nursing care, they have a professional responsibility to ensure that they address their own lack of knowledge and obtain whatever training is necessary such that they can competently perform the functions of a Registered Nurse in Australia, which includes basic mental health care.
Conclusions The authors support the value of MHFA in relation to the purpose for which is it was designed, that is, to promote public awareness and facilitate first response to mental health challenges by non health professionals in the public setting. We consider that future positive outcomes for national mental health should be underpinned by a strengthening of mental health nursing curriculum and that MHFA does not have the design or capacity to meet the educational need of our future Registered Nurse population in Australia, any more than traditional first aid programmes could meet the educational needs for nursing in a medical—surgical or critical care environment. MHFA training is insufficient as a training programme for undergraduate, pre-registration nursing programmes in Australia, primarily because there are vast under met needs for mental health care in Australia (Lourey et al., 2012). If the burden of mental health under met need is to be reduced in Australia, then graduate nurses will need to be better prepared in all health care settings to administer mental health care (Andrews, Sanderson, Corry, & Lapsley, 2000) which is more advanced than basic first aid. To ensure the highest quality standard of care is available for all it is important that nurses continue to advocate effectively both for the strengthening of nursing curricula and the profession of nursing. In doing so, we will also advocate for excellence in nursing care, including mental health
Undergraduate mental health nursing education in Australia: More than Mental Health First Aid nursing care. In this way we can continue to protect the quality of health care for individuals, communities and the nation (Mental Health Nurse Education Taskforce (MHNET), 2008).
Funding This work was funded by the Centre for Mental Health Nursing Innovation, the Institute for Health and Social Science Research, CQ University Australia.
Acknowledgements The authors express their thanks to Dr. Cadeyrn Gaskin who assisted with the literature review for this topic and the nurses who actively participated in the discussion on the Australian College of Mental Health Nurses’ email discussion list. The passion this topic created and the many contributions and ideas nurses put forward were the inspiration for this paper. We hope this paper makes a worthwhile contribution.
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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/coll
Undergraduate mental health nursing education in Australia: More than Mental Health First Aid Brenda Happell, RN, BA (Hons), PhD a,∗, Rhonda Wilson, RN, BNc, MNurs (Hons) b,1, Paul McNamara, FACMHN, RN, BN, MMHN c,2 a
Central Queensland University, Institute for Health and Social Science Research and the Centre for Mental Health Nursing Innovation, Australia b School of Health, University of New England, Australia c Perinatal Mental Health, Cairns & Hinterland Mental Health Service, Australia Received 27 September 2013; received in revised form 21 May 2014; accepted 1 July 2014
KEYWORDS Attitudes to mental illness; Mental Health First Aid; Mental health nursing; Nursing students; Undergraduate nursing
Abstract Mental Health First Aid training is designed to equip people with the skills to help others who may be developing mental health problems or experiencing mental health crises. This training has consistently been shown to increase: (1) the recognition of mental health problems; (2) the extent to which course trainees’ beliefs about treatment align with those of mental health professionals; (3) their intentions to help others; and (4) their confidence in their abilities to assist others. This paper presents a discussion of the potential role of Mental Health First Aid training in undergraduate mental health nursing education. Three databases (CINAHL, Medline, and PsycINFO) were searched to identify literature on Mental Health First Aid. Although Mental Health First Aid training has strong benefits, this first responder level of education is insufficient for nurses, from whom people expect to receive professional care. It is recommended that: (1) Mental Health First Aid training be made a pre-requisite of pre-registration nurse education, (2) registered nurses make a larger contribution to addressing the mental health needs of Australians requiring care, and (3) current registered nurses take responsibility for ensuring that they can provided basic mental health care, including undertaking training to rectify gaps in their knowledge. © 2014 Australian College of Nursing Ltd. Published by Elsevier Ltd.
∗ Corresponding author at: Central Queensland University, Engaged Research Chair in Mental Health Nursing, Director of Institute for Health and Social Science Research, Director of Centre for Mental Health Nursing Innovation, Professor of School of Nursing and Midwifery, Building 18, Bruce Hwy, Rockhampton, Queensland 4702, Australia. Tel.: +61 07 49232164; fax: +61 07 49306402. E-mail addresses: [email protected] (B. Happell), [email protected] (R. Wilson), [email protected] (P. McNamara). 1 Tel.: +61 0267733952. 2 Tel.: +61 07 4226 3411/04 5980 0267; fax: +61 07 4226 6674.
http://dx.doi.org/10.1016/j.colegn.2014.07.003 1322-7696/© 2014 Australian College of Nursing Ltd. Published by Elsevier Ltd.
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Introduction In 2013, Mental Health First Aid (MHFA) were successful in gaining funding from the Australian Department of Health and Aging grant with the aim of training at least one nursing academic from every Australian University (Department of Health & Ageing, 2013) to become a Mental Health First Aid trainer. Upon successful completion of the programme nurse academics are then able and expected to provide this training to undergraduate nursing students. Under this arrangement nursing academics are required to attend a five-day training workshop and complete a supplementary online module. The training workshop largely consists of basic mental health knowledge, well below the level one should expect from nurses appointed as nursing academics. The rationale for requiring academic nurses to attend the MHFA training is to ensure their compliance with instructor materials because the programme is trademark and copyright protected. The infiltration of such rigid compliance to material in the higher education sector is however, cause for concern, because the peer review process that teaching materials are usually subjected to in University processes is circumvented by a trademark organisation. Nurse academics who have undertaken the training are bound by their agreement to comply with administering the MHFA course without changing any of the materials, and by ensuring that it is conducted across a 13 h training period (Mental Health First Aid, 2013). While the intention may be actuarial and risk aversive to protect the MHFA organisation from litigation, it serves to constrict the actions of nursing academics and is restrictive for universities who have their own quality frameworks to adhere to. The regulation of nursing education in this way, and with significant curriculum time requirements amount to a significant proportion of teaching time, and without the flexibility to adapt materials to include relevant regional, international or new research-based evidence is a limitation that needs to be considered carefully. The educational pedagogy of the MHFA may also be poorly aligned to some new and future nursing curriculums. The value or otherwise of MHFA in facilitating the mental health knowledge of nursing students above and beyond the core mental health nursing components would in itself be worthy of further debate. However the focus of this paper is consideration of the potential implications of introducing MHFA into undergraduate nursing curricula. The potential introduction of MHFA must be considered within the broader context of mental health within undergraduate nursing curricula in Australia. An extensive literature now documents the underrepresentation of mental health nursing content in pre-registration nursing in Australia (Brunero, Jeon, & Foster, 2012; Happell & Gaskin, 2013; Moxham, McCann, Usher, Farrell, & Crookes, 2011; Stevens, Browne, & Graham, 2013; Wynaden, 2010, 2012). Mental health nursing content has been the subject of numerous reports and inquiries emphasising the prevalence and severity of mental illness and mental distress within our community and therefore highly relevant for nursing students. However, the underrepresentation of mental health content continues (Happell, 2010). These ongoing issues were acknowledged by the Mental Health Nurse Education Taskforce and informed the development of a framework
B. Happell et al. for mental health nursing in undergraduate nursing curricula (MHNET, 2008). If MHFA is to be offered to all nursing students at the participating university, it is quite likely this will become included as part of core curriculum, to ensure as many students as possible complete it. In light of already crowded curricula (McAllister, Williams, Gamble, Malko-Nyhan, & Jones, 2011), this would need to occur at the expense of other content. The precarious position mental health often occupies that MHFA might be seen as a viable alternative at least in part to the mental health nursing component of undergraduate nursing education in Australia. The authors have all heard statements suggesting that registered nurses and nursing students learned more from MHFA than from their undergraduate mental health nursing component. This appears to reflect a view that the programme is of sufficient quality and more relevant to their educational needs. In an extreme example, an on-line article from the US (Thayer, 2008) describes the MHFA programme as teaching nurses how to respond to mental illness, crediting the programme with the capacity to avert mass killings if sufficient nurses are trained in its use. Clearly this article is an opinion piece rather than research based, and it is not clear how similar or different the content is to that used in the Australian context. Nevertheless, the idea that MHFA might be as good as, or better than mental health nursing education is an issue of concern. The evidence to date is largely anecdotal and we are not intending to present it as definitive. Notwithstanding these limitations, the aim of this paper is to commence the debate about MHFA and its relationship to mental health nursing education. The paper will include: an overview of MHFA, its intended purpose and the evaluation of its effectiveness. This will be discussed in light of a broader focus on undergraduate mental health nursing education; the inherent limitations of MHFA for the education of health professionals; and, the potential implications should MHFA be used as a substitute for all or part of a core mental health component.
Background MHFA is similar to the familiar, established concept of first aid, whereby lay people render assistance to other injured members of their community until professional help is available (Jorm & Kitchener, 2011). It is important to note that MHFA is defined as the help provided to a person developing a mental health problem or in a mental health crisis. The first aid is given until appropriate professional treatment is received or until the crisis resolves (Kitchener, Jorm, & Kelly, 2010). There are five steps to guide the implementation of MHFA and these are: (1) assess risk of suicide or harm, (2) listen non-judgementally, (3) give support and information, (4) encourage person to get appropriate professional help, and (5) encourage self-help strategies (Kitchener et al., 2010). It is anticipated that any person, regardless of vocation, once they have undertaken a 12 h MHFA training programme could render this type of assistance, in much the same way as a traditional first-aider could render basic life support assistance, until such time as professional help is available.
Undergraduate mental health nursing education in Australia: More than Mental Health First Aid Many Australian adults and young people may have limited knowledge about how to respond if someone close to them is developing mental health problems or experiences a mental health crisis (Jorm, Blewitt, Griffiths, Kitchener, & Parslow, 2005; Jorm, Wright, & Morgan, 2007; Yap, Reavley, & Jorm, 2012; Yap, Wright, & Jorm, 2011). As a result MHFA was developed to improve the general communities knowledge about mental health problems, with the intention of overcoming the fear and stigma of mental illness, and to provide skills for people to initiate a response to promote the safety of individuals until professional help can be obtained. MHFA has been a successful international and national initiative, yet despite this success, only 1% of the Australian adult population have been able to complete the Mental Health First Aid training programme over the past 10-year period (Jorm & Kitchener, 2011). MHFA is targeted towards the general population and was not designed for use as a training tool to educate health care professionals.
Literature review Mental health is a priority for future health budgets to continue to address and to plan improvements on a national scale (Lourey, Holland, & Green, 2012). The recent national mental health report card (2012) highlights that every year 3.2 million Australians experience a mental health problem. In addition, annually there are 31.1 million mental health prescriptions filled, yet there are only 900,000 mental health individual consumers who are provided with mental health services (Lourey et al., 2012). There are thought to be about 65,000 suicide attempts every year, but despite this only somewhere between 6% and 8% of the population are budgeted for in regard to mental health care (the report card calls for a budget increase to 12%) (Lourey et al., 2012). It is clearly evident that the Australian population will require an increase in the capacity of mental health service delivery in the near future, and that this circumstance will require a population of skilled nurses, and other health professionals, who have an above basic knowledge of mental health. Three databases (CINAHL, Medline, PsycINFO) were searched to identify literature on MHFA between December 2012 and February 2013. The search was limited to 2002 onwards (being the year when MHFA first appeared in the peer-reviewed literature). Evaluations of the effects of MHFA training have produced positive findings (e.g., Kelly et al., 2011; Kitchener & Jorm, 2002). Evidence from randomised controlled trials have consistently demonstrated that MHFA increases: (1) recognition of mental health problems (except when course attendees are able to identify problems, such as depression, prior to training); (2) the extent to which course participants’ beliefs about treatment align with those of mental health professionals; (3) their intentions to help others; and (4) confidence in their abilities to assist others. MHFA training also reduces the stigma associated with mental health conditions. Generally, the changes evident at post-test are maintained at 6 months (e.g., Jorm, Kitchener, Sawyer, Scales, & Cvetkovski, 2010). These outcomes have been demonstrated with a diverse range of audiences, including members of the Chinese and Vietnamese communities in Melbourne (Lam, Jorm, & Wong,
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2010; Minas, Colucci, & Jorm, 2009), people who advise and support farmers (Hossain, Gorman, & Eley, 2009; Hossain, Gorman, Eley, & Coutts, 2009; Hossain, Gorman, Eley, & Coutts, 2010), rural support workers and community volunteers (Sartore et al., 2008), and pharmacy students (O’Reilly, Bell, Kelly, & Chen, 2011). MHFA is effective when taught by one of its developers (e.g., Kitchener & Jorm, 2004) or by trained members of the public (Jorm, Kitchener, O‘Kearney, & Dear, 2004). It is evident that MHFA has been useful in increasing mental health awareness amongst the general public, and that there are some benefits which include a stronger bilateral public and professional conversation about mental health. MHFA trainees and some people requiring mental health care have been able to learn some of the language and vocabulary of the mental health professional. However it is important that health professionals do not rely on this improvement for effective bilateral communication and understanding. Despite strong efforts to improve mental health awareness, there are still many people who will not be able to easily articulate the emergence of mental health problems, and who will require the particular help of skilled health professionals who are able to interpret their problems in a mental health framework (Aisbett, Boyd, Francis, Newnham, & Newnham, 2007).
Discussion It is particularly important that health professionals are able to interpret the mental health needs of a person seeking help, particularly as the language of mental health may present a major barrier (Wilson, Cruickshank, & Lea, 2012). Therefore it is necessary that nurses and nurse academics continue to strengthen the development of vital mental health specific communication and assessment skills of new nursing graduates (Mental Health Nurse Education Taskforce (MHNET), 2008). Nurses are the most numerous professionals in mental health services (Australian Institute of Health and Welfare, 2012) and therefore have a disciplinary responsibility to influence the mental health status of the people they care for across all health settings. Nurses are a rich source of social and health capital in the communities in which they live and work, and they represent the bulk of health service delivery across the 24 h period (Boyd, Hayes, Wilson, & Bearsley-Smith, 2008; Wilson, 2009). The capacity to respond to people experiencing significant mental health challenges is as essential skill that all nursing graduates require. However, the professional level mental health care skills expected at this level exceed the mental health awareness outcomes of MHFA, in a similar way that the more physical health focused areas of nursing exceed the content of the traditional first aid programme. Nursing requires a broader range of interventions to be provided over a longer time period than that associated with a first aid response. The MHNET report clearly articulated the minimum mental health content that graduates of undergraduate nursing programmes should be exposed to (MHNET, 2008). It is clearly evident from this work that the content expected to be covered in a Mental Health First Aid programme represents only a small portion of that required for working
436 with people experiencing mental distress. Essential skills include an understanding of the therapeutic relationship, the biopsychosocial model of mental health, social determinants of health, risk assessment and management, physical and psychological treatment modalities, professional, legal and ethical issues and mental health service structures. Furthermore, MHFA takes a predominantly medical-model approach with a focus on signs and symptoms of mental illness. It does not encapsulate the Recovery approach that is now enshrined in mental health policy (Commonwealth of Australia, 2009). The public should have the confidence to anticipate a level of knowledge and subsequent mental health care by professional registered nurses that is of a calibre which exceeds that of a mental health first-aider, or of general members of the public (Wynaden, 2010). Clearly the educational preparation that nurses receive to carry out this type of work requires specific training, and this training needs to be beyond the limits of MHFA (Mental Health Nurse Education Taskforce (MHNET), 2008; Wynaden, 2010). While we are not suggesting MHFA would replace mental health nursing content in its entirety, its inclusion as core would come at the exclusion of other content, potentially other mental health nursing content. This is not generally an expectation with the traditional first aid programme despite acknowledgement of its relevance and importance for nurse. Many pre-registration nursing programmes include first aid certification prior to enrolment or clinical placement. It could be argued that, given the prevalence of mental health problems in Australia, and the likelihood of encountering people with mental health problems in any health setting, that a similar pre-requisite requirement for MHFA certification prior to course enrolment or clinical placement be implemented for all pre-registration nursing programmes in Australia. If this were to be adopted, it would enhance the pre-programme general knowledge of nursing students and would position them towards early adoption of mental health nursing concepts and nursing practice in their programme of study. In so doing, the nursing curriculum would be able to develop stronger mental health nursing features and at an earlier point in the programme. Pre-registration nursing students should expect to study specific and discreet mental health nursing unit/s of study within pre-registration nursing programmes. Mental health nursing curriculum in Australia should be strengthened further, and that additional mental health, social and psychological learning objectives should also be integrated throughout out all nursing curricula, clearly demonstrating the importance of mental health skills and knowledge across all practice settings, in addition to the specialist skills required for practice in mental health settings (Happell, 2006). In addition, the content of specific mental health nursing components of study should be taught by qualified mental health nurses. This view concurs with the recommendations of the Mental Health Nurse Education Taskforce’s Final Report (2008) and with other national nursing scholarship about this issue (Wynaden, 2010). To ensure there is a clear understanding of the differing purposes of MHFA and undergraduate mental health nursing education, the authors pose the following suggestions for further consideration:
B. Happell et al. • MHFA could be considered a prerequisite platform from which pre-registration nursing students come to the commencement of their programme of study. This is consistent with the requirement of many universities that students complete the St John’s Ambulance First Aid Course before undertaking clinical placements. Students would then be equipped with a general knowledge about how to render first assistance to a person with a mental health problem or crisis. This would reduce the burden on already crowded curricula and avoid the substitution of mental health nursing concepts within the programme with content from MHFA, and enhance the development of more effective mental health nursing learning outcomes to meet the broad range of mental health needs across health care settings. • The contributions of Registered Nurses towards meeting the challenges of Australia’s current and future burden of mental ill health needs to be considered carefully. Planning should ensure that the most plentiful health professional group in Australia is influentially positioned to address this important health matter. Nurses should be a prominent national asset in the alleviation of the mental health care burden within Australia. • The responsibility is placed with individual nurses. Where current Registered Nurses consider that they are unequipped, or inadequately educated, to provide initial mental health nursing care, they have a professional responsibility to ensure that they address their own lack of knowledge and obtain whatever training is necessary such that they can competently perform the functions of a Registered Nurse in Australia, which includes basic mental health care.
Conclusions The authors support the value of MHFA in relation to the purpose for which is it was designed, that is, to promote public awareness and facilitate first response to mental health challenges by non health professionals in the public setting. We consider that future positive outcomes for national mental health should be underpinned by a strengthening of mental health nursing curriculum and that MHFA does not have the design or capacity to meet the educational need of our future Registered Nurse population in Australia, any more than traditional first aid programmes could meet the educational needs for nursing in a medical—surgical or critical care environment. MHFA training is insufficient as a training programme for undergraduate, pre-registration nursing programmes in Australia, primarily because there are vast under met needs for mental health care in Australia (Lourey et al., 2012). If the burden of mental health under met need is to be reduced in Australia, then graduate nurses will need to be better prepared in all health care settings to administer mental health care (Andrews, Sanderson, Corry, & Lapsley, 2000) which is more advanced than basic first aid. To ensure the highest quality standard of care is available for all it is important that nurses continue to advocate effectively both for the strengthening of nursing curricula and the profession of nursing. In doing so, we will also advocate for excellence in nursing care, including mental health
Undergraduate mental health nursing education in Australia: More than Mental Health First Aid nursing care. In this way we can continue to protect the quality of health care for individuals, communities and the nation (Mental Health Nurse Education Taskforce (MHNET), 2008).
Funding This work was funded by the Centre for Mental Health Nursing Innovation, the Institute for Health and Social Science Research, CQ University Australia.
Acknowledgements The authors express their thanks to Dr. Cadeyrn Gaskin who assisted with the literature review for this topic and the nurses who actively participated in the discussion on the Australian College of Mental Health Nurses’ email discussion list. The passion this topic created and the many contributions and ideas nurses put forward were the inspiration for this paper. We hope this paper makes a worthwhile contribution.
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