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A comparative cross-sectional questionnaire survey of the work of UK and US mental health nurses
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International Journal of Nursing Studies 44 (2007) 377–385 www.elsevier.com/locate/ijnurstu
A comparative cross-sectional questionnaire survey of the work of UK and US mental health nurses Peter Nolana,, Sayeed Haqueb, Maureen Doranc a
School of Health and Sciences, Staffordshire University and South Staffordshire Healthcare Trust, Blackheath Lane, Stafford, ST18 0AD, UK b Department of Psychiatry, University of Birmingham, UK c Associative Clinical Director, The Veterans’ Administration Medical Centre, Denver, Colorado, UK Received 26 June 2005; received in revised form 24 April 2006; accepted 24 April 2006
Abstract Background: Comparative inter-country research which identifies similarities and differences in the work of mental health nurses in different social and political contexts is an important means of determining how changes in health care systems could lead to better outcomes for patients. Objective: This study sought to compare aspects of the work of nurses in US and UK mental health care settings. Nurses were invited to reflect on aspects of their role including identifying the most and least satisfying elements of their work and suggesting ways in which it could be improved. Methods and participants: A 12-item questionnaire, comprising closed and open-ended questions, based on the literature and the authors’ own experiences of mental health nursing practice, was piloted and subsequently distributed to respondents in both countries. Results: The US nurses tended to be more willing to accept a wider range of clients than their UK counterparts, although they had lower expectations of their clients’ likelihood of recovery. Both groups of nurses felt that being part of a team and having direct contact with clients were the most satisfying aspects of their work, while administration was the least. Although both US and UK nurses utilised a variety of intervention models, it would appear that Cognitive Behavioural Therapy was the favoured model for the majority of nurses. Conclusions: The implications of these findings for the work of nurses and mental health care services in the UK and US, and the purpose, nature and need for future international comparative research are discussed. r 2006 Elsevier Ltd. All rights reserved. Keywords: Inter-country research; Cross-cultural exploration; Role of the nurse
What is already known about the topic?
More international studies are needed to compare the contribution of nurses to alleviating the burden of mental health problems.
The selection, preparation and work of mental health
nurses appear to vary considerably from country to country. Few comparative international studies focusing on the work of mental health nurses exist.
Corresponding author. Tel.: +44 1785 353702.
What this paper adds
It contributes to our understanding of the work of
E-mail address: [email protected] (P. Nolan). 0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2006.04.014
nurses in different countries.
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378
It
defines which aspects of their work nurses find most and least satisfying. It explores nurses’ perceptions of the environmental and cultural factors which influence how they approach their work.
1. Introduction Globalisation, defined as the decoupling of space and time (Giddens, 2001), is now impacting on many aspects of people’s lives including the manner in which health care is provided. Instant communication enables knowledge and culture to be shared around the world in seconds and has implications not only for those with responsibility for planning and financing services, but also for those engaged in delivering them. Health care programmes need to be responsive to global changes and health care personnel will need to become competent in negotiation, analytical and strategic thinking skills, and the assessment of national and cultural differences (Spradley and Allender, 1997; Harris et al., 2001). In mental health, increased sharing of knowledge has enabled nurses in different parts of the world to compare and contrast their work in diverse health care systems and socio-political traditions (Verheis and Kerkstra, 1993; Smoyak, 1996). Hull (1988) suggests that cross-cultural exploration enables us to highlight deficits in our own mental health care and Mead and Ashcroft (2005) argue that international collaboration is one of the principal ways of learning how nurses can improve the work they do.
2. Literature review Although there are few rigorous international comparative studies in mental health nursing, nevertheless the number of such studies is increasing, resulting in a clearer understanding of the nature of the work of mental health nurses worldwide. As this review indicates, studies have been largely researcher-initiated and undertaken independent of each other. The first scholarly work relating to the role and function of the mental health nurse at the beginning of the 20th century appeared in the United States (Nolan et al., 2002) and by the middle of the century, literature from other countries was following suit, seeking to find ways of strengthening the contribution of the nurse to mental health services (Callaway, 2002). During the 1950 s and 1960 s, some attention was given to mental health nursing at professional meetings and international conferences organised by psychiatrists. Although psychiatrists had been making educational visits abroad since the second half of the 19th century, it was not until
the 1950s that the first psychiatric nurses from the UK went to Scandinavia to learn more about their profession in relation to the work being done in other countries (Nolan, 1999). In the early 1960 s, Altschul went to the States for a 1-year study tour and subsequently wrote her seminal book Patient–Nurse Interaction: a study of interactive patterns in acute psychiatric wards, exploring how interpersonal relationships assist recovery from mental illness (Altschul, 1972; Tilley, 2004). Today, international educational exchanges and research collaboration flourish; case management, the Care Programme Approach, drop-in centres, and nurse prescribing have all been heavily influenced by observations made in other countries (Simpson et al., 2003). Smoyak (1996) recommended comparative research as a means of testing the efficacy of nursing in different contexts, and of defining the work that nurses do and the conditions in which it yields the best outcomes. She invited nurse–researchers to go beyond attending conferences in other countries and to seek funding for international studies, despite the reluctance of many funding bodies to consider research of this nature. Work already done in an international context has proved thought-provoking. Barker (2000) reported that clients in Canada and Scotland had similar expectations of the nurse–client relationship, which they saw as finding its natural context in the clinical situation. Adejumo and Ehlers (2001), however, found that mental health nursing was defined very differently in Botswana and Nigeria, two countries which might have been expected to have shared a similar understanding by virtue of their proximity, although in both, the focus of nursing was on caring for groups of people in their everyday social contexts. Bowers et al. (1999) explored the number and nature of violent incidents in in-patient care in five European countries. Considerable differences in the number and nature of such incidents were found. However, the researchers faced methodological difficulties owing to there being no shared definition of violence across the five countries, and no consensus on how to record such incidents. These disparities provided some explanation for the variations in incidence and nature, but could not provide a full explanation. Other factors such as staffing levels, the therapeutic skills of nurses, and the ways in which potential conflict was handled were also considered by the authors to be significant and they called for further studies to ascertain the true prevalence of violence in mental health settings in Europe, its causes and the role of nurses in containing and preventing it. In a similar smaller study, Nolan et al. (2001) found that mental health nurses in England encountered more violence in the course of their work than colleagues in Sweden, and reported that repeated exposure to violent incidents eroded nurses’ self-esteem and job-satisfaction.
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Swedish nurses experienced less violence and had greater support, leading to enhanced professional morale. Weiller et al. (1998) examined provision for patients with anxiety syndromes and high levels of social disability in five European countries. This study took place in the context of European Union and World Health Organisation directives that planners and providers should prioritise services for people with mental health problems in primary care. The researchers concluded that provision was generally poor; in two countries, there were no services at all. The poverty of primary care services meant that some patients would require more expensive treatment following inevitable deterioration. General Practitioners were found to need more training in the management and treatment of mentally ill people but the researchers considered that this would be inadequate without a transformation in the culture of primary care in order to improve mental health services. Yamashita (1998) examined the cultural context in which care is provided, comparing the nature and level of the involvement of family members in Canada and Japan with their mentally ill relatives. Profound differences in how care was described and operationalised were found. Walmsley’s (2000) study assessed how clients in the US and Eire with severe and enduring mental illness were managed using a ‘partial hospitalisation’ strategy. Economic and cultural factors played a part in the differences identified, but professional differences existed over and above these factors. Anders et al. (1999) compared the care of patients held in secure environments in Hawaii and Japan, finding differences in the quality of the working environment and hence in morale and professional standards, and in the relevance of policies which the nurses were required to implement. The authors concluded that nursing practice quickly regresses and becomes fragmented when the environment of care is inappropriate. Lauri et al. (1999) compared nurses’ decision-making processes in mental health settings in Finland, Northern Ireland and the US. In Northern Ireland, nurses tended to use an analytical approach to decision-making; Finnish nurses combined analytical decision-making with intuition, and nurses in the US manifested mainly intuitive decision-making. The researchers could not explain why this should be so although they hypothesised that the nurses were influenced by factors beyond the culture in which they worked. Wright and Smith (1993) found significant differences between the work of nurses in Australia and the US and attributed this predominantly to personality differences rather than environmental or cultural factors. Critically reviewing comparative studies undertaken to date, Whyte et al. (1997) suggested that nurses should consider methodologies that go beyond mere self-reporting by nurses and
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instead embark on more rigorous observational studies which examine what nurses actually do in different countries. It has been argued that the close political and economic ties between the United States and the United Kingdom mean that what happens in America may foreshadow developments in health care in the UK (Putnam, 2001). With this in mind, the present study aimed to compare some aspects of the work of mental health nurses in the UK and the US with the intention of improving understanding of how mental health nursing in this country may evolve, of avoiding pitfalls and maximising opportunities.
3. Methodology Four sites were identified for this study, two in the UK (Staffordshire and Birmingham) and two in the US (Kentucky and Denver), principally because of their proximity to where the authors worked. An opportunistic sample of respondents was invited to participate as long as they satisfied the inclusion criteria which were being appropriately qualified, currently employed in mental health services, in post for at least 3 years and working directly with mental health clients. All respondents described their work as predominantly community-based, although some in both groups stated that they had contact with in-patient services, the extent of which was not explored. Whereas the entire UK sample worked in the National Health Service, the US nurses worked in three healthcare systems, all funded and managed differently, and influencing in their individual ways the type of patients admitted, the interventions provided by nurses and the length of time patients were in receipt of services. A specially designed 12-item questionnaire, based on the literature and the authors’ own experiences and understanding of mental health nursing practice, was piloted and modified in both countries. The questionnaire comprised closed and open-ended questions. The results of the pilot study enabled some modifications to the language used on the questionnaire to be made, to ensure that all the questions could be immediately understood by both sets of respondents. Permission to approach the respondents was sought from the manger in each setting and each respondent was given a full verbal explanation of the study, and given the choice of participating or not. Data collection took 2 days on each site with respondents completing the questionnaire at a time convenient to them.
4. Analysis of data The responses to open-ended questions were categorised by the researchers working first independently and then comparing categories. As will be seen from the
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Findings section, categories were generally easy to establish and there was little or no disagreement between the researchers. The w2 test was used to analyse some of the data.
5. Findings Of the 100 questionnaires distributed in the UK (50 in Staffordshire and 50 in Birmingham) 65 were returned completed (65% response rate; 28 males and 37 females). Eighty questionnaires were distributed in the US (40 in Kentucky and 40 in Denver) and 43 returned (54%; 2 males and 41 females). Therefore, an overall response rate of 60% across the two countries was achieved. There was a significant gender difference between the respondents from the two countries (w2 ¼ 19.047, p-valueo0.001), with many more men responding in the UK than in the US. The mean age of respondents in the UK, with standard deviation, was 41.68 years (SD, 7.06), and in the US, 50.49 years (SD, 7.89), a statistically significant difference (po0:001). The mean number of years in their current post was 7 for the UK nurses and 18 for the US nurses. Respondents were first asked to state the kind of client they least preferred caring for. The UK respondents most frequently mentioned people with a substance abuse problem; those with eating disorders; those with a history of violence and those with marital problems. However, the US nurses were much less likely to cite people with marital problems, eating disorders and a history of violence. They selected as their least favourite clients the parents of disturbed children followed by people with a substance abuse problem. Respondents were asked to indicate their level of agreement (‘strongly agree’, ‘neither agree nor disagree’, ‘strongly disagree’) with a series of statements concerning the work of mental health nurses. Table 1 shows the analysis of their responses. There were no significant differences between the two groups of nurses in response to six of the statements. Both groups agreed that being cost-effective is another term for rationing in mental health care; that they felt their role was threatened when mention is made of primary care teams assuming more responsibility for the delivery of mental health services; that patients with a serious mental illness should always be discouraged from stopping medication, and that community mental health nurses should be able to prescribe medication for their patients. Both disagreed with the statements that the role of ‘Keyworker’ is understood by each member of my team, and that disagreement about care interventions rarely occurs when colleagues in my team are involved with the same client. Three statements elicited responses that were significantly different between the two groups at the 5% level.
Table 1 Responses to the statements about the work of mental health nurses Statements
w2
df
p-Value
Most referrals from primary care are inappropriate The role of ‘Keyworker’ is understood by each member of my team Disagreement about care interventions rarely occurs when colleagues in my team are involved with the same client Being cost-effective is another term for rationing in mental health care I feel my role is threatened when mention is made of primary care teams assuming more responsibility for the delivery of mental health services There is ample time for professional development within my work I can refuse new referrals if my caseload exceeds an agreed number Patients with a serious mental illness should always be discouraged from stopping medication Many staff hold low expectations of clients’ abilities to recover I feel that community mental health nurses are valued in my organisation Community mental health nurses should be able to prescribe medication for their patients
10.062
2
0.007 **
3.119
2
0.210
2.211
2
0.331
0.121
2
0.941
1.753
2
0.416
8.890
2
0.012 *
7.767
2
0.021 *
5.939
2
0.051
6.580
2
0.037 *
9.335
2
0.009 **
4.720
2
0.095
*Significant at 5% level; **Significant at 1% level.
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Significantly more US nurses disagreed with the statement that most referrals from primary care are inappropriate; and significantly more US nurses agreed with the fact that I can refuse new referrals if my caseload exceeds an agreed number, and with the assertion that there is ample time for professional development within my work. Two statements elicited responses that were significantly different between the two groups at the 1% level. Significantly more US nurses felt that many staff hold low expectations of clients’ ability to recover and agreed with the statement that I feel that community mental health nurses are valued in my organization. Respondents were next requested to state what aspects of their work gave them most satisfaction. This question evoked a huge range of responses which were categorised by the researchers working first independently and then together in order to secure agreement. Table 2 presents the categories in rank order: For UK respondents, Client Contact meant ‘being able to assist people’; ‘caring for the enduring mentally ill in their homes’; ‘communicating with ethnic minority families’ and ‘engaging with difficult clients’. Under Using Clinical Skills, respondents mentioned ‘undertaking assessments’; ‘care planning’; ‘having appropriate time and skills’; ‘identifying appropriate treatment’ and ‘implementing evidence based practice’. Knowing I am Doing a Good Job meant ‘seeing patients improve’; ‘having appreciative clients’; ‘helping patients regain independence’ and ‘making a difference to individuals and families’. Team Working comprised ‘feeling part of a team’; ‘sharing ideas and problems and finding team solutions’ and ‘working with a wide range of professionals’. The opportunity to mentor students and improve their own skills as well as the skills of others was the principal aspect enjoyed under the heading of Teaching. US nurses, on the other hand, interpreted Client Contact as meaning ‘supporting individual clients’ and ‘leading therapy groups’. Using Clinical Skills meant being involved in ‘crisis intervention’; ‘developing
Table 2 Aspects of your work that give most satisfaction (numbers rounded to nearest whole figure) UK respondents (n ¼ 65)
US respondents (n ¼ 43)
Client contact Using clinical skills Knowing I am doing a good job Team working
Client contact Using clinical skills Teaching
Teaching
36 (55%) 22 (34%) 22 (34%) 17 (26%) 7 (11%)
Receiving positive feedback Team working Personal growth
25 (58%) 12 (28%) 10 (23%) 7 (16%) 4 (9%) 4 (9%)
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patient care programmes’; ‘medication review’; ‘observing, treating and managing patients’ and ‘doing psychotherapy’. Under the heading Teaching, respondents mentioned most importantly, ‘being with students’; ‘providing clinical supervision’; ‘mentoring and developing staff’ and ‘teaching and educating patients’. Two sub-themes emerged under the heading Receiving Positive Feedback and these were ‘seeing people improve’ and ‘being valued’. Team Working included ‘having support from colleagues’ and ‘working as a member of a team’. Personal Growth meant having a job that involved ‘intellectual stimulation’ and which provided the opportunity for one’s own ‘personal, spiritual and professional growth’. Table 3 provides a summary of respondents’ answers to What aspects of your work give you least satisfaction? Under Administration, the UK respondents mentioned ‘litigation administration’; ‘mindless paper work’; ‘non-clinical-related paperwork’; ‘pointless administration’ and ‘lack of admin support staff’. Lack of Support meant ‘working with difficult staff’; ‘feeling alone’; ‘having work undervalued by other professionals’; ‘lack of cooperation from other services’; ‘lack of managerial support’ and ‘isolation’. Overload included comments such as ‘being expected to know everything’; ‘caring responsibilities for a large number of patients’; ‘having too much to do’; ‘insufficient time for clients’; not having time for one’s self’; ‘too much travelling’ and ‘pressure and stress’. The Poor Communication category gathered together comments such as ‘assessing inappropriate referrals’; ‘un-thoughtful referrals’ and ‘duplication of information’. Meetings was a category of a single word not considered to require further definition by respondents. Lack of Resources was a general complaint, including specifically for two individuals ‘lack of office space’ and ‘having to write notes in longhand and then transfer them to a computer later’. Under ‘Administration’, the US respondents mentioned ‘administration for insurance companies’ and ‘billing insurance companies’. Managed Care caused distress owing to ‘arbitrary decisions made by management’; ‘being audited by managed care companies’; ‘arguing for reimbursement’; ‘being controlled’ and ‘needing authorisation’. Clients led to dissatisfaction when it was a case of ‘chronicity of the patient who does not improve’; ‘families that want quick fixes’; ‘nonrespectful attitudes’ and ‘parents who will not get involved’. Under ‘Lack of Support’, US respondents mentioned ‘dealing with difficult staff’; ‘justifying the work to the general public’ and ‘little support from management’. When it was defined, Lack of Resources meant ‘working with an insufficient budget’; ‘reducing staff numbers’; ‘limited psychiatric resources’ and ‘lack of time to treat effectively’. Respondents were asked to identify the ‘personal values that assist me most in my work’. Many of the
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Table 3 Aspects of work giving least satisfaction (numbers rounded to nearest whole figure)
Table 4 Models of care used by the two groups of respondents (numbers rounded to nearest whole figure)
UK respondents (n ¼ 65)
US respondents (n ¼ 43)
UK nurses (n ¼ 65)
Administration Lack of support Overload Poor communication Meetings Lack of resources
Administration Managed care Lack of resources Clients
CBT Eclectic Peplau Rogers Client-centred Psycho-social interventions Newman Family therapy Humanist Roper Solution-focused Problem-solving Medical model Orem Egan
39 20 18 12
(60%) (31%) (28%) (18%)
8 (12%) 3 (5%)
Lack of support
20 17 6 5
(46%) (39%) (14%) (12%)
4 (9%)
responses tended to describe ‘skills’ or ‘qualities’ rather than ‘values’. Responses were therefore categorised under these three headings but the categories were hard to operationalise. The UK respondents wrote extensively about skills such as the ‘ability to prioritise’ and ‘being organised’ which were mentioned by a third of the sample. ‘Adaptability’ and ‘flexibility’ were considered vital as were ‘being a team player’ and the ‘ability to get on with people’. ‘Communication skills’ were also regularly mentioned. Key personal qualities included being ‘empathic’, ‘non-judgemental’ and ‘caring’; having ‘patience’ and ‘commitment’; being ‘open-minded’, ‘honest’ and having a ‘sense of humour’. ‘Experience of life’ was mentioned by a third of the sample as a personal attribute of great importance in the job. The beliefs and values of the UK respondents included ‘believing in the worth of people’; ‘believing that what I do will have a beneficial effect’; believing that ‘individuals should take responsibility for themselves;’ that ‘people deserve a good service’; that ‘people can change/ recover’ and believing in the ‘value of social inclusion’ and ‘humanistic approaches’. US respondents valued skills of ‘team working’; ‘collaboration’ and ‘being able to challenge’. They felt that personal qualities essential to their work were ‘love of people’; ‘commitment to the clients’ well-being’; ‘respecting people’ and ‘commitment to providing a service for all patients regardless of the ability to pay’. They valued ‘humanistic’ approaches to care; believed in ‘nursing as caring’, that team work should be ‘ethical’ and that it was important to ‘value the individual’. Table 4 summarises their responses to the question ‘what models of care do you normally base your work on’? Although a wide range of models was cited by nurses, respondents were largely in agreement regarding the ones they most regularly use, CBT (UK: 20%; US: 28%), Eclectic (UK: 12%; US: 28%) and Peplau (UK: 15%; US: 23%). The responses suggest that some nurses utilise more than one model, although the questionnaire
US nurses (n ¼ 43) 13 8 10 7 6 5
(20%) (12%) (15%) (11%) (9%) (8%)
CBT Eclectic Peplau Solution-focused Orem Psycho-dynamic
12 12 10 4 3 3
(28%) (28%) (23%) (9%) (7%) (7%)
5 5 4 4 4 3 3 3 3
(8%) (8%) (6%) (6%) (6%) (5%) (5%) (5%) (5%)
Watson Rogers Parse Psycho-analytic Sullivan
3 2 2 2 2
(7%) (5%) (5%) (5%) (5%)
Table 5 Suggestions for improving patient care (numbers rounded to nearest whole figure) UK nurses (n ¼ 65)
US nurses (n ¼ 43)
Reducing referrals and case load Increasing resources Improved access to training Reducing amount of administration Better communication and team working Better access to supervision
Improved education and training Reduced caseloads Improved resources Abolishing managed care
26 (40%)
16 (25%) 9 (14%) 8 (12%)
8 (12%)
Better access to supervision
13 (30%)
12 (28%) 11 (25.5%) 4 (9%)
3 (7%)
4 (6%)
did not elicit under what circumstances they choose certain models. Finally, respondents were asked how the care they provide for clients could be improved (Table 5): Under Reducing Referrals and Case-Loads, the UK respondents mentioned ‘having more appropriate referrals’; ‘lower case-load’; ‘fewer visits to improve quality of care’ and ‘having more time for clients’. Increasing resources meant ‘having more staff’. Under Reducing Amount of Administration, they mentioned ‘less admin-
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istration’ and ‘improved support’. Improved access to training involved ‘attending courses on Brief Therapy’; ‘CBT training’; ‘having specific training in counselling’; ‘more access to training and education’; ‘more personal development’ and ‘skills based training’. Better Communication and Team Working revolved around ‘better liaison with primary care’; ‘better relationships with consultants’; ‘better working with other professionals’; ‘better team organisation’ and ‘joint working with GPs on difficult cases’. Better access to supervision also meant more supervision. For the US respondents, Reduced Case-loads would mean ‘having more time for clients’. Improved education and training necessitated ‘having access to professional education’; ‘learning better ways for helping clients’; ‘more psycho-education programmes’ and ‘more personal development’. Under Improved Resources, respondents mentioned wanting ‘more staff’; ‘more funding’; ‘more space’; ‘more time for admin’ and ‘providing time for treatment team planning and meetings’. Abolishing Managed Care was variously expressed as ‘less managed care involvement’ and ‘less contact with insurance companies’. Like their UK counterparts, the US nurses wanted Better access to supervision and this also meant more supervision.
6. Discussion Any study exploring the work and attitudes of nurses working in different countries, even two which share a common language, and in very different health care contexts, can be accused of attempting to make comparisons where none are possible. However, this study achieved a very high response rate which suggests that the nurses in both the UK and the US felt that the questions they were being asked were relevant to their particular situations. Interpretation of their responses has been undertaken with caution; yet the considerable consensus in terms of the words and phrases used by respondents and the ideas and concepts they put forward make it possible to feel reasonably confident about the conclusions drawn in this section. An important limitation of the study is that very few male US nurses (n ¼ 2) responded to the questionnaire. At the time of data collection, only two men expressed an interest in the study and satisfied the inclusion criteria. Other males with a nursing background who were interested in the study had to be ruled out because of their management roles. It may be the case that males felt less sympathetic than females towards a study emanating from the UK, although there was no obvious evidence of this. The small number of males means that the comparisons between the two groups of nurses are not as strong or perhaps as illuminating as they would otherwise have been.
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It needs also to be borne in mind that the nurses who responded to the study were, in both countries, working in large towns and cities which may involve them in different kinds of work, and in facing different challenges from those working in other settings. While the small number of respondents must be taken into account, it is interesting to note that the mean age of respondents from the US was considerably higher than in the UK, and that US nurses had also spent many more years in their current post. This might suggest that US nurses tend to stay in one post, while their UK counterparts change jobs more regularly. If this observation is accurate, it may reflect the diversity of clients and experiences that US nurses working in private practice can achieve compared to UK nurses who may need to change their jobs regularly in order to achieve the same breadth of experience. It would also appear that US nurses are less likely to label certain groups of clients as their ‘least favourite’, perhaps because they are more confident in their skills to care for diverse clients, or quite simply because the US system of Managed Care obliges them to take whichever clients present to them. UK nurses appeared either to be anxious about or irritated by people who have substance abuse problems, those with eating disorders and those with a history of violence. This is worthy of further investigation. Does this reluctance arise because nurses find these clients unrewarding in terms of ‘cure’ rates, or because they are fearful for their own safety in the case of violent patients? On both sides of the Atlantic, there appears to be cynicism regarding the use of cost-effectiveness as a euphemism for rationing in mental health care. One might have expected that the US respondents would feel positively about community mental health nurses being able to prescribe as nurse prescribing has a long history in the States; it is slightly more surprising that the notion of prescribing is apparently already well-embedded in the UK nursing mentality. US mental health nurses appear to exercise greater control over their work, attracting appropriate referrals from primary care and being able to limit their caseloads. They also seem better supported in terms of professional developmental; all three of these issues caused concern for UK nurses whose job descriptions seem to leave them more open to caseload overload without the buttressing of ongoing training. Both groups of nurses found their major source of job satisfaction in direct contact with clients and their major source of job dissatisfaction in the administrative duties which took them away from clients. Moves in the UK to reduce paperwork for some public sector workers such as police officers need urgently to be translated into the health care sector to enable people to do the work for which they originally entered the service and to which they are presumably best suited. The US nurse
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respondents appeared to feel much more valued for the work they were doing that than their UK colleagues. Desire for recognition may be the reason why UK nurses cited (perhaps somewhat wistfully?) one of the components of job satisfaction as ‘knowing I am doing a good job’, a comment which might hide a lack of such acknowledgement from others. Future studies could usefully explore what aspects of the work of US nurses leads to their feeling more valued than UK nurses, despite the manifold difficulties which they face working within an insurance-driven healthcare system. UK nurses defined the qualities and skills that helped them in their work in relation to the difficulties they perceived they faced as nurses. They considered organisational skills important, presumably because these assisted with a heavy workload, and the ability to work well in a team, perhaps because they so often felt undervalued by other team members. For their part, US nurses valued skills and qualities which helped them in the US health care context: being able to challenge a system driven by money rather than by client need; commitment to the client’s well-being which is perhaps overlooked when insurance companies determine the nature and level of care; and commitment to providing a service regardless of the ability to pay, perhaps indicating their sense of injustice when only the wealthy have easy access to services. Thus health care professionals value qualities that enable them to cope with the job they have to do in the place they have to do it, over and above generic qualities which might apply to all healthcare work. This is despite the fact that both groups of nurses were using the same models of care. The request for more training came from both groups and probably reflects the perceived difficulties of working with clients with complex and multiple pathologies when resources do not allow nurses to give the time they feel individual clients require. The request for more training may be closely linked to complaints about lack of support which surfaced in other areas of the questionnaire. Training needs can never perhaps be ultimately satisfied, but where nurses feel that their work is undervalued, and that they are often asked to do work which they do not see as their principal role, the demand for more training is likely to emerge as a compensatory mechanism. There may be many explanations for why UK nurses express unease about dealing with violent or potentially violent patients, and US nurses do not. Speculative reasons may include inadequate training of UK nurses in how to defuse potentially violent situations and in how to handle them should they occur. Media coverage of adverse incidents where patients were incorrectly restrained may have fuelled anxiety on the part of UK nurses generally. UK nurses may feel that support from medical and management staff is lacking if incidents occur and that they will shoulder the blame while other
staff groups cover their own backs. In the US, the situation may be different. Insurance companies may filter out highly challenging patients, who could prove costly in terms of the time, human and material resources they require. It may be that the training of US nurses in handling violent events is superior to that of their UK counterparts. The responses of UK and US nurses to violent patients is an area of difference which is one of considerable interest and deserves further research attention.
7. Conclusion This study confirms the work of Weiller et al. (1998), Yamashita (1998) and Nolan et al. (2001), in relation to similarities and differences in the work of mental health nurses. However, the present study moves a little further in exploring the key question as to the influence that different organisational cultures may have on how individual nurses and teams of nurses construct their role. Seeking to account for these differences and to project how changes in the nursing culture in any particular country might affect outcomes for patients must now be the focus of research (Wright and Smith (1993). In terms of helping focus the needs of UK mental health nurses by contrasting them with those of colleagues in the US, this study supports Smoyak’s (1996) claim that there is much to be gained from comparative studies and the analyses they promote.
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ARTICLE IN PRESS P. Nolan et al. / International Journal of Nursing Studies 44 (2007) 377–385 Harris, H., Brewster, C., Sparrow, P., 2001. Globalisation and HR. Chartered Institute of Personnel and Development (CIPD), London. Hull, D.L., 1988. Science as a Process. The University of Chicago Press, Chicago and London. Lauri, S., Salanterae, S., Gilje, F., Klose, P., 1999. Decision making of psychiatric nurses in Finland, Northern Ireland and the United States. Journal of Professional Nursing 15, 275–280. Mead, G., Ashcroft, J., 2005. The Case for Inter-Professional Collaboration. Blackwell, Oxford. Nolan, P., 1999. Community psychiatric nursing. In: Freeman, H. (Ed.), A Century of Psychiatry. Mosby-Wolfe, London, pp. 332–333. Nolan, P., Soares, J., Dallender, J., Thomsen, S., Arnetz, B., 2001. A comparative study of the experiences of violence of English and Swedish mental health nurses. International Journal of Nursing Studies 38, 419–426. Nolan, P., Bourke, P., Doran, M., 2002. UK and US clinical mental health nurse specialists’ perceptions of their work. Journal of Psychiatric and Mental Health Nursing 9, 293–300. Putnam, R., 2001. Bowling Alone. Simon and Schuster, New York. Simpson, A., Miller, C., Bowers, L., 2003. The history of the Care Programme Approach in England: Where did it come from? Journal of Mental Health 12, 489–504.
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Smoyak, S., 1996. International net-worker: a network for psychiatric and mental health nurses around the world. Nursing Times 92, 93. Spradley, B.W., Allender, J.A., 1997. Readings in Community Health Nursing. Lippincott, New York. Tilley, S., 2004. Re-Reading Altschul: A Festschrift. Hypatia Trust, Penzance. Verheis, R.A., Kerkstra, A., 1993. International comparative study of community nursing. Journal of Advanced Nursing 18, 1852–1853. Walmsley, P., 2000. Partial to holistic care. Nursing Times 96, 38–39. Weiller, E., Bisserbe, J., Maier, W., Lecrubier, Y., 1998. Prevalence and recognition of anxiety syndromes in five European primary care settings. British Journal of Psychiatry 173, 18–23. Whyte, C., Motyka, M., Motyka, H., Wsolak, R., 1997. Polish and British nurses responses to patient need. Nursing Standard 38, 43–47. Wright, C., Smith, J., 1993. Personality profiles of nurses: a comparison between Australia and US research findings. Australian Journal of Advanced Nursing 10, 10–19. Yamashita, M., 1998. Family coping with mental illness: a comparative study. Journal of Psychiatric and Mental Health Nursing 5, 515–523.
International Journal of Nursing Studies 44 (2007) 377–385 www.elsevier.com/locate/ijnurstu
A comparative cross-sectional questionnaire survey of the work of UK and US mental health nurses Peter Nolana,, Sayeed Haqueb, Maureen Doranc a
School of Health and Sciences, Staffordshire University and South Staffordshire Healthcare Trust, Blackheath Lane, Stafford, ST18 0AD, UK b Department of Psychiatry, University of Birmingham, UK c Associative Clinical Director, The Veterans’ Administration Medical Centre, Denver, Colorado, UK Received 26 June 2005; received in revised form 24 April 2006; accepted 24 April 2006
Abstract Background: Comparative inter-country research which identifies similarities and differences in the work of mental health nurses in different social and political contexts is an important means of determining how changes in health care systems could lead to better outcomes for patients. Objective: This study sought to compare aspects of the work of nurses in US and UK mental health care settings. Nurses were invited to reflect on aspects of their role including identifying the most and least satisfying elements of their work and suggesting ways in which it could be improved. Methods and participants: A 12-item questionnaire, comprising closed and open-ended questions, based on the literature and the authors’ own experiences of mental health nursing practice, was piloted and subsequently distributed to respondents in both countries. Results: The US nurses tended to be more willing to accept a wider range of clients than their UK counterparts, although they had lower expectations of their clients’ likelihood of recovery. Both groups of nurses felt that being part of a team and having direct contact with clients were the most satisfying aspects of their work, while administration was the least. Although both US and UK nurses utilised a variety of intervention models, it would appear that Cognitive Behavioural Therapy was the favoured model for the majority of nurses. Conclusions: The implications of these findings for the work of nurses and mental health care services in the UK and US, and the purpose, nature and need for future international comparative research are discussed. r 2006 Elsevier Ltd. All rights reserved. Keywords: Inter-country research; Cross-cultural exploration; Role of the nurse
What is already known about the topic?
More international studies are needed to compare the contribution of nurses to alleviating the burden of mental health problems.
The selection, preparation and work of mental health
nurses appear to vary considerably from country to country. Few comparative international studies focusing on the work of mental health nurses exist.
Corresponding author. Tel.: +44 1785 353702.
What this paper adds
It contributes to our understanding of the work of
E-mail address: [email protected] (P. Nolan). 0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2006.04.014
nurses in different countries.
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378
It
defines which aspects of their work nurses find most and least satisfying. It explores nurses’ perceptions of the environmental and cultural factors which influence how they approach their work.
1. Introduction Globalisation, defined as the decoupling of space and time (Giddens, 2001), is now impacting on many aspects of people’s lives including the manner in which health care is provided. Instant communication enables knowledge and culture to be shared around the world in seconds and has implications not only for those with responsibility for planning and financing services, but also for those engaged in delivering them. Health care programmes need to be responsive to global changes and health care personnel will need to become competent in negotiation, analytical and strategic thinking skills, and the assessment of national and cultural differences (Spradley and Allender, 1997; Harris et al., 2001). In mental health, increased sharing of knowledge has enabled nurses in different parts of the world to compare and contrast their work in diverse health care systems and socio-political traditions (Verheis and Kerkstra, 1993; Smoyak, 1996). Hull (1988) suggests that cross-cultural exploration enables us to highlight deficits in our own mental health care and Mead and Ashcroft (2005) argue that international collaboration is one of the principal ways of learning how nurses can improve the work they do.
2. Literature review Although there are few rigorous international comparative studies in mental health nursing, nevertheless the number of such studies is increasing, resulting in a clearer understanding of the nature of the work of mental health nurses worldwide. As this review indicates, studies have been largely researcher-initiated and undertaken independent of each other. The first scholarly work relating to the role and function of the mental health nurse at the beginning of the 20th century appeared in the United States (Nolan et al., 2002) and by the middle of the century, literature from other countries was following suit, seeking to find ways of strengthening the contribution of the nurse to mental health services (Callaway, 2002). During the 1950 s and 1960 s, some attention was given to mental health nursing at professional meetings and international conferences organised by psychiatrists. Although psychiatrists had been making educational visits abroad since the second half of the 19th century, it was not until
the 1950s that the first psychiatric nurses from the UK went to Scandinavia to learn more about their profession in relation to the work being done in other countries (Nolan, 1999). In the early 1960 s, Altschul went to the States for a 1-year study tour and subsequently wrote her seminal book Patient–Nurse Interaction: a study of interactive patterns in acute psychiatric wards, exploring how interpersonal relationships assist recovery from mental illness (Altschul, 1972; Tilley, 2004). Today, international educational exchanges and research collaboration flourish; case management, the Care Programme Approach, drop-in centres, and nurse prescribing have all been heavily influenced by observations made in other countries (Simpson et al., 2003). Smoyak (1996) recommended comparative research as a means of testing the efficacy of nursing in different contexts, and of defining the work that nurses do and the conditions in which it yields the best outcomes. She invited nurse–researchers to go beyond attending conferences in other countries and to seek funding for international studies, despite the reluctance of many funding bodies to consider research of this nature. Work already done in an international context has proved thought-provoking. Barker (2000) reported that clients in Canada and Scotland had similar expectations of the nurse–client relationship, which they saw as finding its natural context in the clinical situation. Adejumo and Ehlers (2001), however, found that mental health nursing was defined very differently in Botswana and Nigeria, two countries which might have been expected to have shared a similar understanding by virtue of their proximity, although in both, the focus of nursing was on caring for groups of people in their everyday social contexts. Bowers et al. (1999) explored the number and nature of violent incidents in in-patient care in five European countries. Considerable differences in the number and nature of such incidents were found. However, the researchers faced methodological difficulties owing to there being no shared definition of violence across the five countries, and no consensus on how to record such incidents. These disparities provided some explanation for the variations in incidence and nature, but could not provide a full explanation. Other factors such as staffing levels, the therapeutic skills of nurses, and the ways in which potential conflict was handled were also considered by the authors to be significant and they called for further studies to ascertain the true prevalence of violence in mental health settings in Europe, its causes and the role of nurses in containing and preventing it. In a similar smaller study, Nolan et al. (2001) found that mental health nurses in England encountered more violence in the course of their work than colleagues in Sweden, and reported that repeated exposure to violent incidents eroded nurses’ self-esteem and job-satisfaction.
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Swedish nurses experienced less violence and had greater support, leading to enhanced professional morale. Weiller et al. (1998) examined provision for patients with anxiety syndromes and high levels of social disability in five European countries. This study took place in the context of European Union and World Health Organisation directives that planners and providers should prioritise services for people with mental health problems in primary care. The researchers concluded that provision was generally poor; in two countries, there were no services at all. The poverty of primary care services meant that some patients would require more expensive treatment following inevitable deterioration. General Practitioners were found to need more training in the management and treatment of mentally ill people but the researchers considered that this would be inadequate without a transformation in the culture of primary care in order to improve mental health services. Yamashita (1998) examined the cultural context in which care is provided, comparing the nature and level of the involvement of family members in Canada and Japan with their mentally ill relatives. Profound differences in how care was described and operationalised were found. Walmsley’s (2000) study assessed how clients in the US and Eire with severe and enduring mental illness were managed using a ‘partial hospitalisation’ strategy. Economic and cultural factors played a part in the differences identified, but professional differences existed over and above these factors. Anders et al. (1999) compared the care of patients held in secure environments in Hawaii and Japan, finding differences in the quality of the working environment and hence in morale and professional standards, and in the relevance of policies which the nurses were required to implement. The authors concluded that nursing practice quickly regresses and becomes fragmented when the environment of care is inappropriate. Lauri et al. (1999) compared nurses’ decision-making processes in mental health settings in Finland, Northern Ireland and the US. In Northern Ireland, nurses tended to use an analytical approach to decision-making; Finnish nurses combined analytical decision-making with intuition, and nurses in the US manifested mainly intuitive decision-making. The researchers could not explain why this should be so although they hypothesised that the nurses were influenced by factors beyond the culture in which they worked. Wright and Smith (1993) found significant differences between the work of nurses in Australia and the US and attributed this predominantly to personality differences rather than environmental or cultural factors. Critically reviewing comparative studies undertaken to date, Whyte et al. (1997) suggested that nurses should consider methodologies that go beyond mere self-reporting by nurses and
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instead embark on more rigorous observational studies which examine what nurses actually do in different countries. It has been argued that the close political and economic ties between the United States and the United Kingdom mean that what happens in America may foreshadow developments in health care in the UK (Putnam, 2001). With this in mind, the present study aimed to compare some aspects of the work of mental health nurses in the UK and the US with the intention of improving understanding of how mental health nursing in this country may evolve, of avoiding pitfalls and maximising opportunities.
3. Methodology Four sites were identified for this study, two in the UK (Staffordshire and Birmingham) and two in the US (Kentucky and Denver), principally because of their proximity to where the authors worked. An opportunistic sample of respondents was invited to participate as long as they satisfied the inclusion criteria which were being appropriately qualified, currently employed in mental health services, in post for at least 3 years and working directly with mental health clients. All respondents described their work as predominantly community-based, although some in both groups stated that they had contact with in-patient services, the extent of which was not explored. Whereas the entire UK sample worked in the National Health Service, the US nurses worked in three healthcare systems, all funded and managed differently, and influencing in their individual ways the type of patients admitted, the interventions provided by nurses and the length of time patients were in receipt of services. A specially designed 12-item questionnaire, based on the literature and the authors’ own experiences and understanding of mental health nursing practice, was piloted and modified in both countries. The questionnaire comprised closed and open-ended questions. The results of the pilot study enabled some modifications to the language used on the questionnaire to be made, to ensure that all the questions could be immediately understood by both sets of respondents. Permission to approach the respondents was sought from the manger in each setting and each respondent was given a full verbal explanation of the study, and given the choice of participating or not. Data collection took 2 days on each site with respondents completing the questionnaire at a time convenient to them.
4. Analysis of data The responses to open-ended questions were categorised by the researchers working first independently and then comparing categories. As will be seen from the
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Findings section, categories were generally easy to establish and there was little or no disagreement between the researchers. The w2 test was used to analyse some of the data.
5. Findings Of the 100 questionnaires distributed in the UK (50 in Staffordshire and 50 in Birmingham) 65 were returned completed (65% response rate; 28 males and 37 females). Eighty questionnaires were distributed in the US (40 in Kentucky and 40 in Denver) and 43 returned (54%; 2 males and 41 females). Therefore, an overall response rate of 60% across the two countries was achieved. There was a significant gender difference between the respondents from the two countries (w2 ¼ 19.047, p-valueo0.001), with many more men responding in the UK than in the US. The mean age of respondents in the UK, with standard deviation, was 41.68 years (SD, 7.06), and in the US, 50.49 years (SD, 7.89), a statistically significant difference (po0:001). The mean number of years in their current post was 7 for the UK nurses and 18 for the US nurses. Respondents were first asked to state the kind of client they least preferred caring for. The UK respondents most frequently mentioned people with a substance abuse problem; those with eating disorders; those with a history of violence and those with marital problems. However, the US nurses were much less likely to cite people with marital problems, eating disorders and a history of violence. They selected as their least favourite clients the parents of disturbed children followed by people with a substance abuse problem. Respondents were asked to indicate their level of agreement (‘strongly agree’, ‘neither agree nor disagree’, ‘strongly disagree’) with a series of statements concerning the work of mental health nurses. Table 1 shows the analysis of their responses. There were no significant differences between the two groups of nurses in response to six of the statements. Both groups agreed that being cost-effective is another term for rationing in mental health care; that they felt their role was threatened when mention is made of primary care teams assuming more responsibility for the delivery of mental health services; that patients with a serious mental illness should always be discouraged from stopping medication, and that community mental health nurses should be able to prescribe medication for their patients. Both disagreed with the statements that the role of ‘Keyworker’ is understood by each member of my team, and that disagreement about care interventions rarely occurs when colleagues in my team are involved with the same client. Three statements elicited responses that were significantly different between the two groups at the 5% level.
Table 1 Responses to the statements about the work of mental health nurses Statements
w2
df
p-Value
Most referrals from primary care are inappropriate The role of ‘Keyworker’ is understood by each member of my team Disagreement about care interventions rarely occurs when colleagues in my team are involved with the same client Being cost-effective is another term for rationing in mental health care I feel my role is threatened when mention is made of primary care teams assuming more responsibility for the delivery of mental health services There is ample time for professional development within my work I can refuse new referrals if my caseload exceeds an agreed number Patients with a serious mental illness should always be discouraged from stopping medication Many staff hold low expectations of clients’ abilities to recover I feel that community mental health nurses are valued in my organisation Community mental health nurses should be able to prescribe medication for their patients
10.062
2
0.007 **
3.119
2
0.210
2.211
2
0.331
0.121
2
0.941
1.753
2
0.416
8.890
2
0.012 *
7.767
2
0.021 *
5.939
2
0.051
6.580
2
0.037 *
9.335
2
0.009 **
4.720
2
0.095
*Significant at 5% level; **Significant at 1% level.
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Significantly more US nurses disagreed with the statement that most referrals from primary care are inappropriate; and significantly more US nurses agreed with the fact that I can refuse new referrals if my caseload exceeds an agreed number, and with the assertion that there is ample time for professional development within my work. Two statements elicited responses that were significantly different between the two groups at the 1% level. Significantly more US nurses felt that many staff hold low expectations of clients’ ability to recover and agreed with the statement that I feel that community mental health nurses are valued in my organization. Respondents were next requested to state what aspects of their work gave them most satisfaction. This question evoked a huge range of responses which were categorised by the researchers working first independently and then together in order to secure agreement. Table 2 presents the categories in rank order: For UK respondents, Client Contact meant ‘being able to assist people’; ‘caring for the enduring mentally ill in their homes’; ‘communicating with ethnic minority families’ and ‘engaging with difficult clients’. Under Using Clinical Skills, respondents mentioned ‘undertaking assessments’; ‘care planning’; ‘having appropriate time and skills’; ‘identifying appropriate treatment’ and ‘implementing evidence based practice’. Knowing I am Doing a Good Job meant ‘seeing patients improve’; ‘having appreciative clients’; ‘helping patients regain independence’ and ‘making a difference to individuals and families’. Team Working comprised ‘feeling part of a team’; ‘sharing ideas and problems and finding team solutions’ and ‘working with a wide range of professionals’. The opportunity to mentor students and improve their own skills as well as the skills of others was the principal aspect enjoyed under the heading of Teaching. US nurses, on the other hand, interpreted Client Contact as meaning ‘supporting individual clients’ and ‘leading therapy groups’. Using Clinical Skills meant being involved in ‘crisis intervention’; ‘developing
Table 2 Aspects of your work that give most satisfaction (numbers rounded to nearest whole figure) UK respondents (n ¼ 65)
US respondents (n ¼ 43)
Client contact Using clinical skills Knowing I am doing a good job Team working
Client contact Using clinical skills Teaching
Teaching
36 (55%) 22 (34%) 22 (34%) 17 (26%) 7 (11%)
Receiving positive feedback Team working Personal growth
25 (58%) 12 (28%) 10 (23%) 7 (16%) 4 (9%) 4 (9%)
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patient care programmes’; ‘medication review’; ‘observing, treating and managing patients’ and ‘doing psychotherapy’. Under the heading Teaching, respondents mentioned most importantly, ‘being with students’; ‘providing clinical supervision’; ‘mentoring and developing staff’ and ‘teaching and educating patients’. Two sub-themes emerged under the heading Receiving Positive Feedback and these were ‘seeing people improve’ and ‘being valued’. Team Working included ‘having support from colleagues’ and ‘working as a member of a team’. Personal Growth meant having a job that involved ‘intellectual stimulation’ and which provided the opportunity for one’s own ‘personal, spiritual and professional growth’. Table 3 provides a summary of respondents’ answers to What aspects of your work give you least satisfaction? Under Administration, the UK respondents mentioned ‘litigation administration’; ‘mindless paper work’; ‘non-clinical-related paperwork’; ‘pointless administration’ and ‘lack of admin support staff’. Lack of Support meant ‘working with difficult staff’; ‘feeling alone’; ‘having work undervalued by other professionals’; ‘lack of cooperation from other services’; ‘lack of managerial support’ and ‘isolation’. Overload included comments such as ‘being expected to know everything’; ‘caring responsibilities for a large number of patients’; ‘having too much to do’; ‘insufficient time for clients’; not having time for one’s self’; ‘too much travelling’ and ‘pressure and stress’. The Poor Communication category gathered together comments such as ‘assessing inappropriate referrals’; ‘un-thoughtful referrals’ and ‘duplication of information’. Meetings was a category of a single word not considered to require further definition by respondents. Lack of Resources was a general complaint, including specifically for two individuals ‘lack of office space’ and ‘having to write notes in longhand and then transfer them to a computer later’. Under ‘Administration’, the US respondents mentioned ‘administration for insurance companies’ and ‘billing insurance companies’. Managed Care caused distress owing to ‘arbitrary decisions made by management’; ‘being audited by managed care companies’; ‘arguing for reimbursement’; ‘being controlled’ and ‘needing authorisation’. Clients led to dissatisfaction when it was a case of ‘chronicity of the patient who does not improve’; ‘families that want quick fixes’; ‘nonrespectful attitudes’ and ‘parents who will not get involved’. Under ‘Lack of Support’, US respondents mentioned ‘dealing with difficult staff’; ‘justifying the work to the general public’ and ‘little support from management’. When it was defined, Lack of Resources meant ‘working with an insufficient budget’; ‘reducing staff numbers’; ‘limited psychiatric resources’ and ‘lack of time to treat effectively’. Respondents were asked to identify the ‘personal values that assist me most in my work’. Many of the
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Table 3 Aspects of work giving least satisfaction (numbers rounded to nearest whole figure)
Table 4 Models of care used by the two groups of respondents (numbers rounded to nearest whole figure)
UK respondents (n ¼ 65)
US respondents (n ¼ 43)
UK nurses (n ¼ 65)
Administration Lack of support Overload Poor communication Meetings Lack of resources
Administration Managed care Lack of resources Clients
CBT Eclectic Peplau Rogers Client-centred Psycho-social interventions Newman Family therapy Humanist Roper Solution-focused Problem-solving Medical model Orem Egan
39 20 18 12
(60%) (31%) (28%) (18%)
8 (12%) 3 (5%)
Lack of support
20 17 6 5
(46%) (39%) (14%) (12%)
4 (9%)
responses tended to describe ‘skills’ or ‘qualities’ rather than ‘values’. Responses were therefore categorised under these three headings but the categories were hard to operationalise. The UK respondents wrote extensively about skills such as the ‘ability to prioritise’ and ‘being organised’ which were mentioned by a third of the sample. ‘Adaptability’ and ‘flexibility’ were considered vital as were ‘being a team player’ and the ‘ability to get on with people’. ‘Communication skills’ were also regularly mentioned. Key personal qualities included being ‘empathic’, ‘non-judgemental’ and ‘caring’; having ‘patience’ and ‘commitment’; being ‘open-minded’, ‘honest’ and having a ‘sense of humour’. ‘Experience of life’ was mentioned by a third of the sample as a personal attribute of great importance in the job. The beliefs and values of the UK respondents included ‘believing in the worth of people’; ‘believing that what I do will have a beneficial effect’; believing that ‘individuals should take responsibility for themselves;’ that ‘people deserve a good service’; that ‘people can change/ recover’ and believing in the ‘value of social inclusion’ and ‘humanistic approaches’. US respondents valued skills of ‘team working’; ‘collaboration’ and ‘being able to challenge’. They felt that personal qualities essential to their work were ‘love of people’; ‘commitment to the clients’ well-being’; ‘respecting people’ and ‘commitment to providing a service for all patients regardless of the ability to pay’. They valued ‘humanistic’ approaches to care; believed in ‘nursing as caring’, that team work should be ‘ethical’ and that it was important to ‘value the individual’. Table 4 summarises their responses to the question ‘what models of care do you normally base your work on’? Although a wide range of models was cited by nurses, respondents were largely in agreement regarding the ones they most regularly use, CBT (UK: 20%; US: 28%), Eclectic (UK: 12%; US: 28%) and Peplau (UK: 15%; US: 23%). The responses suggest that some nurses utilise more than one model, although the questionnaire
US nurses (n ¼ 43) 13 8 10 7 6 5
(20%) (12%) (15%) (11%) (9%) (8%)
CBT Eclectic Peplau Solution-focused Orem Psycho-dynamic
12 12 10 4 3 3
(28%) (28%) (23%) (9%) (7%) (7%)
5 5 4 4 4 3 3 3 3
(8%) (8%) (6%) (6%) (6%) (5%) (5%) (5%) (5%)
Watson Rogers Parse Psycho-analytic Sullivan
3 2 2 2 2
(7%) (5%) (5%) (5%) (5%)
Table 5 Suggestions for improving patient care (numbers rounded to nearest whole figure) UK nurses (n ¼ 65)
US nurses (n ¼ 43)
Reducing referrals and case load Increasing resources Improved access to training Reducing amount of administration Better communication and team working Better access to supervision
Improved education and training Reduced caseloads Improved resources Abolishing managed care
26 (40%)
16 (25%) 9 (14%) 8 (12%)
8 (12%)
Better access to supervision
13 (30%)
12 (28%) 11 (25.5%) 4 (9%)
3 (7%)
4 (6%)
did not elicit under what circumstances they choose certain models. Finally, respondents were asked how the care they provide for clients could be improved (Table 5): Under Reducing Referrals and Case-Loads, the UK respondents mentioned ‘having more appropriate referrals’; ‘lower case-load’; ‘fewer visits to improve quality of care’ and ‘having more time for clients’. Increasing resources meant ‘having more staff’. Under Reducing Amount of Administration, they mentioned ‘less admin-
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istration’ and ‘improved support’. Improved access to training involved ‘attending courses on Brief Therapy’; ‘CBT training’; ‘having specific training in counselling’; ‘more access to training and education’; ‘more personal development’ and ‘skills based training’. Better Communication and Team Working revolved around ‘better liaison with primary care’; ‘better relationships with consultants’; ‘better working with other professionals’; ‘better team organisation’ and ‘joint working with GPs on difficult cases’. Better access to supervision also meant more supervision. For the US respondents, Reduced Case-loads would mean ‘having more time for clients’. Improved education and training necessitated ‘having access to professional education’; ‘learning better ways for helping clients’; ‘more psycho-education programmes’ and ‘more personal development’. Under Improved Resources, respondents mentioned wanting ‘more staff’; ‘more funding’; ‘more space’; ‘more time for admin’ and ‘providing time for treatment team planning and meetings’. Abolishing Managed Care was variously expressed as ‘less managed care involvement’ and ‘less contact with insurance companies’. Like their UK counterparts, the US nurses wanted Better access to supervision and this also meant more supervision.
6. Discussion Any study exploring the work and attitudes of nurses working in different countries, even two which share a common language, and in very different health care contexts, can be accused of attempting to make comparisons where none are possible. However, this study achieved a very high response rate which suggests that the nurses in both the UK and the US felt that the questions they were being asked were relevant to their particular situations. Interpretation of their responses has been undertaken with caution; yet the considerable consensus in terms of the words and phrases used by respondents and the ideas and concepts they put forward make it possible to feel reasonably confident about the conclusions drawn in this section. An important limitation of the study is that very few male US nurses (n ¼ 2) responded to the questionnaire. At the time of data collection, only two men expressed an interest in the study and satisfied the inclusion criteria. Other males with a nursing background who were interested in the study had to be ruled out because of their management roles. It may be the case that males felt less sympathetic than females towards a study emanating from the UK, although there was no obvious evidence of this. The small number of males means that the comparisons between the two groups of nurses are not as strong or perhaps as illuminating as they would otherwise have been.
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It needs also to be borne in mind that the nurses who responded to the study were, in both countries, working in large towns and cities which may involve them in different kinds of work, and in facing different challenges from those working in other settings. While the small number of respondents must be taken into account, it is interesting to note that the mean age of respondents from the US was considerably higher than in the UK, and that US nurses had also spent many more years in their current post. This might suggest that US nurses tend to stay in one post, while their UK counterparts change jobs more regularly. If this observation is accurate, it may reflect the diversity of clients and experiences that US nurses working in private practice can achieve compared to UK nurses who may need to change their jobs regularly in order to achieve the same breadth of experience. It would also appear that US nurses are less likely to label certain groups of clients as their ‘least favourite’, perhaps because they are more confident in their skills to care for diverse clients, or quite simply because the US system of Managed Care obliges them to take whichever clients present to them. UK nurses appeared either to be anxious about or irritated by people who have substance abuse problems, those with eating disorders and those with a history of violence. This is worthy of further investigation. Does this reluctance arise because nurses find these clients unrewarding in terms of ‘cure’ rates, or because they are fearful for their own safety in the case of violent patients? On both sides of the Atlantic, there appears to be cynicism regarding the use of cost-effectiveness as a euphemism for rationing in mental health care. One might have expected that the US respondents would feel positively about community mental health nurses being able to prescribe as nurse prescribing has a long history in the States; it is slightly more surprising that the notion of prescribing is apparently already well-embedded in the UK nursing mentality. US mental health nurses appear to exercise greater control over their work, attracting appropriate referrals from primary care and being able to limit their caseloads. They also seem better supported in terms of professional developmental; all three of these issues caused concern for UK nurses whose job descriptions seem to leave them more open to caseload overload without the buttressing of ongoing training. Both groups of nurses found their major source of job satisfaction in direct contact with clients and their major source of job dissatisfaction in the administrative duties which took them away from clients. Moves in the UK to reduce paperwork for some public sector workers such as police officers need urgently to be translated into the health care sector to enable people to do the work for which they originally entered the service and to which they are presumably best suited. The US nurse
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respondents appeared to feel much more valued for the work they were doing that than their UK colleagues. Desire for recognition may be the reason why UK nurses cited (perhaps somewhat wistfully?) one of the components of job satisfaction as ‘knowing I am doing a good job’, a comment which might hide a lack of such acknowledgement from others. Future studies could usefully explore what aspects of the work of US nurses leads to their feeling more valued than UK nurses, despite the manifold difficulties which they face working within an insurance-driven healthcare system. UK nurses defined the qualities and skills that helped them in their work in relation to the difficulties they perceived they faced as nurses. They considered organisational skills important, presumably because these assisted with a heavy workload, and the ability to work well in a team, perhaps because they so often felt undervalued by other team members. For their part, US nurses valued skills and qualities which helped them in the US health care context: being able to challenge a system driven by money rather than by client need; commitment to the client’s well-being which is perhaps overlooked when insurance companies determine the nature and level of care; and commitment to providing a service regardless of the ability to pay, perhaps indicating their sense of injustice when only the wealthy have easy access to services. Thus health care professionals value qualities that enable them to cope with the job they have to do in the place they have to do it, over and above generic qualities which might apply to all healthcare work. This is despite the fact that both groups of nurses were using the same models of care. The request for more training came from both groups and probably reflects the perceived difficulties of working with clients with complex and multiple pathologies when resources do not allow nurses to give the time they feel individual clients require. The request for more training may be closely linked to complaints about lack of support which surfaced in other areas of the questionnaire. Training needs can never perhaps be ultimately satisfied, but where nurses feel that their work is undervalued, and that they are often asked to do work which they do not see as their principal role, the demand for more training is likely to emerge as a compensatory mechanism. There may be many explanations for why UK nurses express unease about dealing with violent or potentially violent patients, and US nurses do not. Speculative reasons may include inadequate training of UK nurses in how to defuse potentially violent situations and in how to handle them should they occur. Media coverage of adverse incidents where patients were incorrectly restrained may have fuelled anxiety on the part of UK nurses generally. UK nurses may feel that support from medical and management staff is lacking if incidents occur and that they will shoulder the blame while other
staff groups cover their own backs. In the US, the situation may be different. Insurance companies may filter out highly challenging patients, who could prove costly in terms of the time, human and material resources they require. It may be that the training of US nurses in handling violent events is superior to that of their UK counterparts. The responses of UK and US nurses to violent patients is an area of difference which is one of considerable interest and deserves further research attention.
7. Conclusion This study confirms the work of Weiller et al. (1998), Yamashita (1998) and Nolan et al. (2001), in relation to similarities and differences in the work of mental health nurses. However, the present study moves a little further in exploring the key question as to the influence that different organisational cultures may have on how individual nurses and teams of nurses construct their role. Seeking to account for these differences and to project how changes in the nursing culture in any particular country might affect outcomes for patients must now be the focus of research (Wright and Smith (1993). In terms of helping focus the needs of UK mental health nurses by contrasting them with those of colleagues in the US, this study supports Smoyak’s (1996) claim that there is much to be gained from comparative studies and the analyses they promote.
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