Nursing Leadership, 23(Special Issue) May 2010: 101-112.doi:10.12927/cjnl.2010.21750
The Demonstration Projects: Papers
Growing Practice Specialists in Mental Health: Addressing Stigma and Recruitment with a Nursing Residency Program
Despite the growing prevalence and healthcare needs of people living with mental illness, the stigma associated with mental health nursing continues to present challenges to recruiting new nurses to this sector. As a key recruitment strategy, five mental health hospitals and three educational institutions collaborated to develop and pilot an innovative nursing residency program. The purpose of the Mental Health Nursing Residency Program was to dispel myths associated with practising in the sector by promoting mental health as a vibrant speciality and offering a unique opportunity to gain specialized competencies. The program curriculum combines protected clinical time, collaborative learning and mentored clinical practice. Evaluation results show significant benefits to clinical practice and an improved ability to recruit and retain nurses. Nursing leadership was crucial at multiple levels for success. In this paper, we describe our journey in designing and implementing a nursing residency program for other nurse leaders interested in providing a similar program to build on our experience.
To meet the increased demand for mental health services that are integrated and recovery oriented, an effective healthcare professional workforce is required (The Standing Senate Committee on Social Affairs, Science and Technology 2006). The psychiatric and mental health nurse is a healthcare professional who is an essential part of this workforce. Psychiatric and mental health nursing is a specialized field that requires unique competencies to provide care for those living with mental health issues. It is one of the most complex and demanding areas of nursing practice. Establishing therapeutic relationships with persons living with mental illness and their families requires psychiatric and mental health nurses to enact specialized assessment and communication competencies to address this vulnerable population's mental health, cognitive and behavioural issues.
Despite the demand, significant challenges exist in recruiting and retaining a skilled and sustainable supply of psychiatric and mental health nurses in Ontario and beyond. The shortage of nurses in mental health is evident in national and provincial data indicating that only 5.3% (12,976) of Canadian nurses reported their primary area of responsibility as psychiatry/mental (Canadian Institute of Health Information 2007). Moreover, in 2007 the addictions and mental health sector had the third highest vacancy rate for nursing (7.75%) after the community sector (8.74%) and complex continuing care and rehabilitation sectors (8.24%) (Ontario Hospital Association 2007). In the last decade, there have been concerted efforts to recruit and retain nurses through initiatives such as the Nursing Graduate Guarantee program funded by the Ontario Ministry of Health and Long-Term Care (MOHLTC). However, this initiative is not being fully utilized by the mental health sector, as new graduates are not applying to work at tertiary mental health facilities upon graduation.
A key challenge to recruiting and retaining nurses in the mental health sector is attributed to the stigma associated with society's view of mental illness. "Courtesy stigma," or stigma by association (Goffman 1963), affects everything and everyone surrounding persons living with mental illness (Falk 2001; Smith 2002). Courtesy stigma results in family members of persons living with mental illness experiencing fear, loss, lowered self-esteem, shame, secrecy, distrust, anger, inability to cope, hopelessness and helplessness (Gullekson 1992).
Mental health professionals are also negatively affected by courtesy stigma and are often viewed as being mentally abnormal, corrupt or evil (Kendell 2004). Psychiatric treatments are often viewed with suspicion and overly scrutinized (Sartorius 2004). Psychiatric and mental health nursing is viewed as a less desirable career choice in comparison with other sectors, due to misconceptions about the nature of the skills required to practice in the sector and the lack of appreciation for career opportunities. Challenges to recruiting into other specialty nursing areas (e.g., long-term care) have also resulted from perceived stereotypes and myths related to both the population (elderly residents) and the type of competencies required to provide nursing care (Dumas et al. 2009).
While there is a dearth of empirical research on stigma within the psychiatric and mental health nursing profession, it is widely acknowledged across this and other nursing sectors that mental health is not seen as a specialty with a complex knowledge and skill base. In conversations with several nursing students over the years, the authors of this article have heard that many view this area as one where the requisite nursing knowledge and skills are "soft," with little opportunity for future professional growth. Too often there is a lack of expert mental health faculty to champion the care needs of those who suffer with a mental illness and demonstrate the complex interpersonal capacity essential to caring for this population. It is no surprise that students interested in mental health report being advised to consider medical–surgical specialties as an initial career choice to consolidate their nursing skills prior to considering the mental health sector as an option. However, supporting patients to return to a state of mental health and well-being is profoundly valuable and just as satisfying as caring for those with a physical illness.
Among practising nurses, a frequently heard sentiment is that mental health should be left to the end of a nurse's career after one has gained specialized skills and rewarding experiences in other sectors. Mid-career nurses are reluctant to transfer to psychiatric and mental health nursing as they fear losing their existing competencies. In reality, working in psychiatric and mental health nursing requires multiple competencies, given the rate of concurrent disorders as well as complex issues such as workplace violence (Happell and Gough 2007; Valente and Wright 2007). It is critical for the current psychiatric and mental health nursing workforce to have the opportunity to enhance their knowledge and skills to current best practices.
Recognizing the stigma associated with mental health nursing practice and the need to develop specialized psychiatric and mental health nursing competencies, a residency program was designed and piloted. The Mental Health Nursing Residency Program brought together five tertiary psychiatric hospitals and three educational institutions. The mental health facilities involved were the Centre for Addiction and Mental Health; the Mental Health Centre Penetanguishene; Ontario Shores Centre for Mental Health Sciences; Providence Care Mental Health Services, Kingston; and the Royal Ottawa Health Care Group. The academic partners were Algonquin College, the University of Ontario Institute of Technology and the University of Ottawa. Funding for the program was provided by the Nursing Secretariat of Ontario's Ministry of Health and Long-Term Care, as part of Ontario's Comprehensive Nursing Strategy. The purpose of this paper is to describe the journey taken in creating and piloting an innovative Mental Health Nursing Residency Program. We discuss the successes and challenges we encountered during this journey, the positive impacts that were made and what the road ahead offers.
The Mental Health Nursing Residency Program
A 12-week mental health residency program was designed and piloted from January to November 2008. The goals of the residency program were twofold: (1) support nurses new to the mental health sector by providing them with an opportunity to develop the competencies required to provide exceptional patient care, and (2) dispel myths and highlight opportunities associated with mental health as a career choice, thereby helping to address the stigma associated with working in the mental health sector. Although targeted to the new nurse graduate, the residency program also supported nurses new to the mental health system, while providing an opportunity for professional development and career enhancement for experienced nurses working in the sector.
The planning and design of the residency program took place from January to August 2008 and involved several activities, including developing a shared vision, goals and objectives for the program; identifying key activities and associated timelines; establishing a project structure; and defining the terms of the collaboration using a memorandum of understanding. The structure of the collaboration consisted of a steering committee composed of the chief nurse executive of each of the five hospitals and key representatives from the academic partners, as well as five teams, each focusing on a specific area of the program – marketing/recruitment, curriculum development, residency implementation, evaluation and knowledge transfer.
The marketing team was responsible for developing a strategy to raise the profile of mental health nursing in order to recruit new nurse graduates to the participating mental health organizations. Each organization set a goal of recruiting five nurse graduates. Senior students as well as faculty who would potentially be advising students in their career selection were targeted. The marketing strategy was multi-faceted and included:
- Developing a homepage (www.beamentalhealthnurse.ca) that described the benefits of joining the mental health sector and provided information on how to apply to the residency program;
- Posting job descriptions on each facility's website;
- Profiling the position at the MOHLTC HealthForceOntario Nursing Graduate Guarantee portal;
- Distributing posters and bookmarks at universities and colleges;
- Liaising with the deans of nursing and other academia at Ontario educational institutions; and
- Marketing by word of mouth.
Each organization was responsible for interviewing and selecting their nursing residents.
The curriculum team developed the educational material and delivery approach for the residency program. Curriculum development involved an extensive literature review, including best practices in psychiatric and mental health nursing and education and learning models to support knowledge transfer. The curriculum was based on Canadian and international core mental health nursing standards, competencies, knowledge and skills. It was circulated to a panel of eight key informants who were known as mental health practice leaders in Canada. With feedback from this group, and with content from the Canadian Standards of Psychiatric and Mental Health Nursing Framework (Canadian Federation of Mental Health Nurses 2006), the curriculum was refined. Educational materials were developed utilizing the knowledge, practices and experiences of the project partners. The program was 12 weeks in length, or 450 hours. Of these, 40 hours consisted of core centralized education provided by subject matter experts to all partner organizations at the same time through videoconference; 90 consisted of decentralized learning, provided separately at each partner organization; 218 (approximately 50%) consisted of direct clinical practice; and the remaining 102 focused on mentor/resident collaboration, online learning activities and journalling.
The implementation team was charged with implementing activities to prepare the residents, mentors and their host organizations for the residency program, as well as providing oversight for the duration of the program. A joint orientation session was held for the mentors from all of the organizations. A program "kick-off day" introduced the residents to the program and to each other, and site-specific orientations were provided thereafter. Each week, residents completed readings, met over videoconference for centralized education and discussion and completed clinical activities and journalling. Program implementation was managed at each site by a site coordinator. The implementation team stayed connected by email and teleconferences to discuss and resolve issues. At the conclusion of the residency program, the implementation team held a "graduation day" to showcase the accomplishments of the residents and to acknowledge the mentors' contribution.
The evaluation team developed an evaluation framework that included the key questions, methodology and tools that would be used to gather, analyze and report findings. To ensure a comprehensive and objective evaluation, an external third-party was engaged. The evaluation framework consisted of five questions: (1) Of the mental health nursing core competencies, which competencies are critical to teach new graduates? (2) What should the format for developing these competencies be? (3) What is the effect of the residency program on the competencies of new graduates? (4) What is the effect of the residency program on the ability of the mental health sector to attract and retain new graduates? and (5) What are the lessons learned by the demonstration project team about the development and implementation of a residency program for new graduates? The evaluation methodology included the following components: a pre–post survey, interviews and focus groups with residency participants and a formative evaluation involving all program sites. Table 1 provides an overview of the evaluation components.
|Table 1. Mental health nursing residency program evaluation methodology|
|Residents pre–post survey||Program expectations, Clinical Confidence Scale (Bell et al. 1998) and Mental Health Recovery Attitudes (RAQ-16) HCRI-RT (Steffen et al. 1999)|
|Project mid-term focus group||All-site videoconference with residents, mentors and site leads|
|Resident focus groups post-residency||Focus groups with the residents|
|Site interviews post-residency||In-person visits to each project site to interview the chief nurses, site coordinators and mentors|
Knowledge Transfer (KT) and Sustainability
The KT team's overall objectives were to develop a sustainability strategy and develop and disseminate the "deliverables" associated with this initiative. These included a toolkit, a nursing leadership conference/symposium, presentations and publications, and transforming the program into a format that would be widely accessible. In addition, the team was responsible for making recommendations for sustaining the initiative within and external to the participating organizations.
Results and Discussion
Twenty nurses participated in the Mental Health Nursing Residency Program; 60% (12) were new graduates and 40% (8) were mid- and late-career nurses. This group represents 76% of the goal for number of residents. The nursing residents' demographics are provided in Table 2.
|Table 2. Mental health nursing residency program resident demographics|
|Characteristics||Percentage (N = 20)|
Sixteen of the residents (80%) and 18 mentors (90%) participated in the focus groups; 48 people participated in the mid-term formative evaluation. Post-residency interviews were completed with all five site leads.
As further described below, the impact of the Mental Health Nursing Residency Program included an improved ability to attract new nurse graduates to the mental health sector, enhanced nursing competencies of new and mid-career nurses and improved nurse retention.
Residency Program Content
Overall, 89% of the 20 residents who participated in the post-residency survey stated that the program met all or many of their expectations. Qualitative data from residents and mentors validated the need for a post-graduate program to support psychiatric and mental health nurses with clinical practice. The data suggest that there is benefit to basing the program on the conceptual model of recovery: the belief that the patient is ever-changing, desiring to move toward health, and that recovery is about the patient's efforts to change. Other specific models of mental healthcare, such as the "tidal model" (Barker and Buchanan-Barker 2005) and "solution-focused nursing" (McAllister 2007), were helpful as examples to support this philosophy. All seven standards of the Canadian Standards for Psychiatric Mental Health Nursing (CFMHN 2006) were critical to include in the program. Residents felt that the program should focus less on readings and theory and more on practical knowledge and activities. Content for further emphasis included an overview of major mental illnesses, therapies/medications, and tools and strategies for mental health status assessment.
Residency Program Format
Overall, residents, mentors and demonstration project partners felt that the format of the demonstration project was appropriate. Residents stated that at least a 50% allocation of the program to direct clinical practice was critical. Time spent with mentors was also cited as valuable for understanding and applying the information learned during the program. Instead of having time allocated to clinical practice each day, residents preferred blocked clinical time that was uninterrupted by other learning activities. Residents found that the learning and interaction with other residents at other sites through video-conferencing was innovative and effective when there was active discussion.
Impact on Nursing Competency
The evaluation indicates that the residency program supports nurses in developing the competencies, knowledge and skills required to adapt to the changing specialty of recovery-based, consumer-focused mental healthcare. Quantitative data from administration of the Mental Health Nursing Clinical Confidence Scale (Bell et al. 1998) showed an improvement in all 20 items, and 75% of these improvements were statistically significant. Similarly, there were improvements in 12 of the 16 items, or 75%, of the Recovery Attitudes Questionnaire (RAQ-16) HCRI-RT (Steffen et al. 1999). Residents stated that they gained a substantial level of confidence in their abilities to provide patient-focused care, including in empathizing and communicating with patients. Knowledge about diagnoses and the effects of medication were enhanced, as were psychosocial assessment and care planning.
Impact on Other Nurses and Health Professionals
Nursing competence and capacity have also been developed in the nurse mentors who participated in the program, as they had the opportunity to update their own skills while supporting their residents. The residency program positively influenced other nurses and healthcare professionals in the practice setting as well, as many were intrigued and had questions about the program, the role of the residents and the curriculum.
Dispelling the Myths: Impact on Recruitment and Retention
While the residency program and marketing approaches previously described were effective at generating interest, the participating organizations still faced serious challenges in recruiting new nurse graduates due to the myths and stigma associating with psychiatric and mental health nursing. Of the 20 residents, only 12 (60%) were new graduates, and the remainder were mid- and late-career nurses new to mental health. Nevertheless, the majority of participants stated that the program provided them an invaluable opportunity for fine-tuning their skills and validated their interest in practising in the field. Despite the recruitment challenges, the residency program dispelled myths and highlighted opportunities associated with mental health as a career choice. This is evident in the following results: 75% of residents surveyed after the program said that they were highly interested, and 22% were interested, in mental health nursing as a career after having participated. All residents indicated that they would recommend practising in the mental health sector as a career choice to other nurses.
Spreading the Innovation and Sustainability
Much has been gained from this initiative through several organizations collaborating to address the stigma against nursing in mental health. The knowledge gained by the participating organizations has been made available through several external knowledge transfer activities. These include presentations at ministry-led forums, nursing conferences and meetings with nurse leaders and educators at other tertiary mental health and acute care facilities. In addition, a toolkit that provides step-by-step guidelines, tips and techniques to any organization interested in developing a nursing residency program was developed. The toolkit, Growing Practice Specialists: Developing and Operating Your Own Nursing Residency Program: A Toolkit for Health Care Organizations, is in keeping with the foundational message of "growing" and reflects the developmental nature of the residency.
Since the initial cohort of residents completed the program, the residency curriculum and format have been refined to reflect the evaluation results. The program has been made available online at www.mhnursingresidency.com in a modular "pick-and-choose" format, making it easily accessed by mental health nurses at any time and in any setting. The toolkit, which is applicable to any health sector, is also available for download from the site.
All collaborating organizations remain committed to the transferability and sustainability of the outcomes. Each organization has developed its own sustainability strategy to ensure that the knowledge residents gained during the program is maintained and spread to other staff. A key sustainability strategy that many of the organizations adopted was the operation of ongoing site-specific residency programs. These are being offered not only to new nurse graduates, but also to nurses new to the mental health sector and to late-career nurses. Previous program participants have been particularly effective as mentors to new residents and current staff. Ongoing communication to obtain buy-in from senior management, nurse managers and other professions has also been instrumental in sustaining knowledge. Partners continue to identify new opportunities to work together to further advance psychiatric and mental health nursing.
Conclusion and Future Directions
The Mental Health Nursing Residency Program has enhanced nursing competence, highlighted the need for greater mental health nursing capacity in Ontario and dispelled myths associated with this speciality. The ongoing implementation of the Mental Health Nursing Residency Program in the pilot sites for both new and mid-career nurses, as well as in other mental health facilities, will continue to contribute to the ability of the sector and Ontario to attract and retain nurses in the mental health field. The participating organizations have experienced a substantial increase in new graduate applicants, and these individuals all cite the residency program as something that drew them to the organization.
Given the nature of the demonstration project funding source, the mental health nursing residency program focused primarily on addressing health human resource needs, including recruitment, retention and competency development. As such, these aspects were the primary evaluation dimensions. In offering and evaluating future residency programs, it would be vital to assess their impact on patient care. In addition, examining in detail the extent to which and how such mental health residency programs contribute to addressing stigma within the profession would offer invaluable lessons.
The Mental Health Nursing Residency Program was a successful pilot project made possible with the support of government funding. However, as with other educational interventions, building a sustainable approach to capacity development across the entire mental health sector remains crucial. The residency program was founded on adult learning principles that emphasize experiential knowledge gained through the application of knowledge in practice. Advocating for more content in undergraduate programs would also contribute to strengthening mental health nursing capacity.
As many clients with mental health disorders are in acute, long-term and community care, there is great potential for extending the residency program through existing or alternate approaches to these areas. Additional linkages and partnerships with nurse leaders in other mental health organizations and healthcare sectors are required to build on the residency program, exchange knowledge and continue advancing the nursing profession as a whole.
About the Author
San Ng, BSc, MBA, PhD(c), Principal, Vision & Results Inc., Toronto, ON
Linda Kessler, RN, BScN, BA, MHSc, Clinical Educator, Mental Health Quinte Health Care, Belleville, ON
Rani Srivastava, RN, PhD, Deputy Chief, Nursing Practice, Centre for Addiction and Mental Health, Toronto, ON
Janice Dusek, RN, BSN, MS, MBA, CHE, Chief Nursing Executive and Vice President, Interprofessional Affairs, Quality and Safety, Ontario Shores Centre for Mental Health Sciences, Whitby, ON
Deborah Duncan, RN, Vice President Tertiary Care and Chief Nursing Executive, Mental Health Centre Penetanguishene, Penetanguishene, ON
Margaret Tansey, RN, MSc(A), CPMHN(C), Vice President, Professional Practice and Chief Nursing Executive, Royal Ottawa Health Care Group, Ottawa, ON
Lianne Jeffs, RN, MSc, PhD(c), Director of Nursing/Clinical Research Scientist – Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Early Nursing Research Career Award – Ministry of Health and Long-Term Care, Toronto, ON
Correspondence may be directed to: San Ng, Email: firstname.lastname@example.org.
The Mental Health Nursing Residency Program demonstration project was funded by the Nursing Secretariat of Ontario's Ministry of Health and Long-Term Care.
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