Abstract
Nurses represent more than 50% of the national mental health workforce [1,2] and are responsible for a wide range of services in community, rehabilitation and hospital environments [3]. Whether in the hospital or community environment, nurses work as part of a multidisciplinary team. Mental health nurses and psychiatrists often need to work collaboratively with consumers to provide a consumer-focused, highquality, continuous service. However, professional groups have been shown to have a surprisingly poor level of knowledge about each other [4]. For multidisciplinary teams to be effective, it is imperative that mental health professionals have a better understanding of each other's beliefs and expectations.
Recently, Jorm et al. conducted a national survey of health professional and public beliefs regarding interventions, prognosis and discrimination for mental disorders [5–9]. This research indicated similarities in the beliefs of general practitioners, psychiatrists and clinical psychologists about interventions most often advocated for schizophrenia and depression. However, psychiatrists were less likely than general practitioners and clinical psychologists to advocate psychosocial and lifestyle interventions [6]. Clinical psychologists were less likely than the other professional groups to advocate specifically medical interventions [6].
Some large differences in beliefs between the professional groups and the public were also identified. The public rated as harmful many treatments that the professional groups overwhelmingly considered helpful [5]. The public also tended to view changes in lifestyle factors, such as vitamins and diet, as helpful more often than the professionals [5]. Mental health nurses are the largest mental health professional group and often have the most contact with consumers [10,11], but they were not included in this previous research.
While professionals show substantial consensus in their beliefs about interventions, there are also important differences within professional groups. Australian and international studies have shown that attitudes towards treatment and prognostic expectations differ, depending on the age and gender of the practitioner [6]. Among medical practitioners, younger, female professionals had a broader view of treatments they considered to be helpful [6]. However, it is also important to note that political, professional and educational changes may have affected beliefs and knowledge. Within mental health nursing these include the shift away from working in separate, psychiatric institutional facilities to working in the community and in psychiatric wards of general hospitals, the integration with general undergraduate nursing and the move from hospital-based to university-based training [2,12].
Recent Australian research indicates that the attitudes of mental health nurses do vary depending on treatment setting [13]. In one study, community nurses tended to have a psychological attitude towards treatment whereas hospital nurses tended to have a more organic approach to treatment [13]. Happell [14] concluded that tertiary-educated, Australian mental health nurses were more flexible, enthusiastic, and had a broader theoretical knowledge than hospital-based psychiatric nurses. The effects of work setting and education on mental health nurses' beliefs about interventions and outcomes therefore needs to be investigated.
The relationships between professional groups create a structural context for professional and public beliefs. Hierarchies and competition exist between professional groups. There are many negative beliefs about psychiatry within the medical profession [15] and about mental health nursing among nursing students [16]. Speedy [17] noted that there has been considerable opposition to the expanding role of the nurse. She claimed that other health professions have difficulty relinquishing the control they exercise in directing nursing care. Inter-professional power relationships, changes in policy and the multidisciplinary care environment all impact on the roles of the professional groups, consumers and service quality. Consequently understanding the fundamental beliefs of the key care-providers is pivotal.
The primary objective of this paper is to assess mental health nurses' beliefs about interventions for depression and schizophrenia, to compare these beliefs with those of psychiatrists and the public and to evaluate the impact of mental health nurse characteristics upon beliefs. Psychiatrists were specifically chosen for comparison because of their collaborative professional relationship with mental health nurses. The purpose of this paper is to provide a description of existing beliefs so as to inform and facilitate communication between professional groups and the public.
Method
The present research adds mental health nurses to the database of general public, psychiatrists, general practitioners and clinical psychologists previously developed by Jorm et al [5–9]. The procedure and survey for the current research was adopted from the existing research to ensure the comparability of results.
The population and sample
In 1995 the Australian Bureau of Statistics interviewed a nationally representative sample of 2031 Australian adults, aged 18–74 as part of a random household survey [7]. In a second study [5], the national register of medical practitioners (Medicare Provider File) was used to survey all 1580 Australian psychiatrists [5]. For the current study, permission was gained for a postal survey of the 980 Australian individual members of the Australian and New Zealand College of Mental Health Nursing (ANZCMHN). Full membership of the ANZCMHN is generally restricted to registered nurses, although no mental health qualifications or experience are required. Consequently, members of the ANZCMHN evidence a diverse range of backgrounds and qualifications. The requirements for membership are currently under review.
The questionnaire
The general public were interviewed using a face-to-face schedule. Conducting face-to-face interviews with mental health professionals was not feasible, so questions from the survey of the general public were modified to create a self-completion, postal questionnaire [5]. Each questionnaire contained a vignette with either a male or a female, with symptoms meeting both ICD-10 [18] and DSM-IV [19] minimum diagnostic criteria for schizophrenia or depression. The disorder and gender were randomly allocated to an equal number of nurses.
The vignette was followed by an open ended question asking ‘what, if anything, is wrong with John/Mary’ and ‘do you think they need professional help’ (yes or no). Participants then rated whether a range of people, medications, treatments and lifestyle changes would be helpful, harmful or neither for the person described in the vignette. Participants were also asked to rate the likely prognosis and long-term outcomes for John/Mary and whether John/Mary would experience discrimination from others in the community. However, only the results concerning the beliefs about interventions are reported in this publication.
The wording of some of the questions in the public survey was altered to allow for professional knowledge of treatments. The terms ‘sedatives/hypnotics’ were substituted for ‘sleeping pills’ and ‘antianxiety agents’ was substituted for ‘tranquillisers such as valium’ [5]. Only mental health nurses were asked to rate the helpfulness of the nursing profession. A review of nursing literature and consultation with the ANZCMHN indicated that type of education (hospital-based vs university), qualification level, work type and setting (community vs hospital) might influence mental health nurses' attitudes. Consequently, questions were designed to investigate the effects of these factors on the attitudes of mental health nurses.
Procedure
Nurses were assigned identification numbers and the allocated vignette was coded and noted. A response card and/or reminder procedure from a study by Baume and O'Malley [20] was adopted for the mental health professional surveys to increase the response rate. A reminder with a questionnaire has been shown to significantly increase (by 13%) the response rate of health professionals, while written reminders without an instrument were not associated with higher response rates [21]. Nurses who did not respond within 5 weeks were sent a reminder letter, second questionnaire (with the same designated vignette) and response card. The overall design enabled reminders to be mailed while maintaining the anonymity of respondents and equal distribution of vignette types.
Ethical considerations
The original ethics approval by The Australian National University was extended to cover mental health nurses.
Statistical analyses
Parametric statistics (analysis of variance) were used for basic descriptive purposes. Adding across items to create a scale resulted in a distribution that was not highly skewed. However, non-parametric tests were used in the analysis of individual interventions and factors affecting intervention beliefs because the responses were on three-point scales and often had highly skewed distributions.
Mann-Whitney U-tests were used to compare the intervention beliefs of mental health nurses with those of psychiatrists and the public. The number of tests between groups was limited by comparing the intervention beliefs of psychiatrists and the general public with those of mental health nurses. Direct comparisons of psychiatrists with the general public have been reported previously [5]. Mann-Whitney U-tests (comparing two independent variables) or Kruskal-Wallis H-tests (comparing k independent variables) were also used to determine whether intervention beliefs were affected by the characteristics of mental health nurses.
A significance level of p < 0.01 was chosen for all tests. This was designed to minimise type I errors (from the multiple testing procedure) and to preclude findings that had little substantive significance even though statistically significant (from the large sample size).
Results
The response rate for the postal survey of mental health nurses (70%) was slightly lower than for the previous survey of psychiatrists (75%). The Australian Bureau of Statistics obtained interviews with the general public in 85% of households where contact was made.
‘Schizophrenia’ or ‘psychosis’ was mentioned by a total of 92.1% of mental health nurses to describe the person in the schizophrenia vignette. For the depression vignette, 98.5% of mental health nurses mentioned depression. These results confirm that the study accessed beliefs about schizophrenia and depression as described in the vignettes.
One-way analysis of variance showed that the mean number of interventions considered helpful was significantly higher for mental health nurses than for psychiatrists for both schizophrenia (mean = 14.09, SE = 0.25 vs mean = 11.92, SE = 0.19) and depression (mean = 16.30, SE = 0.27 vs mean = 15.23, SE = 0.22), respectively. It was not possible to include the general public in this analysis because of differences in the intervention survey items.
Interventions most often considered helpful and harmful
For the schizophrenia vignette, Table 1 shows that mental health nurses were most likely to rate their own profession, psychiatrists, antipsychotic medication, admission to a psychiatric ward, general practitioners (GPs) and clinical psychologists as helpful (indicated by values greater than 0.75). Similarly, the majority of psychiatrists also advocated GPs, psychiatrists, antipsychotic medication and admission to a psychiatric ward of a hospital. However, the general public most often believed that the following interventions were helpful: getting out and about, becoming more physically active, seeing a counsellor or GP and taking courses on relaxation. Dealing with problems by oneself was most often seen as harmful by nurses and psychiatrists for the person in the schizophrenia vignette. However, the general public most often reported electroconvulsive therapy (ECT) as harmful.
Mean ratings of the helpfulness of various possible interventions for the person in the depression and schizophrenia vignettes (rating scale: 1 = helpful, 0 = neither helpful nor harmful, −1 = harmful)
For the depression vignette, Table 1 also shows that mental health nurses tended to recommend themselves, antidepressants, psychiatrists, counselling, clinical psychologists, courses on relaxation, stress management, meditation or yoga, GPs and a counsellor as helpful for the person described. Similarly, a large proportion of psychiatrists also advocated GPs, psychiatrists, antidepressants, clinical psychologists and cognitive-behavioural therapy. By contrast, the general public most often advocated GPs, becoming physically more active, courses on relaxation, stress management, meditation or yoga, getting out and about more, a counsellor, close friends and close family [5].
Analgesic and antipsychotic medication and patients' dealing with problems by themselves were most often seen as harmful for the person in the depression vignette by mental health nurses and psychiatrists. Electroconvulsive therapy, admission to a psychiatric ward, antianxiety and antipsychotic medication and sedatives/hypnotics were most often seen as harmful by the general public.
Intervention belief differences
For the schizophrenia vignette, Table 1 shows that mental health nurses were significantly more positive than psychiatrists about many interventions, including seeing a naturopath or herbalist, taking vitamins or sedatives, courses on relaxation, stress management, meditation or yoga, seeing a counsellor, close friends, taking antianxiety agents, becoming more physically active, reading self-help books, getting out more, having hypnosis and a special diet. Nurses tended to be more negative about a GP, antibiotics, admission to a psychiatric ward of a hospital and ECT.
For the depression vignette, Table 1 indicates that nurses were more positive than the psychiatrists about a GP, a naturopath or herbalist, a counsellor, vitamins, sedatives/hypnotics, becoming more active, courses on relaxation, counselling and a special diet. Nurses were significantly less likely than psychiatrists to advocate admission to a psychiatric ward and ECT for the person in the depression vignette.
For the schizophrenia vignette, Mann-Whitney U-tests showed differences between mental health nurses and the general public for almost all of the interventions. Table 1 shows that the beliefs of mental health nurses and the general public significantly differed regarding nearly all of the interventions most often considered helpful by mental health nurses: seeing psychiatrists, taking antipsychotic medication, admission to a psychiatric ward and clinical psychologists. The exception was beliefs about GPs.
For the depression vignette, Table 1 shows that the public were significantly more negative than the nurses about the helpfulness of antidepressants, psychiatrists and clinical psychologists; these were some of the interventions most often supported by mental health nurses. However, the nurses and public had similar beliefs (there were no significant differences) about the helpfulness of GPs, counsellors, telephone counselling, social workers, naturopaths or herbalists, the clergy, antipsychotic medication, courses on relaxation, stress management, meditation or yoga, cutting out alcohol altogether and hypnosis. Significant belief differences were evident between all other interventions listed in Table 1.
Factors affecting the beliefs of mental health nurses
Analysis of variance tests indicated that mental health nurses considered significantly more interventions to be helpful for depression (mean = 17.29; SE = 0.27) than for schizophrenia (mean = 15.08; SE = 0.25).
The schizophrenia vignette
Sex of the person in the vignette, respondents' frequency of contact with the problem described in the vignette and respondents' having completed university as opposed to hospital-based training did not significantly affect mental health nurses' intervention beliefs for the schizophrenia vignette. Male nurses believed that having an occasional alcoholic drink to relax would be harmful less often than female nurses (means of −0.05 vs −0.27, p = 0.001). Table 2 shows that younger mental health nurses more often believed close family and friends to be helpful than older nurses. Table 2 also shows that hospital-based nurses were most likely to consider psychotherapy, admission to a psychiatric ward and ECT to be helpful (or less harmful) for the person in the schizophrenia vignette. Mental health nurses working in education most often believed that ECT was likely to be harmful. Community and ‘other’ nurses tended to believe that hypnosis was harmful more often than nurses working in hospital and education environments. Mental health nurses with completed graduate qualifications were more likely to be positive about close friends, hypnosis and dealing with problems oneself for the schizophrenia vignette.
Mean ratings of helpfulness for the factors affecting mental health nurses' beliefs about interventions for schizophrenia
The depression vignette
For the depression vignette, there was no difference in the beliefs of nurses according to the highest, completed level of qualification. However, mental health nurses were more likely to believe that telephone counselling services (e.g. Lifeline) would be helpful for John than for Mary (means of 0.70 vs 0.53, p = 0.006). Male nurses were less likely than female mental health nurses to believed that GPs would be helpful (means of 0.68 vs 0.86, p = 0.001). Table 3 shows that younger nurses tended to believe that help from close friends, a naturopath or herbalist, hypnosis and sedatives/hypnotics were helpful (or less harmful) more often than did older nurses. In contrast, younger nurses tended to believe that patients' dealing with problems by themselves would be more likely to be harmful than did older nurses.
Mean ratings of helpfulness for the factors affecting mental health nurses' beliefs about interventions for depression
Hospital nurses were most likely to indicate that admission to a psychiatric ward of a hospital, and ECT would be helpful for the person described in the depression vignette (see Table 3). Mental health nurses working in education tended to consider anti-depressants to be helpful less often than did nurses working in hospital, community or other work settings. Education nurses were also less likely to consider patients' dealing with problems themselves to be harmful and more likely to consider admission to a psychiatric ward and ECT to be harmful.
Nurses who had more contact with depression tended to be more positive about antidepressants (mean for daily = 0.97, weekly = 0.96, monthly = 0.70 and less than monthly = 0.92, p = 0.007) and admission to a psychiatric ward (mean for daily = 0.37, weekly = 0.11, monthly = −0.23, less than monthly = 0.02, p = 0.002). Mental health nurses with any university-based training tended to consider close friends, a naturopath and an occasional alcoholic drink to be helpful more often than did nurses from the hospital-based system alone (see Table 3).
Because qualifications differ by age, it is possible that age could be producing the qualification effects. To adjust for the effects of age, a multiple logistic regression analysis was carried out in which age and qualifications were simultaneously entered as predictors of helpful or harmful ratings. This showed that the age and qualification type independently affected beliefs about the helpfulness of friends (p < 0.05). The effects of qualification type on beliefs about the helpfulness of an alcoholic drink also remained significant after adjusting for age (p < 0.01). Similarly, qualification level independently affected beliefs about the harmfulness of helping oneself and using hypnosis (p < 0.01).
Discussion
Interventions beliefs: the professional and public context
A large proportion of mental health nurses and psychiatrists tended to agree about the interventions that were most helpful, particularly for schizophrenia. These included seeing a psychiatrist, taking anti-psychotic medication, being admitted to a psychiatric ward for schizophrenia; and seeing a GP, psychiatrist, or clinical psychologist, and taking antidepressants for depression.
Despite these broad areas of agreement, a comparison of mental health nurses' and psychiatrists' intervention beliefs showed a large number of significant differences. Mental health nurses believed a larger number of interventions to be helpful than did psychiatrists, for both schizophrenia and depression. There was a general trend for mental health nurses to rate lifestyle (such as naturopaths and vitamins) and psychological interventions (such as counselling) as helpful more often than did psychiatrists. Additionally, nurses tended to rate some medical interventions less often as helpful. These included having ECT and seeing GPs for both vignettes, and admission to a psychiatric ward for schizophrenia. These differences are of particular concern given that mental health nurses often work alongside and in close consultation with psychiatrists.
The previous public and professional research indicated serious discrepancies about interventions that were perceived as helpful by professionals, but as harmful by the public [5]. This trend was evident for antidepressants for depression and antipsychotic medication and admission to a psychiatric ward for schizophrenia [5]. Mental health nurses and the public had divergent ideas about the interventions likely to be helpful for both schizophrenia and depression. In general, mental health nurses were more positive about medical interventions than the public, while the public more often considered lifestyle interventions to be helpful. These findings reinforce concerns that considerable effort should be made to acknowledge and reconcile professional and public beliefs about these interventions [5].
Despite the differences, mental health nurses tended to bridge the gap between the psychiatrist's and public's beliefs. Jorm et al. [5] found that there were interventions which the public tended to rate as helpful, but that the professionals perceived as harmful or useless, such as vitamins and minerals and special diets for both depression and schizophrenia, and lifestyle interventions for schizophrenia. International and Australian literature indicates that the public are more likely to endorse ‘alternative’ methods such as natural remedies, vitamins, and meditation and are more likely to be negative about medical, drug interventions for both schizophrenia and depression [5,22–24]. The present study found that while not necessarily agreeing with the public, the nurses' beliefs often lay between the other professional groups and the public for some of the lifestyle and non-standard interventions.
Walter [25] reported that consumers and carers perceived the quality of care to be worse from psychiatrists and medical practitioners than from other Australian health professionals such as nurses and occupational therapists. Research in Australia and the USA also indicates that families of consumers were more satisfied with their contact with psychologists, nurses and case managers than with psychiatrists [25,26]. The tendency for mental health nurses to bridge the beliefs of psychiatrists and the public may contribute to more positive consumer and carer perceptions about the nursing profession and facilitate optimal care and communication between psychiatrists and the public.
Factors affecting intervention beliefs
Not many factors strongly affected mental health nurses' beliefs about interventions. However, the present research indicates that age has an influence on nurses' beliefs about interventions. Younger nurses seem to be introducing a less negative pattern of ideas about particular lifestyle interventions, particularly for depression. Jorm et al. [9] found that younge rmembers of the public were more positive than older people about psychological interventions for the depression vignette. Jorm et al. [6] also found that younger psychiatrists believed a wider range of interventions to be helpful for both schizophrenia and depression, but particularly for depression. Younger psychiatrists tended to believe that psychosocial interventions were helpful more often than did their older colleagues.
Beliefs are embedded within complex, interactive power relations between practitioners, the professional institutions, the wider political and public context. It would appear that younger mental health care workers are introducing more positive and less negative beliefs about some lifestyle and non-standard interventions. This attitude change was evident for both vignettes, but change was strongest for depression. Age differences could reflect a cohort effect or the time practitioners are exposed to the beliefs of their professions. Time and exposure could create pressure on practitioners to conform to the more medical, institutionalised beliefs of the profession. New, young practitioners with non-conforming beliefs may also leave the profession. However, it is possible that the beliefs of younger practitioners are an indication of future professional attitudes.
The current research supports claims that work environments affect professional beliefs. However, belief differences were not evident across a wide range of interventions. Nurses tended to be more positive about interventions that were specific to their work setting. It was also interesting to note that nurses working in education tended to consider some of the more standard interventions such as anti-depressants for depression to be helpful less often than did nurses from other work settings. This group has potential influence over future nursing and public beliefs. However, a larger, more clearly defined sample of nurse educators would be warranted before conclusions could be drawn.
For schizophrenia, nurses with higher qualifications were found to believe lifestyle interventions to be harmful less often, while nurses with tertiary education (compared with those with hospital-based training) were more likely to consider particular lifestyle interventions to be helpful. These findings remained significant after controlling for age. Given that all nurses are now receiving university training, these differences may also indicate the direction of future beliefs.
Nurses were shown to have more positive beliefs than psychiatrists about particular non-standard interventions: taking vitamins and minerals, sedatives, courses on relaxation, seeing a naturopath and a special diet. However, not many of these interventions emerged as being affected by any of the nursing and demographic characteristics under investigation. Consequently, it seems unlikely that nurses' and psychiatrists' divergent beliefs can be explained by differences in these characteristics.
Limitations
The present study was limited by the nature and source of the mental health nursing sample. Membership with the ANZCMHN is voluntary and does not include enrolled nurses working in mental health care. The members may be older and better educated [11]. Consequently, caution must be taken in making generalisations to the wider mental health nurse workforce.
The members of the public were personally interviewed whereas the professionals responded anonymously with a questionnaire. Consequently, the public's more positive beliefs could have been influenced by situational pressure to respond in a socially desirable manner [6]. It was also not possible to evaluate how well the professionals' responses reflected their beliefs and actions in practice. Additionally, the health professionals were constrained to given forced-choice options and minimal case information in the vignette.
This study was designed to evaluate belief differences between those who had experienced university training and those who had hospital-based training. Evaluating the effects of training is complicated by the diversity of state-based changes within Australian mental health services, nursing education and policy. Additionally, the current study was limited by a small sample of younger nurses. Further exploration of the wide range of nurses' experiences and beliefs would increase our understanding of how the changes to mental health nursing profession have affected services. It could also provide insight into the dominant nursing beliefs of the future.
Conclusions
Mental health nurses have time-intensive contact, in a variety of roles, with consumers, the general public and other professional groups. Nurses contribute to mental health services and the community as educators, carers and crisis workers in many roles and work settings. The current multidisciplinary approach to mental health care provides an opportunity to take advantage of a wide range of beliefs, knowledge and experience. For this to be achieved, professionals and policy makers need to be aware of their own beliefs as well as the beliefs of others.