Psychiatric Nursing Education: Challenges and Solutions

Introduction

There is a growing demand for nursing professionals, with rapid proliferation of educational programs for nurses. Nursing education requires opportunities for hands-on clinical practice, yet locating sites for practice is non-trivial, requiring considerable creativity from nursing educators and clinical support staff. These challenges can be particularly difficult for mental health practice. For example, the dynamic is altered when the instructor is present for a student-client one-on-one interaction, yet the instructor's presence may be required (Kidd et al., 2012).

Past mental healthcare courses for nurses used psychosocial assessment tools and/or work with processed client recordings. Another approach is standardized patients (Robinson-Smith et al., 2009); Kameg et al. (2009) mentions instructor-manipulated patient simulations. Instructional plans always must account for factors such as clinical/laboratory space, instructor/scheduling time, and equipment costs (Brown, 2008).

Personal and Global Perspectives on Mental Health Nursing

Presently, many professional registered nurses are not always enabled to fully utilize their extensive educational training. Amending this situation could considerably improve long- and short-term health care needs and be personally beneficial. The shortage of primary care physicians could be addressed through utilization of Advanced Practice Registered Nurses (APRNs), freeing primary care physicians for more complex cases (Reinhard and Hassmiller, n.d.). The World Health Organization (WHO; 2007) reported insufficient nurses in mental health areas. Thornicroft (2008) addressed the mental health stigma preventing individuals from seeking assistance; the mental health arena is under-funded and neglected, and mental health nursing is under-populated (Kakuma et al., 2011).

As many as 54% of healthcare workers needed in lower income countries are nurses, to address a nearly 1.18 million mental health professional deficit. For nurses themselves, lack of security and safety in the mental health environment, stigma, and disinterest also contribute to the shortage, affecting retention as well. Lower income countries lack qualified specialist support, and there is limited mental health training for nurses even though nurses may be the only mental health practitioners (Kusano, 2013). While mental healthcare is obviously important, global access to services is limited and/or absent, and mental health is often not a focus of prevention, treatment, or education.

In the use of pedagogical methodologies that foster student understanding, a variety of factors must be considered, including structured environment, interactions, activities, and student-learning situations (Dabbagh & Bannan-Ritland, 2005; Savery & Duffy, 1995). The constructivism approach to pedagogy utilizes experiential lessons for nursing students, providing concrete experiences, enabling active experiences that enhance information processing, and providing opportunities for reflection. Simply stated, problem solving is best learned through direct experience (Dass et al., 2011, p. 92).

Pedagogical Approaches: Literature and Critical Analysis

One novel educational tool in nursing is the Second Life (SL) online simulation, which many think of as a simple game. In SL, the individual invents a persona called an avatar that can move freely in an environment resembling a cartoon world and interact with others. Interaction as an avatar, and with various other avatars, provides students an opportunity to test interpersonal skills and theoretical knowledge. SL also provides pedagogical opportunities for the instructor. Use of SL should address human elements that are an inherent part of leadership and communication for the simulation to be effective and meaningful (Rogers, 2011). The virtual environment of SL is appealing to many students because it is relatively unstructured (Ferguson, 2011). However, without an appropriate pedagogical framework, this tool is not useful for nursing mental health education.

Dass and colleagues (2011) reviewed 15 case studies of virtual worlds and described SL-learning factors: appropriate computer technology, availability of skilled technical support, ability of students to function in the simulated environment, and activities designed to fit with and enhance course learning objectives (Dass et al., 2011; Kidd et al., 2012). Skiba (2009, p. 129) found the use of SL for nursing pedagogy to be beneficial because it enabled experimentation, collaboration, role-playing, and student-faculty interactions. Students rated SL as more useful than webinars and found it a better tool for learning (Johnson et al., 2009). Kilmon and colleagues (2010) commented that standardization of virtual world scenarios enabled evaluation, recording, and monitoring of student performances; distance learning is also facilitated (Inman et al., 2010).

The use of SL in nursing pedagogy is not without inherent difficulties: instructor and technician time in course development, student-based cultural differences for avatar social interactions, and typical computer-usage difficulties (Inman et al., 2010). As well, there is increased learning time for students and instructors, logistical issues, and time pressures (Chang et al., 2009). Understanding SL was more difficult for older students, who reported difficulties in a computerized environment. Equipment demands are higher and more expensive. The correlation of the SL game with mental health nursing requires considerable ingenuity from instructors; not every student appreciates this teaching method (Skiba, 2009). However, both Skiba (2009) and Kidd et al. (2012) observe that once students become familiar with SL and understand its applicability to mental health nursing, initial obstacles become unimportant.

In developing nations, mental health conditions cause an enormous societal burden, yet mental health is under-resourced; both workforce inadequacies and infrastructure weaknesses are increasingly recognized. Public health bioethical principles include non-malfeasance, justice, beneficence, and respect for all individuals. These principles are not upheld when stigma and/or discrimination occur against individuals having mental disorders. For these individuals, absence and/or limited access to appropriate mental healthcare contributes to their inability to fully participate in society.

Health Care Ethics and Diversity

Mental health is closely associated with Millennium Development Goals (United Nations, n.d.) including labor force participation, education, and health. Communities, families, and patients suffer when access to health care is limited; economic development and initiatives designed to decrease poverty are hampered. Examples include increased unemployment, healthcare expenditures, absenteeism from work, and dropouts from education. Addressing unmet mental health needs can improve lives and livelihoods. However, issues of stigma, inadequate professional nursing staff, and healthcare support must be addressed. Ngui et al. (2012) suggest integration of mental health services with primary care, particularly for economically challenged nations.

There are immense global ethical issues concerning inequalities in mental healthcare, worsened because they remain largely undocumented and underestimated. As described by Chisholm et al. (2007), Kessler et al. (2005a, 2005b), and Wittchen, Jonsson, and Olesen (2005), in a single year 30% of the global population may have a mental disorder, with nearly two-thirds of those individuals going untreated. Both Prince et al. (2007) and Murray and Lopez (1996) describe the immense toll of psychoses, alcohol and substance abuse, and depression as part of the global 14% incidence of neuropsychiatric disorders. Furthermore, alarming projections of nearly 15% global incidence of mental health issues occurring by 2020 are striking. These figures include anxiety, substance-related disorders, and depression, potentially debilitating more individuals than the combined effects of wars, heart disease, traffic accidents, and HIV/AIDS. As stated by Murray and Lopez (1996), as many as 28% of global disabilities may be derived from neuropsychiatric health issues.

Economic, Political, and Global Perspectives

Mental health was not listed as a Millennium Development Goal (United Nations, n.d.). The World Health Organization (WHO) defines health inequalities as variances in health or in the distribution of health determinants between different population groups (WHO, 2007). When there is an unjust situation, it may be called an inequity, and clearly there are mental health inequities globally (Kawachi, Subramanian, & Almeida-Filho, 2002). These inequities include concerns regarding gender, racial and ethnic background, urban and rural location, and socioeconomic status.

Unfortunately, the correlation between mental disorders and socioeconomic status includes a higher predominance of the economically challenged (Dalgard, 2008; Hunt, McEwen, & McKenna, 1979; Kessler et al., 1994). The likelihood of mental disorders is higher among the poor in nearly all countries; poverty is thus, according to Murali and Oyebode (2004), both a determinant and a consequence of poor mental health. As well, there is a cyclic relationship between mental disorders and poverty, with decreased ability to sustain or obtain employment and decreased external and internal functionality. Concomitantly, those in poverty are more likely to develop mental disorders (Ngui et al., 2012; Bostock, 2004; Das et al., 2007; Murali & Oyebode, 2004).

Education of Advanced Practice Nurses: Challenges and Strategies

The potential offered by the increased presence of Advanced Practice Nurses (APRNs) is immense. Although practical barriers exist, innovative directions being introduced by practicing APRNs and nursing educators and administrators offer significant hope to make a real difference for patients, families, and global change. Health care is changing its very face as its holistic nature is realized and as the disenfranchised are included in mental healthcare. APRNs will not only serve the present generation, but will also make future differences. With establishment of the practice doctorate, nurse educators foresee a future in which nurses reach their full personal and societal potential in practice on a clinical level.