Voices From Practice: Mental Health Nurses Identify Research Priorities

Patricia Davidson, Marilyn Merritt-Gray, Judith Buchanan, and Julia Noel

Through a collaborative research project, nurse clinicians and nurse academics identified and prioritized the most important research questions arising from the current and future practice of mental health nurses in an eastern Canadian region. Study methods included the Delphi technique and a nominal group survey approach. Nine categories of research questions emerged. The top four categories are discussed under the headings: Preparation of Helpers, the Service System, Caregiver Needs, and Clients With Major Behavior Problems. This timely study offers explicit direction for psychiatric and mental health nursing practice and research, and for the development of social policy. Copyright © 1997 by W.B. Saunders Company

N 'URSING RESEARCH at its best is an integral part of nursing practice, forming the founda-

tion for safe, secure, and effective practice (Parker, Gordon, & Brannon, 1992; Bowman, Alverez, Evans, Smith, & O'Brien, 1992) and continuing to strengthen the 'evidence-base' of practice (Simp- son, 1996). Yet for nurses in practice, research findings will be used only if research addresses what they perceive to be significant clinical prac- tice problems (Fawcett, 1984). In light of current economic realities and limited human resources, the careful identification and setting of research priorities is becoming critical. A strong commit- ment to research-based practice will be a require- ment for all nurse practitioners, educators, adminis- trators, and researchers in the new millennium (MacPhail, 1996).

Based on a belief that nurses consistently do

From the Faculty of Nursing, University of New Bruns- wick, Fredericton; and the Department of Nursing, Uni- versity of New Brunswick, Saint John, New Brunswick, Canada.

Supported by funding from MindCare New Bruns- wick, New Brunswick, Canada.

Address reprint requests to Patricia Davidson, RN, MN, Assistant Professor, Faculty of Nursing, University of New Brunswick, P.O. Box 4400, Fredericton, NB, E3B 5A3, Canada.

Copyright © 1997 by W.B. Saunders Company 0883-9417/97/1106-000753.00/0

informal research, a team of mental health nurse researchers interested in enhancing psychiatric and mental health nursing (PMHN) practice engaged experienced clinicians into the research process. As Gallop (1996) suggests nurses' experiential and intuitive knowledge enables them to recognize what is happening and what needs to happen. Although clinical research priorities for generalist and specialty nursing practice have been success- fully identified and used in the past, clinically based research priorities have not been identified for psychiatric and mental health nursing practice. Thus, the major goal of this descriptive study was to identify and prioritize research questions arising from mental health nurses' current and future practice that have the greatest potential to posi- tively affect the care and welfare of mental health consumers. Benefits have been identified from university faculty collaborating with nurses in practice (Gagliardi, 1996). Subgoals of this project were: to enhance the collaborative relationship between academic nurse researchers and mental health nurses involved in direct client/patient care; to foster mental health nurses' interest in research and an openness to systematic questioning of current clinical practices, and to develop a core of practice-based nurses willing to be involved in future research projects.

340 Archives of Psychiatric Nursing, Vol. XI, No. 6 (December), 1997: pp 340-345

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RESEARCH METHOD

This descriptive study was conducted in two phases. In Phase I the Delphi survey method was used for data collection purposes. The Delphi technique is a group process survey method origi- nally developed by Dalkey and associates of the Rand Corporation (Couper, 1984). It has been effectively used for social and economic planning, evaluation of research projects and priorities, edu- cational innovation, and in industry (Lindeman, 1975). The Delphi technique provides a relatively rapid and efficient way to obtain a consensus opinion or judgment of a wide variety of key informants without the need for face-to-face inter- action (Burns & Grove, 1987). The advantage of such iteration is that in successive rounds, partici- pant experts can either agree or disagree with positions presented without the social influence of face-to-face dialogue (Couper, 1984). Feedback may persuade participants to consider items they might have previously overlooked or thought unim- portant. They may in the end not agree with the viewpoint expressed by other participants but can reach a consensus about how items should be ranked. Typically, the process involves four or five rounds of questionnaires.

During Phase II, a modified version of a nominal group survey method was used. The nominal group approach (Ridgeway & Carling, 1987) ensures that all group members are given an opportunity to express their opinions and thoughts on the particu- lar subject. Some anonymity can be maintained by participants writing their responses as an alterna- tive to verbally expressing them. After a brief opportunity for clarification or comment, partici- pants can rank order their choices which can be verbally shared or submitted to the researchers as a "secret bMlot."

Sample

A convenience sample was gathered, consisting of 20% of the approximately 430 mental health nurses practising within the formal mental health service sector of New Brunswick (an eastern Cana- dian province). The sample equitably represented the region's linguistic and geographic differences as well as the practice areas (operational units) of community, acute, and tertiary level service sec- tors.

The directors of nursing divisions of each se- lected operational unit were asked to identify

potential participant-nurses whom they believed would meet the following selection criteria:

• Have at least 5 years of clinical experience in mental health nursing;

• Viewed by their peers as particularly °fin tune" with patients/clients needs;

• Are aware of aspects of nursing practice for which the scientific basis is inadequate or the outcome of an intervention uncertain; and

• Are interested and willing to participate in the study.

Participants' anonymity and right to refuse to participate without repercussion were respected. Employers were not made aware of which employ- ees decided to participate.

It was assumed many of the potential partici- pants would have limited experience with the generation of formal research questions, and thus might be intimidated by the research process. The need to sensitively engage the participants so they would become involved and remain committed to the process was critical. Initially, the research team developed a module to assist prospective partici- pants in the task of generating research questions. The preliminary survey questionnaire was pilot tested using the research team as subjects. Particu- lar attention was given to: the clarity of written instructions, the approximate amount of time it would take to complete the task, and the general comprehension of the specific questions asked. Revisions were made as a result of the pilot test.

Phase h Delphi Survey Technique

Individual researchers visited potential partici- pants in their practice setting to explain what the expectations would be if they chose to become involved in the project. The module (referred to above) was used to assist in the process of develop- ing research questions. Ninety-two psychiatric/ mental health nurses consented to participate and form the panel of expert participants.

First round. Each participant expert (92) was asked to generate five research questions believed to have the potential to enhance the outcomes for consumers (clients/patients) of current and future mental health services. The 252 questions gener- ated by this process had many commonalities and overlapping themes. A subgroup of the research team categorized and integrated the submitted questions until 88 remained.

342 DAVIDSON ET AL

Second round. A bilingual (English and French) questionnaire containing 88 randomly organized questions was sent out. Participants were requested to rank each question in order of importance using a 7-point likert scale. Sixty-eight participants re- sponded. The responses were analysed using sum- mary statistics. There was very little deviation in the ranking of the questions as participants ranked almost all of the questions on the extreme upper end of the likert scale. No questions were elimi- nated on this round.

Third round. The third round questionnaire contained the same 88 questions ranked in the order established by the second round. Participants were asked to provide rationale to either support or to clarify their position for questions they ranked outside of the bounds of 70% of the other re- sponses. They were invited to comment on, or to clarify their position, on any of the other questions. Comments were compiled and synthesized to re- flect common themes and were included in a fourth round questionnaire.

It should be noted that at this time nearly 2 years had lapsed from the time the process had begun. Members of the research team contacted the partici- pants to encourage them to consider ways they could discriminate more carefully among the ques- tions, and to prevent them from disengaging from the process.

Fourth round. In round four, participants were again asked to rank order the original 88 questions considering their peers' comments from round three. Fifty-five nurses responded to this round and a statistical analysis similar to the second round was completed. Once again, there was little discrimi- nation in the ranking of the questions and only 38 could be eliminated, leaving 50 to be prioritized. It was evident the Delphi technique was not effec- tively engaging the participant group in meaningful priority setting. Maintaining a commitment to the project became difficult for participants and some members of the research team. Consequently, an alternative method was chosen to expedite the process.

Phase II: Nominal Group Survey Approach

Focus groups using a modified nominal group approach format were used in the second phase of the data collection process. Focus group partici- pants were drawn from the original Phase i sample.

Before meeting with the participants, the re- search team met to pilot the focus group format and

to reorganize the questionnaire to reflect the recur- ring themes evident in the remaining 50 research questions. Questions were clustered under nine categories which represented the dominant themes and the categories were named (see Table 1) by the research team through a consensus process.

Focus groups were strategically organized to accommodate participants living in all parts of the province, to equitably represent all service sectors and to respect linguistic (French or English) prefer- ences. The groups were small (a maximum of 6 participants) and structured so as to facilitate full participation and to last no longer than 90 minutes. The goal of the focus groups was to have each participant rank the questions clustered under each category in terms of research urgency and then to rank order the nine categories.

Participants were given an opportunity to ex- press their views on the issues with as little influence from the group as possible. In addition, they were provided with index cards on which to write comments and rank order each of the ques- tions under a particular category. Next they were invited to comment broadly on all of the questions and categories to provide direction for future researchers and/or funding agencies. All comments were recorded and subsequently analysed for recur- rent themes. Finally, each participant was given 10 markers and asked to identify on a card the categories in most need of research. Ranking cards were submitted to the researchers for tabulation.

FINDINGS

Despite the difficulty these nurse participants had in prioritizing the 88 questions in the original questionnaire, when given an opportunity to dis- criminate between the nine research categories in focus groups they were quite decisive. The order of importance of the categories of research questions was determined as well as the most critical ques- tions under each category. Four categories scored

Table 1. Categories

1. Preparation of Helpers 2. Service System 3. Caregiver needs 4. Major Behavior Problems 5. Abuse 6. Assaultive Behavior 7. Helping Relationships 8. Community Integration 9. Medication Use

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significantly higher than the remaining five. Table 1 lists the categories ranked in order of importance.

A brief review of the top four categories is presented here. Where possible the actual words of participants are included and appear as quotations. There has been no intention to interpret the mean- ing of any of the comments.

1. Preparation of Helpers

Under this category the following questions are identified by the nurse participants as most in need of research:

A. How does having nurses certified/specialized in mental health nursing affect client care and outcome?

B. Beyond teaching about psychiatric disorders and communication skills in basic nursing programs, what else is needed to facilitate students gaining an holistic view of mental health clients?

C. What are the implications for client outcome of nurses providing services for which they are not adequately prepared and/or mandated to do?

Although the description of the helper could include non-nurses, the comments are primarily related to nurses and their educational preparation and continuing educational needs. Despite their collective years of experience the participants ex- pressed that they frequently feel inadequately pre- pared to do their work. Although stressing the need to identify curriculum essential for the PMHN, the nurse participants acknowledge that preparation is not solely within the educational domain. They wonder if other factors such as, attitudes, personal- ity traits, biases/prejudices, "common sense" and experience make "some nurses excellent without [additional] training?" Threaded through responses is the notion that the role or professional image of the PMHN is unclear to nurses, other disciplines, and the public. They want to know what a PMHN is in terms of specialization, cross-specialization and certification and how specialized preparation en- hances the quality of client care and/or increases nurses' confidence?

2. The Service System

Questions considered the most in need of re- search in this category include:

A. How is client outcome affected by the avail-

ability of a 24-hour crisis service and appro- priate follow-up care for individuals who are discharged from a psychiatric unit?

B. How have the recent budget cut backs and the changes to the New Brunswick health care system affected the nature, quality, and level of care mental health consumers receive (e.g., client acuity, individual client contract, availability of services experienced and con- tinuity of care)?

C. How will the current move toward a greater emphasis on crisis intervention and reduced emphasis on prevention affect care and out- come for mental health clients?

The affect of budget cuts and service restructur- ing was a dominant theme of discussions related to this category. Concern was expressed that the fragmented system is not targeting prevention as a priority. Participants emphasized that research ini- tiatives should focus on prevention and the effective- ness of mental health promotion activities on client outcomes. They stressed a need for multidisci- plinary research initiatives, for the dissemination and interpretation (for application purposes) of available research and for the clarification of roles and mandates for various helpers and/or programs. Although a few participants were ambivalent about nursing undertaking research initiatives targeting system problems, many did wonder if such re- search could be designed to influence government policy. As one participant asked, "How can the system make the most effective and efficient use of its resources, and what is the role for the nurse in that efficient system?" Central to this discussion was the notion of power. "Having the power to influence my work environment and my methods of care delivery gives me a sense of control over a large part of my life. Consequently I 'm a more effective worker. Consequently my clients benefit." However, many nurses expressed feelings of pow- erlessness related to a perceived lack of control over their work and/or work related decisions. "The nursing voice affects the outcome, yet it is hard to make it heard."

3. Caregiver Needs

The need for research that explored caregiver needs was identified by the participants in the following questions:

A. What factors influence the potential burnout of nurses after 5 to 10 years of practice and

344 DAVIDSON ET AL

what can help them to evolve and grow in their role as a mental health practitioner?

B. What resources are most effective in meeting the needs of caregivers working with individu- als with identified major behavioural prob- lems (e.g., clients who do not engage in the treatment program)?

C. What roles do special care home staff have in influencing client outcome and how can these roles become more constructive?

Because nurses or other caregivers working in mental health often feel like victims "of prejudice and labeling by others including nurses," partici- pants identified support and validation of the psychi- atric caregiver role as important issues. They expressed a need to know: "How do nurses manage work-life stressors over time? What strategies work and allow for growth? what resources are needed to sustain nurse-caregivers?" Because changes in the system have limited the options for "burned out" caregivers to move on, participants wonder what "specialized supports or counseling services for caregivers" need to be developed and what strategies encourage caregivers to seek help? Ques- tioning why in the same setting, some caregivers remain motivated and flourish whereas others burn out, they stressed a need to look at the person- environment fit. Participants were also concerned that the needs of families, residential care home (RCH) staff or operators, and other informal care- givers be addressed. Indicating that residential care homes have the potential to either "make or break" clients' community tenure, participants stressed a need to identify the strengths and limitations of the role of RCH staff. Additionally, they questioned whether families who felt supported in their care giving roles managed crisis better than those who perceive a lack of support?

4. Clients With Major Behavior Problems

Questions ranked by the participants as most in need of research in this category include:

A. What approaches are the most effective in meeting the long-term needs of clients with identified major behavioral problems (e.g., clients who do not engage in the treatment program)?

B. What approaches are the most effective when intervening with clients who repeatedly threaten suicide, have significant difficulty

coping with daily problems, are frequent users of the system with minimal outcome?

C. How do the attitudes of staff toward clients with major behavioral problems influence client outcome?

There was general agreement among participants that this label refers to a mixed group of clientele who are frequently in a psychiatric crisis and use the system repeatedly with limited benefits. Al- though they stressed "that this client group poses a major professional challenge, and our attitudes as nurses can undermine a positive outcome," they caution that "no 'recipe' " is possible and indi- vidual approaches are important. Integrated with these comments is a message that nurses feel "helpless" to address this population's needs be- cause of a perceived limited control over client care issues. Because multiple players and service sec- tors are involved, issues related to the most suitable place to treat persons with major behavioral prob- lems, how best to organize and deliver services, qualifications of care providers, and the impact of these factors on clients and on the system as a whole (family, caregivers, hospital, community) need to be explored. Participants suggest that not only front line people, but those "in authority" and the "decision makers" need more education on the seriousness of this practice issue. A clear direction was that " . . . information on approaches that dem- onstrate effectiveness in intervening with this group would be most helpful as this group of individuals is taking more and more of our limited time."

The remaining categories which ranked signifi- cantly below the previous four categories include: abuse, assaultive behavior, the helping relationship, community integration, and medication. The partici- pants acknowledged that these issues are of con- cern to PMHNs yet a more pressing need is to have existing research findings made more readily avail- able to practitioners.

DISCUSSION

Although the nurse participants in this study were identified as experts by their peers, they frequently felt unprepared for the clinical situations that confronted them in their everyday practice. Thus, they identified an urgent need for research that explores what it is that nurses need to know to achieve and maintain their basic standards of practice which "serve as a basis for performance

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evaluation and as a clarification of the areas of nurses' accountabil i ty" (Austin, Gallop, Harris, & Spencer, 1996, p. 111). Canadian Standards of Psychiatric and Mental Health Nursing currently exist (cited in Haber, Krainovich-Miller, McMahon & Price-Hoskins, 1997) and could serve to guide the development of educational and research pro- grams.

With the recent restructuring of the service delivery system and the increasing complexi ty of client needs the personal and professional integrity of both formal and informal caregivers must be identified. Montgomery (1993) attests to emotional risks inherent in caring for others and suggests that caregivers may need to protect themselves by disengaging from those for whom they are ex- pected to provide care, Rather than blame caregiv- ers for personal deficits and/or ignore their self-care needs a concerted effort could be made to identify what helps them function better in their work environments and maintain their sense of personal and professional worth over time.

Participants cautioned researchers to be aware of the differences in staffing and program needs from urban to rural settings and to be cognizant of the multiple factors (e.g., housing, income assistance, or meaningful work) that can have an impact on clients ' mental health and well-being. A continued surveillance of the environment for upcoming trends and issues so that research could be used in a more proactive fashion is critical. By systemati- cally identifying the most significant aspects of mental health practice in this region, direction has been provided for future research agendas.

CONCLUSION

The findings of this collaborative research project between nurse clinicians and nurse academics affirm that this partnership is valuable in identify- ing issues embedded in the everyday practice of mental health nursing most in need of research attention. This t imely but long overdue study offers explicit direction for researchers, funding agencies, pol icy developers, and for the clarification of the scope of nursing research.

ACKNOWLEDGMENT

Special acknowledgment goes to other members of the research team: Bernadette Castonguay, Nursing Home Services of New Brunswick, Fredericton; Jean Doucet, Community Mental Health Services, St. Stephen; Carole Pontbriand, Centre Hospitier Restigouche, Campbellton; and Velma Wade, Univer- sit6 de Moncton, Moncton, New Brunswick, Canada.

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