International Journal of Nursing Practice 2009; 15: 250–256
SCHOLARLY PAPER
Australian nursing curricula and mental health recruitment ijn_1751
250..256
Philip Warelow RN PhD Senior Lecturer, School of Nursing, University of Ballarat, Ballarat, Victoria, Australia
Karen-Leigh Edward RN PhD Research Assistant, Australian Catholic University, St. Vincent’s Centre for Nursing Research, Melbourne, Victoria, Australia
Accepted for publication March 2009 Warelow P, Edward K-L. International Journal of Nursing Practice 2009; 15: 250–256 Australian nursing curricula and mental health recruitment Debate about nursing curricula has been on the forefront of industry and academia in Australia particularly since the shift from the ‘apprenticeship style’ of training for nurses to a university-based, comprehensive, bachelor’s degree. There is the suggestion that university-based courses are rather inflexible and take for granted that the provision of mental health nursing across what is an essentially general course will ultimately attract the numbers of quality staff members required to fill speciality positions in mental health. Recent literature advocates for a direct entry undergraduate mental health programme in Australia, similar to that in the UK. This is suggested as one of many strategies to address the growing disparity between the demand and the supply for effective mental health treatment and care. The support of preceptor staff in the clinical field in terms of workloads, supervision and professional development are also identified as areas for attention. Another strategy that this paper addresses is the increased support of student preceptors in the areas of workload, supervision and professional development, whereas they forge organizational links between the tertiary sector and industry to facilitate enhanced communication channels between the theoretical curriculum (the theory) and the clinical sites (the practice). Additionally, increasing the mental health content in current curricula to a level that reflects hospital-based and community mental health needs is also required. Key words: comprehensive degree, mental health, training, undergraduate curricula.
INTRODUCTION This paper will discuss aspects of nursing in the undergraduate curricula and how it relates to mental health recruitment difficulties in Australia. Discussion about nursing curricula has been at the forefront of industry and
Correspondence: Philip Warelow, School of Nursing, University of Ballarat, Mt. Helen Campus, University Drive, Ballarat, VIC 3353, Australia. Email:
[email protected] © 2009 Blackwell Publishing Asia Pty Ltd
the subject of academic debate in Australia since the move from the apprenticeship style of training to a universitybased comprehensive bachelor of nursing degree. This paper will consider the educational shift in nursing preparation in terms of skill mastery, theory to practice synthesis for specialized domains of health in which these comprehensively trained nurses are expected to work effectively. Comprehensive courses (programmes that prepare nurses for beginning practice in a range of health-care contexts) were originally designed to educate and prepare doi:10.1111/j.1440-172X.2009.01751.x
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nursing students who could begin clinical practice in many different nursing areas, in essence to prepare and blur the differences between the psychiatric, intellectual disability and the general nursing registers and prepare nurses for all practice eventualities. With this in mind, the term multiskilling entered nursing discourse and despite some of its drawbacks, one can argue/understand that it does have some place in the overall provision of health care, particularly in mental health. Multiskilling is the application of skills that allow nurses to practise across a range of different clinical areas and in essence perform a number of different roles that allow nurses to explore the care continuum from much wider perspectives. Some argue this differently,1 suggesting that the comprehensive nursing programme could actually be detrimental with nurses being less skilled overall, whereby, some nursing graduates have a little knowledge about everything and an in-depth knowledge of very little, potentially leading to inadequate skill set preparation with which to work in specialty areas such as mental health. Taking into account these matters, with hindsight, has resulted in recruitment and retention difficulties both in Australia and overseas whereby, only a limited number of recruits have been captured using a comprehensive degree programme as a process of nursing preparation.
DIRECT ENTRY Stuhlmiller argues for a direct entry undergraduate mental health nursing programme, similar to that in the UK, as a strategy to address the growing disparity between the demand and the supply for effective mental health training, treatment and care.2 There has been a notable decline of students choosing mental health as a career option in Australia since the introduction of university-based comprehensive nurse education programmes. Specialist undergraduate nursing degree programmes ceased to exist when specialization of practice became the focus of postgraduate education—that is, nursing specialization to specific areas or domains of health care occurs post bachelors degree.3 It is reasonable to say that the number of students looking to complete a mental health major (completing extra units in mental health) has yet to be evaluated at any depth, but this initiative looks quite promising as it directs the student towards a specific career goal. As an overview, comprehensively prepared nurses have been found to be mostly unskilled and mostly unprepared (outside of the mental health major) in a mental health setting and often require
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additional training to undertake safe and professional clinical practice in mental health arenas.4,5 Curricula and qualification inconsistencies across Australia along with clinically outdated educators (who have not been in recent clinical practice) mean that even minimum standards for practice preparation are currently not being met.2,4,6 Holmes7 and Happell4,8–10 both express concern about how comprehensively trained nurses from the university system translate their newly acquired skills to clinical practice. According to Happell, new graduates lack prerequisite confidence and the skill level of mental health nurses, saying they feel theoretically prepared but often lack the confidence to apply their theory to practice because they often feel afraid and apprehensive about their first experiences in a mental health setting.4 This introductory glimpse at mental health often excludes these nurses from choosing postgraduate options in mental health nursing, which suggests that unless we prepare students better in these areas the result will always be the same and recruitment and retention will remain a significant issue facing this area of nursing practice.
THEORY TO PRACTICE—BARRIERS TO SPECIALIZATION The newly acquired skills required to practise well from a comprehensive standpoint in all of the areas contained in the undergraduate degree programme would require that programme to be at least 7 or 8 years in duration. To increase the mental health components of the undergraduate programme would be difficult because academics responsible for curriculum development of the programme would be faced with the dilemma of what to eliminate in the educational content from the overall programme to allow for more content in mental health.11 This of course would be the problem in all other inclusions to the curriculum as the programme is already at full to bursting point. A postgraduate option would probably be more viable, as the costs of expanding mental health across the comprehensive degree programme as well as other areas would be/could be largely prohibitive. In Victoria, Australia, in 2002, the Nurses Board released a discussion paper on the review of the mental health/psychiatric nursing component of the undergraduate nursing programme.12 The paper agreed that current content and clinical experience specified in undergraduate programmes were not sufficient for beginning practice in mental health, which it described as an important area of nursing. Overall, the review group found that there was a © 2009 Blackwell Publishing Asia Pty Ltd
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wide variation in the quantity and quality of both theoretical content and clinical experience in mental health nursing. The review group made a number of recommendations for undergraduate courses in mental health. Among those recommendations were that mental health nursing content be evident in each of the 3 years of the undergraduate course, and that at least 4 weeks (20 days) clinical experiences were to be specified for mental health. Additionally, the review advocated that all or part of the final clinical experience block be offered in the area of mental health nursing to facilitate consolidation of learning in this area in all undergraduate nursing courses. The review provided discussion of some of the issues with undergraduate mental health nursing education in Victoria, and barriers to subsequent specialization. Among the main points were that comprehensive nursing education in Victoria has not met the needs of mental health nursing, from either a generalist or a specialist perspective. Importantly, the review suggested that the content of undergraduate courses does not reflect the prevalence of mental health problems within the general health-care setting or general community. Despite the review’s recommendations, nursing students consider providing care for patients experiencing mental health problems to be difficult, outside of their skill areas and that their attitudes towards these patients tended to be quite negative, often reflective of stereotypes and stigma, and were harnessed across a lack of fundamental knowledge about mental health.4,12 Holmes suggests caution, feeling that in the future nursing might pay a costly price for some of the inadequacies and decisions made about the profession today.13 He argues about ‘demolition by neglect’ where the required care and the financial costs of such care are in many cases shifted to families. He also suggests that mental health nursing care is not seen as essential within comprehensive university programmes and that those who hold the purse strings tend to see mental health nursing as more a ‘common sense’ approach that can be taught by almost anyone. Happell, drawing on experience in the tertiary sector, speculates about the choices students are encouraged to make from engagement in comprehensive programmes.4 Happell suggests that many students tend to adopt the romanticized or idealized notions of nursing (‘I became a nurse become Mum was . . .’) offered by the media.4,14–18 This implies that undergraduate nursing students might hold preconceived ideas about the most desirable areas in © 2009 Blackwell Publishing Asia Pty Ltd
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which to practise nursing following graduation. Wells and McElwee suggest that dedicated studies and careful impact statements be undertaken to differentiate the obvious differences between mental health and general nursing and the different nature of the candidates.19 They imply that the attitudes, of young people towards those with mental illness, are so important for their impact on recruitment. Mental health nursing, according to Martin and Happell, is ‘clearly located at the least popular end of the scale’ as student nurses progress through and complete their comprehensive programmes.20 Muldoon and Reilly suggest, ‘all student nurses have similar career aspirations—they are hoping to become nurses’.21 In practice, however, certain nursing specialities are likely to be viewed as more or less attractive with the ‘All Saints’ variety not really adding much in its general depiction of what nursing really involves.
NURSING EDUCATION IN AUSTRALIA The 1994 National Review of Nursing Education (NRNE) had as its key objective the assessment of whether the transfer of nursing and nursing education into the university sector had resulted in wider and therefore better professional preparation and career choices for nurses.22 The scope of the 1994 review included many issues in common with those of the more recent NRNE (2001), but it did so in a different context, as universities have now had time to consolidate nursing as a profession and begin to develop research strength and scholarship. Similarly, Australia can also look to international trends related to nursing education, in which there has been a shift towards a universitybased model in Scandinavian countries, Canada, the UK and Ireland. Australia has been at the forefront of this shift and is generally regarded as ‘one of the leaders in nursing education’.22,23 The story is more mixed in the USA as preparation of registered nurses varies from state to state and some nurses are still prepared in hospital settings such as in Pennsylvania, New Jersey and Ohio but other states have hospital-sponsored diploma training programmes. There are also nurses nursing programmes that include baccalaureate preparation. The following brief overview of the nursing preparation in a number of countries provides insight into the larger context of international nursing education most significant for Australian nursing.23 The apprenticeship vs. the tertiary model of nursing preparation is interesting because, aside from the different modes of teaching, each
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model added another dimension to the preparation of nurses. Under the tertiary system, nurses are no longer employees when they first begin their training. This means that students are not employed by the training hospital as they were under the apprenticeship model while they undertake their full-time degree programmes, and so the ‘full-time’ nature of the course requires them to undertake other employment to support themselves and their families. This is clearly a significant tension across the current training and pedagogical framework. Most students are therefore required to work and often have difficulty with geographically distant clinical placements and being dislocated from their home base often requiring them to rent while away on placement and pay (a second) rent to their original lodgings. It is pretence to suggest that this is not significant. If you then add the deinstitutionalization issue involved with mental health and the more community-oriented approach to nursing care, this means that clinical placements for students have become harder to find and geographical relocation needs to occur to find suitable venues. From an Australian perspective, country hospitals are crying out for potential recruitment of staff members to both general and mental health nursing, yet government policy tends to locate and focus infrastructure resources on the city centres and geographical relocation of nursing students for their clinical placements is not a high priority. This issue was in part addressed in England in the early 1970s by the introduction of the Briggs Report.
NURSING EDUCATION IN THE UK AND IRELAND In England, the Briggs Report recommended the establishment of an independent system of nurse education to cut the nexus between nurse education and the staffing needs of hospitals.24 The committee argued that the preparation of nurses using an educational model would improve the clinical content of the nurse education curriculum. In 1986, the British Government supported a phased transfer of nursing education into the tertiary education sector with the first diplomates appearing in the mid-1990s.25 Under ‘The Project 2000’ scheme, this transfer continues. These arrangements provide new nurses with a diploma-level qualification. Wales, Scotland and Northern Ireland have had degree programmes for nurses running in tandem with hospital training for many years. From the 2001–2002 academic years, Wales only offered degree programmes for nurses, and Scotland
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planned to have only degree programmes by 2005. The system of nursing preparation has been a focus of considerable recent policy debate, and a new structure is being implemented for the regulation and management of nursing in the UK.23 Once again, despite some glowing reports by those instrumental in these changes from hospital to university-based training, anecdotal evidence suggests that: neither the transition nor the eventual result are embraced with open arms by the nursing staff in the clinical setting, citing theory to practice gaps as being the main concern.23 In Ireland, the 1998 Report of the Commission on Nursing recommended that pre-registration nursing education be based on a 4-year degree programme, incorporating 1 year of employment with structured clinical placements in a health service. It recommended that pre-registration nurse education be fully integrated into a tertiary framework, with the new degree programme commenced at the start of the 2002 academic year. General nursing, psychiatric nursing and mental retardation nursing developed as separate streams in Ireland, and the Report recommended that three discrete programmes for nursing should be retained. An advisory board has been established to provide advice and set directions in the development of specialist nursing and postregistration education programmes.23 From the point of view argued above, many would advocate that the current system is not satisfactory and significantly different from the original prototype.
NURSING EDUCATION IN THE USA AND CANADA The USA has a less uniform approach to models of nurse preparation. Education models vary from state to state and this would be problematic both for the profession and for students who might anticipate travelling or moving to another state. There is still some preparation of registered nurses in hospitals in some states, among these Pennsylvania, New Jersey and Ohio, but hospitalsponsored diploma training programmes (baccalaureate programmes, associate degree programmes and diploma programmes)26 provided < 10% of new nurses in the USA in 1998. There is evidence that hospitals are selecting nurses with baccalaureate preparation over those with associate degrees.27 Although it is difficult to categorize nurses in the USA, they can be described as falling into © 2009 Blackwell Publishing Asia Pty Ltd
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three main groups: practical/vocational nurses, registered professional nurses and advanced practice nurses.23 A significant point about nursing in the USA related to mental health is that psychiatry is a postgraduate speciality. This means that: psychiatric nurses are often considered more high status as they can be the first point of contact and in some cases the sole primary healthcare provider.23 They are often Masters Graduates and because of this would be very costly to employ for health service providers. Canada has a mixed model for the preparation of registered nurses that involves community college and baccalaureate programmes. The former programmes were instituted in the 1970s and were originally a 2-year diploma. In 1999, the Nursing Task Force recommended to the Ontario Government that beginning in 2005 the minimum entry-to-practice requirement for new registered nurses be a Bachelor of Science—Nursing (BScN). The Task Force also recommended an increase in the length of preparation for registered practical nurses from three to four semesters.28
NURSING CURRICULA AND EDUCATION AND TRAINING INSTITUTIONS Universities and training institutions, both government and non-government, have a key role in defining the discipline and profession of nursing. They engage in the development of nursing as an evidence-based profession with this view becoming more acceptable although some consider aspects of evidence-based practice as problematic, with French29 and Hunter and Pittman30 suggesting a cautionary approach should be adopted as the subjectivity of evidence-based practice tends to dislocate the research process from the quality assurance processes in nursing at the practitioner level, leading to disenchantment.29 Evidenced-based practice has been gaining momentum in nursing since the 1990s.31 Evidenced-based practice skills include asking answerable questions, finding the best available evidence, critically appraising research reports, and determining relevance, applicability and transferability of the evidence to practice.32 The challenge for nursing educators is to equip nurses to read, critically analyse and appropriately put into practice research-based and other evidence for their practice. © 2009 Blackwell Publishing Asia Pty Ltd
The changes in responsibility for the initial preparation of nurses recognize the need for high levels of expertise combined with breadth of education, and the articulation of nursing with a range of careers, both professional and semiprofessional.23 Price et al. argue that because of funding cuts and the rationalization and downsizing of educational programmes there is an inability to attract quality teachers of mental health nursing to academic positions.33 Australian universities, because of this, despite their achievements in developing nurse education and related research, are less than successful in preparing sufficient undergraduate nursing students for their role as beginning practitioners of mental health nursing.
FUTURE CONSIDERATIONS FOR NURSING CURRICULA On a more positive note, small numbers of students are attracted to mental health nursing by some universitybased programmes. These students choose mental health nursing because of their initial desire to enter this speciality area and by a very special group of academics who work extraordinarily hard in facilitating this as a career option by using an array of resources.3 This appears to be similar across the postgraduate mental health courses as the take-up rate of postgraduate places in mental health nursing courses is also inadequate to meet the future human resource needs of mental health services. According to the Regulation, Roles and Competency Development report, workforce education and training, the development of intersectoral partnerships, and the increasing role that consumers and their carers play in service delivery are all significant and need to be taken into consideration for future directions in nursing.34 Some of these points are also addressed within the Australian NRNE discussion paper,23 indicating that the future directions of mental health issues are still at the crossroads. These overarching principles suggest that university-based courses are inflexible and that the provision of mental health nursing across what is essentially a generalist course will not attract the requisite numbers of quality staff members required to fill positions in mental health nursing. Staff members who attempt to offer quality teaching and learning in these specialty areas are quickly burnt out by lack of financial support from their organization, large workloads, the financial difficulty associated with providing adequate supervision for undergraduate students, and the ability to place students in appropriate clinical placements across a shrinking deinstitutionalized
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nursing environment.1 Students require precedent knowledge of mental health practices with which to provide a solid foundation on which to build contemporary nursing skills in mental health, which could include some historical markers on which to benchmark their practice.
CONCLUSION Warelow and Edward suggest historical components related to the evolution of mental health nursing practices should be included in undergraduate comprehensive degree programmes, which would offer significant insights into mental health nursing and its practice.35 Inclusion of historical and contemporary education in the domain of caring in mental health nursing provides an opportunity for facilitating construction of ideas for students in terms of understandings developed in contemporary mental health practices.35 Knowledge of where mental health nursing has been can inform beginning nurses of where the profession is heading, and could possibly inspire these graduate nurses to participate in the practice and the further development of mental health nursing. A UK study by Liggins and Hatcher36 highlighted the major stigma that existed towards mental illness within general hospital settings and other studies reveal negative attitudes towards mental illness and mental health practices among general nurses.7,37 Inspiring nursing students about mental health and addressing the associated stigma directed at mentally ill people38 might make mental health nursing a more attractive career option for nurses. Fundamental recruitment problems are believed to reflect the negative attitudes undergraduates hold in relation to mental health and being significantly less prepared in mental health practice than for other nursing practice areas. Clearly, other countries are experiencing similar recruitment and retention problems as Australia and many would appear to have the same concerns as we experience here. The comprehensive degree attracts many university entrants with only a small number being attracted to mental health nursing as a graduate option. Preparation of mental health workers is still a shortfall within the university curricula and national and international experiences appear to bear this out. Added to this, the range of difficulties associated with finding suitable clinical venues and the general depiction of mental health promulgated by the media gives some underlying reasons why mental health is not everybody’s first choice or particularly popular in career choice. On the positive side of
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the equation, graduate nurse programs have been identified as an important and useful recruitment strategy, but graduates who choose to specialize in mental health nursing experience additional issues to other disciplines, largely reflective of their inadequate exposure to the theory and clinical practice of this field. This might affect the type of transitional support they require.2 We indirectly suggest that there are a range of strategies that have the potential to improve the recruitment and retention of nurses to mental health. These would include changing our thinking about mental health and destigmatizing it as a career choice for prospective undergraduate students entering nursing. The expansion of mental health content in the university curriculum, and the facilitation of greater theoretical and historical content in the current mental health units, and by re-thinking the timing and length of mental health clinical placements will add depth and credibility to the overall programme. Thus, offering greater support to nursing students in the development of their mental health praxis, and having the potential to make mental health nursing less daunting as a potential career choice.
REFERENCES 1 Clinton M, Hazelton M. Scoping study of the Australian mental health nursing workforce. Final report. Report of the Australian and New Zealand College of Mental Health nurses incorporated to the Mental Health Branch of the Commonwealth Department of Health and Aged Care, Australia, January 2000. 2 Stuhlmiller C. Rethinking mental health nursing education in Australia: A case for direct entry. International Journal of Mental Health Nursing 2005; 14: 156–160. 3 Edward K, Hercelinskyj G, Warelow P, Munro IL. Simulation to practice: Developing nursing skills in mental health: An Australian perspective. International Journal of Health Education 2007; 10: 60–64. 4 Happell B. Psychiatric/mental health nursing education in Victoria, Australia: Barriers to specialization. Archives of Psychiatric Nursing 2006; 20: 76–81. 5 Warelow P, Edward K. Evidence-based mental health nursing in Australia: Our history and our future. International Journal of Mental Health Nursing 2007; 16: 57–61. 6 Happell B. Nursing clinical development units—A strategy to promote the relationship between practice and academia. International Journal of Psychiatric Nursing Research 2006; 11: 1322–1330. 7 Holmes CA. The slow death of psychiatric nursing: What next? Journal of Psychiatric and Mental Health Nursing 2006; 13: 401–415. © 2009 Blackwell Publishing Asia Pty Ltd
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8 Happell B. The role of nursing education in the perpetuation of inequality. Nurse Education Today 2002; 22: 632– 640. 9 Happell B. Mental health nursing: The need to distinguish between generic and specialist skills. Australian Electronic Journal of Nursing Education 2002; 8: 8. 10 Happell B, Rushworth L. Psychiatric nursing: Can education help it become more popular? Australian Electronic Journal of Nursing Education 1999; 5: 58. 11 Warelow P. The significance of gender to Australian psychiatric nursing (PhD). Townsville, Qld, Australia: James CooK University, 2004. 12 NBV. Nurses Board of Victoria; Review of Mental Health/ Psychiatric Nursing Component of the Undergraduate Nursing Program: Discussion Paper. Melbourne, Vic., Australia: Nurses Board of Victoria, 2002. 13 Holmes C. Guest editorial. Journal of Psychiatric and Mental Health Nursing 2001; 8: 379–381. 14 Happell B. Who wants to be a psychiatric nurse? Novice student nurses’ interest in psychiatric nursing. Journal of Psychiatric and Mental Health Nursing 1999; 6: 479–484. 15 Happell B. Nurse education: Is it responding to the forces of supply and demand? Nursing Economics1999; 17: 252– 256. 16 Happell B. Psychiatric nursing education: Can it make a difference? International Journal of Psychiatric Nursing Research 2000; 6: 657–669. 17 Happell B. Can education make a difference to undergraduate nursing students’ attitudes to psychiatric nursing? Contemporary Nurse 2000; 9: 40–50. 18 Happell B. The influence of education on the career preferences of undergraduate nursing students. Australian Electronic Journal of Nursing Education 2002; 8: 18. 19 Wells J, McElwee C. The recruitment crisis in nursing: Placing Irish psychiatric nursing in context—a review. Journal of Advanced Nursing 2000; 32: 10–18. 20 Martin T, Happell B. Undergraduate nursing students’ views of mental health nursing in the forensic environment. Australian and New Zealand Journal of Mental Health Nursing 2001; 10: 116–125. 21 Muldoon O, Reilly J. Career choice in nursing students: Gendered constructs as psychological barriers. Journal of Advanced Nursing 2003; 43: 93–100. 22 NRNE. Nursing Education in Australian Universities: Report of the National Review of Nurse Education in the Higher Education Sector 1994 and Beyond. Canberra: Commonwealth Department of Human Services and Health, 1994. 23 NRNE. National Review of Nursing Education: Discussion Paper. Canberra: Commonwealth of Australia, 2001.
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24 DHSS. Briggs Report: Department of Health and Social Security Report of the Committee on Nursing. London: HMSO, 1972. 25 Degeling P, Hill M, Kennedy J, Coyle C, Maxwell S. A cross-national study of differences in the identities of nursing in England and Australia and how this has affected nurses’ capacity to respond to hospital reform. Nursing Inquiry 2000; 7: 120–135. 26 Fagin C. How should nursing respond to the third report of the Pew Health Professions Commission? Online Journal of Issues in Nursing. 2000. Available from URL: http://www. nursingworld.org/ojin/rpc5/tpc5_2.htm. Accessed 24 January 2008. 27 Heller B, Oros M, Durney-Crowley J. The Future of Nursing Education: Ten Trends to Watch. 1999. Available from URL: http://www.nln.org/nlnjournal/infotrends.htm. Accessed 26 January 2008. 28 OMH. Ontario’s Report of the Nursing Task Force: Good Nursing, Good Health: An Investment for the 21st Century. Report of the Nursing Task Force. Toronto: Ontario Ministry of Health, 1999. 29 French P. What is the evidence on evidence-based nursing? An epistemological concern. Journal of Advanced Nursing 2002; 37: 250–257. 30 Hunter S, Pittman L. Evidence-based nursing practice: A cautionary note. Australian Nursing Journal 1999; 6: 35. 31 Larkin M, Griffith C, Capasso V et al. Promoting research utilization using a conceptual framework. Journal of Nursing Administration 2007; 37: 510–516. 32 Cannon S, Boswell C, Robinson M. Evidence-based nursing. Making research come alive at the bedside. Nursing Management 2007; 38: 16–17. 33 Price K, Heartfield M, Gibson T. Nursing career pathways project. Report 01/16 to the Evaluations and Investigations Program. Canberra: Higher Education Division, Department of Education, Science and Training, 2001. 34 Bryant R. Regulation, Roles and Competency Development. Geneva: International Council of Nurses, 2005. 35 Warelow P, Edward K. Evidence-based mental health nursing in Australia: Our history and our future. International Journal of Mental Health Nursing 2007; 16: 57–61. 36 Liggins J, Hatcher S. Stigma toward the mentally ill in the general hospital: A qualitative study. General Hospital Psychiatry 2005; 27: 359–364. 37 Brinn F. Patients with mental illness: General nurses’ attitudes and expectations. Nursing Standard 2000; 14: 32–36. 38 Crisp A, Gelder M, Rix S, Meltzer H, Rowlands O. Stigmatisation of people with mental illnesses. British Journal of Psychiatry 2000; 177: 4–7.
