The differences and commonalities between United Kingdom and Canadian Psychiatric/Mental Health nursing: a personal reflection

The contemporary, secular, media literature is replete with references to globalisation and the notion of 'the global community'. It is within this context that the I recently moved from the University of Ulster, via the University of Alberta, to the University of Northern British Columbia, Canada. This trans-Atlantic odyssey has ushered me into making some comparisons between Canadian and UK Psychiatric/Mental Health (P/MH) nursing issues. Having been asked to write this editorial, it needs to be acknowledged that what follows is necessarily personal and reflective rather than empirically based. Furthermore, it would be arrogant of me to assume that my experience is representative of all P/MH nurses in Canada and the UK. Nevertheless, my recent move places me in the relatively rare position of having first-hand experience of P/MH nursing and associated issues in three Universities/Provinces across two counties. Consequently, there may be some merit in making these comparisons, particularly if they offer any insights into the problems facing the 'global community' of P/MH nurses. One issue that is common to both Canada and the UK is the distinct shortage of P/MH nurses. In 1998, the education committee of the Canadian Federation of Mental Health Nurses issued a position paper (Chan et al. 1998, p. 1). They declared that they were concerned about the quantity and quality of undergraduate P/MH nurse educational preparation. Further, the evidence was that when Canadian nursing students had an option to elect a psychiatric rotation (clinical placement), they did not do so since 'P/MH nursing is not an area in which they choose to practice in after graduation' (original emphasis). Similar concerns regarding the recruitment and retention of P/MH nurses exist in the UK. The numbers of students applying for P/MH nurse training have historically been, and continue to be, significantly lower than those applying for adult (General) nursing. This commonality begs several questions including: What is it about P/MH nursing that discourages many students from considering this speciality as a career option? In way of a response, perhaps there are differences in the type of person who is drawn to P/MH nursing rather than adult (General) nursing. According to Altschul (1997, p. 4): I believe the difference in the kind of people attracted to psychiatric nursing remains. She continues: My experience tells me that psychiatric nurses are people who are fascinated by other people's behaviour, their thoughts, their peculiarities. They are people who are non-judgemental and not easily shocked. The limited body of evidence in this area is consistent in showing fundamental differences in attitude, and these findings support Altschul's assertions regarding the greater 'liberal mindedness' of P/MH nurses. Indeed, such findings lead Clarke (2000) to assert that choosing a nursing speciality is not an external, objective act but is instead a reflection of a person's core values. I am not surprised then that there is a global shortage of P/MH nurses, reflected in both Canada and the UK, since such people are hard to come by. To find such people who can refrain from passing judgement on clients, even though the client's behaviour may be abhorrent, is not easy. The real essence of this practice is rarely spelled out. While most (if not all) nurses would claim to aspire to non-judgemental practice, the realities of being able to form a therapeutic relationship with a client who has sexual feelings towards children, or a client who has been convicted of a violent crime, make massive demands upon the nurse's willingness to adopt a non-judgemental attitude. Hence, if we are to attract more nurses to the speciality, as an academy we need to do a better job of 'selling' the intrinsic awards of such highly demanding practice. One obvious difference between Canada and the UK is the educational preparation of P/MH nurses. The majority of registered nurse preparation in Canada follows the 'generic' model. Whereas, in the UK, there is a separate part of the registrar for P/MH nurses and in order to be eligible for registration on this part of the registrar, the nurse must undergo a specialist P/MH nurse education. Interestingly, a phenomenon peculiar to 'Western' Canadian provinces (e.g. British Columbia, Alberta, Saskatchewan and Manitoba), is the existence of a separate registrative body for P/MH nurses and a separate pre-registration P/MH nurse education program. The difference in educational preparation of P/MH nurses raise the issue of the generic or speciality model as the most appropriate pre-registration nurse education preparation. Some generic nursing education models are underpinned by the belief that nursing students need not have specific clinical experiences on psychiatric placements and that psychiatric nursing skills can be learned in any setting. This has led to the situation where, in many Canadian colleges and University schools of nursing, psychiatric or mental illness rotations are not required (Chan et al. 1998). I cannot help but wonder what the reaction would be if the opposite situation was proposed; namely that a generic nurse undertook all his/her placements on psychiatric units and merely had to apply the medical/surgical content? Epistemological arguments aside, there may be more pragmatic and persuasive arguments that can be made when one considers the key point of the first section of this editorial – the global shortage of P/MH nurses. There is a sizeable literature that suggests first-hand experience of specialist psychiatric clinical placement not only begins to challenge some of the students' inappropriate stereotypes and myths about people with mental health problems, but simultaneously introduces the students to the subtle, sometimes less obvious, rewards of working in this area. Where nursing speciality shortages have been identified in the past, additional access to those specific clinical placements has had a clear impact on the shortage of nurses. If such a relatively small exposure to P/MH nursing has a positive impact on recruitment to the speciality, one might extrapolate that having an educational experience dedicated to P/MH nursing would thus produce the highest chance of retaining the nurse within the speciality after he/she graduates. Of course, such positions are somewhat simplistic, and there are also significant problems in attracting people to specialist psychiatric nursing programs. Nevertheless, there is an evidence based argument for including (and increasing) psychiatric clinical placements for students as a means to enhance retention. One thing that particularly struck me when I came to Canada was the similarity in both the location and the style, or architectural design, of the psychiatric hospital. The 'arms length' location of these Canadian hospitals suggested to me the same under-pinning dynamic that drove the location of UK asylums – the desire to keep those different, 'mental patients' away from the rest of the 'normal' people. It is not by accident that so many of these hospitals are built so far from the city centres. Historical myths of the contagious nature of mental illness were proliferate at the time that these hospitals were constructed, and some would say that such myths are still in evidence today. So we build these asylums far away from us and thus won't be contaminated. The location of such buildings may even add to the ongoing stigma of mental health problems; it keeps mental health problems less visible; surrounded in mystery; perpetuates the myth of difference rather than 'sameness'. The obvious similarities led me to wonder about post-colonial influence. As a country now in the Commonwealth, it would be difficult to ignore the British, colonial influence on some aspects of Canadian culture. One such influence, in my view, is the post-colonial legacy of attitudes towards mental illness and care of the person with mental health problems. Mass media (mis)representations of mental illness and people with mental health problems are evident in both Canada and the UK. Stereotypes and myths of mental illness are common to both. As a consequence, many of the resultant mental health care policies and legislation in Canada have many similarities with UK policy and legislation. While both Canada and the UK have national suicide rates that are lower than many countries, both these nations show significant rises in national suicide rates since the 1950s. Both countries also share a similar pattern of differences between the rates for completed suicides of males/females. Males, in both countries, continue to be around three times more likely to complete than females. In the UK, differences exist in the suicide rates for each of the countries (e.g. England/Wales has an annual rate of suicide of 10.0 per 100 000 people, whereas Scotland has an annual rate of 17.3 per 100 000). Similarly, in Canada, certain Provinces have a disturbingly (and as yet unexplained) significantly higher rate than others. For example, in Alberta the current suicide rate for males is 26.2 per 100 000 and for females, 6.6 per 100 000. Paradoxically, while it can be seen that suicide continues to represent a clear public health issue for both Canada and the UK, neither nation can be complacent where care of the suicidal person is concerned. Many of the identified deficits that have been documented in the UK are similarly evident in Canada. In witnessing 'care' of the suicidal person in several Canadian hospitals, it is clear that such 'care' is still largely driven by custodial rather than therapeutic concerns. 'Observations' remain the principle 'modus operandi' for 'care' of the suicidal client. Specific training for care of the suicidal person appears to be hard to find if not non-existent. In one hospital, security guards rather than P/MH nurses carry out the 'observations' of the suicidal person. Even though such a situation leaves me feeling very uncomfortable, in some ways, this 'care' delivery model may be more honest than those which claim to provide more than custodial care, yet in reality, often don't. It is evident that 'models' of care for the suicidal person in both Canada and the UK still emphasise the notion of making the person 'physically' safe (Cutcliffe 2002). Such models appear to be based on the premise of maintaining the person's safety while they are in 'suicidal crisis' and then gradually reducing the level of observations; perhaps simultaneously administering anti-depressant medication. Patterns of admission and discharge of suicidal clients clearly imply such a premise, wherein (most often), suicidal clients have very short lengths of stay. While these 'crisis' based models of care may have merit, alternative views are beginning to emerge which posit the suicidal person as needing far more long term formal input. Lastly, very much like the UK, there is currently no empirically induced theory for Canadian P/MH nurses that underpins the care of the suicidal person. Acknowledging this deficit, and the nation-wide problem of suicide, the Canadian Federal government instigated the National Task Force on Suicide. More recently, the Canadian Institutes for Health Research and Health Canada invited a collection of researchers, clinicians, policy makers and other stakeholders to Montreal to begin work on a national Canadian suicide research strategy. I was immensely heartened by the willingness and openness of all the participants to utilise a range of research methodologies, to embrace a genuine multidisciplinary approach and perhaps most encouragingly, to adopt an integrative, pluralistic approach to understanding suicide and care of the suicidal person. In conclusion, I return to the notion of difference and 'sameness' between Canadian and UK P/MH nurses. Ward (2003) has asserted the position that wherever mental health nurses are, they will frequently face the same problems; albeit, experienced and subsequently responded to, in the cultural and political context in which they are encountered. My own recent trans-Atlantic experience would lend some support to this position. Ward (2003) goes on to postulate that even within such similarity, it is in exploring the differences that professional stagnation is avoided. While I would not dispute Ward's assertions, there is still utility in understanding the 'sameness'. Van Manen (2002, p. 61) makes this point when he states: We need to examine how people differ by being attentive to what we share in common, by showing how we are different through sameness. Consequently, there is still a great deal of merit in utilising the lessons learned in other countries; in essence applying the 'sameness' to our discipline-related issues, particularly when the countries share strong cultural, post-colonial commonalities and 'sameness', such as the commonality between Canada and the UK. In so doing, the international academy or 'global community' of P/MH nurses only stands to gain.

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