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International Journal of Nursing Studies 44 (2007) 377–385

www.elsevier.com/locate/ijnurstu

A comparative cross-sectional questionnaire survey of thework of UK and US mental health nurses

Peter Nolana,�, Sayeed Haqueb, Maureen Doranc

aSchool of Health and Sciences, Staffordshire University and South Staffordshire Healthcare Trust, Blackheath Lane,

Stafford, ST18 0AD, UKbDepartment of Psychiatry, University of Birmingham, UK

cAssociative Clinical Director, The Veterans’ Administration Medical Centre, Denver, Colorado, UK

Received 26 June 2005; received in revised form 24 April 2006; accepted 24 April 2006

Abstract

Background: Comparative inter-country research which identifies similarities and differences in the work of mental

health nurses in different social and political contexts is an important means of determining how changes in health care

systems could lead to better outcomes for patients.

Objective: This study sought to compare aspects of the work of nurses in US and UK mental health care settings.

Nurses were invited to reflect on aspects of their role including identifying the most and least satisfying elements of their

work and suggesting ways in which it could be improved.

Methods and participants: A 12-item questionnaire, comprising closed and open-ended questions, based on the

literature and the authors’ own experiences of mental health nursing practice, was piloted and subsequently distributed

to respondents in both countries.

Results: The US nurses tended to be more willing to accept a wider range of clients than their UK counterparts,

although they had lower expectations of their clients’ likelihood of recovery. Both groups of nurses felt that being part

of a team and having direct contact with clients were the most satisfying aspects of their work, while administration was

the least. Although both US and UK nurses utilised a variety of intervention models, it would appear that Cognitive

Behavioural Therapy was the favoured model for the majority of nurses.

Conclusions: The implications of these findings for the work of nurses and mental health care services in the UK and

US, and the purpose, nature and need for future international comparative research are discussed.

r 2006 Elsevier Ltd. All rights reserved.

Keywords: Inter-country research; Cross-cultural exploration; Role of the nurse

What is already known about the topic?

�

The selection, preparation and work of mental health

nurses appear to vary considerably from country to

country.

�

Few comparative international studies focusing on

the work of mental health nurses exist.

e front matter r 2006 Elsevier Ltd. All rights reserve

urstu.2006.04.014

ing author. Tel.: +441785 353702.

ess: peter.nolan@staffs.ac.uk (P. Nolan).

�

d.

More international studies are needed to compare the

contribution of nurses to alleviating the burden of

mental health problems.

What this paper adds

�

It contributes to our understanding of the work of

nurses in different countries.

ARTICLE IN PRESSP. Nolan et al. / International Journal of Nursing Studies 44 (2007) 377–385378

�

It defines which aspects of their work nurses find

most and least satisfying.

�

It explores nurses’ perceptions of the environmental

and cultural factors which influence how they

approach their work.

1. Introduction

Globalisation, defined as the decoupling of space and

time (Giddens, 2001), is now impacting on many aspects

of people’s lives including the manner in which health

care is provided. Instant communication enables knowl-

edge and culture to be shared around the world in

seconds and has implications not only for those with

responsibility for planning and financing services, but

also for those engaged in delivering them. Health care

programmes need to be responsive to global changes

and health care personnel will need to become compe-

tent in negotiation, analytical and strategic thinking

skills, and the assessment of national and cultural

differences (Spradley and Allender, 1997; Harris et al.,

2001). In mental health, increased sharing of knowledge

has enabled nurses in different parts of the world to

compare and contrast their work in diverse health care

systems and socio-political traditions (Verheis and

Kerkstra, 1993; Smoyak, 1996). Hull (1988) suggests

that cross-cultural exploration enables us to highlight

deficits in our own mental health care and Mead and

Ashcroft (2005) argue that international collaboration is

one of the principal ways of learning how nurses can

improve the work they do.

2. Literature review

Although there are few rigorous international com-

parative studies in mental health nursing, nevertheless

the number of such studies is increasing, resulting in a

clearer understanding of the nature of the work of

mental health nurses worldwide. As this review in-

dicates, studies have been largely researcher-initiated

and undertaken independent of each other. The first

scholarly work relating to the role and function of the

mental health nurse at the beginning of the 20th century

appeared in the United States (Nolan et al., 2002) and

by the middle of the century, literature from other

countries was following suit, seeking to find ways of

strengthening the contribution of the nurse to mental

health services (Callaway, 2002). During the 1950 s and

1960 s, some attention was given to mental health

nursing at professional meetings and international

conferences organised by psychiatrists. Although psy-

chiatrists had been making educational visits abroad

since the second half of the 19th century, it was not until

the 1950s that the first psychiatric nurses from the UK

went to Scandinavia to learn more about their profes-

sion in relation to the work being done in other

countries (Nolan, 1999). In the early 1960 s, Altschul

went to the States for a 1-year study tour and

subsequently wrote her seminal book Patient–Nurse

Interaction: a study of interactive patterns in acute

psychiatric wards, exploring how interpersonal relation-

ships assist recovery from mental illness (Altschul, 1972;

Tilley, 2004). Today, international educational ex-

changes and research collaboration flourish; case man-

agement, the Care Programme Approach, drop-in

centres, and nurse prescribing have all been heavily

influenced by observations made in other countries

(Simpson et al., 2003).

Smoyak (1996) recommended comparative research as

a means of testing the efficacy of nursing in different

contexts, and of defining the work that nurses do and

the conditions in which it yields the best outcomes. She

invited nurse–researchers to go beyond attending con-

ferences in other countries and to seek funding for

international studies, despite the reluctance of many

funding bodies to consider research of this nature.

Work already done in an international context has

proved thought-provoking. Barker (2000) reported that

clients in Canada and Scotland had similar expectations

of the nurse–client relationship, which they saw as

finding its natural context in the clinical situation.

Adejumo and Ehlers (2001), however, found that mental

health nursing was defined very differently in Botswana

and Nigeria, two countries which might have been

expected to have shared a similar understanding by

virtue of their proximity, although in both, the focus of

nursing was on caring for groups of people in their

everyday social contexts.

Bowers et al. (1999) explored the number and nature

of violent incidents in in-patient care in five European

countries. Considerable differences in the number and

nature of such incidents were found. However, the

researchers faced methodological difficulties owing to

there being no shared definition of violence across the

five countries, and no consensus on how to record such

incidents. These disparities provided some explanation

for the variations in incidence and nature, but could not

provide a full explanation. Other factors such as staffing

levels, the therapeutic skills of nurses, and the ways in

which potential conflict was handled were also con-

sidered by the authors to be significant and they called

for further studies to ascertain the true prevalence of

violence in mental health settings in Europe, its causes

and the role of nurses in containing and preventing it. In

a similar smaller study, Nolan et al. (2001) found that

mental health nurses in England encountered more

violence in the course of their work than colleagues in

Sweden, and reported that repeated exposure to violent

incidents eroded nurses’ self-esteem and job-satisfaction.

ARTICLE IN PRESSP. Nolan et al. / International Journal of Nursing Studies 44 (2007) 377–385 379

Swedish nurses experienced less violence and had greater

support, leading to enhanced professional morale.

Weiller et al. (1998) examined provision for patients

with anxiety syndromes and high levels of social

disability in five European countries. This study took

place in the context of European Union and World

Health Organisation directives that planners and provi-

ders should prioritise services for people with mental

health problems in primary care. The researchers

concluded that provision was generally poor; in two

countries, there were no services at all. The poverty of

primary care services meant that some patients would

require more expensive treatment following inevitable

deterioration. General Practitioners were found to need

more training in the management and treatment of

mentally ill people but the researchers considered that

this would be inadequate without a transformation in

the culture of primary care in order to improve mental

health services.

Yamashita (1998) examined the cultural context in

which care is provided, comparing the nature and level

of the involvement of family members in Canada and

Japan with their mentally ill relatives. Profound

differences in how care was described and operationa-

lised were found.

Walmsley’s (2000) study assessed how clients in the

US and Eire with severe and enduring mental illness

were managed using a ‘partial hospitalisation’ strategy.

Economic and cultural factors played a part in the

differences identified, but professional differences ex-

isted over and above these factors. Anders et al. (1999)

compared the care of patients held in secure environ-

ments in Hawaii and Japan, finding differences in the

quality of the working environment and hence in morale

and professional standards, and in the relevance of

policies which the nurses were required to implement.

The authors concluded that nursing practice quickly

regresses and becomes fragmented when the environ-

ment of care is inappropriate.

Lauri et al. (1999) compared nurses’ decision-making

processes in mental health settings in Finland, Northern

Ireland and the US. In Northern Ireland, nurses tended

to use an analytical approach to decision-making;

Finnish nurses combined analytical decision-making

with intuition, and nurses in the US manifested mainly

intuitive decision-making. The researchers could not

explain why this should be so although they hypothe-

sised that the nurses were influenced by factors beyond

the culture in which they worked. Wright and Smith

(1993) found significant differences between the work of

nurses in Australia and the US and attributed this

predominantly to personality differences rather than

environmental or cultural factors. Critically reviewing

comparative studies undertaken to date, Whyte et al.

(1997) suggested that nurses should consider methodol-

ogies that go beyond mere self-reporting by nurses and

instead embark on more rigorous observational studies

which examine what nurses actually do in different

countries.

It has been argued that the close political and

economic ties between the United States and the United

Kingdom mean that what happens in America may

foreshadow developments in health care in the UK

(Putnam, 2001). With this in mind, the present study

aimed to compare some aspects of the work of mental

health nurses in the UK and the US with the intention of

improving understanding of how mental health nursing

in this country may evolve, of avoiding pitfalls and

maximising opportunities.

3. Methodology

Four sites were identified for this study, two in the UK

(Staffordshire and Birmingham) and two in the US

(Kentucky and Denver), principally because of their

proximity to where the authors worked. An opportunistic

sample of respondents was invited to participate as long as

they satisfied the inclusion criteria which were being

appropriately qualified, currently employed in mental

health services, in post for at least 3 years and working

directly with mental health clients. All respondents

described their work as predominantly community-based,

although some in both groups stated that they had contact

with in-patient services, the extent of which was not

explored. Whereas the entire UK sample worked in the

National Health Service, the US nurses worked in three

healthcare systems, all funded and managed differently,

and influencing in their individual ways the type of patients

admitted, the interventions provided by nurses and the

length of time patients were in receipt of services. A

specially designed 12-item questionnaire, based on the

literature and the authors’ own experiences and under-

standing of mental health nursing practice, was piloted and

modified in both countries. The questionnaire comprised

closed and open-ended questions. The results of the pilot

study enabled some modifications to the language used on

the questionnaire to be made, to ensure that all the

questions could be immediately understood by both sets of

respondents. Permission to approach the respondents was

sought from the manger in each setting and each

respondent was given a full verbal explanation of the

study, and given the choice of participating or not. Data

collection took 2 days on each site with respondents

completing the questionnaire at a time convenient to them.

4. Analysis of data

The responses to open-ended questions were cate-

gorised by the researchers working first independently

and then comparing categories. As will be seen from the

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Table 1

Responses to the statements about the work of mental health

nurses

2

P. Nolan et al. / International Journal of Nursing Studies 44 (2007) 377–385380

Findings section, categories were generally easy to

establish and there was little or no disagreement between

the researchers. The w2 test was used to analyse some of

the data.

Statements w df p-Value

Most referrals from

primary care are

inappropriate

10.062 2 0.007 **

The role of

‘Keyworker’ is

understood by each

member of my team

3.119 2 0.210

Disagreement about

care interventions

rarely occurs when

colleagues in my team

are involved with the

same client

2.211 2 0.331

Being cost-effective is

another term for

rationing in mental

health care

0.121 2 0.941

I feel my role is

threatened when

mention is made of

primary care teams

assuming more

responsibility for the

delivery of mental

health services

1.753 2 0.416

There is ample time

for professional

development within

my work

8.890 2 0.012 *

I can refuse new

referrals if my

caseload exceeds an

agreed number

7.767 2 0.021 *

Patients with a

serious mental illness

should always be

discouraged from

stopping medication

5.939 2 0.051

Many staff hold low

expectations of

clients’ abilities to

recover

6.580 2 0.037 *

I feel that community

mental health nurses

are valued in my

organisation

9.335 2 0.009 **

Community mental

health nurses should

be able to prescribe

medication for their

patients

4.720 2 0.095

*Significant at 5% level; **Significant at 1% level.

5. Findings

Of the 100 questionnaires distributed in the UK (50 in

Staffordshire and 50 in Birmingham) 65 were returned

completed (65% response rate; 28 males and 37

females). Eighty questionnaires were distributed in the

US (40 in Kentucky and 40 in Denver) and 43 returned

(54%; 2 males and 41 females). Therefore, an overall

response rate of 60% across the two countries was

achieved. There was a significant gender difference

between the respondents from the two countries

(w2 ¼ 19.047, p-valueo0.001), with many more men

responding in the UK than in the US. The mean age of

respondents in the UK, with standard deviation, was

41.68 years (SD, 7.06), and in the US, 50.49 years (SD,

7.89), a statistically significant difference (po0:001). Themean number of years in their current post was 7 for the

UK nurses and 18 for the US nurses.

Respondents were first asked to state the kind of client

they least preferred caring for. The UK respondents

most frequently mentioned people with a substance

abuse problem; those with eating disorders; those with a

history of violence and those with marital problems.

However, the US nurses were much less likely to cite

people with marital problems, eating disorders and a

history of violence. They selected as their least favourite

clients the parents of disturbed children followed by

people with a substance abuse problem.

Respondents were asked to indicate their level of

agreement (‘strongly agree’, ‘neither agree nor disagree’,

‘strongly disagree’) with a series of statements concern-

ing the work of mental health nurses. Table 1 shows the

analysis of their responses.

There were no significant differences between the two

groups of nurses in response to six of the statements.

Both groups agreed that being cost-effective is another

term for rationing in mental health care; that they felt

their role was threatened when mention is made of

primary care teams assuming more responsibility for the

delivery of mental health services; that patients with a

serious mental illness should always be discouraged from

stopping medication, and that community mental health

nurses should be able to prescribe medication for their

patients. Both disagreed with the statements that the role

of ‘Keyworker’ is understood by each member of my team,

and that disagreement about care interventions rarely

occurs when colleagues in my team are involved with the

same client.

Three statements elicited responses that were signifi-

cantly different between the two groups at the 5% level.

ARTICLE IN PRESSP. Nolan et al. / International Journal of Nursing Studies 44 (2007) 377–385 381

Significantly more US nurses disagreed with the state-

ment that most referrals from primary care are inap-

propriate; and significantly more US nurses agreed with

the fact that I can refuse new referrals if my caseload

exceeds an agreed number, and with the assertion that

there is ample time for professional development within

my work. Two statements elicited responses that were

significantly different between the two groups at the 1%

level. Significantly more US nurses felt that many staff

hold low expectations of clients’ ability to recover and

agreed with the statement that I feel that community

mental health nurses are valued in my organization.

Respondents were next requested to state what

aspects of their work gave them most satisfaction. This

question evoked a huge range of responses which were

categorised by the researchers working first indepen-

dently and then together in order to secure agreement.

Table 2 presents the categories in rank order:

For UK respondents, Client Contact meant ‘being

able to assist people’; ‘caring for the enduring mentally

ill in their homes’; ‘communicating with ethnic minority

families’ and ‘engaging with difficult clients’. Under

Using Clinical Skills, respondents mentioned ‘under-

taking assessments’; ‘care planning’; ‘having appropriate

time and skills’; ‘identifying appropriate treatment’ and

‘implementing evidence based practice’. Knowing I am

Doing a Good Job meant ‘seeing patients improve’;

‘having appreciative clients’; ‘helping patients regain

independence’ and ‘making a difference to individuals

and families’. Team Working comprised ‘feeling part of a

team’; ‘sharing ideas and problems and finding team

solutions’ and ‘working with a wide range of profes-

sionals’. The opportunity to mentor students and

improve their own skills as well as the skills of others

was the principal aspect enjoyed under the heading of

Teaching.

US nurses, on the other hand, interpreted Client

Contact as meaning ‘supporting individual clients’ and

‘leading therapy groups’. Using Clinical Skills meant

being involved in ‘crisis intervention’; ‘developing

Table 2

Aspects of your work that give most satisfaction (numbers

rounded to nearest whole figure)

UK respondents (n ¼ 65) US respondents (n ¼ 43)

Client contact 36 (55%) Client contact 25 (58%)

Using clinical

skills

22 (34%) Using clinical

skills

12 (28%)

Knowing I am

doing a good job

22 (34%) Teaching 10 (23%)

Team working 17 (26%) Receiving

positive feedback

7 (16%)

Teaching 7 (11%) Team working 4 (9%)

Personal growth 4 (9%)

patient care programmes’; ‘medication review’; ‘obser-

ving, treating and managing patients’ and ‘doing

psychotherapy’. Under the heading Teaching, respon-

dents mentioned most importantly, ‘being with stu-

dents’; ‘providing clinical supervision’; ‘mentoring and

developing staff’ and ‘teaching and educating patients’.

Two sub-themes emerged under the heading Receiving

Positive Feedback and these were ‘seeing people im-

prove’ and ‘being valued’. Team Working included

‘having support from colleagues’ and ‘working as a

member of a team’. Personal Growth meant having a job

that involved ‘intellectual stimulation’ and which

provided the opportunity for one’s own ‘personal,

spiritual and professional growth’.

Table 3 provides a summary of respondents’ answers

to What aspects of your work give you least satisfaction?

Under Administration, the UK respondents men-

tioned ‘litigation administration’; ‘mindless paper work’;

‘non-clinical-related paperwork’; ‘pointless administra-

tion’ and ‘lack of admin support staff’. Lack of Support

meant ‘working with difficult staff’; ‘feeling alone’;

‘having work undervalued by other professionals’; ‘lack

of cooperation from other services’; ‘lack of managerial

support’ and ‘isolation’. Overload included comments

such as ‘being expected to know everything’; ‘caring

responsibilities for a large number of patients’; ‘having

too much to do’; ‘insufficient time for clients’; not

having time for one’s self’; ‘too much travelling’ and

‘pressure and stress’. The Poor Communication category

gathered together comments such as ‘assessing inap-

propriate referrals’; ‘un-thoughtful referrals’ and ‘dupli-

cation of information’. Meetings was a category of a

single word not considered to require further definition

by respondents. Lack of Resources was a general

complaint, including specifically for two individuals

‘lack of office space’ and ‘having to write notes in

longhand and then transfer them to a computer later’.

Under ‘Administration’, the US respondents men-

tioned ‘administration for insurance companies’ and

‘billing insurance companies’. Managed Care caused

distress owing to ‘arbitrary decisions made by manage-

ment’; ‘being audited by managed care companies’;

‘arguing for reimbursement’; ‘being controlled’ and

‘needing authorisation’. Clients led to dissatisfaction

when it was a case of ‘chronicity of the patient who does

not improve’; ‘families that want quick fixes’; ‘non-

respectful attitudes’ and ‘parents who will not get

involved’. Under ‘Lack of Support’, US respondents

mentioned ‘dealing with difficult staff’; ‘justifying the

work to the general public’ and ‘little support from

management’. When it was defined, Lack of Resources

meant ‘working with an insufficient budget’; ‘reducing

staff numbers’; ‘limited psychiatric resources’ and ‘lack

of time to treat effectively’.

Respondents were asked to identify the ‘personal

values that assist me most in my work’. Many of the

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Table 3

Aspects of work giving least satisfaction (numbers rounded to

nearest whole figure)

UK respondents (n ¼ 65) US respondents (n ¼ 43)

Administration 39 (60%) Administration 20 (46%)

Lack of support 20 (31%) Managed care 17 (39%)

Overload 18 (28%) Lack of resources 6 (14%)

Poor

communication

12 (18%) Clients 5 (12%)

Meetings 8 (12%) Lack of support 4 (9%)

Lack of resources 3 (5%)

Table 4

Models of care used by the two groups of respondents (numbers

rounded to nearest whole figure)

UK nurses (n ¼ 65) US nurses (n ¼ 43)

CBT 13 (20%) CBT 12 (28%)

Eclectic 8 (12%) Eclectic 12 (28%)

Peplau 10 (15%) Peplau 10 (23%)

Rogers 7 (11%) Solution-focused 4 (9%)

Client-centred 6 (9%) Orem 3 (7%)

Psycho-social

interventions

5 (8%) Psycho-dynamic 3 (7%)

Newman 5 (8%) Watson 3 (7%)

Family therapy 5 (8%) Rogers 2 (5%)

Humanist 4 (6%) Parse 2 (5%)

Roper 4 (6%) Psycho-analytic 2 (5%)

Solution-focused 4 (6%) Sullivan 2 (5%)

Problem-solving 3 (5%)

Medical model 3 (5%)

Orem 3 (5%)

Egan 3 (5%)

Table 5

Suggestions for improving patient care (numbers rounded to

nearest whole figure)

UK nurses (n ¼ 65) US nurses (n ¼ 43)

Reducing

referrals and

case load

26 (40%) Improved

education and

training

13 (30%)

Increasing

resources

16 (25%) Reduced case-

loads

12 (28%)

Improved access

to training

9 (14%) Improved

resources

11 (25.5%)

Reducing

amount of

administration

8 (12%) Abolishing

managed care

4 (9%)

Better

communication

and team

working

8 (12%) Better access to

supervision

3 (7%)

Better access to

supervision

4 (6%)

P. Nolan et al. / International Journal of Nursing Studies 44 (2007) 377–385382

responses tended to describe ‘skills’ or ‘qualities’ rather

than ‘values’. Responses were therefore categorised

under these three headings but the categories were hard

to operationalise.

The UK respondents wrote extensively about skills

such as the ‘ability to prioritise’ and ‘being organised’

which were mentioned by a third of the sample.

‘Adaptability’ and ‘flexibility’ were considered vital as

were ‘being a team player’ and the ‘ability to get on with

people’. ‘Communication skills’ were also regularly

mentioned. Key personal qualities included being

‘empathic’, ‘non-judgemental’ and ‘caring’; having

‘patience’ and ‘commitment’; being ‘open-minded’,

‘honest’ and having a ‘sense of humour’. ‘Experience

of life’ was mentioned by a third of the sample as a

personal attribute of great importance in the job. The

beliefs and values of the UK respondents included

‘believing in the worth of people’; ‘believing that what I

do will have a beneficial effect’; believing that ‘indivi-

duals should take responsibility for themselves;’ that

‘people deserve a good service’; that ‘people can change/

recover’ and believing in the ‘value of social inclusion’

and ‘humanistic approaches’.

US respondents valued skills of ‘team working’;

‘collaboration’ and ‘being able to challenge’. They felt

that personal qualities essential to their work were ‘love

of people’; ‘commitment to the clients’ well-being’;

‘respecting people’ and ‘commitment to providing a

service for all patients regardless of the ability to pay’.

They valued ‘humanistic’ approaches to care; believed in

‘nursing as caring’, that team work should be ‘ethical’

and that it was important to ‘value the individual’.

Table 4 summarises their responses to the question

‘what models of care do you normally base your work

on’?

Although a wide range of models was cited by nurses,

respondents were largely in agreement regarding the

ones they most regularly use, CBT (UK: 20%; US:

28%), Eclectic (UK: 12%; US: 28%) and Peplau (UK:

15%; US: 23%). The responses suggest that some nurses

utilise more than one model, although the questionnaire

did not elicit under what circumstances they choose

certain models.

Finally, respondents were asked how the care they

provide for clients could be improved (Table 5):

Under Reducing Referrals and Case-Loads, the UK

respondents mentioned ‘having more appropriate refer-

rals’; ‘lower case-load’; ‘fewer visits to improve quality

of care’ and ‘having more time for clients’. Increasing

resources meant ‘having more staff’. Under Reducing

Amount of Administration, they mentioned ‘less admin-

ARTICLE IN PRESSP. Nolan et al. / International Journal of Nursing Studies 44 (2007) 377–385 383

istration’ and ‘improved support’. Improved access to

training involved ‘attending courses on Brief Therapy’;

‘CBT training’; ‘having specific training in counselling’;

‘more access to training and education’; ‘more personal

development’ and ‘skills based training’. Better Commu-

nication and Team Working revolved around ‘better

liaison with primary care’; ‘better relationships with

consultants’; ‘better working with other professionals’;

‘better team organisation’ and ‘joint working with GPs

on difficult cases’. Better access to supervision also meant

more supervision.

For the US respondents, Reduced Case-loads would

mean ‘having more time for clients’. Improved education

and training necessitated ‘having access to professional

education’; ‘learning better ways for helping clients’;

‘more psycho-education programmes’ and ‘more perso-

nal development’. Under Improved Resources, respon-

dents mentioned wanting ‘more staff’; ‘more funding’;

‘more space’; ‘more time for admin’ and ‘providing time

for treatment team planning and meetings’. Abolishing

Managed Care was variously expressed as ‘less managed

care involvement’ and ‘less contact with insurance

companies’. Like their UK counterparts, the US nurses

wanted Better access to supervision and this also meant

more supervision.

6. Discussion

Any study exploring the work and attitudes of nurses

working in different countries, even two which share a

common language, and in very different health care

contexts, can be accused of attempting to make

comparisons where none are possible. However, this

study achieved a very high response rate which suggests

that the nurses in both the UK and the US felt that the

questions they were being asked were relevant to their

particular situations. Interpretation of their responses

has been undertaken with caution; yet the considerable

consensus in terms of the words and phrases used by

respondents and the ideas and concepts they put

forward make it possible to feel reasonably confident

about the conclusions drawn in this section.

An important limitation of the study is that very few

male US nurses (n ¼ 2) responded to the questionnaire.

At the time of data collection, only two men expressed

an interest in the study and satisfied the inclusion

criteria. Other males with a nursing background who

were interested in the study had to be ruled out because

of their management roles. It may be the case that males

felt less sympathetic than females towards a study

emanating from the UK, although there was no obvious

evidence of this. The small number of males means that

the comparisons between the two groups of nurses are

not as strong or perhaps as illuminating as they would

otherwise have been.

It needs also to be borne in mind that the nurses who

responded to the study were, in both countries, working

in large towns and cities which may involve them in

different kinds of work, and in facing different

challenges from those working in other settings.

While the small number of respondents must be taken

into account, it is interesting to note that the mean age

of respondents from the US was considerably higher

than in the UK, and that US nurses had also spent many

more years in their current post. This might suggest that

US nurses tend to stay in one post, while their UK

counterparts change jobs more regularly. If this

observation is accurate, it may reflect the diversity of

clients and experiences that US nurses working in

private practice can achieve compared to UK nurses

who may need to change their jobs regularly in order to

achieve the same breadth of experience. It would also

appear that US nurses are less likely to label certain

groups of clients as their ‘least favourite’, perhaps

because they are more confident in their skills to care

for diverse clients, or quite simply because the US

system of Managed Care obliges them to take whichever

clients present to them. UK nurses appeared either to be

anxious about or irritated by people who have substance

abuse problems, those with eating disorders and those

with a history of violence. This is worthy of further

investigation. Does this reluctance arise because nurses

find these clients unrewarding in terms of ‘cure’ rates, or

because they are fearful for their own safety in the case

of violent patients?

On both sides of the Atlantic, there appears to be

cynicism regarding the use of cost-effectiveness as a

euphemism for rationing in mental health care. One

might have expected that the US respondents would feel

positively about community mental health nurses being

able to prescribe as nurse prescribing has a long history

in the States; it is slightly more surprising that the notion

of prescribing is apparently already well-embedded in

the UK nursing mentality.

US mental health nurses appear to exercise greater

control over their work, attracting appropriate referrals

from primary care and being able to limit their case-

loads. They also seem better supported in terms of

professional developmental; all three of these issues

caused concern for UK nurses whose job descriptions

seem to leave them more open to caseload overload

without the buttressing of ongoing training.

Both groups of nurses found their major source of job

satisfaction in direct contact with clients and their major

source of job dissatisfaction in the administrative duties

which took them away from clients. Moves in the UK to

reduce paperwork for some public sector workers such

as police officers need urgently to be translated into the

health care sector to enable people to do the work

for which they originally entered the service and to

which they are presumably best suited. The US nurse

ARTICLE IN PRESSP. Nolan et al. / International Journal of Nursing Studies 44 (2007) 377–385384

respondents appeared to feel much more valued for the

work they were doing that than their UK colleagues.

Desire for recognition may be the reason why UK

nurses cited (perhaps somewhat wistfully?) one of the

components of job satisfaction as ‘knowing I am doing a

good job’, a comment which might hide a lack of such

acknowledgement from others. Future studies could

usefully explore what aspects of the work of US nurses

leads to their feeling more valued than UK nurses,

despite the manifold difficulties which they face working

within an insurance-driven healthcare system.

UK nurses defined the qualities and skills that helped

them in their work in relation to the difficulties they

perceived they faced as nurses. They considered organi-

sational skills important, presumably because these

assisted with a heavy workload, and the ability to work

well in a team, perhaps because they so often felt

undervalued by other team members. For their part, US

nurses valued skills and qualities which helped them in

the US health care context: being able to challenge a

system driven by money rather than by client need;

commitment to the client’s well-being which is perhaps

overlooked when insurance companies determine the

nature and level of care; and commitment to providing a

service regardless of the ability to pay, perhaps

indicating their sense of injustice when only the wealthy

have easy access to services. Thus health care profes-

sionals value qualities that enable them to cope with the

job they have to do in the place they have to do it, over

and above generic qualities which might apply to all

healthcare work. This is despite the fact that both

groups of nurses were using the same models of care.

The request for more training came from both groups

and probably reflects the perceived difficulties of work-

ing with clients with complex and multiple pathologies

when resources do not allow nurses to give the time they

feel individual clients require. The request for more

training may be closely linked to complaints about lack

of support which surfaced in other areas of the

questionnaire. Training needs can never perhaps be

ultimately satisfied, but where nurses feel that their work

is undervalued, and that they are often asked to do work

which they do not see as their principal role, the demand

for more training is likely to emerge as a compensatory

mechanism.

There may be many explanations for why UK nurses

express unease about dealing with violent or potentially

violent patients, and US nurses do not. Speculative

reasons may include inadequate training of UK nurses

in how to defuse potentially violent situations and in

how to handle them should they occur. Media coverage

of adverse incidents where patients were incorrectly

restrained may have fuelled anxiety on the part of UK

nurses generally. UK nurses may feel that support from

medical and management staff is lacking if incidents

occur and that they will shoulder the blame while other

staff groups cover their own backs. In the US, the

situation may be different. Insurance companies may

filter out highly challenging patients, who could prove

costly in terms of the time, human and material

resources they require. It may be that the training of

US nurses in handling violent events is superior to that

of their UK counterparts. The responses of UK and US

nurses to violent patients is an area of difference which is

one of considerable interest and deserves further

research attention.

7. Conclusion

This study confirms the work of Weiller et al. (1998),

Yamashita (1998) and Nolan et al. (2001), in relation to

similarities and differences in the work of mental health

nurses. However, the present study moves a little further

in exploring the key question as to the influence that

different organisational cultures may have on how

individual nurses and teams of nurses construct their

role. Seeking to account for these differences and to

project how changes in the nursing culture in any

particular country might affect outcomes for patients

must now be the focus of research (Wright and Smith

(1993). In terms of helping focus the needs of UK mental

health nurses by contrasting them with those of

colleagues in the US, this study supports Smoyak’s

(1996) claim that there is much to be gained from

comparative studies and the analyses they promote.

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