Nurse Education in Practice (2005) 5, 109–116

Nurse

www.elsevierhealth.com/journals/nepr

Educationin Practice

Recruitment and retention initiatives:nursing students’ satisfaction withclinical experience in the mental health field

Michelle Clearya,*, Brenda Happellb,1

a Clinical Nurse Consultant, Central Sydney Area Mental Health Service, PO Box 1,Rozelle NSW 2039, Australiab Centre for Psychiatric Nursing Research and Practice, School of Nursing,The University of Melbourne, Level 1, 723 Swanston Street, Carlton, Vic. 3010, Australia

Accepted 8 June 2004

Summary The difficulty in attracting graduates of undergraduate nursing pro-grams into mental health remains a challenge for the field. Positive clinical experi-ence has been identified as a potential strategy in encouraging students to regardmental health nursing positively. This paper reports the findings of a survey admin-istered to Undergraduate Nursing Students and Trainee Enrolled Nurses within themental health area. The purpose of the survey was to measure satisfaction with clin-ical placements within an Area Mental Health Service. The information providedfrom the survey is directing the on-going development of clinical placements, clin-ical supports, education programs and recruitment and retention initiatives fornurses within the Central Sydney Area Mental Health Service. The findings indicate agenerally high level of satisfaction with the clinical placement undertaken, howevera number of strategies to improve satisfaction with placements were identified.

�c 2004 Elsevier Ltd. All rights reserved.

KEYWORDSMental health nursing;Recruitment;Retention;Clinical supports;Education;Enrolled Nurses

1d

9

b

Introduction

It is commonly understood that Australia, like manyparts of the world, is experiencing a crisis in the re-

471-5953/$ - see front matter �c 2004 Elsevier Ltd. All rights reseoi:10.1016/j.nepr.2004.06.001

* Corresponding author. Tel.: +61-2-9556-9100; fax: +61-2-818-5712.

E-mail addresses: michelle.cleary@email.cs.nsw.gov.au,.happell@nursing.unimelb.edu.au.1 Tel.: +61-3-8344-0769; fax: +61-3-9342-4172.

cruitment of new graduates into the field of mentalhealth nursing (Happell, 1998; Stevens and Dulhunty,1997). The abolition of educational programs thatprovide direct entry into mental health nursingnow means that the nursing workforce can onlybe recruited from the pool of graduates from com-prehensive undergraduate nursing programs. Thishas created severe shortages in appropriately

rved.

110 M. Cleary, B. Happell

qualified nursing staff within this area of practice(Clinton and Hazelton, 2000).

The stated aim of comprehensive nursing educa-tion was to prepare graduates for practice at a be-ginning level in all areas of nursing includingmental health. A review of the available literature,however, clearly demonstrates that the currentclinical and theoretical content devoted to mentalhealth is minimal and unsatisfactory (Clinton andHazelton, 2000; Farrell and Carr, 1996; Happell,1998; Wynaden et al., 2000).

The shortage of nurses is by no means restrictedto the mental health field. Recently published in-quiries into the nursing profession in Australia high-lighted the inadequacy of the current three yearcurriculum in providing sufficient breadth anddepth of theoretical and clinical content to enablestudents to develop beginning level skills in a broadrange of health care settings (Commonwealth ofAustralia, 2002; Senate Community Affairs Refer-ence Committee, 2002).

The situation is, however, potentially more seri-ous for mental health nursing than for most areasof nursing practice. Undergraduate nursing stu-dents do not always regard mental health nursingfavourably as an area for future employment. It ap-pears that students share the negative stereotypesheld by the general population. Their attitudes to-wards people experiencing a mental illness reflectsfear and mistrust, and the nursing role is viewed asroutine and mundane in comparison to other areasof nursing speciality (Happell, 1999; Munnukkaet al., 2002; Stevens and Dulhunty, 1997).

A positive clinical experience has been recog-nised as a major strategy in influencing the atti-tudes of nursing students towards a morefavourable perception of mental illness and mentalhealth nursing (Ferguson and Hope, 1999; Happell,2001; Pye and Whyte, 1996; Rushworth and Hap-pell, 1998; Stevens and Dulhunty, 1997). Clinicalexperience in the mental health field thereforeprovides a valuable opportunity for recruitmentthrough increasing nursing students’ knowledge ofand confidence in the field through presenting apositive image of mental health nursing.

In order to maximise the benefits of clinical ex-perience for nursing students, the evaluation ofclinical placements is crucial, not only to deter-mine the extent to which students are satisfiedwith the experience provided, but also to deter-mine ways in which the placements can be im-proved to better meet the needs of students.

Central Sydney Area Mental Health Service(CSAMHS) recognises the potential of clinical experi-ence as a recruitment strategy and therefore aims toprovide clinical placements to nursing students that

are challenging, rewarding and productive. Supportsare provided to ensure that students are providedwith a range of experiences to meet their learningobjectives as set down by the education institution.It is also expected that students will have their ownlearning objectives to enhance their understandingand appreciation of mental health nursing and stu-dents are encouraged and assisted to identify these.CSAMHS aims to provide effective and enjoyableclinical placements that will encourage nursesto consider mental health nursing as a viable careeroption.

To date the emphasis has been placed on strat-egies to promote a positive clinical experiencefor undergraduate nursing students (Ferguson andHope, 1999; Happell, 2001; Pye and Whyte, 1996;Rushworth and Happell, 1998; Stevens and Dulhun-ty, 1997) with the absence of research addressingissues relating to second level nurses (known inAustralia as enrolled nurses or division 2 nurses).The lack of attention to enrolled nurses is surpris-ing. They currently constitute approximately 18%of the mental health nursing workforce and there-fore represent a significant source of labour (Aus-tralian Institute of Health and Welfare, 2003). Inrecognition of the totality of the mental healthnursing workforce, the current evaluation includesboth undergraduate nursing students and traineeenrolled students.

Methodology

The setting

CSAMHS provides mental health services to 71 sub-urbs of Central and Inner Western Sydney with amulticultural population of 500,000. Mental healthclinical specialties include: acute and intensivecare, crisis intervention, aboriginal mental health,drug health, child and adolescent, rehabilitationand recovery, psychiatry of old age, communitybased care, therapy and group work, consultationand liaison and eating disorders. There are also arange of special initiatives (e.g., early psychosis in-tervention, psychosis and substance use, familiesand mental health, consumer consultants, 1800 ac-cess line) and speciality fields (e.g., health infor-mation and technology, research, education,health promotion) to facilitate the provision ofcomprehensive and integrated mental health serv-ice delivery.

Recruitment and retention initiatives: nursing students’ 111

Nursing programs

The Rozelle Hospital as a teaching hospital withinCSAHS offers clinical placements to Trainee En-rolled nurses as an elective speciality (mentalhealth) rotation within the State Department ofHealth Trainee Enrolled Nurse training program.Rotations vary from three weeks to seven weeks.An on-site Clinical Nurse Consultant (CNC) providesformal orientation, ongoing education and clinicalfacilitation.

CSAMHS provides just over 200 clinical place-ments across the academic year to nursing under-graduates from seven universities. Theseplacements range from three to seven weeks. Stu-dents are accepted during both the second andthird year of the course. Placement areas includeinpatient and community services.

Aim of the study

The aim of this study was to measure satisfactionwith nursing placements and rotations. It was in-tended that the findings provide direction for theon-going development and improvement of clinicalplacements, clinical supports, education programsand recruitment and retention initiatives withinCSAMHS.

Participants

The target group was trainee enrolled nurses(TENs) and undergraduate nurses (UGs) during theirmental health clinical placement. This included 76TENs and 160 UGs.

The survey

A nursing survey was constructed by the authors inconsultation with key personnel. During piloting,agreement was reached on the structure of the sur-vey, target groups and timelines for implementa-tion. The nursing survey tool comprises fivemodules: demographics, orientation, clinical sup-ports, education and completion of program. Theorientation module was only included in the ques-tionnaire distributed to TENs as TENs are employedby the Area health service and work on the wardsas part of the numbers. Therefore they receive a for-mal CSAMHS orientation. On the other hand, UGs aresupernumerary during their placement; they receivea less extensive formal CSAMHS orientation. Allocat-ed preceptors and university clinical facilitators in

collaboration with the CSAMHS Education Centreare responsible for providing UGs orientation.

The orientation module sought opinions aboutthe usefulness of orientation packages and re-quired respondents to indicate the perceivedhelpfulness of 11 items provided during theirorientation. The clinical supports referred to theviews and experiences of students in relation tothe perceived helpfulness of a range of supports.The survey sought feedback in relation to educa-tion, knowledge, confidence and subjective assess-ment of competence. The questions werepresented using a four-point scale of options (very,moderately, only a little, not at all). Respondents’were asked to rate their knowledge and confidencein relation to a range of items. In the final module,completion of program, participants were askedabout their interest in working in mental health,if their placement had influenced their intent towork in mental health and whether they would rec-ommend the program to others.

Data analysis

Data were entered into a prepared Statistical Pack-age for the Social Sciences (SPSS version 10) work-sheet and are presented as observed rates andfrequencies. The findings are presented as descrip-tive statistics. Lists displayed in the tables wererank ordered to assist interpretation.

Findings

Seventy-six questionnaires were administered toTENs and 160 to UGs. All participants returnedquestionnaires representing a return rate of 100%.The demographic data indicates that the majorityof students were female. The age of participantsin both groups demonstrates that the greatest pro-portion were aged 21–30, followed by 21 or lessand 31–40. The smallest number of participantswas aged over 40. Further information is providedin Table 1.

Orientation

All TENs undertake a formal CSAMHS orientation atthe commencement of their placement supple-mented by a staff handbook. Eighty seven percentof respondents indicated the handbook was moder-ately to very useful. Table 2 presents the items

Table 3 Satisfaction (moderately to verya) withclinical supports

UGs (%) TENs (%)

Helpfulness of nursingstaff on the unit

91 97

Supportiveness ofclinical facilitator

87 85

Supportiveness of nursingstaff on the unit

86 99

Availability of clinicalfacilitator

85 82

Supportiveness of wardpreceptor

81 83

The process of performancereview

79 91

Helpfulness of other healthprofessionals on the unit

76 75

Availability of ward preceptor 74 75Feedback received on progressfrom staff

68 83

a The remainder of respondents rated their satisfaction as‘only a little’, ‘not at all’ or ‘not provided’.

Table 1 Demographic profile of survey respondents

TENs UGs

N % N %

Total survey 76 160population 76 100 160 100

Response rateSexMale 20 26 23 14Female 56 74 137 86

Age group (years)a

21or less 20 26 50 3121–30 25 33 58 3731–40 18 24 36 23>40 13 17 15 9a 1 UG did not provide their age.

112 M. Cleary, B. Happell

provided at orientation identified as helpful (as op-posed to not helpful or not provided).

Most TENs (87%) indicated that the orientationprovided was moderately to very useful to the clin-ical speciality when they started work, almost allrecalled receiving an induction/orientation pack-age at their first clinical placement (95%). Themajority of participants (86%) found the induction/orientation package to be moderately to very useful.

Table 2 Helpfulness of orientation

Helpfulness of orientation TENSa (%)

What to do if you need toreport sick

96

Information on policyand procedures

93

Information on the AreaMental Health Service

93

Information about who to contactfor clinical support

90

Information about rosters 88Relevance of information providedto starting clinical placement

88

Support mechanisms such asEmployee Assistance Programs

86

Information about leave entitlements 82Information about clinical rotations 78Information on clinical specialityareas (e.g., different areas)

72

Information about preceptorshipprogram

61

a The remainder of respondents rated the task as ‘nothelpful’ or ‘not provided’.

Clinical supports

A four point scale (very, moderately, only a little,not at all) was used to determine satisfaction withclinical supports. The findings suggest a relativelyhigh level of satisfaction with the clinical supportsprovided. A moderate to high level of satisfactionwas indicated, ranging from 68% for feedbackreceived on progress to 91% for the helpfulness ofnursing staff by UGs and from 75% for the help-fulness of other health professionals and theavailability of ward preceptors, to 99% for thesupportiveness of nursing staff from TENs. Furtherinformation is provided in Table 3.

Respondents were asked if they had found clini-cal supports helpful or not helpful in relation toeight specific areas of skill and knowledge develop-ment. Overall the participants found the supportsto be moderately or very helpful, ranging from81% for completing nursing documentation, to98% for the development of knowledge from UGsand 85% for nursing documentation to 95% for un-derstanding the needs of consumers. Further infor-mation is presented in Table 4.

Responses to the open-ended questions by UGsregarding the clinical facilitators included ‘very in-formative’, ‘extremely helpful’, provided opportu-nity for ‘learning experiences’, ‘to debrief andbring meaning and understanding to my experienc-es’. However, the need for facilitators to visit stu-

Recruitment and retention initiatives: nursing students’ 113

dents and nursing staff at their placement locationwas raised.

Generally, UGs reported RNs as ‘welcoming’,‘very friendly’, ‘extremely helpful’, providing ‘ex-cellent support’ and ‘beneficial feedback’. One re-spondent summed up the many positive comments‘I have never worked anywhere during placementwhere the staff were so professional yet friendlyand so easily approachable, willing to teach allthey can’. While many staff were regarded as ‘verysupportive [and] went to extremes to help’, a fewUGs claimed that ‘nursing staff should show a littlemore interest in the students’. It has subsequentlybeen suggested that dissatisfied respondents werenot allocated a preceptor or that some nurses‘were not willing (seemed unwilling) to have a stu-dent follow them/tag along for part of a shift – itmade me feel a bit unwanted’. Furthermore, someUGs indicated they would prefer ‘more time forclinical placements’. Other suggestions for im-provement included agreement on ‘structured lev-els of opportunity’ with comment about some tasksbeing ‘allowed 1 day but prohibited the next. . .make[s] it difficult. . . to learn’.

Education

In the educationmodule, respondents were asked torate education components on a 5-point scale, rang-ing from poor to excellent. The responses suggestthe majority of participants considered the stand-ard of the educational components to be at leastfair. Further information is presented in Table 5.

Perceived knowledge and confidence

The majority of participants considered themselvesto be moderately to very knowledgeable in theirknowledge of mental illness (UGs 83%, TENs 76%),Mental Health Act (UGs 57%, TENs 65%), minimumstandards for clinical documentation (UGs 78%,TENs 79%) and managing challenging behaviours(UGs 59%, TENs 77%). Respondents also consideredthemselves to be moderately to very confident inundertaking a mental status examination (UGs85%, TENs 45%) completing nursing documentation(UGs 83%, TENs 88%), but indicated less confidencein conducting a group (UGs 50%, TENs 62%) and con-ducting a counselling session (UGs 35%, TENs 36%).

However some participants (UG 23%; TENs 16%)indicated they would like to see further revisionsto the education component of the program. Revi-sions included visits to other units, settings (hospi-tal and community). Among topics mentioned by

UGs for inclusion in further program revisions wereethical/moral considerations, admission assess-ments, psychotherapy, research, counselling tech-niques, drug and alcohol, community issues,medication, the Mental Health Act, ECT, mental ill-ness, treatments, eating disorders and safety issues(managing challenging and aggressive behaviour).

The TENs also indicated their desire for clearerexpectations/guidelines for TEN participation.Many positive comments were made by TENs aboutthe resource information provided, the ‘support-ive’ and ‘educated’ staff’ and the ‘interesting’and ‘well run’ program. Some suggested further re-visions could include depression, case studies/re-views, vocabulary specific to psychiatric nursingand managing challenging behaviours. Eighty onepercent of TENs were interested in enrolling in auniversity education program with the aim of be-coming a registered nurse.

Program completion

For the majority of respondents this was their firstplacement in a mental health setting (UGs 81%;TENs 84%). Most respondents indicated they weremostly/very much satisfied (as opposed to some-what or not at all satisfied) with the CSAMHS pro-gramme (UGs 89%; TENs 90%).

Additional comments from TENs included ‘en-joyable’, ‘good contact with the patients’, ‘it is agood introduction to mental health’ and ‘bestplacement I have had all year’. UG comments weremostly positive, ‘supportive’, ‘helpful’ staff, ‘in-teresting’ placements and a willingness by staffto share their ‘knowledge’.

Expectations

Most participants indicated that the program wasbetter than expected (UG 70%; TENs 60%). Almosta third of UGs (27%) and TENs (33%) consideredthe program to be as expected, with very few con-sidering the program to be worse than expected.For TENs many ‘preconceived ideas were wrong’,for example, feeling ‘scared (due to things I hadheard by people)’ or ‘very nervous about workingin a mental health hospital’ or expecting ‘to seelots of aggression’. Whereas UG comments wereabout developing skills, knowledge and confidence,enjoying the placement and feeling ‘supported’.

Most participants believed that their placementprovided an overview of the speciality areas ofmental health nursing (UGs=78%, TENs=74%). Themajority of respondents (UGs=95%, TENs=97%).

Table 4 Helpfulness (as opposed to not helpful ornot provided) of clinical supports

UGs (%) TENs (%)

Development of knowledge 98 93Understanding the needsof consumers

94 95

Development of skills 94 93Development ofself-awareness/insights

92 87

Professional development 88 89Understanding the MentalHealth Act

86 88

Completing nursing assessments 86 89Completing nursingdocumentation

81 85

114 M. Cleary, B. Happell

considered that the knowledge and skills gainedfrom the program had increased their understand-ing of the role of the mental health nurse and theirconfidence to work in mental health nursing.

Table 5 Rating of education components

Poor(%)

Fair(%)

Go(%

Scheduling of theoreticalcomponents of your programUGs 1 19 45TENs 5 18 43

Topics included in thecourse programUGs 1 18 37TENs 5 15 38

Relevance of theoreticalcomponent of the program toclinical placements/rotationsUGs 2 17 34TENs 8 13 36

Assessment Tasks/AssignmentsUGs 1 24 24TENs 7 9 34

Marking of assignmentsUGs 2 18 31TENs 3 5 33

Feedback on your AssessmentTask/AssignmentUGs 3 17 29TENs 4 8 32

Interest in working in mental health

A substantial increase in interest in working inmental health was observed as a result of clinicalexperience at CSAMHS. Prior to participation inthe program, 36% of UGs indicated that they werenot at all interested in this practice area, 26% stat-ed they had only a little interest, a further 26%were moderately interested and only 12% were veryinterested. On the completion of the program 33%identified themselves as very interested, 39% asmoderately interested, 17% as only a little interestedand only 11% indicated no interest.

A more pronounced trend was noted for TENs. Atthe commencement of the program 24% indicatedno interest, 30% suggested little interest, 32% weremoderately interested and 14% were very interest-ed. At the completion of the program, the vast ma-jority was either very or moderately interested(42% very interested, 42% moderately interested),with only 13% indicating only a little interest and3% with no interest.

od)

Verygood (%)

Excellent(%)

Notapplicable (%)

23 5 716 7 11

31 6 723 7 12

28 12 718 13 12

20 4 2716 14 20

15 5 2912 10 37

15 7 2918 14 24

Recruitment and retention initiatives: nursing students’ 115

In regard to working in mental health nursing,64% of TENs indicated they intend to work in men-tal health nursing and 45% of UGs also indicatedtheir intent. It was particularly interesting to notethat more than 50% of TENs and UGs completed anexpression of interest to obtain further informationabout working in CSAMHS (TENs 53%; UGs 55%). Fi-nally, it was encouraging to see that the majorityof respondents (UGs=97%, TENs=83%) would rec-ommend the program to others.

Program advice

Respondents were asked what advice they wouldgive to assist in completing the program. The ma-jority of additional comments made by UG nursesconcerned the ‘excellent programme’, a ‘greatlearning experience’ with ‘supportive’, ‘kind andconsiderate staff’. Typical advice: ‘Ask a lot ofquestions and listen, go with an open mind, be pre-pared for anything’; ‘Do not be scared. Forget anyperceptions that you have’; ‘Get involved, partici-pate in everything. Watch and listen – observe asmuch as you can’; ‘Remember the ‘‘well’’ part ofthe patients’; ‘ Be enthusiastic and jump at everyopportunity to learn’; ‘Supportive environment.Offers many opportunities; ‘Always ask if you don’tunderstand. Be aware that these clients are peopletoo. Always keep a comfortable distance’; and,‘Have confidence in yourself. Be willing to makethe most of it. Interact as much as possible withthe patients’.

For TENs, the program was cited as ‘excellent’,and the hospital a ‘great place to work at’, ‘veryfriendly’. Typical advice: ‘Do not be afraid to askquestions’; ‘Keep an open mind’; ‘Seek assistanceif not sure’; ‘Spend time with patients’; ‘Studyhard, be interested and teach yourself. Learn asmuch as you can’; ‘Boundaries’; and, ‘Do not havepreconceived ideas in relation to mental healthnursing’.

Discussion

The findings from this study suggest a high level ofsatisfaction with clinical placements from the per-spective of both UGs and TENs. Analysis of the re-sults suggests that students found all aspects ofthe program to be substantially positive, with themajority of students considering that the place-ment had exceeded their expectations. The find-ings highlight the fact that clinical supports were

helpful in understanding the Mental Health Act,completing nursing assessment/documentation,developing skills, knowledge and self-awareness,professional development, and gaining an under-standing of the needs of people who have a mentalillness.

The provision of a high quality clinical place-ment in mental health for nursing students is un-doubtedly a desirable end in itself. However, inorder to address the recruitment crisis identifiedin the literature (Happell, 1998; Stevens and Dulh-unty, 1997), it is vital that clinical placements pro-duce a more positive view of mental health nursingas a future career option. These results suggestthat likelihood of the students pursuing a careerin mental health is considerably more likely follow-ing completion of the program. The impact of clin-ical experience on students’ attitudes towards acareer in mental health has been documented inthe literature (Ferguson and Hope, 1999; Granskaret al., 2001; Happell, 2001; Pye and Whyte, 1996;Rushworth and Happell, 1998; Stevens and Dulhunty,1997), however the results of the current studyshow a more pronounced trend in favour of mentalhealth.

Despite the high level of satisfaction achieved,maintaining a high quality clinical placement is un-doubtedly an ongoing process. From this evaluationa number of areas were identified were further at-tention is required. Preceptorship is probably themost significant. It is essential that all studentsare allocated a well-prepared and interested pre-ceptor and that where possible they work similarshifts to their preceptor. UGs also requested thatuniversity clinical supervisors visit wards. Therewas diversity among responses with regard to expe-rience with preceptors and clinical facilitators. Theformulation of guidelines to support clinical place-ments would be a useful beginning point in address-ing these issues. Furthermore, these guidelinesmay help clarify expectations for student place-ments. Some respondents indicated they were un-certain as to what activities they were permittedto undertake and conflicting staff instructions fur-ther exacerbated this situation.

Other areas for improvement identified throughthis evaluation include the provision of a tour oroverview of the Area Mental Health Service forTENs and UGs. The implications of providing tworotations during clinical placements also warrantfurther investigation.

It is important to acknowledge the limitations ofthis study. Although the sample size and returnrate were both quite high, the study was conductedin only one area mental health service in New SouthWales, and it is therefore difficult to determine the

116 M. Cleary, B. Happell

extent to which these findings are transferable toother settings. Furthermore, although participantshave indicated a strong interest in entering themental health field following graduation, their atti-tudes are likely to be affected by recent experi-ence in this field, and the impact may belessened by subsequent clinical placements inother areas. One of the particular strengths of thisstudy is that it includes enrolled nurses, a signifi-cant proportion of the mental health nursing work-force that has traditionally not been addressed inthe research literature. Moreover, it demonstratesthe desire of many TENs to become RNs, a viablecareer pathway.

Conclusions

The findings of this study suggest that a positiveplacement can produce more favourable attitudesto mental health nursing. The ongoing monitoringof nursing students’ satisfaction with clinical expe-rience is crucial if the recruitment of sufficientnumbers of nurses into the mental health field isto be achieved.

Acknowledgements

The authors thank respondents for completing thesurvey; Charles Linsell, Amelia Merriman-Renu, Eti-enne Kitto and Caryl Palmer for their assistance;Gary Rowley and Clair Edwards for their continuedsupport for nursing initiatives; and, Raighne Jordanfor her review of the survey.

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