EDUCATIONAL ISSUES IN NURSING PRACTICE

The views of mental health nurses on continuing professional

development
Michelle Cleary, Jan Horsfall, Maureen OHara-Aarons, Debra Jackson and Glenn E Hunt

Aims and objectives. To determine clinical mental health nurses views and preferences about continuing professional devel-
opment.
Background. Participation in continuing professional development is now expected for nurse and midwifery registration.
However, it is unclear how clinically based mental health nurses view continuing professional development and its relevance to
career intentions.
Design. Qualitative.
Method. Semi-structured face-to-face interviews with mental health nurses (n = 50) drawn from inpatient mental health units.
Results. The most prominent factor identified through this research is that the majority of the fifty participants valued
continuing professional development and sought more opportunities to participate. They particularly favoured in-house locally
based sessions targeting patient-related clinical skills enhancement. Importantly, this interest in continuing professional
development was not confined to new graduates needing to consolidate their skills. Work-based flexibility, the types of courses
available and opportunities for study leave were also identified as important factors. Of the 50 nurses interviewed, 40%
expressed a desire for continuing professional development vis-a`-vis remaining in the service; 30% of nurses responded to the
same question with an emphasis on the importance of collegial support amongst peers and management; and 30% of the nurses
indicated their primary focus for continuing professional development was to further their tertiary studies.
Conclusions. These results are not only timely given the requirements around continuing professional development, but are also
important to drive improvements in quality continuing professional development where needs are prioritised, discussed and
agreed on.
Relevance to clinical practice. Findings from this study highlight the value clinical nurses place on having access to work-based
and clinically focussed education and development. Relevant on-the-job professional education has the potential to improve job
satisfaction and retention of clinical nurses, thus ultimately directly and positively influence patient care.

Key words: continuing professional development, employment intentions, inpatient mental health nurses, nurse retention,
tertiary education

Accepted for publication: 29 January 2011

Authors: Michelle Cleary, PhD, Associate Professor, Family and
Community Health Research Group (FaCH), School of Nursing and
Midwifery, University of Western Sydney; Jan Horsfall, RN, PhD,
Research Officer, Sydney South West Area Mental Health Service,
Concord Hospital; Maureen OHara-Aarons, RN, MN, Research
Officer, Family and Community Health Research Group (FaCH),
School of Nursing and Midwifery, University of Western Sydney;
Debra Jackson, RN, PhD, Professor, Faculty of Nursing, Midwifery
& Health, University of Technology, Sydney (UTS); Glenn E Hunt,
PhD, Associate Professor, Sydney South West Area Mental Health
Service, Concord Hospital and Discipline of Psychiatry, University of
Sydney, Sydney, NSW, Australia
Correspondence: Michelle Cleary, Associate Professor (Mental
Health Nursing), Family and Community Health Research Group
(FaCH), School of Nursing & Midwifery, University of Western
Sydney, Locked Bag 1797, Penrith South DC NSW 1797, Australia.
Telephone: + 61 2 9685 9068.
E-mail: m.cleary@uws.edu.au

 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 35613566 3561
doi: 10.1111/j.1365-2702.2011.03745.x
M Cleary et al.
Introduction
The Council of Australian Governments recently introduced
a single national registration and accreditation scheme The
Nursing and Midwifery Board of Australia. Revised registra-
tion standards define the requirements that nurses must meet
to be registered: these include annual participation in at least
20 hours of continuing professional development (CPD).
This CPD must be directly relevant to the nurse or midwifes
context of practice. The Nursing and Midwifery Board of
Australia define CPD as:
the means by which members of the profession maintain, improve
and broaden their knowledge, expertise and competence and develop
the personal and professional qualities required throughout their
professional lives. The CPD cycle involves reviewing practice,
identifying learning needs, planning and participating in relevant
learning activities and reflecting on the value of those activities.
(Australian Nursing and Midwifery Council 2010, p. 1).
Professional development is a part of professional responsi-
bility and accountability and essential to organisational and
professional success (OSullivan 2004). Contemporary health
service settings are very busy, and nursing care is often
multifactorial, requiring a committed and motivated work-
force having to enhance a diverse repertoire of knowledge
and skills (Shermont et al. 2009). This is against a backdrop
of continuing reorganisation, restructuring and other changes
in the health care sector.
Undergraduate nursing education cannot realistically
provide all the required knowledge, and CPD initiatives
often target this cohort at the expense of more experienced
staff. Hence, there is the additional challenge for CPD
providers to ensure appropriate opportunities for the con-
tinued practice development for both new and experienced
nurses. CPD can incorporate up-to-date multimodal teach-
ing methods to integrate theory and practice in the
classroom and the clinical area (Henderson & Winch
2008). Health system policy changes, complex patient
profiles, best practice updates and mandated CPD are
imperative reminders that health professionals are on a
lifelong learning trajectory (Munro 2008).
It is important that the continuing professional develop-
ment providers assume that all staff are adult learners; that
they clearly set out program aims; and that sessions must be
evaluated for evidence of specific clinical learning (Knight
2002, p. 237). According to OSullivan (2004, p. 174), the
purpose of participating in CPD is to enhance the outcome of
patient care by improving practice, through activities like
reflection, evaluation and consideration of the evidence base
so that patients receive care that is effective and consistent
3562  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 35613566
with best practice. CPD is relevant to all staff for knowledge
development, skill acquisition, changes in professional
practice, to recruit and retain a competent nursing workforce
and to provide quality patient care (Covell 2009). Other
benefits of CPD include increasing nurse confidence and
motivation, improving networking opportunities and enhanc-
ing organisational commitment.
The supply and demand for professional development are
influenced by the professions need to develop, to acquire new
skills, cost incurred (personal and financial), mandatory
accreditation, professional recognition and the potential
reward through the career development framework of the
employer (Munro 2008, p. 954). Supporting these profes-
sional development initiatives is costly to the health service,
and in the current climate, most organisations are keen to see
designated relevant outcomes. The use of resources for
professional development purposes is offset by gains for
participants, patients, colleagues and the health service at
large. Ultimately, a key challenge is to move the staff
development of nurses from the margins of daily practice
(fitting in, time allowed) to becoming a commitment of the
organisation, that is, included in core business and planning
of clinical activities (Henderson & Winch 2008, p. 167).
In some settings, the same nurses tend to continue to apply to
participate in the various professional development opportu-
nities on offer. According to Covells (2009) review of CPD,
participation positively influences recruitment and retention;
thus, a decrease in organisational costs associated with human
resources will result. It follows then that nurses who undertake
relevant CPD are more likely to advance their career than those
who do not. The reasons nurses follow one pathway over
another in the profession are unclear, but understanding their
rationale is an important issue, not only for workforce
retention, but also for particular clinical settings and specialties
because different organisations vary in their ability to
recruit and retain staff (Marsland & Hickey 2003). Thus, the
increasing necessity of congruence between staff needs and
employer demands indicates the relevance of career planning
for mental health nurses as teams/groups and as individuals.
To achieve this, systematic feedback from a range of nurses
is important to develop appropriate professional develop-
ment plans to address future mental health nursing and
employer requirements. The aim of this study is to ascertain
clinical nurses views and preferences regarding CPD and
their employment intentions.
Methods
The study was approved by the Executive of the Hospital
Human Research Ethics Committee, and reciprocal approval
Educational issues in nursing practice
was given by the University Human Research Ethics Com-
mittee. The setting for this study was a large mental health
centre in Sydney, Australia. The study was conducted in
August-September 2010. Over three weeks, an experienced
mental health nurse (external to the study setting who is a
previous employee of the Area Mental Health Service)
conducted several rounds of inpatient units three to four
times a week. The use of a skilled interviewer familiar with
routines and procedures in the setting also contributed to
minimal disruption in the wards. The researcher greeted staff,
stated the purpose of the study and invited enrolled and
registered nurses working in the inpatient area mental health
service to become participates. The face-to-face interview was
voluntary, and no identifying information was listed on the
proforma used to note comments verbatim.
Structured interview questions were selected to focus on
nurses perceptions of factors that have helped them to stay in
the mental health service and/or to develop their career,
qualities that they value in a mental health nursing role
model, their professional development plans for the next two
years and general comments about the service or mental
health nursing (positive or negative), particularly in relation
to recruitment and/or retention. Participants were also
encouraged to discuss any other issues they considered
important in relation to professional development. The
written questions were provided to participants beforehand,
so that they would have time to consider the topics and
prepare for the interview.
The present study focuses on data arising from responses to
two questions: one focusing on what would encourage
respondents to continue to work in the same service or to
develop their career; and the other targeted their professional
development plans. Transcripts were read, coded, reviewed
and categorised to identify recurring topics that reflected
participants views, knowledge and experiences.
Results
Fifty interviews were completed. Forty-seven of the intervie-
wees were RNs, and three had EN qualifications; four RN
respondents were Nurse Unit Managers or Clinical Nurse
Specialists.
Factors that will encourage nurses to remain in their
present health service
The strongest response to this question devolved on systemic
practicalities relating to continued professional develop-
ment. Twenty of the 50 respondents nominated issues
regarding flexibility, types of courses and study leave
 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 35613566
Professional development
opportunities being relevant to their future in the health
service. Amongst the twenty interviewees to focus on
professional development courses as a key to their future,
fourteen had been mental health nurses for five or more
years. This question also evoked 15 responses relating to
support in the working environment. Eleven of the respon-
dents specifically mentioned clinical skills development using
terms such as in-service, ward-based training and skills
development. Eleven interviewees raised the issue of staffing
levels.
Flexibility relates to: course availability on different days
and times; greater access; course location should be local
rather than requiring travel; making it easier to take the time
off and leave the ward to attend sessions; and a greater focus
knowledge and practice enhancement. Participants seek more
diverse courses than those that are mandatory or are
routinely available, especially those that facilitated upgrading
clinical skills, with regular predictable offerings. Amongst the
twenty respondents, a preference for structured learning
opportunities specifically pertaining to inpatient complexities
in their clinical setting was mentioned. Study leave responses
included: making more nurses aware of study leave avail-
ability; opportunities for more nurses to take study leave; and
matching study days to those on which the tertiary course
was taught.
Fifteen respondents expressed the view that a supportive
work environment is one that encourages them to stay. Apart
from frequent use of the word support in response to this
question, other terms used included: mentoring; morale;
valuing staff and their specific contributions; team work; and
positive and supportive relationships with management and
administration.
Opportunities specifically for clinical skills development
was important for eleven respondents in relation to their
intentions to remain in their present place of employment.
Staffing levels were also important for these nurses, and
eleven interviewees nominated flexible rostering and better
staff patient ratios as conducive to retention.
Professional development plans
In line with the large cohort designating the importance of
professional development, flexibility and access to CPD,
fifteen of the respondents intended to pursue further
studies. Thirteen of these had been mental health nurses
for up to four years; the other two had been working in
this specialty for eighteen or more years. The plans ranged
from completing their bachelors degree to postgraduate
diplomas, masters degrees and a PhD, with the majority
targeting either a diploma or a masters. It may be
3563
M Cleary et al.
important to note that only three of this tertiary-oriented
cohort specifically mentioned clinical skills in response
to the previous research question, although this may be
over-reading the data.
The second most commonly expressed desire eight
respondents was to pursue practice diversity in mental
health. These respondents wished to broaden their clinical
practice expertise in different but related mental health
domains, including longer-term care, community settings and
drug and alcohol nursing. Again, the profile of interviewees
particularly wishing to extend their clinical knowledge
included five of the eight with up to five years mental health
nursing experience and three with ten or more years of
experience.
Given that 13 of the interviewees have worked in mental
health for twenty or more years, most of these nurses were
not intending to pursue further formal studies nor were they
intending to progress up the clinical career ladder. Only six
respondents expected to seek Clinical Nurse Specialist (CNS)
or Clinical Nurse Consultant (CNC) positions. Four of these
had up to five years experience, and two had seven or more
years in mental health nursing.
In summary, amongst these interviewees, the most numer-
ically significant finding was that 40% of the nurses said they
would seek future professional opportunities with a prefer-
ence for clinically based programs that were flexible regard-
ing when and where they were offered. The cohort included
nurses with a wide range of experience (up to 40 years). The
second most significant response was the importance of
support amongst peers and those with higher status for
their workplace satisfaction and intentions to remain in their
present workplace. The third most numerically significant
group were recent graduates (most have up to four years
mental health experience) whose primary professional devel-
opment plans were oriented towards further tertiary study.
Only one of the fifteen respondents intended to take up
postgraduate studies with the long-term aim of attaining a
CNS position.
Discussion
These results are by and large consistent with the growing
body of nursing literature on this topic (Gould et al.
2007, Munro 2008, Cleary et al. 2009, Covell 2009, Sher-
mont et al. 2009), although to our knowledge no
recent studies have specifically explored the needs of inpatient
mental health nurses. Findings are therefore important to
drive improvements in quality continuing professional
development where needs are prioritised, discussed and
agreed on.
3564  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 35613566
The interviewers use of rounds enabled the research team
to assess expectations and perceptions of mental health
nurses about professional development and career pathways
in a collegial and timely way (Haas & Gold 1993). This
personal approach to collecting and verifying information
involves face-to-face contact to facilitate access and negoti-
ation of a time and place for individual nurses convenient for
them in their practice on that day (Lee & Manley 2008). The
use of a skilled interviewer familiar with routines and
procedures in the setting also contributed to minimal disrup-
tion in the wards.
The three outstanding messages from the interviews are
40% of the nurses expressed a desire for CPD vis-a`-vis
remaining in the service; 30% of nurses responded to the
same question with an emphasis on the importance of
collegial support amongst peers and management; and 30%
of the nurses responded their primary focus for CPD was to
further their tertiary studies. The first is perhaps the most
surprising outcome of the study.
Drey et al. (2007) found that the absence of relevant
training was cited as a reason for lack of job satisfaction. The
current results support this view. Such a strong positive
interest in CPD in response to the question that asked what
would encourage them to continue to work in the present
health service indicates a significant proportion of nurses
actively desiring and seeking CPD. It is possible that
the recent legislative changes mandating CPD as a condition
for registration has had the intended effect of promoting
such programs; however, often compulsory requirements
in Australia create resistance and a backlash (for example,
resentment for two decades that nursing required a tertiary
degree to become an RN). According to Drey et al. (2007),
senior nurses tended not to undertake CPD. This is not
supported by the present study wherein 50% of the intervie-
wees expressed a specific desire for CPD, and given their
range of length of mental health experience, senior nurses in
this sample were not averse to CPD.
In a UK study (Gould et al. 2007) that explored nurses
experience of CPD, most of the respondents were positive,
but managers were deemed to be gatekeepers to course
admission and the implementation of new knowledge and
expertise. The flexibility subset of the data indicating a strong
desire for CPD participation appears to support concerns
about gatekeepers, in that respondents indicated that their
needs were not necessarily met by virtue of being unable to
leave the ward, having courses in distant locations, course
days and times being fixed and more applicants than places.
Munro (2008) also points out that nurses perceive employers
as being unsupportive about access to CPD. If CPD is closely
related to job satisfaction, and this is in turn linked to mental
Educational issues in nursing practice
health nurse retention, then health services will have to face
hard decisions in the near future given the scarcity of nurses
in Australia and elsewhere.
Supportive staff emerges as a key factor nurses take into
account regarding whether they will stay in a given
workplace. Simple things like acknowledgement of con-
structive and effective interventions and praise-giving by all
levels of staff are important for mental health nurses
working under pressure (Huseman 2009). Contemporary
research into mental health nurse concerns and expectations
endorses mental health nurses expectations of and need for
support. For example, interviewees in Cleary and Freemans
(2005) and Hummelvoll and Severinssons (2001) work
described their peers as supportive. Deacon et al. (2006)
extend this by acknowledging the importance of both
personal closeness and professional cohesion to mental
health nursing team work. This is because of the centrality
of clear and specific (and sometimes urgent) communication
(Fourie et al. 2005, Chiovitti 2008, Bjorkdahl et al. 2010),
and interpersonal interdependence in the milieu to keep the
environment safe, especially in acute inpatient units (Berg &
Hallberg 2000).
The expectation of further tertiary studies arose as the
third important issue arising from responses to the two
research questions. As the great majority of respondents with
these intentions had been mental health nurses for a
comparatively short period (up to and including four years),
this need may reflect a realistic awareness of their need to
build on their mental health knowledge base. These results
may reveal an awareness of a lifelong learning approach to
professional development (Munro 2008). Perhaps the focus
of the majority of respondents with an interest in academic
studies indicates a connection between theory and practice,
which is supported in the present data by the fact that
only three of those intending to do further studies also
mentioned the need to develop skills or the desire for
workshops as well.
As with all studies, there are strengths and limitations. The
strengths include the ability to ascertain feedback discreetly
with the ultimate aim of improving pathways for nurses
professional development. Findings also contribute to the
literature as to requested needs. The generalisability of results
is limited as only nurses from one large mental health
inpatient setting were interviewed. Other limitations include,
not being able to explore the views of participants in greater
depth, the inpatient focus and that it is relatively small scale
in nature.
 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 35613566
Professional development
Conclusion
Findings from his study show how clinically based mental
health nurses view CPD and its relevance to career inten-
tions. A significant majority of the interviewees value CPD
and seek further opportunities to participate, particularly in
locally based sessions targeting patient-related clinical skills
enhancement. This most important finding was that this was
not confined to new graduates needing to consolidate their
practice. Further, by and large, comparatively new RNs are
not overambitious, but do seek further knowledge and
clinical experience, including the opportunity to diversify
their mental health practice. These results are not only timely
given the mandatory requirements around CPD, but are also
important to drive improvements in quality continuing
professional development where needs are prioritised,
discussed and agreed on.
Relevance to clinical practice
As a means of enhancing quality care for patients and
families, there is an increasing move in many parts of the
world towards compulsory CPD for nurses. This creates
even more of an impetus to ensure that the education
provided for clinical nurses is relevant and applicable to
their clinical practice. Relevant on-the-job professional
education has the potential to improve job satisfaction and
retention of clinical nurses, thus ultimately positively influ-
ence patient care.
Acknowledgements
The project was funded by the School of Nursing and
Midwifery, University of Western Sydney. We thank Loren
Sharrock for her support of the project.
Contributions
Study design: MC, GH; data collection and analysis:
MC, JH, MO and manuscript preparation: MC, JH, MO,
DJ, GH.
Conflict of interest
The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of the
article.
3565
M Cleary et al.

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