review article an analysis of canadian psychiatric mental...

Hindawi Publishing CorporationISRN NursingVolume 2013, Article ID 184024, 13 pageshttp://dx.doi.org/10.1155/2013/184024

Review ArticleAn Analysis of Canadian Psychiatric Mental HealthNursing through the Junctures of History, Gender, NursingEducation, and Quality of Work Life in Ontario, Manitoba,Alberta, and Saskatchewan

Mary Smith1 and Nazilla Khanlou2

1 Queen’s University, Kingston, ON, Canada K7L 3N62 School of Nursing, Faculty of Health, York University, 4700 Keele Street, Toronto, ON, Canada M3J 1P3

Correspondence should be addressed to Mary Smith; [email protected]

Received 22 February 2013; Accepted 7 April 2013

Academic Editors: N. M. C. Alexandre and R. Northway

Copyright © 2013 M. Smith and N. Khanlou. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

A society that values mental health and helps people live enjoyable andmeaningful lives is a clear aspiration echoed throughout ourCanadian health care system. The Mental Health Commission of Canada has put forth a framework for a mental health strategywith goals that reflect the virtue of optimal mental health for all Canadians (Mental Health Commission Canada, 2009). Canadiannurses, the largest group of health care workers, have a vital role in achieving these goals. In Canada, two-thirds of those whoexperience mental health problems do not receive mental health services (Statistics Canada, 2003). Through a gendered, critical,and sociological perspective the goal of this paper is to further understand how the past has shaped the present state of psychiatricmental health nursing (PMHN).This integrative literature review offers a depiction of Canadian PMHN in light of the intersectionsof history, gender, education, and quality of nursing work life. Fourteen articles were selected, which provide a partial reflectionof contemporary Canadian PMHN. Findings include the association between gender and professional status, inconsistencies inpsychiatric nursing education, and the limitations for Canadian nurse practitioners to advance the role of the psychiatric mentalhealth nurse practitioner.

1. Introduction

The account of the way Canadian psychiatric mental healthnursing (PMHN) has emerged into its current state canprovide an insightful perspective that fosters a better under-standing of its present challenges and opportunities. Thisreview paper examines the development of Canadian PMHNin Ontario and the western provinces since the beginningof the 20th century. Canada consists of 3 territories and 10provinces. With a population of approximately 34,880,500,Canada had the highest growth rate of the G8 countries inthe 2011/2012 period [1].

In Canada, registered nurses (RNs), registered psychiatricnurses (RPNs), licensed practical nurses (LPNs), and nursepractitioners are employed in the area of psychiatric ormental health care. RPNs are a regulated separate profession

in the provinces of Manitoba, Saskatchewan, Alberta, andBritish Columbia (For the purposes of this paper RPN refersto registered psychiatric nurses that are only legislated inthe four western provinces. In Ontario, registered practicalnurses, also abbreviated to RPN, provide care in all settingsand are not solely specific to or trained in the area ofpsychiatric mental health. When RPN is used in this paper,the reference is to registered psychiatric nurses.)

Statistics on the various types of nursing professionsemployed in psychiatric or mental health care can reflectpertinent conditions in relation to the Canadian mentalhealth system. For instance, in 2010, 5.1% of all RNs inCanadawereworking in themental health care sector, a slightdecrease from 2007 where 5.2 were employed in this samearea [2]. In Ontario alone, between 1993 and 2003, there hasbeen a 29.4% drop in the number of nurses working in the

2 ISRN Nursing

psychiatric sector [3].The number of RPNs increased by 3.8%since 2007 but the RPN workforce remained at 1.5%. Theproportion of full timeRPNs in psychiatric nursing decreasedfrom 67.8% in 2007 to 62.2% in 2011.The RPN profession alsohas the highest percentage of males, 22%, of all the Canadiannursing professions [2]. According to the Canadian NursesAssociation, nurse practitioners (NPs) account for 0.9% ofthe entire number of RNs [4]. Of the 2,486 NPs employed inCanada, 1,482 or 60%work inOntario.The percentage of NPsworking in psychiatric mental health in 2010 was 1.4% [4].

The statistics concerning the employment of nurses in themental health care sector are meaningful when considered inlight of the statistics concerning howmany people in Canadasuffer from mental health problems. The Canadian Commu-nity Health Survey by Statistics Canada was completed in2003 and is scheduled again in 2013. This will enable furthercomparisons of how Canada fairs in terms of prevalenceof mental health disorders and the mental health servicesavailable [5]. In 2003, it revealed that two-thirds of those whoexperience mental health problems do not receive mentalhealth services [6]. Furthermore, persons living with mentalillness may have difficulty competing for limited health caredue to high rates of poverty and disability [7]. In 2012, theInstitute for Clinical Evaluative Sciences and Public HealthOntario released the report “Opening eyes, opening minds: theOntario burden of mental illness and addictions report” [8].This report measures the extent of mental illnesses in Ontarioin comparison with the prevalence of other medical condi-tions. Addictions and mental illnesses represent an enlargingburden. The need for improved accessibility of mental healthservices is emphasized [8]. The size of the PMHN workforceand the accessibility of services may impact mental healthcare for Canadians.

Historically, the deinstitutionalization trend that began inthe 1960s resulted in many persons with mental illness beingreleased into the community where a serious lack of mentalhealth services prevailed [9]. This led to a significant portionof individuals with mental illness to become imprisonedin jails or detention centers with limited access to mentalhealth care. Additionally, a revolving door phenomenonoccurred where previously institutionalized individuals werereadmitted into acute psychiatric care settings [9].

To further understand the Canadian context for PMHN,it is useful to be familiar with developments concerningmental health care in Canada. There are recent major ini-tiatives underway in Canada with regards to mental healthreform. In 2005, a national review of the Canadian mentalhealth system took place as outlined in the Kirby report[10]. In 2006, the Standing Senate Committee on SocialAffairs, Science and Technology completed the final reportentitled “Out of the shadows at last—transforming mentalhealth, mental illness and addiction services in Canada” [11].As the mental health care system was considered to befragmented, the final report made recommendations forthe reformation of mental health care. The assembly of aMental Health Commission to enable a national strategyfor mental health care was emphasized by Michael Kirby,the chairman of the Standing Senate Committee on SocialAffairs. Funding for the commission came in 2007, and in

2009, the Mental Health Commission of Canada released theframework “Towards recovery and well-being: a frameworkfor a mental health strategy for Canada” [12]. Seven goalsare set in this framework that represent how a transformedsystem will appear. The goals depict that everyone shouldhave the opportunity for optimum mental health and well-being [12]. The Mental Health Commission has recognizedthat there is a lack of opportunities for Canadianswithmentalhealth disorders to achieve optimummental health.This callsfor key stakeholders, that is, groups interested in respondingto people with mental health concerns, to address ways tofurther the provision of mental health care. Nurses are thelargest group of healthcare providers, and nurses who providemental health care are important stakeholders in meeting themental health care needs of Canadians.

In 2012, the Mental Health Commission of Canadareleased the blueprint “Changing directions, changing lives:the mental health strategy for Canada” [13]. Six strategicdirections are given in this report including the provisionof mental health services and treatments accessible to thepeople who need them. Reference to the vital role nurseshave in conjunction with the team of health care providersto fully achieve the strategic directions is not explicit inthe 2012 report. Community health nurses are instrumen-tal in providing mental health care in the community. Inaddition, NPs are becoming increasingly more common inproviding primary health care within Canada. Their role inthe assessment, diagnosis, and treatment of mental healthdisorders may be extremely useful to further the strategicdirection concerning enhanced accessibility to treatment.Collectively, nurses and nurse practitioners have a critical rolein the strategic direction as identified by the Mental HealthCommission of Canada. A national strategy is needed, andmental health care providers will need to be included in thisstrategy according to the Kirby report [10]. Nurses who formthe largest group of health care workers in Canada may needto be strong stakeholders in the strategic direction for mentalhealth care inCanada.The commissionhas yet to clearly voicehow health care and nurses will be reorganized to supportaccessible services and treatments.

Kirby [14] indicates the pivotal position that mentalhealth care providers have and also addresses concernsregarding the stress levels and mental health of healthcare professionals themselves. Indeed this leads to concernsregarding the quality of nursing work life for PMHN and howthis specialty is responding to the demands of the mentalhealth care system. The analysis of the history of CanadianPMHN can enable a better understanding of why PMHN istheway it is today.With this understanding, opportunities forfurther PMHN development, education, and future researchmay surface.

Given the need for increased accessibility to mentalhealth care and treatment, it is helpful to further explorehow nursing will move to foster improved mental healthcare. At this time, there is a shortage of research studiesthat look at how the current nursing workforce specificallyaddresses improved accessibility tomental health care. Careerpathways to become NPs that specifically work in mentalhealth are lacking, where NPsmay diagnosis and treat mental

ISRN Nursing 3

Table 1: Studies using a gendered, critical and sociological perspective relevant to PMHN.

Author and date Purpose Design/methodology/approach Province Sample size Findings

Wall (2010) [20]

To critique nursingresearch on nursingpractice environmentsusing a criticalsociological perspectiveTo propose a paradigmfor future research

Review of research on nursingpractice environmentsSociological concepts are linkedto variables in the nursingliterature

Refers to nursingin general withinthe Canadiancontext

NA

Nurses’ job satisfactioncan be linked to genderknowledge,professionalization, andorganization not justmanagement concerns

McGibbon et al.(2010) [21]

To reformulate thenature of nursing stresswith regards to context

Interviews, participantobservation, and focus groupswith pediatric ICU nursesTheoretical perspective usesSmith’s critical sociologicalframe of institutionalethnography

Study occurswithin the provinceof Ontario

23 nurses

Six main forms ofstress—emotionaldistress, constancy ofpresence, burden ofresponsibility,negotiating hierarchicalpower, engaging inbodily caring, and beingmothers, daughters,aunts, and sisters

health conditions. As an NP working in mental health care,the options for pursing advanced mental health nursingeducation in Canada are limited. PMHN education variesacross Canada and unlike the United States there is no legis-lated psychiatric mental health nurse practitioner (PMHNP)role. Also RPNs may wish to become advanced practicenurses or PMHNPs that are able to diagnose or prescribepsychotropic medications. A regulated PMHMP’s role mayfurther the accessibility of mental health care in Canada.There are opportunities for nurses to achieve a master’sdegree in mental health in Manitoba; however, there are noprograms in Canada that specifically yield PMHNPs thatmay diagnose or prescribe medications particular to mentalhealth care. The educational programs for nurses also vary ineach province in terms of content and the prerequisites. Withthe variety of different educational approaches to PMHNin Canada, the career path to advance nursing practice inPMHN is complicated. An RPN in the western provinceshas had different preparation than an RN working in mentalhealth care inOntario. How these diverse PMHNeducationalapproaches have come to be and their implications forCanadian PMHNcan provide useful insights to inform futuredirections to PMHN in Canada.

2. Materials and Methods

2.1. Review Aims and Research Question. The purpose ofthis inquiry is to understand the current state of mentalhealth nursing in Canada through the intersections of his-tory, gender, nursing education, and quality of work life asevidenced by the existing research and literature.The researchquestion that guided it was as follows: what does the researchreveal about contemporary Canadian PMHN in terms of thejunctures of history, gender, education, and quality of PMHNwork life?

An integrative methodology was determined to be mostsuitable for this review due to the scarcity of data on theorganization and efficacy of Canadian PMHN. Rigor was

maintained through evaluating primary sources for method-ological quality. The integrative review includes the stages ofproblem identification, literature search, data evaluation, dataanalysis, and presentation.

2.2. Integrative Review. Whittemore and Knafl [15] explainthat the integrative review is particularly suited to inquirieswith limited existing empirical research. Historical events inPMHN are relevant to how this field has come to be. Yet fewresearch studies exist on Canadian PMHN, and the studiesare in the form of social historical analyses that reflect onthe events of the past. Moreover, there is a paucity of datapertaining to Canadian NPs specific to mental health careand NP mental health education. Sociological, critical, andsocial historical analyses, reports, and surveys on Canadiannursing and Canadian mental health care offered insight intothe field of Canadian PMHN that furthered this inquiry(see Tables 1, 2, and 3). In the integrative review, accordingto Whittemore and Knafl [15], diverse methodologies maybe incorporated to further a comprehensive grasp of issuessuited to the complexities of health care. Both quantitativeand qualitative research may contribute to the perspectiveconcerning a phenomenon. The culmination, analysis, andevaluation of diverse data and research regarding PMHNenabled a perspective that may begin to further understand-ing mental health care in Canada in light of the lackingresearch solely pertaining to Canadian PMHN or PMHNPs.

2.3.Theoretical Perspective. A sociological perspective allowsfor a critical assessment of common assumptions and fostersrecognition of opportunities and constraints that shape ourcircumstances, the interplay between societal forces andpersonal lives, and of human diversity [16]. In addition, theconcept of gender stratification is comprehensively analyzedwithin sociology and is applicable to the topic of this paper.Gender stratification concerns the imbalanced division ofprivilege and power between females and males [17]. Asociological perspective is appropriate for this inquiry as

4 ISRN Nursing

Table 2: History, gender, and educational implications for Canadian psychiatric mental health nursing.

Author and date Purpose Design/methodology/approach Province Sample size Findings

Tipliski (2004)[23]

How Canadianpsychiatric nursingdeveloped into twoentirely differentmodels?

Historical analysis—casestudies in the provinces ofOntario, Manitoba, andSaskatchewan

Ontario,Manitoba,andSaskatchewan

Not applicable(NA)

PMHN development canbe understood throughpsychiatry’s authority inthe context of the genderlimitations traditionallyimposed upon womenand nurse leadersOntario nurse leaderstook control of psychiatricnursing, whereas inManitoba andSaskatchewan they did not

Dooley (2004)[24]

Historical account ofManitoba’s distinctmental health nursing

Labour history—historicalanalysis—oral testimony ofManitoba’s nursing graduatesfrom the 1930s

Manitoba NA

Manitoba—distinct classof PMHN giving rise tothe regional differenceswhere psychiatric nursingeducation is notintegrated into generalnursing education

Hicks (2008)[25]

Examination offactors that leadManitoba to adopt thewestern style ofPMHN and RPN class

Genealogical analysis fromarchives, interviews, andsecondary sources

Manitoba NA

RPN in Manitoba is apolitical, contingentdevelopment that willevolve

Hicks (2011) [27]Historical account ofprofessionalization ofManitoba’s RPNs

Historical analysis fromarchives and secondary sources Manitoba NA

RPN profession inManitoba arose to fillinadequately staffedmental hospitals thendeveloped into aspecialized workforce

Boschma et al.(2005) [9]

How gender shapedtraining, workopportunities, andprofessional identityof PMHN?

Social history method ofanalysis—interviews withquestionnaires of PMH nurseswho practiced between1939–1990

Alberta 34 women, 9men

Alberta’s PMHNprofessional identityshaped by gendered careethic

Boschma (2012)[26]

Exploration of howpsychiatric nursesunderstand and createtheir role in Alberta

Historical analysis, case study,and oral history interviews Alberta NA

Alberta’s presentcommunity mental healthservice is evolved andtransformed from theprior institutional practice

nurses are employed within gendered hierarchal structuresthat interact and are influenced by the larger political con-text.

Feminist theories, emerging from a sociological per-spective, address patriarchy, power structures, and genderinequality. They are concerned with the societal organizationand interactions that maintain male authority and femalesubordination [18]. A feminist perspective enables the depic-tion of the social structures leading to the devaluation ofwomen. Social order then becomes the problem rather thanwomen themselves [18]. The intent in this work is not todevalue women or nurses but, rather, to illuminate the socialstructures that have persevered throughout history and haveinfluenced PMHN education and quality of work life. Thesociological perspective applied here encompasses feministconcepts.

A sociological perspective also bridges history and howthings are today. Wright [19] calls this way of thinking thesociological imagination that grasps the connection betweenhistory and the way we are and the way we are becoming.Thehistory of PMHN seen through a sociological perspective canpromote an understanding of its current state.

2.4. Search Strategies. The primary literature search involveddatabases, the internet, and published online journals. Thedatabases included CINAHL, PsycINFO, Evidence-BasedMental Health, Cochrane, PubMed, and ProQuest. Publishedonline journals were accessed through Blackwell Synergyand Sage. Primary search results were then analyzed tosearch their references for secondary sources of interest. Thedatabases were accessed through the York University Library,Toronto, Ontario and Queens University Library, Kingston,

ISRN Nursing 5

Table3:Ca

nadian

mentalh

ealth

psychiatric

quality

ofnu

rses

worklife.

Author

anddate

Purpose

Design/metho

dology/app

roach

Province

Samples

ize

Find

ings

Robinson

etal.(2003)

[33]

Toexam

inep

revalence,

distrib

ution,

correla

tes,and

predicatorso

fvicarious

traumaa

ndbu

rnou

tamon

gregiste

redpsychiatric

nurses

(RPN

s)in

Manito

ba

Survey

containedtheM

aslach

Burnou

tinventory,the

Traumatic

StressInstitu

teBe

liefS

cale(TSIBS

),andas

ectio

non

PTSD

Manito

ba295surveysreturned,

respon

serateof

29%

RPNse

xperiencinghigh

levelsof

emotional

exhaustio

nandhigh

erlevelsof

person

alaccomplish

ment.Nosig

nificantd

ifference

onthe

TSIBS

Ryan-N

icho

lls(200

4)[34]

Toaddressimpactof

health

reform

onRP

Npractice

Focusg

roup

sManito

ba33

Increase

inindepend

ence.Insuffi

cientp

reparatio

nforn

ewroles,current,andfuture

shortage

ofRP

Ns

StatisticsC

anada

(200

6)Find

ings

from

the2

005National

Survey

oftheW

orkand

Health

ofNurses[31]

Toassessworkandhealth

ofCa

nadian

nurses

Survey

Allprovinces

1900

0nu

rses

inclu

ding

RNs,

licensedpractic

alnu

rses

(LPN

s),and

RPNs

Mentaland

physicalhealth

prob

lemso

fnurses

linkedto

workstr

ess,lowautono

my,shift

work,

poor

physician-nu

rser

elationships,low

supp

ort,

andlack

ofrespect

Health

Canada

(2002):

“Our

health,our

future:

creatin

gqua

lity

workplacesfor

Cana

dian

nurses,fina

lreportoftheC

anadian

NursingA

dviso

ryCo

mmittee”[29]

Toim

proveq

ualityof

nursing

worklife

6researches

&inform

ationprojects

Allprovinces

(i)Paucity

ofdataon

licensedpractic

alnu

rses

and

RPNs

(ii)5

1recom

mendatio

ns(3

categorie

s):(1)

implem

entcon

ditio

nsto

resolvew

orkload,

overtim

e,andabsenteeism

anddecrease

nonn

ursin

gtasks;(2)createp

rofessionalpractice

environm

entinleadership,edu

catio

n,and

preventio

nof

violence

andabuse;(3)m

onito

rworkplacesa

ndhealth

ofnu

rses,accreditatio

n,andresearch

anddissem

inateinformationto

keep

nurses

inform

ed

Maslove

andFo

oks

(200

4)[30]

Tolearnwhatactions

toim

plem

entrecom

mendatio

nby

theC

anadianNursin

gAd

visory

Com

mittee

(CNAC

)madeinthe2

002“O

urhealth,

ourfuture:creatin

gqua

lity

workplacesforC

anadian

nurses”r

eport

Scan

ofweb

sites,letterto

stakeholdersto

learnwhath

adbeen

done,interview

swith

key

inform

ants,

andpresentatio

nwith

14representativ

esfro

mnu

rsing

stakeholdersin

Otta

wa

Allprovinces

94stakeholders,14

keyinform

ants

Increasednu

mbero

fedu

catio

nseatsfor

RNs,

LPNs,andRP

Ns,workloadmeasurementsystems,

increasednu

mbero

ffulltim

eposition

s,nu

rse

mentors,and

flexibles

cheduling—

progressno

tun

iform

butcon

centratein

acutec

arer

atherthan

commun

ity;respo

nsibilityto

carryou

trecommendatio

nsisun

clear,needforC

NAC

s,leadership

position,

fund

ing,survey,

accreditatio

n,research

toidentifyprob

lems

Health

Canada

(2007):

“Thew

orking

cond

itions

ofnu

rses:confro

nting

thechallenges”[32]

Toexam

iner

esearchon

the

stateo

fCanada’s

nurses

and

implicationfora

larger

health

care

syste

m

Bulletin

Allprovinces

NA

Workplace

andworkforce

issuesrequire

collabo

ratio

nandgovernmentinvolvement

6 ISRN Nursing

Ontario. Texts were borrowed through the assistance ofthe librarian at Waypoint Centre for Mental Health Care,Penetanguishene, Ontario.

Through combinations of keywords, topics searched forincluded psychiatric nurses in Canada, Canadian psychiatricnursing history, Canadian psychiatric nursing education,Canadian mental health nursing, Canadian psychiatric men-tal health nursing, Canadian nurses and gender, quality of lifefor Canadian psychiatric mental health nurses, stress experi-enced by psychiatric nurses in Canada, registered psychiatricnurses in Canada, work stress of nurses working in mentalhealth, literature review on psychiatric mental health nursingin Canada, sociological perspective of psychiatric nursing,psychiatric mental health nurse practitioner, mental healthnurse practitioner education, and sociology of nursing stress.

The searches included English language reports, studies,reviews, editorials, and narratives and was limited to Cana-dian sources and Canadian PMHN. The intent was to betterunderstand the Canadian context of PMHN. Internationalcomparisons were beyond the scope of this undertaking.With regards to the unique Canadian historical influencesshaping PMHN, 14 studies were selected as relevant. Therewas a lack of studies that focused solely on the CanadianPMHN experience as many reports included RPNs andRNs. RNs in the provinces east of Manitoba do not have aseparate psychiatric regulation, as do the western provinces.No studies were found on the education in Canada for NPsin mental health. As a result data often combines all nurses.This made it difficult to discern the unique state of CanadianPMHN from that of all Canadian nurses.

3. Results

The results from the literature review are divided into threesections.Thefirst section reviews the literature from2 sourcesthat include a critical sociological perspective. The nextsection considers the interrelation of history, gender, and thedevelopment of education for Canadian PMHN through thereview of 6 social, historical, and analytical studies. The finalsection focuses on the quality of Canadian mental healthpsychiatric nurses work life from 6 survey reports.

3.1. Studies with a Sociological Perspective Relevant to PMHN.Wall [20] utilized a sociological outlook, as described inSection 2.3, to critique nursing practice settings and nurs-ing research. The experiences of nurses can be furtherunderstood through a lens that encompasses professional-ization and organizational influences. In addition, genderis ingrained in all of nursing where a patriarchal culturemanifests. According to Wall [20], the control of medicineover nursing is evident in nursing’s utilization of quantitativeapproaches in research that is consistent with the historyof medicine. Health care, being a largely institutionalizedentity, has its ownway of socializing nursing and continues toplace medicine at the apex of health care despite health carereformation. Conversely, Wall [20] does not comment on thesocialization or culture of medicine with regards to gender, asmedicine being once an overwhelmingly male profession has

increased the number of female practitioners. Furthermore,the discussion by Wall [20] discusses nursing in generaland does not specify particular sectors of nursing such asNPs. Nevertheless, a critical sociological paradigm may helpto further understand issues in nursing and PMHN relatedto knowledge, gender, professionalization, and organizations[20].

McGibbon et al. [21] utilized Smith’s [22] sociologicalframe of institutional ethnography to reconsider the stress innursing through interviews, focus groups, and observation ofpediatric intensive care nurses [21, 22]. Results suggest thatstress is framed within the social structure of organizationsthat may have hierarchical and power-based relations. Artic-ulating patient matters may be challenging in organizationswith hierarchical systems. This may contribute to the levelof stress nurses experience. Studies concerning nursing stressor vicarious trauma often neglect how gender influences thelife of nurses. Theories that are utilized in nursing researchmay avoid gender analysis. Without a gendered analysis,occupational stress may not be illuminated or solutions maynot be identified. Nursing may further benefit by utilizinga gender perspective in research to potentially unveil socialpatterns that may influence teamwork and collaboration.Gender, race, and class are aspects of nurses’ identities butmay not be within the range of the theory utilized for theresearch. This may lead to research that may neglect iden-tification of concerns for nurses [21]. The critical genderedand sociological perspectives as depicted by Wall [20] andMcGibbon et al. [21] provided the lens in how PMHN isperceived in relation to the following results.

3.2. Intersections of History, Gender, and Education for Cana-dian PMHN. Tipliski [23] contributes to the understandingof Canadian PMHN history in the study entitled “Partingat the crossroads: the emergence of education for psychiatricnursing in three Canadian provinces,” 1909–1955. Genderedroles may have permitted psychiatry to maintain controlof psychiatric nursing education in the western provinces.Unlike Ontario, where nurses were able to assume controlover PMHN, thereby allowing PMHN incorporation intogeneral nursing education, the provinces of Manitoba andSaskatchewan permitted psychiatry to prevent themerging ofPMHNwith general nursing. From here, as Tipliski explains,two different models for Canadian PMHN education devel-oped leading to the class of the RPN that only exists in thewestern provinces [23]. This may have fostered a partition inthe PMHN nursing force in Canada, as the RPN designationpresents a separate regulation of nurses that is nonexistenteast of Manitoba.

Tipliski [23] describes how the nursing leaders ofSaskatchewan and Manitoba failed to assert control overnursing education. In 1955, the Canadian Nurses Association(CNA) recognized how the separate training that was occur-ring in the western provinces was not conducive to the effortsto professionalized nursing for all of Canada. Unfortunately,a progressivemovement by the nursing leaders of that time tobring psychiatric nursing under the umbrella of general nurs-ing in the 1950s dissolved.This left the western provinces with

ISRN Nursing 7

a split nursing educational approach where psychiatric nursetraining remained separate from general nursing educationand in the hands of psychiatrists [23]. Although psychiatricnursing is no longer controlled by the psychiatrists in thewestern provinces, separate training for RPNs remains. Fromthis perspective, it can be appreciated how female nursingleaders in Ontario influenced historical developments tointegrate psychiatric nursing education, which was consistentwith earlier efforts made by CNA to converge the psychi-atric nursing education with general nursing in the westernprovinces. Ontario nurse leaders were able to gain controlover their own nursing education and practice and wereaided by the government. Tipliski [23] explains how theOntario male medical superintendents attempted to keepmental nursing separate from general nursing thus hinderingthe professionalization of nursing. The contributions fromNettie Fidler in 1933, a nurse graduate from the TorontoGeneral Hospital, together with a report by Professor GeorgeWeir that recommended the merging of general with mentalnursing, stimulated the progression by the Registered NursesAssociation of Ontario (RNAO) to advocate for closure of theseparate schools providing only mental health training [23].It is possible that this accountmay overlook some of the otherpossibilities accounting for how PMHN developed in diverseways, yet Tipliski [23] provides a description of the historyof PMHN that may help to explain how gender dynamicsinfluenced the development of PMHN inCanada.Despite thevariation between educational approaches that resulted in theRPN designation for the provinces east of Ontario, there is alack of evidence revealing how PMHN care varies given thediffering education preparations.

Of interest is Tipliski’s [23] reference to how gender mayhave been a factor in the development of the RPNdesignationof the western provinces.This relates to the feminist conceptsof patriarchy. Brown [18] defines patriarchy as a social systemthat holds several assumptions. One assumption portrayswomen as being assigned a social function. In nursing, asTipliski [23] depicts nurses were assumed to be fitting toprovide care due to their female gender with their inherentability to nurture. The view of female nurses as nurturersmay have been a patriarchal belief held by the male medi-cal superintendents. Another patriarchal assumption is thatwomen are thought of as weaker and less strong. Tipliski [23]also considers the patriarchal context of PMHN, where thenurse leaders of the western provinces may have struggledagainst the authority of the medical profession. On the otherhand, Tipliski [23] does not speak of the power issues betweengeneral nursing and medicine or the professionalizationthe regulated psychiatric nurses of the western provincesexperienced.

Dooley [24] argues that the separate class of psychiatricnurses in Manitoba developed their own unique craft thatis specialized for the mentally ill population. In this study,the account fromManitoba mental health nurses of the 1930ssupports the view that the development of their nursingprofession was the outcome of their cooperation with physi-cians. Female mental health nurses in Manitoba consideredthemselves skilled and at a higher level than the male atten-dants. The female nurses were often in supervisory positions

directing the personal care given by the male attendants.Thiscontrasts with Tipliski’s [23] view on the separate division ofpsychiatric nursing being related to paternalistic structuresand in which female mental nurses could not overcomemale physicians and psychiatrist’s domination that soughtcontrol and power. Yet the Manitoba mental health nursesthat would become RPNs asserted their distinct class, andthis has enabled the continuation of the separate trainingfor mental health nursing that continues to manifest insidethe western provinces. Evidence to suggest that the separatedivisions of psychiatric nursing education in Canada thathave any effect on the quality of mental health care has notbeen substantiated in research.

One must also acknowledge the circumstances thatinfluenced Canadian women as nursing leaders in the past.For instance, Dooley [24] describes the social context ofthe interwar years where women were looking for ways tosupport themselves, and mental health nursing provided away to live that would provide regular meals and housing formental health nurses. From this description, it is possible thatPMHN also developed in diverse ways in Canada as a resultof social and economic circumstances in addition to genderinfluences, that have yet to be fully explored.

Hicks [25] provides further details concerningManitoba’sadoption of the RPNmodel.Through a genealogical analysis,the study considers historical circumstances that led to theRPN model. Gender stands out as a main influence in thismovement where the male leaders of the psychiatric nursingassociations of the adjacent western provinces were influen-tial in drawing Manitoba to call for the distinct nursing class.The male nurses of the RPN psychiatric nursing associationsin the western provinces developed a collegial relationshipwith the male attendants of Manitoba who sought RPNstatus. This presents an interesting insight with regards togender, in that the men were able to increase their strengthand power through the joining with the male psychiatricnurses of Manitoba. This also diverges form Tipliski’s viewwhere the psychiatric nurses were submissive to medicalauthority in relation to the female gender. In addition, theseparate psychiatric RPN distinction was favored by the malemedical superintendents as there was a lack of interest bythe general nurses to work in psychiatry [25], which mayhave also furthered the movement towards the RPN class.Hicks [25] considers the large number of male attendantsand the significance of gender in the creation of the RPNdesignation. Male attendants provided custodial care andsought to provide nursing care that would elevate the statusof the male attendants. Unlike Dooley [24] and Tipliski[23] who focus on the female gender of nursing, Hicks [25]depicts the collegiality and support of male RPN leaders ofthe western provinces. The Canadian Council of PsychiatricNursing provided support to the Manitoba attendants whosought RPN status [25]. The RPN emergence may be seenas a way for the male gender to enter into nursing in a timewhere nursing was culturally enshrined as a female role andthe attendants of psychiatric institution sought status andclass through the RPN profession. In this way, Hick’s studydemonstrates how male gender has influenced the history ofCanadian PMHN [25].

8 ISRN Nursing

Boschma et al. [9] examined nurses’ stories that furtherthe understanding of the development of PMHN in Alberta.RN status was recognized as being desirable for PMHN andcould be achieved by mental health nurses by taking an extra18 months of training in a general hospital after completing2 years in a psychiatric hospital. Women were sought asnurses by the governing psychiatrists for their caring andcompassionate nature. The male attendants were excludedfrom nursing because of their gender and became increas-ingly resentful. The male attendants sought recognition andprofessional status. Like Saskatchewan, the separate statusfrom RNs was lobbied for by the male attendants and in 1963registration was given to psychiatric nurses [9]. In this sense,the development of the separate RPN status stems from thegender division that favoured RN status to females leavingmale mental health attendants to seek professional status bybecoming RPNs. Similar toHicks [25], Boschma et al. [9] alsoindicate the influence ofmale attendants.This differs from theview held by Tipliski [23] that mainly denotes the oppressionof largely female nurses by the medical superintendents.Likewise, the account by Hicks [25] and Boschma et al. [9]also varies from the perspective by Dooley [24]. Dooley [24]explains that the female psychiatric nurses saw the RPNcategory as separate and offering more to the mental healthcare of patients than the general nurse education could offer.Despite the development of the RPN class, mental healthcare in Alberta continued to suffer and the need for furthereducation continued pressure to achieve RN status [9].

Professionalization through the regulation of RPNs isdescribed further by the interweaving of data fromBoschma’scase study of community mental health in Alberta [26] andHick’s historical review of psychiatric nursing in Manitoba[27]. Boschma [26] explains that Alberta graduates from themental hospitals that started in the 1930s met with resistancefrom the general nursing organizations leading to the forma-tion of the separate professional organization for RPNs. Hicks[27], consistent with Tipliski [23], indicates that the AlbertaAssociation of Registered Nurses (AARN) had opposed theplan by superintendent Charles Baragar to establish a pro-gram to train psychiatric nurses. The AARN recommendedthat general nurses may complete a postgraduate psychiatriccourse or combine with general nursing students during athird year of training. They also suggested the hiring ofgeneral nurses who were unemployed. Baragar, however,was able to succeed in his intentions through his appeal tothe minister of health, and the program was implemented.This program included a total of 4 years of instruction atthe mental hospital with 2 of these years occurring at thegeneral hospital.Male attendantswere restricted fromattend-ing and had to complete a three-year psychiatric program.The male attendants went on to successfully lobby for theAlberta psychiatric professional nursing association [27].Hicks [27] explains that the association’s activities duringthat period may have been more union type activities ratherthan professional. In the 1950s, the movement to form thepsychiatric nursing association was developing in Manitoba.The Canadian Nurses Association recommended combiningthe RN and psychiatric training programs in disapprovalof the two models emerging for psychiatric nursing in

Canada. Despite efforts to organize this endeavour, CanadianNurses Association’s (CNA) plans were never realized [27].Boschma [26] and Hicks [27] further explicate that beyondthe development of the RPN profession to meet the poorstaffing of the mental health facilities, the profession ofpsychiatric nursing in the western provinces grew to deliver amuch needed service that provides specialized mental healthnursing differing from what general nursing could supply.The RPN profession may advance mental health nursingknowledge and care through the experiences gained from thisprofession’s unique historical development.

3.3. Quality of Canadian Mental Health Psychiatric NursesWork Life. In 2001, the Canadian Nursing Advisory Com-mittee (CNAC) formed as a result of the recommendationsby the Advisory Committee on Health Human Resources(ACHHR). The ACHHR’s first recommendation of the Nurs-ing Strategy for Canada [28] was to create the CNAC.The CNAC included nursing representatives from the threenursing professions of RNs, RPNs, and LPNs. The CNAC’smain goal concerned the quality of nursing work life andthe identification of provincial and territorial strategies toenhance nursing work life. With the shrinking workforce thiswas deemed a high priority. The CNAC’s recommendationsconcern all nursing workplaces including settings that pro-vide PMHN.

The CNAC commissioned 6 projects which looked atstrategies to improve workplaces, costs related to absenteeismand overtime, workload issues, satisfaction of nurses in theworkplace, workplace respect, and autonomy and health careorganizational structures [29]. As a result, 51 recommen-dations were made to the ACHHR. The recommendationscan be summarized into three categories. The first categoryconcerns management issues and resources. There is a needto reduce nursing’s pace and intensity, increase full timework,decrease sick time and overtime, and enable full scope ofpractice. The second recommendation speaks to professionalwork settings that foster a thriving and dedicated workforce.Respect for nurses is key to this recommendation, as wellas education at the master and doctoral levels. Educationfor nurses should be accessible in remote and rural areas.Violence and abuse in the workplace must be addressed.In the third recommendation, monitoring of the health ofnurses and workplaces and disseminating information tokeep nurse abreast of initiatives and education are considered.Accreditation, awards to promote quality of nursing worklife, continued research on the nursing workforce, imple-mentation of regional nursing committee recommendations,national nursing retention, and recruitment campaigns witha heightened emphasis for diverse and aboriginal groups area few activities mentioned within this recommendation [29].

The recommendations strive to rectify the main issuesthat concern the shortage of nurses, the lack of educationalopportunities, the limited scope of nursing practice, and theunfavourable working conditions, which are also applicableto the RPNs and RNs who provide PMHN. However, theCNAC recommendations lack consideration of gender and itsintersection with professionalization and workplace culture

ISRN Nursing 9

that culminate in the core of issues, including patriarchalculture- and power-based hierarchical organizations thatimpact nursing work lives [20, 21]. Lacking also from theCNAC recommendations is reference to PMHN being astakeholder in mental health. As a stakeholder, PMHN needsto organize as a united front, so that its voice is heard.This may be challenging as more powerful stakeholders, likemedicine, have traditionally dominated health care [20, 21].

Maslove and Fooks [30] conducted a study to determinethe degree of implementation of the 51 CNAC recom-mendations made in 2002 as requested by the Office ofNursing Policy at Health Canada. Policies of the stakeholderorganizations were assessed to determine their impact onfacilitating the implementation of the recommendations.Their methodology included scanning of websites, send-ing letters to 94 stakeholders to determine their progress,and interviewing 14 informants to identify barriers andsupports. The 94 stakeholders included employer organiza-tions, the federal government, provincial/territorial govern-ments, unions, professional associations/regulators, educa-tors, research community, and national organizations. Therewas a 50% response rate from stakeholders. Findings werethen shared with nursing stakeholders at a roundtable toenable feedback [30].

The recommendation to increase the number of educa-tion seats occurred in a uniform manner. However, otherrecommendations occurred in some areas but not all, andthere was difficulty in determining what had occurrednationwide. Implementation of the recommendations includ-ing workload measurement systems, increased full timepositions, analyzing sick time, increasing nurse mentors,and flexible scheduling were not consistently taking placethroughout Canada. Key informants favoured regulation atthe provincial versus the national level. The lack of stablefunding was depicted as a barrier to implementation of therecommendation to develop secure jobs. The varying profes-sional associations and regulatory colleges that exist in eachprovince may complicate assigning recommendations [30].Respondents addressed lack of interest from governmentregarding nursing issues. Accountability is seen as critical toimplementation of the recommendationsmade by theCNAC.Determining what organizations should be responsible foris a priority concern, and employers need support to enableimprovements that will impact nursing quality of work life[30]. Organizations may require government funding inorder to implement the recommendations that will enhancenursing work environments.

Together, the CNAC’s recommendations [29] and thestudy by Maslove and Fooks [30] include data from RPNsand general nurses who also provide psychiatric care in theprovinces east of Manitoba. Issues pertaining to violenceand abuse were seen as priority issues [30]. Poor workingconditions may negatively impact quality care, and the lackof action and accountability by organizational and provincialterritorial leaders and their support to employers [30] mayadversely impact the mental health of both nurses and theCanadian population, which they serve.

Findings from the 2005 National Survey of the Work andHealth of Nurses (NSWHN) [31] examined the health of

Canadian regulated nurses as related to their work environ-ment. The data as presented here was collected between 2005and 2006. Nineteen thousand nurses inclusive of RNs, RPNs,and LPNs were surveyed with a response rate of 80%. Morethan one-quarter reported being physically assaulted. Of noteis that 44% of males reported assault compared to 28% offemale nurses. The reasons for this finding are not elaboratedupon in the 2005 NSWHN. It is not known if this points tomale nurses being more likely to be assaulted or more likelyto report assault. Forty-four percent of nurses reported emo-tional abuse. High physical demands were reported by 75%of LPNs, 60% of RNs, and 45% of RPNs. Gender differencewas not specified for physical demands, that is, if male orfemale nurses reported higher physical demands.Thementalhealth of nurses was adversely associated with evening shiftsand employment in long-term care facilities. Lack of respectand low support from coworkers and superiors were linkedwith poorer mental health. In addition, the mental health ofnurses was also affected by elevated job strain, low autonomyand control, and poor physician relations. One in ten nursesreported having depression and needing to take time off inrelation to their mental health. The finding of depression innurses is compared with the overall employed populationthat utilized data from the Workplace and Employee Survey,Labour Force Survey, and theCommunityHealth Survey [31];however, comparisons with specific groups or professions arenot explicit. Of all nurses, including both male and female,9% experienced depression. The experience of depression bysex was not included for nurses but for all; employed the4% of men and 7% of women experienced depression. Alsoat the time of this study in 2005, one-fifth reported theirmental health difficulties interfering with their jobs. Qualityof care was negatively affected by inadequate staffing. Thirty-eight percent of nurses felt that staffing was inadequate.Improvements in quality care were related to improvedmanagement and more staffing [31]. The findings of thissurvey may further illuminate the working conditions fornurses and the implications for their mental and physicalhealth.

The Health Policy Research Bulletin (HPRB) is publishedusually twice yearly by Health Canada with the purpose ofreinforcing the evidence that supports decision making inhealth policy. In 2007, the HPRB’s issue, titled “The workingconditions of nurses: confronting the challenge” [32], focusedon theCanadian nurses’ working conditions and implicationsfor the country’s health care system. Between 1997 and 2005overtime by RPNs, LPNs, and RNS increased in all areaswhere nurses work by 58%. In light of the high overtimerates, it is questionable if the current level of full-time nursingpositions in mental health care in Canada is sufficient toadequately care for those with mental illness. All areas innursing face similar pressures concerning increased overtimeand a need for more full time work; however, mental healthsettings entail frequent interactions with challenging anddifficult behaviours. This may intensify the stress on nursesworking in mental health care where there is shortage of full-time nurses.

Robinson et al. [33] conducted a study with a cross-sectional design. A survey of 1015 RPNs in Manitoba was

10 ISRN Nursing

conducted to determine the predictors, prevalence, corre-lates, and distribution of vicarious trauma and burnout.The survey included the Maslach Burnout Inventory, theTraumatic Stress Institute Belief Scale, and a section on post-traumatic stress disorder (PTSD) symptoms. Seventy-ninepercent of the respondents were female, and 20.2%weremale.Emotional exhaustion was the highest in RPNs working incommunity services and acute care hospitals. Constant inter-ruptions, burdensome responsibility, increased trauma work,depersonalization, and elevated vicarious trauma scores werelinked with higher emotional exhaustion levels. With regardsto vicarious trauma, 21% had persistent thoughts in relationto client trauma, and 30% experienced a heightened levelof arousal. Client trauma is the exposure to a stressfulexperience that overwhelms a person’s coping mechanism.Fifty-five percent of those involved in client trauma met onecriteria of PTSD, and 48% responded that symptoms weretroublesome to some degree. Lack of peer support and skillsto deal with trauma could be rectified by increased educationand team building. The RPNs in this study also reported ahigh level of personal accomplishment, which is associatedwith low burnout [33]. Personal accomplishment includesthe perception that clients are improving and the RPNs havethe skills necessary to help individuals with mental healthdisorders.The study is significant in that it mirrors the resultsof the studies in the preceding discussion concerning nursingquality of work life. Stress is evident in nurses working inmental health care and impacts the mental health of thecaregivers. On the other hand, personal accomplishment washigh amongst the RPNs, and this may decrease burnout. Howthis impacts client care requires further study.

Ryan-Nicholls [34] studied the repercussions of healthreform in RPNs. Seven focus groups with RPNs from adiversity of health care settings took place in Manitoba overa nine-month period. The themes that emerged consisted ofchanges from institutional care to the community, variationsin professional position, primary and secondary care and pre-vention, lack of provincial communication, and consistencyamongst policies. Deinstitutionalization was considered tohave largely impacted the practice setting of RPNs. Thischange led to an extension of their roles inmany different set-tings including emergency departments, treatment centers,and acute psychiatry. RPN professional status has requireda move to more autonomous roles within the primarycare setting where professional competence is emphasized.Emphasis on health promotion and prevention is in contrastto the traditional approaches that focused on treating illnessesin institutionalized settings. Study participants described lackof consistency with mental health standards, protocols, andpolicies in the region.This was not conducive to the provisionof mental health services [34].

In the same study, the RPNs became more familiarwith the growing emphasis client-centered care and theneed for mental health consumers to be involved in thedecision making process. The transition from the traditionalinstitutionalized care where decisions were made for theclients had left some RPNs feeling unprepared and concernedthat the client may not choose what is best for them. Theimportance of engaging the family has becomemore apparent

and this contrasts to the way care was provided in the pastwhere family involvement was limited in the institutionalsetting [34]. The education of RPNs and RNs is essential tomeet the changing approaches to caring for those withmentalillness and the growing recognition of the impact of socialdeterminants of health on the health andwell-being of diversepopulations. There is scant research that clearly indicateshow the diverse educational preparation of nurses workingin psychiatric care impacts the quality of care for personswith mental health disorders. Given the burden of mentalillness in Canada there is need formore research that analyzesthe psychiatric educational preparation of nurses in relationto accessibility to mental health care and therapeutic andtreatment outcomes. Client-centered care requires advocacyand involvement with family and community beyond theconfines of institutional care and this may require increasededucation specific to the changing dynamics of mental healthcare within the community setting.

According to Ryan-Nicholls [34], the shortage of RPNsis a concern of the existing RPNs. Previously, it was believedthat deinstitutionalizationwould perhaps leave RPNswithoutjobs. Now, there are not enough RPNs to fill the vacant posi-tions. In addition, participants in the focus groups discussedconcern about the 2-year diploma program changing intothe 4-year baccalaureate degree for RPNs, graduating only15 students per year as compared to 60 students per yearfrom the diploma program [34]. Therefore, the issues forRPNs parallel to the issues of the broader nursing workforce,where the shift to higher education has impacted the sizeof the nursing workforce, but at the same time the nursinggraduates of today have increased knowledge to meet thecurrent challenges of health care.

4. Discussion

The diversity between the organization of PMHN and edu-cation between the western provinces and the rest of Canadahas connections with events of the past and intersects withgender, professionalization, and the predominating organiza-tional culture. The historical analyses of nursing may fosteradditional inquiries that may benefit nursing knowledgethrough learning from past approaches and gaining newperspectives.

Overall PMHN in Canada is challenged to further itselfto meet the lack of accessible mental health services. Thereis evidence that nurses are stressed, and there is a needto enhance a coordinated national approach for advanceddegrees in PMHN. The lack of a uniform approach toPMHNeducation inCanada has consequences for the furtherdevelopment of PMHN and may generate barriers to furtherPMHN to meet the growing mental health care challenges.The implementation of standards by the Canadian Federationof Mental Health Nursing is brought to the discussion herein order to explain how standards are an important way toaddress the diverse forms of PMHNeducation.The standardsfoster an overarching educational approach for PMHN thatenables quality PMHN practice. In 2006, the third edition ofthe Canadian standards for psychiatric-mental health nursingwas released in an effort to prompt nurses to adopt the

ISRN Nursing 11

standards into daily practice and further nursing reflectionon their work [35]. The latest standards were developedafter consultation with Canadian consumers of mental healthacross Canada. Beal et al. [36] acknowledge that systemicissues, that is, labeling, stigma, caregiver, and treatment role,affect PMHNbut emphasize the need for nurses to know theirclientele to foster therapeutic relationships. Systemic factorsincluding workforce size, workload, violence in the work-place, nursing scope of practice, and accessibility to PMHNmay have important implications for PMHN and their dailypractice. PMHN education strives to produce nurses whosepractice meets or exceedes the standards [36]. However,systemic factorsmust be addressed to foster PMHN’s deliveryof high quality care that are consistent with the standardsfor psychiatric-mental health nursing. Furthermore, as aninfluential and strong stakeholder that can affect change inmental health care, PMHN may benefit from a uniformeducational process throughout Canada.

Also of concern is the mental health of nurses whoexperience high stress. As nurses are mostly women andnurses form the largest group of health care providers,the ramifications for the health and productivity of theCanadian society are especially disconcerting if the majorityof nurses are experiencing reduced quality of work life. AsWall [20] and McGibbon et al. [21] point out, a sociologicalparadigm enables the discussion of sensitive issues includingthe gendered impact over nursing and the need for researchfromaperspective that views critically the influence of genderon quality of nursing work life. The labour divisions inorganizations where nurses practice are entrenched in hier-archal power struggles that undermine nursing knowledgeand autonomy and contribute to poor quality of work life andstress.

4.1. Limitations of Review. There were limitations encoun-tered in this review. Although several studies were found inrelation to the history of PMHN for the western provincesand Ontario, no studies were located that convey the fullPMHN history of eastern Canada. While there were gov-ernment documents concerning the quality of work life forall nurses, it was difficult to abstract information specificto PMHN from these documents. For instance, althoughthe NSWHN found a high incidence of depression amongstnurses, the percentage of nurses in PMHN experiencingdepression was not given. It is acknowledged that the wholepuzzle of what PMHN is like in Canada is not complete.Furthermore, as NPs are becoming more established withinthe Canadian health care system there is a need for increasedresearch that reveals NP mental health care initiatives andactivities. At present, there is a lack of research pertaining toCanadian NPs employed in mental health and their qualityof work life. Despite this, the findings reported here depictimportant points regarding the issues that concern all ofPMHN and how they impact the provision of mental healthcare for Canadians.

4.2. Implications for Nursing Practice. While NPs have madesignificant progress in achieving prescriptive authority in

the area of primary care, minimal movement has occurredregarding the feasibility of NPs specializing in mental health.In Canada, there are no educational programs or legislatedprovisions for NPs who wish to specialize as a psychiatricNP or who already have extensive experience providingmental health care [37]. The existing situation for NPspracticing within mental health care settings is hamperedby the absence of recognition for the psychiatric mentalhealth nurse practitioner (PMHNP) in Canada. Prescriptiveauthority can only be obtained in Ontario through regis-tration in the extended class in the designated specialties,NP paediatrics, NP-Primary Health Care and NP-Adult. Theeducational programs that prepare NPs for these special-ties focus on the medical and physiological aspects of thespecialties with limited content on mental health [37]. In2011, open prescribing became possible for Ontario NPs.The Nursing Act, 1991, no longer stipulates the prescribingof only listed medications by NPs [38]. With the exceptionof medications under the Controlled Drugs and SubstancesAct, NPs are now able to prescribe medications commonlyused in mental health care. This allows NPs to furthertheir care for clients needing mental health care; however,it may also point to the need for comprehensive mentalhealth training for NPs. It beckons further exploration if theexisting mental health nursing programs offered throughoutCanada could enable the development of PMHNP programsthat would enable RNs or RPNs and NPs to obtain thecompetencies of the PMHNP. Communities with insufficientmental health care resources may be better served by nurseswith an expanded scope of practice with specialized mentalhealth education. In addition, although there have beenchanges to legislation, specifically regulation 965 of thePublic Hospitals Act, that gives admitting and dischargingprivileges to NPs; changes to the mental health act havenot been made and regulated forms enabling admission toa hospital for psychiatric assessment cannot be completedby Canadian NPs [37]. When the NP is the person’s maincare provider, it would seem prudent that the NP should beinvolved in decisions concerning psychiatric admission anddischarge.

The variability of PMHN in Canada presents both chal-lenges and opportunities to the advancement of PMHNeducation. Given the challenge for increased accessibility tomental health care services and treatments, the developmentof already existing nursing programs in Canada could bondby striving to achieve the same psychiatric educational nurs-ing standards. To furthermental health care itmay be possiblefor all nursing programs to uphold the same standardsfor psychiatric nursing education. The CNA motioned aresolution in 2005 to include RPNs as it was recognized thata separate national level for RPNs would hinder professionalnursing practice and the power for Canadian nurses toadvocate for change [39]. Amending the division betweenRPN and RNs and to enable certification and eligibilityof CNA membership for both groups may strengthen theCanadian PMHN workforce. Gallop [40] considers howthe education system in Canada lacks prospects for nursesworking in mental health to obtain advanced degrees inPMHN, although, as previously mentioned, there is new

12 ISRN Nursing

potential for RPNs and nurses to obtain master degreesspecializing in mental health nursing west of Ontario. Asmental health care is no longer confined to institutionalsettings and mental health training is pertinent to all areasof health care, the necessity for advanced mental healtheducation is relevant to all health care settings where nursespractice. Nursing needs to facilitate advanced education inmental health so that people within the primary care settingalso benefit from the knowledge and expertise of nurses whohave additional mental health education. Bridging programsor additional educational opportunities for psychiatric nurseswishing to broaden their knowledge specifically to prescribepsychiatric treatments or medications may be helpful. Part-nerships between provincial nursing bodies to foster nationalstandards for PMHN education and bridging programsto a PMHNP program if developed may represent newopportunities for all Canadian nurses. The report entitled“Canadian nursing education in Canada statistics,” 2009-2010[41], conducted by the Canadian Nurses Association (CNA)and the Canadian Association of Schools of Nursing (CASN),reveals an increase of 64.3% from 2009 to 2010 for graduatesfor doctoral programs [41]. In 2010, 47.6% of NPs had amaster’s, and 0.8% of NP had a doctorate degree [4]. Morenurses and NPs are acquiring advanced degrees. With thistrend for advanced education, it is likely that mental healtheducation for all nurses and nursing research pertaining tomental health and PMHN will flourish. Advanced PMHNeducation offers possibilities to further mental health care forCanadians.

5. Conclusion

PMHN in Canada must take action to meet the goals as setout by the Mental Health Commission of Canada. Nationalstandards for psychiatric nursing education for all Canadiannursing education programs may positively impact mentalhealth care. Advanced education for PMHN including thedevelopment of a Canadian PMHNP program may furtherthe accessibility of psychiatric treatments. Psychiatric mentalhealth education for all nurses will complement primaryhealth care and the provision of mental health care ingeneral hospitals and community settings. Efforts to uniteand form partnerships with the varying groups providingPMHNat a national levelmay empower PMHNas a powerfulstakeholder in mental health care reform. Also, the mentalhealth of nurses in light of their quality of work life is ared flag for all leaders in the Canadian health care system.There is a need to understand the circumstances of nurseswith regards to occupational stress and barriers to advancededucation inmental health nursing. Although the full pictureof what Canadian mental health nursing looks like todaycannot be fully realized by this synthesis, important issuesfacing PMHN have been identified through the analysis ofhistory and application of a critical and gendered sociologicallens. Another chapter on the evolution of Canadian PMHNhas yet to be written; hopefully, it will entail how PMHNworks together with all stakeholders equally to provide thebest care possible.

References

[1] Statistics Canada, “Canada’s population estimates: age andsex,” 2012, http://www.statcan.gc.ca/daily-quotidien/120927/dq120927b-eng.pdf.

[2] Canadian Institute for Health Information, “Regulated Nurses:Canadian Trends, 2006 to 2010,” 2012, https://secure.cihi.ca/free products/Regulated Nurses EN.pdf.

[3] M. Alameddine, A. Laporte, A. Baumann et al., “Where arenurses working? Employment patterns by sub-sector in On-tario, Canada,” Healthcare Policy, vol. 1, no. 3, pp. 65–86, 2006.

[4] CanadianNurses Association, “2010Workforce Profile of NursePractitioners in Canada,” 2012, http://www2.cna-aiic.ca/CNA/documents/pdf/publications/2010 NP Profiles e.pdf.

[5] Statistics Canada, “Canadian Community Health Survey—Mental Health (CCHS),” 2012, http://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&SDDS=5015&lang=en&db=imdb&adm=8&dis=2.

[6] Statistics Canada, “Canadian Community Health Survey: Men-tal Health andWell Being,” 2003, http://www.statcan.gc.ca/dai-ly-quotidien/030903/dq030903a-eng.htm.

[7] Health Canada, “Sharing the Learning. The Health Tran-sition Fund. Ottawa: Health Canada,” 2002, http://www.hc-sc.gc.ca/hcs-sss/alt formats/hpb-dgps/pdf/pubs/2002-htf-fass-prim/2002-htf-fass-prim-eng.pdf.

[8] S. Ratnsingham, J. Cairney, J. Rehm, H. Manson, and P. A.Kurdyak, “Opening eyes, opening minds: the ontario burden ofmental illness and addictions report,” An ICES/PHO Report,Institute for Clinical Evaluative Sciences and Public HealthOntario, Toronto, Canada, 2012, http://www.oahpp.ca/res-ources/documents/reports/opening-eyes-mental-health/PHO-ICES%20Opening%20Eyes%20Opening%20Minds%20Report%20-%20Oct%202012%20final.pdf.

[9] G. Boschma, O. Yonge, and L. Mychajlunow, “Gender and pro-fessional identity in psychiatric nursing practice in Alberta,Canada, 1930–75,” Nursing Inquiry, vol. 12, no. 4, pp. 243–255,2005.

[10] M. J. Kirby, “Mental health reform for Canada in the 21stcentury: getting there from here,” Canadian Public Policy: Ana-lyse de Politique, vol. 31, s1, pp. 5–12, 2005.

[11] The Standing Senate Committee on Social Affairs, Science andTechnology, “Out of the shadows at last: transforming mentalhealth, mental illness and addiction services in Canada,” 2006,www.parl.gc.ca/39/1/parlbus/commbus/senate/com-e/soci-e/rep-e/rep02may06-e.htm.

[12] Mental Health Commission Canada, “Toward recovery andwell being: a framework for a mental health strategy forCanada,” 2009, http://www.mentalhealthcommission.ca/Site-CollectionDocuments/boarddocs/15507 MHCC EN final.pdf.

[13] Mental Health Commission of Canada, “Changing direc-tions, changing lives: the mental health strategy for Canada,”2012, http://strategy.mentalhealthcommission.ca/pdf/strategy-images-en.pdf.

[14] M.Kirby, “Mental health inCanada: out of the shadows forever,”CanadianMedical Association Journal, vol. 178, no. 10, pp. 1320–1322, 2008.

[15] R. Whittemore and K. Knafl, “The integrative review: updatedmethodology,” Journal of Advanced Nursing, vol. 52, no. 5, pp.546–553, 2005.

[16] J. J. Macionis and L. M. Gerber, Sociology, Pearson EducationCanada, Toronto, Canada, 5th edition, 2005.

ISRN Nursing 13

[17] R. J. Brym,New Society: Sociology for the 21st Century, HarcourtCanada, Toronto, Ontario., 2001.

[18] L. S. Brown, “Feminist therapy,” in Handbook of PsychologicalChange: Psychotherapy Process and Practice for the 21st Century,C. R. Snyder and R. E. Ingram, Eds., pp. 358–380, Wiley, NewYork, NY, USA, 2000.

[19] M. C. Wright, The Sociological Imagination, Oxford UniversityPress, New York, NY, USA, 1959.

[20] S. Wall, “Critical perspectives in the study of nursing work,”Journal of Health, Organisation and Management, vol. 24, no.2, pp. 145–166, 2010.

[21] E. McGibbon, E. Peter, and R. Gallop, “An institutional ethnog-raphy of nurses’ stress,” Qualitative Health Research, vol. 20, no.10, pp. 1353–1378, 2010.

[22] D. Smith, The Everyday World as Problematic: A FeministSociology, University of Toronto Press., Toronto, Canada, 1987.

[23] V. M. Tipliski, “Parting at the crossroads: the emergence ofeducation for psychiatric nursing in three Canadian provinces,1909–1955,” Canadian Bulletin of Medical History, vol. 21, no. 2,pp. 253–279, 2004.

[24] C. Dooley, “‘They gave their care, but we gave loving care’:defining and defending the boundaries of skill and craft in thenursing service of a Manitoba mental hospital during the greatdepression,” Canadian Bulletin of Medical History, vol. 21, no. 2,pp. 229–251, 2004.

[25] S. C. Hicks, From Barnyards to Besides to Books and Beyond:TheEvolution and Professionalization of Registered Psychiatric Nurs-ing in Manitoba, 1955–1989, University of ManitobaCanada,2008.

[26] G. Boschma, “Community mental health nursing in Alberta,Canada: an oral history,” Nursing History Review, vol. 20, pp.103–135, 2012.

[27] B. Hicks, “Gender, politics, and regionalism: factors in theevolution of registered psychiatric nursing in Manitoba, 1920–1960,” Nursing History Review, vol. 19, pp. 103–126, 2011.

[28] Advisory Committee onHealth Human Resources,TheNursingStrategy for Canada, Health Canada, Ottawa, Canada, 2000.

[29] Health Canada, “Our Health, Our Future: Creating QualityWorkplaces for Canadian Nurse, Final Report of the CanadianNursing Advisory Committee, Advisory Committee on HealthHuman Resources,” 2002, http://www.hc-sc.gc.ca/hcs-sss/altformats/hpb-dgps/pdf/pubs/2002-cnac-cccsi-final/2002-cnac-cccsi-final-eng.pdf.

[30] L. Maslove and C. Fooks, “Our Health, Our Future: CreatingQualtiy Workplaces for Canadian Nurses: A Progress Reporton Implementing the Final Report of Canadian Nursing Advi-sory Committee,” Canadian Policy Research Networks, 2004,http://www.cprn.org/documents/30762 en.pdf.

[31] Statistics Canada, Special Surveys Division, “Findings from the2005 National Survey of the Work and Health of Nurses,” 2006,http://www.statcan.gc.ca/daily-quotidien/061211/dq061211b-eng.htm.

[32] Health Canada, “The working conditions of nurses: Con-fronting theChallenges,” 2007, http://www.hc-sc.gc.ca/sr-sr/altformats/hpb-dgps/pdf/pubs/hpr-rps/bull/2007-nurses-infirm-ieres/2007-nurses-infirmieres-eng.pdf.

[33] J. R. Robinson, K. Clements, and C. Land, “Workplace stressamong psychiatric nurses: prevalence, distribution, correlates,& predictors,” Journal of Psychosocial Nursing andMentalHealthServices, vol. 41, no. 4, pp. 32–41, 2003.

[34] K. D. Ryan-Nicholls, “Impact of health reform on registeredpsychiatric nursing practice,” Journal of Psychiatric and MentalHealth Nursing, vol. 11, no. 6, pp. 644–653, 2004.

[35] Canadian Federation of Mental Health Nurses, “The Cana-dian Standards for Psychiatric-Mental Health Nursing (3rded.),” 2006, http://cfmhn.ca/sites/cfmhn.ca/files/CFMHN%20standards%201.pdf.

[36] G. Beal, A. Chan, S. Chapman et al., “Consumer input intostandards revision: changing practice,” Journal of Psychiatricand Mental Health Nursing, vol. 14, no. 1, pp. 13–20, 2007.

[37] C. Forchuk and R. Kohr, “Prescriptive authority for nurses: theCanadian perspective,” Perspectives in Psychiatric Care, vol. 45,no. 1, pp. 3–8, 2009.

[38] College of Nurses of Ontario, “NP Diagnostic and PrescriptiveAuthority,” 2012.

[39] Canadian Nurses Association, “Resolution 2. Inclusion of Psy-chiatric Nurses,” 2005, http://www.cna-nurses.ca/CNA/about/meetings/resolutions 2005/resolutions 02 e.aspx.

[40] R. Gallop, “Advanced practice psychiatric nursing in Canada,”International society of psychiatric nurses [ISPN], 2007,http://www.ispn-psych.org/html/what canada.html.

[41] Canadian Nurses Association (CNA) and the CanadianAssociation of Schools of Nursing (CASN), “Nursing Educationin Canada Statistics, 2009-2010,” 2012, http://www2.cna-aiic.ca/CNA/documents/pdf/publications/Education Statistics Re-port 2009 2010 e.pdf.

Submit your manuscripts athttp://www.hindawi.com

EndocrinologyInternational Journal of

Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014


Gastroenterology Research and Practice

Breast CancerInternational Journal of


HematologyAdvances in


ScientificaHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014

PediatricsInternational Journal of



Advances in

Urology

HepatologyInternational Journal of


InflammationInternational Journal of


The Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014


Computational and Mathematical Methods in Medicine


BioMed Research International


Surgery Research and Practice

Current Gerontology& Geriatrics Research

Hindawi Publishing Corporationhttp://www.hindawi.com

Volume 2014


NursingResearch and Practice

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

HypertensionInternational Journal of


Prostate CancerHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014


Surgical OncologyInternational Journal of