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| Journal of the New Zealand Medical Association,
25-June-2010, Vol 123 No 1317
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Professional development perceptions and activities
of psychiatrists and mental health nurses in New Zealand
Nikolaos Kazantzis, Sarah J Calvert, David E Orlinsky, Sally
Rooke, Kevin Ronan, Paul Merrick
Professional development in mental health extends beyond
continuing medical education or maintenance of competence; it is a career-long
journey encompassing growth in confidence, self-awareness, knowledge, skill, and
professional identity. Professional development may also provide an important
source of satisfaction and sustenance to counteract the emotionally draining
experiences considered inevitable when providing
psychotherapy.1
Research on professional development among psychiatrists and
mental health nurses has increased recently, but little New Zealand data exists.
Differences in requirements for training and certification/
registration,2 different work
settings,3 and higher caseloads are known to
characterise the context for psychiatrists,4
and therefore data gathered elsewhere do not necessarily generalize to New
Zealand practitioners.
These differences have been implicated in the current
shortage of psychiatrists in New Zealand, with one study noting trainee
dissatisfaction with caseloads and resources.5
A general survey of 239 New Zealand psychiatrists (56% response rate) found that
75% experienced moderate or high levels of emotional
exhaustion.6
To the best of our knowledge, there has been only one prior
survey of professional development among New Zealand
psychiatrists.7 The study included 18
psychiatrists working at public health hospitals and aimed to explore a range of
development issues including training in psychotherapy.
The majority of those surveyed had been trained in
individual or groups psychotherapy format (n=13 and n=18, respectively), whereas
some had received training in drug abreaction (n=9), behaviour therapy (n=6),
and hypnosis (n=4). The changes that have occurred in training and programmes in
the three decades following the publication of this study limit the extent to
which the data can be taken as indicative of current practice.
There is also lack of published research for mental health
nurses in New Zealand. Limited opportunities for advanced training in
psychotherapy for nurses are well known.8
As nurses constitute the largest single professional group
in the New Zealand mental health workforce, and training models exist for
teaching evidence-based therapies (e.g. Cognitive Behaviour
Therapy,9,10 there is a potential for nurses to
make substantial contributions to the population of psychotherapy
practitioners.11
The Collaborative Research Network Study
(CRN)—Members of the Society for Psychotherapy Research organized
a CRN in 1989 to initiate research on the development of mental health
professionals. 5000 practitioners of all training backgrounds, career levels,
orientations, and countries have now participated in the survey asking for
perceptions over the course of the career.12
The questionnaire was designed to examine practitioner perspectives on
development, and dimensions of practitioner development over the entire career
span using a cross-sectional approach.13
The present study represents the New Zealand portion of this
research program, designed to collect data for contribution to the
cross-national CRN database. The New Zealand sample of psychiatrists and nurses
are compared to samples from Canada and the United States using the same
research methodology.
Perceptions of development across the
career—The benefits of accumulated experience, such as increased
competence and greater complexity of clinical reasoning, are known to be
important for psychiatrists.14 However,
fatigue, loss of motivation and enthusiasm, and difficulty remaining up to date
with current research also increase with
experience.15
Nurses report a shift to more complex and efficient clinical
perception and decision making with
experience.16 However, few studies have
examined development as a multifaceted, complex process among nurses, instead
favouring evaluation of specific technical
skills.17 Therefore, professional development
patterns over the career span are unclear.
The present study is the first to have quantitatively
examined New Zealand psychiatrists’ and mental health nurses’
general perceptions of their development or compare these with Canadian and
United States samples.
Use of professional development
activities—Sigmund Freud proposed a ‘tripartite
model’ of psychoanalytic training advocating for the use of supervision,
formal training, and personal therapy. The model has formed the basis of
training in psychological therapies
internationally.18
Supervision is typically considered a training cornerstone
promoting the development of clinicians’ skills, knowledge and
professional identity while simultaneously protecting patients and ensuring good
practice. Supervision has demonstrated positive effects, such as reducing stress
and improving patient care and clinician
cooperation.19
Formal training also plays an important role in professional
development by providing the knowledge base needed to equip graduates for
practice in multiple mental health
settings.20
Personal therapy has been proposed to improve therapeutic
skill, emotional functioning, self-awareness and empathy, and to enhance
one’s understanding of therapeutic techniques and personal
dynamics.21 There is evidence to suggest that
psychiatrists in other countries view personal therapy as essential to their
professional development,22 even though the
actual use of personal therapy differs (i.e. 32% in South Korea and 99% in
France).23
The CRN study is the first to collect data on the use of
supervision, training and personal therapy by psychiatrists or mental health
nurses among a large international sample. The present study explored New
Zealand psychiatrists’ and mental health nurses’ use of didactic
teaching, supervision of case-work and personal therapy. The survey included
practitioners’ evaluations the usefulness of supervision, training, and
personal therapy.
MethodQuestionnaire instrument—The
CRN’s Development of Psychotherapists Common Core Questionnaire (DPCCQ) is
a composite measure that explores perceptions of professional development,
personal and practice characteristics, and has been used widely in
research.24 Two DPCCQ scales were used for the
first study aim (exploring development perceptions): Current Development
(assessing current professional growth), and Overall Development (assessing
development from first case to most ).25
Overall Development is comprised of three subscales:
Retrospected Career Development (perceptions since the career outset), Felt
Therapeutic Mastery (perceptions of current therapeutic proficiency, assumed to
reflect accumulated development) and Skill Change (perceived skill change since
career outset).25
Several questions were utilised to assess use of
supervision, training, and personal therapy (e.g., “How much formal case
supervision have you received for your therapeutic work?”) Perceptions of
the usefulness of supervision, training, and personal therapy were surveyed
through ratings of influence, and 14 professional activities and work-related
variables were assessed for their influence [–3 (very negative
influence) to +3 (very positive influence)] on overall
development. Seven other relevant activities were also surveyed for comparison
purposes.
Procedure—New Zealand and
international data were collected as part of the CRN study of mental health
professionals’ professional development. CRN methodology has been
described in detail elsewhere,(26) but was
essentially aimed at gathering a diverse, heterogeneous database which could
then be disaggregated into meaningful subgroups. New Zealand data was collected
by the senior author between 1998 and 2000, through the distribution of 350
flyers inserted into newsletters of the New Zealand College of Psychiatrists,
New Zealand Nurses Organisation and other professional organizations where
psychiatrists and nurses might be members. Those who returned flyers were sent a
copy of the questionnaire and a prepaid return envelope. Participation was
entirely voluntary and anonymous.
Forty-six psychiatrists and 38 nurses returned flyers,
and of these, 26 psychiatrists and 18 nurses returned completed questionnaires.
These represent 57% and 47% response rates, respectively.
Data analysis—To enable
comparisons between New Zealand, Canadian, and USA samples with different sample
sizes, the standardised effect size index (d) was calculated. Effect
sizes were calculated by using the New Zealand sample as the comparison group.
The New Zealand mean was entered as the first group, so that a positive d
always indicates a higher score for New Zealand, and a negative d
indicates a higher score for the comparison country (Canada or the United
States).
Conventions are used to guide interpretation of effect
sizes, where an effect size of 0.2 is considered small, 0.5 is considered
medium, and 0.8 is considered large (27).
Influence of supervision, training and personal therapy were converted to ranks,
where the highest mean rating was assigned a ranking of ‘1’ and so
forth.
ResultsSample—The present study analyses
data for 26 New Zealand psychiatrists and 18 mental health nurses. The New
Zealand psychiatrist sample is compared with CRN samples of psychiatrists from
Canada (N=24) and the United States (N=53). The New Zealand nurses sample is
compared with nurses from Canada (N=4) and the United States (N=20).
Table 1 displays basic demographic characteristics for the
three samples.
Table 1. Demographic details
Note: NS vary slightly due to missing
data; aMean ratings, on a
scale of influence on therapeutic practice (scale ranges 0–5). Multiple
ratings allowed.
Psychiatrists—The proportion of male
psychiatrists was far higher in the Canadian and USA samples (74% and 60%
respectively, versus 46% in the New Zealand sample). The New Zealand sample had
a mean age of 51.0 (range = 37 to 77 years), had spent between 2 and 42 years in
practice, and had a mean practice duration of 18.5 years.
Theoretical orientation was assessed by asking “How
much is your current therapeutic practice guided by each of the following
theoretical frameworks?” Respondents rated analytic/psychodynamic,
behavioural, cognitive, humanistic and systems theory from 0 (not at
all) to 5 (very greatly). New Zealand samples rated the cognitive,
humanistic and systemic orientations as having greater influence on their
therapeutic work.
The New Zealand psychiatrist sample reported an average of
35.4 hours per week in various mental health settings (SD = 16.1; range
10–70), including an average of 11 hours providing therapy (SD = 12.5,
range 0–46 hours). The most common work-setting was public outpatient
practice (42% of the sample). Independent private practice (39%) and public
inpatient settings (12%) were also popular settings for therapeutic work. The
average caseload reported was 9.6 patients (SD = 9.9; range 0–35).
Nurses—The New Zealand nurse sample
reported working an average of 32.9 hours in various mental health settings per
week (SD = 12.1; range = 8 to 48 hours), with an average of 16.3 hours
conducting therapy (SD = 10.3, range = 0 to 36 hours). The most common work
settings were public outpatient and independent private practices, with 44% of
the sample engaging in some therapeutic work in each of these settings. The
average caseload reported was 30 patients (SD = 22.5; range = 3 to 100
patients).
Perceptions of development across the
career—Table 2 presents perceptions of development. Mean ratings
of development were above the mid-point (2.5) for all samples, indicating that
practitioners perceived themselves both to have developed considerably since the
beginning of their career, and to be experiencing development currently.
However, ratings were higher among nurses than psychiatrists.
Table 2 Means for current and overall
development
Note: Bold type represents
‘small’ effect sizes (d) ≥ 0.2). Bold, underlined type
indicates medium effects (d ≥ 0.5). Bold, double underline type indicates
large effects (d ≥ 0.8). Effect sizes represent comparisons with New
Zealand, within that particular profession. All scales except Skill Change range
0-5; Skill Change potentially ranges -5 to +5. RCD = Retrospected Career
Development; FTM = Felt Therapeutic Mastery; SC = Skill Change.
Comparing New Zealand psychiatrists’ perceptions of
Current Development with the Canadian and USA samples produced negative effect
sizes greater than the criterion for a small effect (d = -0.49 for the
comparison with USA and d = -0.30 for the comparison with Canada). New Zealand
psychiatrists’ perceptions of Overall Development were also low compared
with the Canadian sample, with effect sizes ranging from -0.22 (Retrospected
Career Development) to -0.45 (Overall Development). However, New Zealand
psychiatrists’ perceptions of Overall Development exceeded those of the
USA sample.
New Zealand nurses’ ratings were lower than those of
Canadian nurses. New Zealand nurses’ ratings were similar to the USA
sample. However, New Zealand nurses rated their changes in specific skills
(Skill Change) higher than the USA sample (d = 0.51).
Use of supervision, training and personal
therapy—Table 3 shows data for use of supervision, training and
personal therapy.
Table 3. Use of supervision, training and
personal therapy
Note: NS vary slightly for different
analyses due to missing data; aComputed for
those reporting having had therapy.
Psychiatrists—New Zealand
psychiatrists reported having been in regular supervision for an average of 10.7
years. Canadian and USA psychiatrists reported spending less time in supervision
than New Zealand psychiatrists (7.5 years), despite having a much higher mean
practice duration. Approximately half of the New Zealand and USA samples were
currently involved in regular supervision, compared with just 17% of the
Canadian sample.
The Canadian sample reported spending almost twice the time
in formal training (7.6 years, compared with 3.7 years for the New Zealand
sample). The low reported time in training is likely to reflect the focus of
this question, which specified training in therapeutic theory and technique. Of
the three samples, New Zealand psychiatrists were the most likely to have
undergone specialist training in a specific psychotherapy, with 81% of the
sample having done so, compared with 58% of the Canadian sample and 56% of the
USA sample.
The majority of all three samples had experienced personal
therapy: 89% of the New Zealand sample, 75% of the Canadian sample and 59% of
the USA sample. However, the New Zealand sample had spent the least time in
therapy (Mean= 4.8 years), and represented the group with the lowest proportion
of current engagement in personal therapy (16%).
Nurses—A high proportion of nurses in
all three countries reported undergoing supervision and personal therapy.
Eighty-three percent of New Zealand nurses were currently receiving supervision,
and they had been in regular supervision for an average of 8.7 years, compared
with 7.3 years for the Canadian sample and 4.7 years for the USA sample. Nurses
in all samples reported similar levels of training.
Virtually all of the New Zealand sample reported having
undergone personal therapy (94%). As with the psychiatrist sample, New Zealand
nurses had spent less total time in therapy (Mean = 2.7 years) and had the
lowest proportion currently engaged in personal therapy (22%).
Perceived influences of supervision, training and
personal therapy—Table 4 presents ratings of the influence of
supervision, training and personal therapy on development.
Table 4. Perceived influence of sources of
professional development
Note: Table shows mean ratings, which
range from 0 (no influence) to 3 (very positive influence). Rankings are
presented in square brackets. Bold type represents ‘small’ effect
sizes (d ≥ 0.2). Bold, underlined type indicates medium effects (d ≥
0.5). Bold, double underline type indicates large effects (d ≥ 0.8).
Effect sizes represent comparisons with New Zealand. Ratings of two items are
missing for the Canadian sample due to slight differences in the Canadian
version of the DPCCQ; aComputed for those
reporting having had personal therapy.
bComputed for those reporting having given
supervision.
Psychiatrists—New Zealand
psychiatrists rated experience with patients as having the greatest influence on
their professional development, followed by personal therapy. Personal therapy
also received the second highest mean rating among the Canadian sample, and the
highest mean rating among the USA sample. Supervision received the third highest
rating by all three samples.
Formal didactic training (taking courses and seminars) was
rated lower, ranking sixth among Canadian and USA samples, and eighth among the
New Zealand sample. Among the New Zealand sample, activities such as informal
case discussions with colleagues, reading books and journals and working with
co-therapists were perceived to contribute more to professional development than
formal training. Cross-national differences representing a medium effect size
were found on ratings of informal case discussion (d = 0.65 compared with
Canada), working with co-therapists (d = 0.68 compared with US), and conducting
research (d = 0.66 compared with US).
Nurses—New Zealand nurses perceived
their experience with patients as having less influence on their work with
patients. Work with patients was rated the third most influential development
source, following supervision and personal therapy (first equal). The USA sample
gave similar ratings to these sources, with supervision receiving the highest
mean rating, followed by personal therapy, then experience with patients.
Nurses assigned lower ratings to the influence of formal
training, which was ranked fifth (equal with reading books and journals) for the
New Zealand sample, and sixth for the USA sample. The New Zealand sample rated
giving supervision much more highly than the Canadian (d = 0.94) or USA
(d = 0.32) samples.
DiscussionNew Zealand psychiatrists reported a sense of positive
change, attainment of therapeutic mastery and increase in skill across their
careers, but their scores were lower than the Canadian sample and psychiatrists
in other CRN samples.28 It is also noteworthy
that perceptions of “Current Development” were lower among New
Zealand psychiatrists, particularly as current development is unrelated to
extent of experience.29 The current shortage of
psychiatrists in New Zealand, limited resources for professional development,
and high caseloads are likely explanatory
factors.6 New Zealand psychiatrists reported
high rates of specialist psychotherapy training and supervision, but only half
were currently engaged in supervision at the time of the survey. This may be due
to the lack of available supervisors.5
New Zealand nurses reported positive perceptions of
cumulative and current professional development. Nurses also reported higher
ratings of their growth in skill across the career compared with their USA
counterparts. Interestingly, nurses reported involvement in all three activities
specified in the tripartite model, and their use of these activities was
proportionately higher than Canadian and USA samples. All nurses reported having
received specialized training in psychotherapy and personal therapy.
The proportion of New Zealand nurses and psychiatrists who
had undergone personal therapy was high compared with previous surveys of
medical mental health practitioners.30 However,
the proportion actually undergoing therapy at the time of study participation,
and their mean length of time spent in therapy, was low in relation to the
Canadian and USA samples. These cross-national differences are likely to reflect
the higher endorsement of analytic/ psychodynamic orientations, which place
greater emphasis on personal therapy.
New Zealand psychiatrists and nurses’ perceptions of
the influence of supervision, training and personal therapy were similar to
their Canadian and USA counterparts, but different from Australian
trainees(22). Personal therapy was rated as
highly influential, whereas formal training was rated as less influential.
Future research should conduct a more thorough evaluation of past, present, and
intended professional development training.
Work with patients was rated less influential by nurses than
by psychiatrists. It is possible that this relates to the nature of division of
responsibilities involved in the two professions within the public health
system. Replication of this finding would be useful.
Future research—It would be desirable
for future research to examine the influence of activities such as supervision,
training and personal therapy on both current and overall professional
development more objectively. Very little research has been conducted on the
continuation of advanced psychotherapy training in mental health
practitioners’ clinical practice. It would be useful to know more about
the reasons practitioners elect to be involved in professional development
activities such as those covered in the present study. Similarly, it would be
useful to know how those activities are maintained, applied and supported within
a work context, and integrated with other learning in the psychological
therapies.
Limitations—The size of the present
sample was not as large as we would have preferred. However, it should be noted
that sampling busy mental health professionals’ with lengthy self-report
questionnaires is known to yield low response rates. There is also an absence of
information on the entire population of psychotherapy practitioners. It is
likely that the present sample included an over-representation of practitioners
who were interested in professional development or research (i.e. self-selection
bias).
Although an anonymous survey has the potential to reduce
social desirability in responses, the reliance on therapist self-report
introduces potential inaccuracies due to memory and judgment errors.
Nevertheless, psychiatrists and mental health nurses’ personal, subjective
experiences of development are both interesting and important. The age of the
present data are also acknowledged, and readers are advised to consider the
findings in the context of changes to the New Zealand healthcare context.
Competing interests: None known.
Author information: Nikolaos Kazantzis,
Senior Lecturer, School of Psychological Science, La Trobe University,
Melbourne, Australia; Sarah Calvert, Doctoral Student, School of Psychology,
Massey University, Auckland; David Orlinsky, Professor, Committee on Human
Development, University of Chicago, USA; Paul Merrick, Associate Professor,
School of Psychology, Massey University, Auckland; Sally Rooke, Senior Research
Officer, National Cannabis Prevention and Information Centre; Kevin Ronan,
Professor, School of Psychology & Sociology, Central Queensland University,
Rockhampton, Australia
Correspondence: Nikolaos Kazantzis, School
of Psychological Science, La Trobe University, Melbourne, Victoria 3086,
Australia. Email: N.Kazantzis@latrobe.edu.au
References:
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