Journal of the New Zealand Medical Association, 25-June-2010, Vol 123 No 1317
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.
Questionnaire 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.
Sample—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.
New 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
issue | Search journal |
Archived issues | Classifieds
| Hotline (free ads)
Subscribe | Contribute | Advertise | Contact Us | Copyright | Other Journals