International Journal of Nursing Science

p-ISSN: 2167-7441    e-ISSN: 2167-745X

2012;  2(2): 8-13

doi: 10.5923/j.nursing.20120202.01

Organisational Considerations for Supporting Mental Health Nurses (MHN) in Practice

Louise Ward

School of Nursing & Midwifery, Griffith University, Gold Coast, 4214, Australia

Correspondence to: Louise  Ward, School of Nursing & Midwifery, Griffith University, Gold Coast, 4214, Australia.


Copyright © 2012 Scientific & Academic Publishing. All Rights Reserved.


It is estimated that by 2020 15% of the world’s population will be affected by mental illness requiring an inpatient hospital admission. Registered nurses are the largest health care discipline working within inpatient mental health care settings however there is a growing international shortage of registered nurses choosing to work within this specialty. Research reports that issues such as workplace violence, stress and limited career structure are the primary reasons cited by registered nurses for not choosing to work in mental health care. This paper reports on the findings of a study that explored the workplace practices and experiences of registered nurses currently working within an acute inpatient facility. Thirteen mental health nurses participated. Individual interviews and focus groups were used to collect the data. A major theme to emerge from the study was Therapeutic relationships. The theme outlined the expertise required to effectively care for clients experiencing mental illness within this environment and the positive rewards experienced by nurses within the therapeutic relationship. A sense of strength, professional pride and dedication emerged from the research data and a distinctive new vision of mental health nursing was defined.

Keywords: Mental Health Nursing Skills, Qualitative Research, Recruitment and Retention

1. Introduction

An ever-increasing number of people are suffering mental illness worldwide estimating that by 2020 15% of the world’s population will be affected[1,22,42]. Mental health nursing (MHN) is the largest professional group caring for the mentally ill however there is an international shortage of nurses choosing to work in this specialty area of care[16,17]. There is ongoing pressure for acute inpatient mental health care facilities to maintain a skilled workforce regardless of this current state of affairs[32]. Research has clearly identifies why nurses ‘choose not’ to work in mental health care[15] however few studies have explored why nurses ‘choose to’ practice within this specialty area of care.
Mental health nursing research has identified workplace stress, occupational Health and Safety, violence and unsupported career development as the contributing factors as to why nurses are ‘not choosing’ this specialty[1,4,9,12,15,22].
Current literature confirms that retaining existing nurses within these environments is increasingly challenging[1,4,9,10,12,22,34]. Consequently, there is a greater reliance on casual in-experienced and unskilled generalist registered nurses working in acute inpatient mental health care facilities casual in-experienced and unskilled generalistregistered nurses working in acute inpatient mental health care facilities due to poor recruitment strategies[4,26]
Research reports a lack of government funding to efficiently manage the current situation and inadequate funding worldwide to better support an under resourced nursing workforce[23,27,42]. Poor recruitment and low retention of registered nurses in mental health care significantly influences patient outcome and recovery. An unskilled workforce has significant implications for mental health patients[32]. Literature confirms an international shortage of mental health nurses complicated by an aging workforce with complex skill mix[16,17].
Understanding why registered nurses choose to work in this specialty area of care and identifying what it is they do will assist organizations recruit and prepare registered nurses for the profession. Listening to the workplace satisfaction of registered nurses working in mental health care may provide us with greater insight into the cultural context of their work environment and provide an opportunity to promote inpatient mental health facilities as a beneficial place to work.[2,10,16,31,35].
Mental health nurses have been defined as ‘generally the only professional group that consumers spend enough time with (particularly in inpatient units) to develop the trust and rapport necessary for therapeutic relationships’ ([8] p.116). A healthy mental health workforce is vital to ensure patients receive optimum care to support their recovery[18,19,28]. Reference[14] conducted a study of 122 nurses and found that mental health nursing was the least-preferred nursing specialty and the specialty considered to require the least amount of skills and knowledge. These findings can potentially present mental health nursing in a negative way limiting nursing recruitment. It is imperative to make visible mental health nursing skills and demonstrate the expertise required to assist patient recovery.
Within Australia, mental health nursing is supported by a set of standards guiding effective practice and appropriate care[2]. These standards support cultural diversity and collaborative partnership. There is a focus on respect for individual choice, enhancing resilience ensuring holistic patient care. There is a commitment to reduce stigma and enhance social inclusion[2]. The standards expect a demonstration of advanced specialized knowledge in mental health care and are an extension of the standards of professional practice expected from registered generalist nurses[6].
As references[3,10,12,23,34] support mental health nursing does not need to be secondary to the professions of psychology or psychiatry as it has its own knowledge and provides its own independent professional service. In order to avoid the past predictions made by[8,11] it is important to acknowledge that ‘When nurses fail to articulate precisely what they do for patients they allow themselves to become a background presence, almost invisible and easily marginalized’. Research in the United Kingdom associates the decline in those choosing to study mental health nursing with a lack of clear role definition and perceived value of the profession (Wells, 1999).
A study undertaken by reference[7] explored the experience of rural generalist nurses working with mental health clients and found that the nurses’ could clearly identify and articulate the need to have specific ‘knowledge, skills and networks in order to provide effective mental health care’(p. 205). The study highlighted the need for specific skills and knowledge in order to provide effective mental health care. The nurses from the study reported that they could not identify, assess and treat patients with mental illness; and a significant proportion of nurse respondents felt that they could not appropriately advise patients about mental health problems. Therefore it is evident that mental health nursing has specific skills that need to be valued[11,37,38]. Research also suggests however that these skills are difficult to identify because they are not defined in a linear or sequential manner[3,13,29,31,39].
A study undertaken by reference[1] expresses the ongoing problems associated with staff turnover in mental health and how this is reflected in ‘staff morale, productivity, organizational effectiveness and implementation of innovation’ (p.289). The study finds that both work culture and climate impact upon work attitude and subsequently staff turnover.
Research that explores the workplace practice of mental health nurses can assist organisations to better understand the complex roles and responsibilities of these clinicians making visible their skills and specialist knowledge.

2. Method

Following ethical approval an information sheet was placed into the staff ‘communication book’ located in the nurses’ station of an acute inpatient facility in an Australian hospital. The participants that responded and wanted to take part in the study were then provided further information and a consent form to complete. Thirteen registered nurses participated in the study. All participants were working full-time and had worked in acute mental health facilities for over ten years. They had differing levels of experience and education. The participants were from diverse cultural backgrounds, aged between 30-58 years.
To gain a greater understanding of the lived experience of mental health registered nurses working within an acute inpatient facility two focus groups and individual interviews were conducted. Using focus groups within the study enabled participants to discuss their workplace collectively and talk openly about the health care organization and their roles and responsibilities[7].
The first focus group was held prior to the individual interviews and one was held after the individual interviews. The researcher was the scribe and made detailed notes on large sheets of paper highlighting the discussion linking themes and conmen concerns. The focus groups were not recorded. The second focus group was held after the individual interviews. In the second focus group some of the participants raised concerns they had identified in their individual interviews and the group engaged in discussion. This discussion offered an opportunity for the participants to gain further clarification of ideas and contribute further to the conversation.
As reference[20] states:
Focus group interviews can offer a valuable lens into the social world of individuals as a part of a group dynamic but can also potentiate risk and harm to some participants having pre-existing relationships with others in their workplace. As researchers we need to clarify our relational stance and ethical obligations (p.7).
The focus group and individual interviews were based on several open-ended questions to guide discussion. Participants were able to contribute and pose questions to the group creating opportunities for enquiry and debate. This approach supported the individual to reflect and share their experiences. They were able to engage in questioning their current practice and identifying their specific skills. The focus groups were a way for participants to reflect on their achievements in patient care. The focus group ran for 2 hours and the individual interviews ran for approximately 1.5 hours.
Through the use of two focus groups and individual interviews the researcher was able to ‘member check’. Member checking enabled a process for continuous participant confirmation of the ‘findings’ through the course of the study[7,20].

3. Objectives

The objectives of the research were to investigate the experiences and practices of mental health nurses working within an inpatient mental health facility. The study aimed to better understand the skills and knowledge of mental health nurses working within this environment. This qualitative study used focus groups and individual interviews.
The interviews were audio taped, transcribed verbatim. Each transcript was then returned to each participant for checking and critique. This technique, known as ‘member checking’, was used several times within the research process to ensure that the researcher’s analysis was correct and accurate. The participants were involved in the final editing and clarification of the interview/focus group data.
The focus group data and the transcribed recordings of individual interviews were analysed by the researcher using thematic analysis. The process of thematic analysis involved the ‘sorting out’ of information and identifying of similarities and differences in the women participants’ stories. Thematic analysis involved viewing the data, finding patterns, making comparisons, interpreting, sorting, sifting and naming categories. The process of data analysis involved listening to the audiotapes and reading and re-reading the transcripts, coding specific words and highlighting recurrent themes.
Reference[20] confirms that text should be rigorously explored with others to elicit the embedded connotations and implications. Therefore the second focus group became a space in which to clarify assumptions and confirm the lived experiences and practices of the women registered nurses. Interestingly, in this second focus group some participants reported opinions, which were different from those they had expressed in their individual interviews. They had thought further about issues and reframed their ideas or found connections and links to strengthen and reinforce their views. An ethical consideration is that all participants had the opportunity to reflect, revise and alter their words and comments throughout the research process. From the first focus group to the individual interviews, to the second focus group the participants had an opportunity to alter their contribution to the study.

4. Results

A major theme to emerge from within the study was The Therapeutic relationship. The theme highlighted the participant’s workplace satisfaction in helping others and working together as a team. The therapeutic relationship was considered paramount to patient recovery and seen to be built on a number of specific mental health nursing skills. The focus group discussions and the individual interviews revealed comments about education, learning and continued professional development as ‘moving forward’, ‘facilitating change’, keeping skilled’, ‘staying healthy’, ‘being a good nurse’ and ‘providing a high standard of care’. Maintaining skills and learning new information was considered a positive stress management strategy supporting a healthy workplace. New knowledge was seen to be critical to the therapeutic relationship.
The analysis of the interview transcripts and focus group discussions revealed nine specific mental health nursing skills considered essential in establishing an effective therapeutic relationship and critical for providing effective patient care. The skills were identified by each participant and collectively acknowledged in both focus groups. The skills were; nursing knowledge of mental illness, active listening, observation, empathy, reflective practice, patient assessment, problem solving ability, effective use of humour assertiveness.
The nurse participants considered these skills as a framework for their specialty. The participants expressed feelings of professional pride and dedication for mental health nursing and their ability to provide effective patient care. The registered nurse participants were also very clear that these identified skills and the ability to form a therapeutic relationship optimized patient recovery.
Skill 1 Nursing knowledge of mental illness
As one participant stated:
As a nurse we have always known that the patients needs come first but in mental health sometimes their needs aren’t always appropriate. However a patient is still a patient. You need to have a very sound knowledge of mental illness to read what’s going on and be able to work with the patient not against them.
Skill 2 Active listening
A participant identified her ability to care was intrinsically linked to her ability to listen. She said;
I think I am fair to patients and I think I listen to them. Sometimes nothing they say makes sense because of their madness but I am still there for them. Violence is a part of the culture. I hate anger and abuse. I worked out quickly that it wasn’t personal … but you can still feel down after a shift … listening to a patient’s distress and anger about being locked up. Listening is vital to what we do.
Listening, sitting quietly with patients and ‘being in the moment’ were all considered as skills paramount to the profession. The participants spoke about physical contact and the power of therapeutic touch, acknowledging personal space and being aware of facial expression and language.
Ruby conferred saying;
You have to limit set sometimes to fulfill your duty of care. I try to explain things well to patients and have them understand their treatment plan.
Skill 3 Empathy
The nurses demonstrated empathy for their patients and articulated their role as patient advocates.
You know they come in an acute state and they are virtually left in our care and it can be quite frightening for them. So we are also there for[the patients] as advocates. Having empathy is a critical mental health nursing skill in my mind. You have to imagine walking in their shoes to really understand what they might be feeling.
Skill 4 Reflective practice
One participant stated
I need to go home knowing that I’ve done my job to the best of my abilities given the environment ... the patients are entitled to decent health care. They’re some body’s child, somebody’s partner. I have empathy for them and their families. You have to imagine what it would be like to suffer a mental illness to be able to care.
Skill 5 Observation
A participant said:
I have faith that I can help people suffering mental illness and that despite the odds I do make a difference.
The nurse participants spoke about their role as guardians and observers. They spoke about their responsibility to ‘watch’ patients and how at times this process sat them outside the therapeutic relationship. This was most concerning to the participants who clearly articulated that they saw their role as vital to patient treatment and recovery.
It is what we do every day that is important. Being there for our patients, reassuring them, setting boundaries and making sure they eat. This is what we do.
Skill 6 Patient assessment
There were many comments made in the first focus group in relation to the participants’ role as guardians, observers and custodians. Observation was seen as life saving at times. Critical, continuous assessment was valued as vital to ensure the ongoing safety of the patient. The participant expanded on mental health assessment skills and identified the depth of care provided. She said;
We ask the most intrusive questions and we step right inside the boundaries … patients tell nurses all sorts of things. Having really good assessment skills makes it easier to work with a person and to predict a way forward in their care. I assess constantly and I rely on my knowledge. This has been built up over a life time.
Olive spoke about caring and assessment of her patients:
It makes you feel good to see people surviving mental illness. I have experienced awful times when patients have been raped and sexually assaulted and they disclose this to you for the first time. It is incredible to be there for someone and nothing is scripted. You have to think on your feet all of the time. What might comfort or calm someone may silence another.
Skill 7 Problem solving ability
The participants made comment that they brought their own personal style into their practice. Their ability to solve problems, educate and empower clients. One participant stated that;
Being creative and keeping a good sense of humor are important. We should be grateful every day that we are well and happy. As a mental health nurse I can show others I care ... give them a smile or simply tuck them up in bed after they have been manic and awake for days. It is about helping people find peace.
Skill 8 Humour
A participant said;
You have to maintain a sense of humor to function well. You have to communicate effectively with patients. We have a lot of laughter between staff but we do have a very warped sense of humor I think. You have to see the funny side of things or you would just get upset. My practice is built around the way I am with people. Humor is a skill in nursing that is unrated. In mental health when things can be distressing you need to find a way to laugh with your patient, make things lighter than they might be.
Being creative was also considered an essential skill.
Mental health nursing allows me to be more flexible in my approach to nursing. I am able to be more creative with patients that don’t fit into the box. I can create my caring in line with what the patient needs. I can include other disciplines and I can experiment.
Skill 9 Assertiveness
A participant confirmed that being assertive was a necessary skill in mental health care. Assertion was seen as being able to challenge a patient in a therapeutic context and achieve positive outcome. Ruby stated that it was about;
Accepting things and then discouraging behaviors. Accepting a patient who cuts but then discouraging it to continue.
All 13 participants identified the knowledge of mental illness, patient assessment, observation, problem solving ability, active listening, assertiveness, empathy, reflective practice and effective use of humour as influential to effective patient care and paramount to their own professional survival within the profession.

5. Discussion

The number of people suffering mental illness worldwide continues to rise whereas the number of registered nurses choosing to work in mental health care continues to decline[1,3,4,10,14,17,22,24,36,40,41]. This is subsequently causing further strain on nursing recruitment and retention.[5]. This qualitative study has provided an opportunity for registered nurses working in mental health care to share their thoughts and contribute further to our understanding of the experiences and practices of nurses working within this specialty area. This greater level of understanding may assist health care organisations to support registered nurses further in practice. The theme to emerge was The therapeutic relationship. This theme illustrates the nurse participants’ commitment to the profession and their belief that mental health nursing requires specific skill. These skills are essential in the development of therapeutic relationships and critical to better support patient recovery. The skills identified were nursing knowledge of mental illness, patient assessment, observation, problem- solving ability, active listening, assertiveness, empathy, reflective practice and the effective use of humour. Identifying these skills provides organisations with an opportunity to promote mental health nursing as a valuable career path requiring expertise. The participants clearly identify workplace satisfaction through their relationship with the patients. These findings may assist in improving recruitment and retention strategies within the profession.
Mental health nurses from all continents, cultures and care settings continue to describe how their work is undervalued and trivialized[13,33,49]. Mental health is stigmatized within society and it appears that mental health nursing has been stigmatized also. With less nurses choosing mental health as a specialty the mental health nursing profession is at risk. At risk of becoming invisible to the other professions and increasingly undervalued in relation to patient care[5]. Recognizing skills and acknowledging the importance of what registered nursing are currently ‘saying’ is vital to revision mental health nursing for generations to come[6].

6. Conclusions

The research findings are valuable to the mental health profession and extremely relevant to clinical practice as the nurse participants clearly articulated the skills necessary to mental health nursing and necessary to provide care for the mentally ill. The participants were also able to identify positive workplace experiences based on the therapeutic relationships they had with the patients. The limitation of the study was that the registered nurses were all employed within the inpatient facility. It would be beneficial to study the experiences of mental health nurses working in the community to see whether they identified similar skills as highlighted in this study. The skills acknowledged were, knowledge of mental illness, assessment, observation, problem solving skills, active listening, assertiveness, empathy and reflective practice and the effective use of humour. These key skills were considered paramount in not only maintaining professional well-being and job satisfaction but in improving patient outcome and recovery. The mental health nurse participants within the study collectively defined the skills they believed necessary to work effectively with mental health patients.
The research provides organisations with insights into the mental health nursing workforce. Organisations could improve recruitment and retention strategies by highlighting the expertise and skill required to work in mental health care. Through the promotion of mental health nursing and the therapeutic relationship opportunity exists to reduce stigma for the mental health patient and for the mental health nurse. Organisations can align future education and training to mental health nursing skills and practice. Mental health nurses are the largest professional group caring for the mentally ill therefore it is imperative we value their wealth of experience and celebrate their positive workplace experiences.


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