Consumers’ Experiences of Comprehensive-Prepared Graduate Nurses and Their Nursing Care in Acute Mental Health Settings

Abstract

Pre-registration nursing education has long moved away from preparing nurses with mental health specialisation to nurses with comprehensive knowledge and skills. However, the consumers’ experiences of comprehensive-prepared nurses and their nursing care has not been widely explored. This paper reports on a study with consumers to explore their experiences with comprehensive-prepared graduate nurses and the nursing care that they provide in acute mental health settings. An exploratory qualitative study using semi-structured interviews was chosen as the research method. Purposeful sampling recruited 12 consumers and data saturation was achieved. Braun and Clarke’s method of thematic analysis was used to analyse the collected data and three themes emerged. The themes are: (i) You got what it takes to be a mental health nurse, (ii) Slow down and spend quality time with us, and (iii) Read in between the lines when we share our negative lived experiences. The findings are useful for identifying strategies to develop evidence-based nursing education for comprehensive-prepared graduate nurses to improve the consumers’ experiences of their nursing care.

Introduction

The concept of recovery is now embedded within all mental health policies and provisions at the national and international levels to support people with mental disorders (hereafter referred to as consumers) to achieve their personal recovery and have meaningful and purposeful lives (Llewellyn-Beardsley et al., 2019). This concept of recovery was born out of the consumer-survivor movement and highlighted that mental health recovery is about living a satisfying, contributing, and fulfilling life with or without a mental illness (Slade, 2013). As such, mental health services all around the world have restructured how care is being delivered and support consumers to achieve self-management of their mental illness (Gyamfi et al., 2020; Slade, 2013).

Over the last few decades, there has been an expansion of community-based mental health services in Australia to support consumers to live in their residence of choice to avoid becoming dependent and overreliant on inpatient mental health services (Commonwealth of Australia, 2017; Laitila et al., 2018; McSherry, 2020). Community-based ­mental health services are considered best practices for addressing human rights and equality issues, reducing stigma and discrimination, and promoting more person-centred and effective care for consumers (Laitila et al., 2018; McSherry, 2020). As such, consumers will only be admitted to the inpatient mental health units if they are experiencing an acute exacerbation of their mental health symptoms and may require health professionals to support them to get back on track in their recovery journey (Lim et al., 2017).

The shift in the paradigm of care delivery has resulted in health professionals rethinking their clinical practices to support consumers in achieving self-efficacy so that they can manage their mental health disorders effectively (Lim et al., 2019a). Today, health professionals are encouraged to use recovery-oriented mental health practices such as recovery-focused care, trauma-informed care, and strength-based care in all aspects of their care delivery (Beckett et al., 2017; Isobel & Edwards, 2017; Le Boutillier et al., 2015; Lim et al., 2021).

The use of recovery-oriented mental health practices highlights the importance of health professionals engaging consumers as equal partners and achieving co-production of their care and treatment. Co-production refers to health professionals and consumers collaborating as partners to plan person-centred care to support the individual’s recovery (Clark, 2015; Kidd et al., 2015; Roper et al., 2018). This approach to care delivery is a shift away from the traditional paradigm and understanding of mental health care, which typically treats consumers as being less capable of making decisions and looking after themselves (Hansson et al., 2011). It is also a shift away from the traditional care delivery processes, from ‘doing to’ to ‘working with’ consumers and travelling alongside them in their recovery journey (Lim et al., 2017; Slade, 2013). As such, health professionals are encouraged to use this approach of care delivery as it could potentially empower consumers to self-determine their own recovery goals, share clinical decisions made about them, and be actively involved in the process of their care and treatment (Laitila et al., 2018; Park et al., 2014; Slade et al., 2014; Wyder et al., 2017). This is important for consumers to experience self-growth and thereafter improve their sense of self-efficacy and confidence to self-manage their own mental disorder (Coffey et al., 2019; McKeown et al., 2016).

Background

Nurses play an important role in supporting the consumers’ recovery journey due to the amount of presence and time that they spend with individuals in clinical settings (Jeffery & Fuller, 2016; Perlman et al., 2018; Santangelo et al., 2018). With the level of therapeutic nurse-consumer alliances, nurses are more likely to get to know consumers at a personal level such as their strengths and weaknesses, and genuinely engage individuals in co-production when compared to other health professionals (O'Donohue et al., 2023). Besides that, nurses are also the most likely health professional to learn about the consumers’ lived experience of living with a mental health disorder and travel alongside them to promote healing, self-growth, and hope for the future (Lim et al., 2019b). All these highlighted the importance of nurses having specialised knowledge and skills to engage consumers in co-production in all aspects of their care delivery. However, there is currently a lack of mental health contents in the preparation of pre-registered nurses in favour of the comprehensive nursing curricula to prepare future nurses to use this approach of care delivery (Lakeman et al., 2023).

In light of the nursing workforce shortages in Australia, there has been an increase in the number of comprehensive-prepared graduate nurses working in acute mental health settings such as the inpatient units, psychiatric intensive care, and locked wards (Hooper et al., 2016). In acute mental health settings, nurses are frequently faced with the challenge of maintaining a safe and secure environment that is also conducive and therapeutic to support the recovery of consumers (Lau & Hutchinson, 2021). They are also faced with the challenge of supporting consumers to experience personal healing after experiencing a life setback during their short or brief admission to hospital, and to continue with their recovery journey post-discharge (Lim et al., 2019b). With the lack of preparations of comprehensive-prepared graduate nurses entering the mental health nursing workforce, the responsibility may now lie with the nursing education of mental health services to support their nurses to meet the challenges of working in acute mental health settings.

Purpose and aim of this study

This study explored the consumers’ experiences of nursing care to support their recovery in the inpatient mental health units. The aim of this study was to identify specialist components in nursing education for supporting comprehensive-prepared graduate nurses during their transition to mental health nursing. This study is part of a research project that examines the educational needs of comprehensive-prepared graduate nurses during their transition to mental health nursing at Fiona Stanley Fremantle Hospitals Group (FSFHG) in Western Australia. Ethical approval was obtained from the South Metropolitan Health Services Human Research Ethics Committee (RGS5769) and from the Curtin University Human Research Ethics Committee (HRE2023-0109) to conduct this study.

Methods

An exploratory qualitative study using semi-structured interviews was chosen as the research method to gain an understanding of consumers’ experiences of nursing care and their perspectives of how nurses can support their recovery. Purposeful sampling was used and recruited consumers who (i) were aged 18 and above, (ii) have been admitted to the inpatient units to support their recovery, and (iii) were able to provide informed consent. Consumers who volunteered were assessed by the treating team as having the capacity to engage in the semi-structured interview prior to their participation. Verbal and written consents were sought and collected prior to the interview with all participants. Data collection was guided by saturation which was characterised by the absence of new information in subsequent interview guided the data collection process (Kyngäs, 2020).

The collected data were analysed by the fourth author using Braun and Clarke (2012)’s method of thematic analysis to systematically organise and identify the collected data into patterns of meaning across the data set. The coding and construction of themes were checked by the first author who is an experienced qualitative method researcher, and this ensured trustworthiness of the analysis. Subsequently, the identified themes were subjected to a peer review process by the research team to detect any bias. Any discrepancies that arose during the peer review process were discussed with all members of the research team and a consensus was achieved. Lastly, similar themes were grouped together to make sense of the collective ideas and this process facilitated the write up the findings.

Findings

Data collections were performed between the period of August to October 2023. Consumers who were admitted to the inpatient mental health units at Fiona Stanley Hospital and Fremantle Hospital were informed about the study through their treating team. Consumers who were interested in participating were provided with the information sheet about the study and were interviewed individually by either author one, two, or three face-to-face in the private meeting room of the unit that they were admitted. In the end, 12 consumers participated in this study, and they comprised of four females, seven males, and one preferred not to say. Almost (n = 11) all the participants had more than 10 years of being diagnosed with a mental disorder. The demographic information of participants is presented in Table 1. The semi-structured interviews lasted for approximately 20–45 min and were audio-recorded.

Table 1. Demographic information of participants.

Total number of participants	N = 12
Age (Years):
18–19	0
20–29	3
30–39	4
40–49	1
50 and above	4
Gender:
Male	7
Female	4
Prefer not to say	1
Other, please specify:	0
Years diagnosed with a mental disorder:
0–1	1
2–3	0
4–5	0
6–7	0
8–9	0
More than 10 years	11
Number of times admitted to the inpatient mental health unit:
1 time	2
2 times	1
3 times	3
4 times	1
More than 5 times	5
Classifications of primary diagnosis:
Psychosis and schizophrenia	4
Mood disorders	7
Substance use disorders	1

Participants in this study willingly and openly shared their experiences of nursing care during their stay in the inpatient mental health units. This enabled the researchers to obtain an in-depth understanding of the positive and negative aspects of nursing care to identify specific components of nursing education for comprehensive-prepared graduate nurses during their transition to mental health nursing. The analysis of the collected data emerged into three themes: (i) You got what it takes to be a mental health nurse, (ii) Slow down and spend quality time with us, and (iii) Read in between the lines when we share our negative lived experiences.

Theme 1: You got what it takes to be a mental health nurse

Most of the participants in this study shared that they were satisfied with the level of knowledge and skills that nurses have to support their recovery in the inpatient mental health units. Many of the participants shared positively about the nursing care that they had experienced “The nurses here are doing a good job, I think they are professional and every nurse helped me to recover” (P9); “At home I was in a very low mood so I didn’t feel safe at home. I came here as I feel safer” (P5), as “the nurses know what they are doing and are reasonably well experienced and seem quite knowledgeable to work with mental health patients” (P10). “There has been a couple of times where I had a few moments where I was upset and cannot really talk to anyone but the nurses approached me and talk me through the kind of coping strategies” (P12). One of the participants provided details on how nurses were able to supported her mental health recovery during her stay in the hospital:

The first few weeks I was in here, I was sort of barely functioning… every nurse that I met have been really good, they are really nice during my stay, seems to know what they are doing to help me to get on my feet and I don’t have any complaint… They are interested in how you are getting on and actually take time to sit down with you and have a chat and sometimes provide suggestions which helped me get through my problems. (P10)

Although there was a consensus among these participants about the level of nurses’ knowledge and skills, they commented that there were some comprehensive-prepared graduate nurses tend to be more focused on “doing the regular checks, offer assistance with medications” (P6). Participants also shared their beliefs that comprehensive-prepared graduate nurses were more likely to stay within their comfort zone of performing general nursing care instead of using more specialised knowledge and skills as “they are fresh out of uni” (P10); “have just done their general training and may not understand what it is like when caring for mental health patients” (P10) “they don’t have the experience to deal with the complexities of what the patients have been through… [but] what they are doing is not wrong if that is what they know, it is alright” (P8); “I think they may need to have more hands on experiences before they get put into a mental health facility” (P1).

Theme 2: Slow down and spend quality time with us

Majority of the participants shared that they were pleased with the quality of nursing care that they had experienced during their stay in the hospital. “All of the nurses will go out of their way to make your day… it’s not like you are just a number” (P9). As one of the participants stated: Another participant shared her lived experience of how nurses supported her:

On the recovery journey, I think it is easy to beat yourself up all the time. It’s very easy to be negative so it’s good to have the positive reinforcement. A lot of the nurses will take the time to come and talk to you and listen to your problem. The other day I was having a bit of a bad moment and the nurse came up to me and reassured me that I’m doing the right thing and I should be proud of myself and yeah, so it’s good. (P12)

When asked about their experiences with comprehensive-prepared graduate nurses, many of the participants shared positively that “they are friendly” (P12); “their care is genuine” (P11); “they are interested, compassionate, euthusiatic” (P8); “[comprehensively-prepared] graduate nurses are doing a good job, they are very serious, on the job, fun and friendly, yeah there are good laugh with them” (P7). Nevertheless, while the participants acknowledged that comprehensive-prepared graduate nurses were providing the level of care needed to support their recovery, they felt that some nurses tend to “give out the vibes that they are brushing you off, they don’t give you enough time and you know that when they do not sit down and listen to you” (P11); “the care is good but they are genuinely busy… so sometimes they may appear like they don’t have enough patience, don’t want to deal with it, don’t want to talk to us” (P8); “nurses do help out a lot, they do a lot to help us but sometimes their approaches can be too rushed” (P3). As such, one of the participants highlighted the importance of nurses spending more time with consumers in the inpatient mental health units so that “they can get to know me better and can take a walk in my shoes, display more empathy… allowing me more time to cry my pain away” (P4).

Additionally, a few of the participants shared that the amount of time that nurses spent with consumers can directly impact on their experiences with the quality of nursing care. While nurses have a continuous presence in the inpatient mental health units “I noticed that nurses mainly stay in the office and the patients are kind of left to their own devices… there’s not much to fill our time so I’m not sure how that is therapeutic… waiting for us to knock on the door” (P1); “you kind of are alone… sometimes you feel a bit awkward to kind of having to ask nurses to do something for you” (P12). One of the participants commented that “nurses can maybe spend 5 min to chat, you know sort of checking in and ask how are you going? and how are you getting on?” (P10).

Theme 3: Read in between the lines when we share our negative lived experiences

The experiences shared by a number of participants highlighted the importance of nurses to look for the meaning behind the consumers’ negative lived experiences of being in acute mental health settings. Some of the participants expressed that consumers tend to approach nurses, due to their continuous presence in the unit, to seek validations for their negative feelings and discomfort. As such, nurses may need to use more supportive ways of responding to avoid interpersonal conflicts with consumers. “Nurses are very restrictive, you can’t ask to see the social workers and doctors, you cannot make an appointment, you have to wait for them” (P1). “Nurses have too many rules, like even for the dining room, you cannot even get a drink of juice without asking them… like a prison” (P1); “It is excessive that nurses do not allow us to smoke here. We have to smoke when we are stressed. Ideally, we will have dealt with the stress ourselves with a couple of beers and cigarettes” (P9). “Table tennis means a lot to people in here, we told the nurses that the table tennis balls fall through a gap but no one seems to fix the problem” (P5).

Many of the participants felt that comprehensive-prepared graduate nurses were more likely the group of nurses to provide generic responses as “they have to follow the textbooks [strict adherence to policy]… they need to follow instructions from the senior nurses [chain of command]… you know that you are asking [comprehensive-prepared] graduate nurses if you are asking for something that they don’t know [fear of making mistakes]” (P1); “they are pretty much plug and play after their studies” (P7); “they lack in a bit of reasoning skills as they have a structured response” (P12); “they were meant to do the right thing… do everything the same way to what they have learnt” (P2); “just a very blanket approach” (P11). As such, “the way that they communicate with us are very clinical” (P8).

Discussion

This paper reported on a study with consumers in acute mental health settings and explored their experiences of the nursing care and of comprehensive-prepared graduate nurses. A search of literature highlighted a paucity of research conducted with consumers to explore their experiences with comprehensive-prepared graduate nurses and this study therefore contributed valuable understanding of the knowledge gap. Although consumers were frequently involved to co-develop curricula at nursing school levels (Happell et al., 2015, 2019, 2020), our findings of this study highlighted that consumer may also be involved to co-develop specialist components in nursing education for comprehensive-prepared graduate nurses transitioning to mental health nursing. Crowe and Porter (2019) affirmed that the implementation of evidence into routine mental health nursing practice needs to take a consumer-centred design approach.

Firstly, the theme ‘You got what it takes to be a mental health nurse’ highlighted the consumers’ perspectives that comprehensive-prepared graduate nurses need to be supported to develop confidence with their knowledge and skills to practice clinically during the transition process (Kim & Shin, 2020). This is consistent with the findings of Hooper et al. (2016) that comprehensive-prepared graduate nurses reported to have low levels of confidence as beginner clinicians in the field of mental health nursing. Yet, it was encouraging to see that majority of the participants in this study did not feel negatively about the overall quality of nursing care that they had experienced. This is an important findings as comprehensive-prepared graduate nurses were frequently reported in the literature as lacking in their pre-registration nursing education to work in acute mental health settings (Lakeman et al., 2023).

Secondly, the theme ‘Slow down and spend quality time with us’ revealed the consumers’ perspectives that comprehensive-prepared graduate nurses may benefit from having nursing education that supports them to develop specialist communication skills such as counselling or psychotherapy during the transition process. There was a sense that the participants in this study yearned to have more personal interactions with nurses in the clinical environment and travel alongside them in their recovery journey. Our findings are consistent with (Hopkins et al., 2009) that consumers highly valued the attention that nurses gave to their concerns and worries, their dissatisfaction with care and treatment, and their thoughts and emotions rather than just them getting the pills. Yet, the pre-registration education that comprehensive-prepared graduate nurses received had not prepared them to do one-to-one work with individuals with mental disorders (Hopkins et al., 2009). Moreover, supporting comprehensive-prepared graduate nurses to develop specialist communication skills can also improve their self-confidence and self-efficacy to engage consumers in co-production are likely to empower them to experience self-growth, healing, and confidence to self-manage their own mental disorder (Lim et al., 2017; 2019b).

Lastly, the theme “Read in between the lines when we share our negative lived experiences” stressed the consumers’ perspectives that comprehensive-prepared graduate nurses may benefit from having nursing education that can support them to assess, acknowledge, and support consumers to cope with negative lived experiences associated with their stay in the hospital. Previous research had long established that acute mental health settings were often lacking in the provision or availability of activities, contributing to the dissatisfactions, frustrations, and boredom experienced by consumers (Foye et al., 2020). The consumers’ negative lived experiences when admitted to the hospital may potentially remind them of their past negative experiences as such neglect, social discrimination, or trauma, thus impacting on their abilities to cope with the admission stressors (Lim et al., 2019b). As such, consumers are likely to seek support from nurses to alleviate their negative thoughts and emotions. This highlighted the importance of nurses having the confidence to spend time with consumers and to explore the consumers’ past and present lived experiences to gain an understanding of their presenting complaints (Lim et al., 2019b). The improved understanding of the meaning behind the consumers’ complaints will enable nurses to plan and implement more trauma-informed and person-centred care effective for helping the consumers to feel that they are acknowledged and validated (Lim et al., 2019b).

Strengths and limitations of the findings

Firstly, this study was conducted in acute mental health settings based in Western Australia and may therefore limit the findings to settings where the consumers have experienced the same level of nursing care. Nevertheless, the identified themes appeared to be similar with that of consumers in acute mental health settings reported in previous research. As such, we are confident that the findings of this study would be useful for informing nursing education aimed at supporting comprehensive-prepared graduate nurses transitioning to mental health nursing. Secondly, we found it difficult to recruit consumers in acute mental health settings to participate in this study. This may be due to a deficit in the consumers’ knowledge of the nursing education currently available for comprehensive-prepared graduate nurses transitioning to acute mental health setting. As such, considerations may be placed on setting up a consumer advisory group and be involved to work with the nursing education and co-develop evidence-based nursing education for comprehensive-prepared graduate nurses, and be actively involved in future research in this area of importance.

Recommendations from findings

Australia has long moved away from specialisation education in favour of comprehensive nursing education as the requirement for registering as a nurse with the Australia Health Practitioner Regulation Authority. As such, there has been an increase in comprehensive-prepared graduate nurses working in acute mental health settings immediately post-education. This phenomenon was mainly driven by the ongoing nursing workforce shortages and the dilution of skilled mental health nurses (Roche & Duffield, 2007). Therefore, the responsibility may now lie with the mental health services to prepare their nursing workforce with more specialised knowledge and skills to meet the needs and demands of their consumers. The findings of this study are informed by the consumers’ perspectives and is therefore useful for identifying nursing education for comprehensive-prepared graduate nurses to improve their experiences of nursing care.

The findings of this study highlighted that consumers perceived that comprehensive-prepared graduate nurses may need to develop their confidence to more spend time with consumers. If comprehensive-prepared graduate nurses have confidence to engage consumers in micro-conversations, they are more likely to assess and validate the person’s negative lived experiences of being admitted to hospital (Lim, Wynaden, et al., 2023; Sreeram et al., 2023). As such, nursing education may need to support graduate nurses to pragmatically practice and use therapeutic communication skills such as active listening, conflict resolution, de-escalation and strength-based approaches to improve the consumers’ experiences of comprehensive-prepared graduate nurses and their nursing care in acute mental health settings.

Lastly, the findings of this study highlighted that a partnership between the academia and the healthcare setting may be established to cross pollinate the experiences of comprehensive-prepared graduate nurses including nursing students with staff and faculty sharing the teaching in vivo. Having this knoweldge of comprehensive-prepared graduate nurses including nursing students may be useful to support them to plan more industrial meaningful and relevant teaching and learning activities to prepare future nurses to work in acute mental health settings and to meet the needs of consumers (Lim, Kalembo, et al., 2023).

Conclusion

This study is one of the few studies that explored consumers’ experiences of comprehensive-prepared graduate nurses and their nursing care in acute mental health settings and contributed valueable knowledge to this area of importance. While the pre-registration nursing education has been criticised as lacking in mental health content to prepare comprehensive-prepared graduate nurses to work in acute mental health settings, there was no significant difference found in the consumers’ experiences with nursing care between experienced nurses and comprehensive-prepared graduate nurses. Nevertheless, nursing education may need to support comprehensive-prepared graduate nurses to develop more confidence and communication skills to engage consumers in micro-conversations. The findings from this study will be merged with the findings from the other studies in the project that examines the educational needs of comprehensive-prepared graduate nurses to develop evidence-based nursing education.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.