Zombies Wanted! Descriptions of Nurses in Psychiatric-Mental Health Care in Swedish Recruitment Advertisements

Abstract

Knowledge of how nurses are described in recruitment advertisements can aid assessment of the current status of professional psychiatric-mental health nursing and inform services dealing with the challenges of nurse recruitment. This study used content analysis to explore descriptions of nurses in psychiatric-mental health care in a purposive sample of 75 recruitment advertisements collected in Sweden in February 2019. The descriptions were interpreted as focussing on their being willing and able to function in discouraging practice environments, matching the ideal of psychiatric-mental health nursing poorly. The study suggested a need to align the ideals and realities of the nursing profession.

Introduction

Nursing in psychiatric-mental health care has been described as a fading specialty (Lakeman & Molloy, 2018), with a lack of clarity in responsibilities and structure (e.g. Bladon, 2018; Lakeman & Molloy, 2018; Salberg et al., 2019; Terry, 2020). Nurses experience a conflict between the ideals and the realities of psychiatric-mental health nursing (Gabrielsson et al., 2016; Graneheim et al., 2014). Psychiatric-mental health nursing suffers negative consequences of the stigma associated with mental illness (Harrison et al., 2017; Sercu et al., 2015). It has been described by undergraduate nursing students as the least attractive career option, possibly due to low quality clinical placements (Happell et al., 2015; Happell & Gaskin, 2013). Meanwhile, health care faces a critical shortage of nurses specialised in psychiatric-mental health nursing (e.g., American Psychiatric Nurses Association, 2019; British Medical Association, 2019; National Board of Health & Welfare, 2020). A positive image of nursing as a professionally competent and credible field is essential for the recruitment of nurses (McClure et al., 1983). To attract nurses, it is necessary to break down the stigma and raise the profile of psychiatric-mental health nursing (Harrison et al., 2017). Recruitment advertisements might serve as a reflection of contemporary perceptions of the roles and responsibilities of nurses and nursing, and might also reveal conflicting perceptions and expectations of nurses in psychiatric-mental health care.

Background

The theoretical framework of this study is the conceptualisation of nurses as professionals. Definitions of the profession concept have changed over time, and the usefulness of distinct definitions has been questioned (Evetts, 2006). A common core criterion for a ‘profession’ is a close link to higher education and formalised academic training, which guarantees a possibility to practice the profession (Brante, 2013). Classic professions include, for example, physicians and lawyers. In recent decades, some groups traditionally considered to be semi-professions, such as nurses, have claimed to meet the criteria of a profession (Brante, 2013).

In reviewing previous research, we found that public images of psychiatric-mental health nursing did not reflect the profession’s self-image. In Sweden, as in other countries, the overall development of nursing has been towards autonomous practice rather than supplementing medical practice, positioning the registered nurse as ‘the nursing expert’ (Rehn, 2008). Gabrielsson et al. (2020) described psychiatric-mental health nursing as a caring, reflective, and therapeutic practice that promotes recovery and health. Nursing in psychiatric-mental health settings is not aimed only towards specific mental health issues; in a holistic nursing approach, nursing that focusses on strengthening somatic health is crucial to achievement of overall recovery and health (Gabrielsson et al., 2020). Nurses are expected to make crucial contributions in defending humanistic values (Gabrielsson et al., 2016) and developing and upholding person-centred (Barker & Buchanan-Barker, 2011) and safe (Bowers, 2014) care environments. In contrast, research into images of psychiatric-mental health nurses commonly reveal an unflattering view of the profession (Bladon, 2017; De Carlo, 2007; Farrow & O'Brien, 2005; Lakeman & Hurley, 2021). Farrow and O'Brien (2005) examined print media reporting on strike actions undertaken by psychiatric-mental health nurses and identified deprecatory images of nurses, such as them being lazy, inflexible and greedy. De Carlo (2007) examined how films portrayed psychiatric-mental health nursing and found its role to be one of ‘custodial companionship’ in an ‘aberrant, secret, and dangerous world’. In exploring the historical context of psychiatric-mental health nursing, Molloy et al. (2016) found that 1940s and 1950s news media described problems with recruiting, poor practices, and a relatively low status compared with other nursing specialities. Building on examples from narrative literature, Bladon (2017) argued that fictional depictions conveyed an image of psychiatric-mental health nursing as punitive and controlling, and psychiatric-mental health nurses as off-putting and subservient. Lakeman and Hurley (2021) found that nursing research typically described nurses and nursing in a way that reinforced a perception of psychiatric-mental health nurses as lacking in skills and competencies.

Few previous studies have used nurse recruitment advertisements as data (Freeman & Carpenter, 1983; Lacey et al., 2011; Shanks-Meile et al., 1989; Winter & Teare, 2002); none of them has focussed on the description of psychiatric-mental health nurses. Freeman and Carpenter (1983) analysed nurse recruitment advertisements in newspapers and identified a balance of economic and work environment messages. They also examined responses to mock advertisements and found that intent to seek additional information about a position was related to economic information in an advertisement (Freeman & Carpenter, 1983). Shanks-Meile et al. (1989) identified changes in the demand for nurse practitioners by analysing recruitment advertisements. Winter and Teare (2002) analysed advertisements for community children’s nurses and found a diversity of job titles being used, a lack of demand for specialist qualifications, and a lack of clear indications of required skills. Lacey et al. (2011) included attributes present in critical care nurse recruitment advertisements in a meta-synthesis of organisational job satisfaction, assuming that employers would advertise the features of their organisation that they believed to be important and attractive to candidates. They identified benefits, facilities, unique features, and education-growth opportunities as job satisfaction factors in critical care nurse recruitment advertisements. We considered it safe to assume that psychiatric-mental health care services spend substantial amounts of time and money on nurse recruitment and that the main purpose of recruitment advertisements is to attract potential candidates to a specific position. Thus, the descriptions of psychiatric-mental health nurses in recruitment advertisements should reflect the employers’ images of psychiatric-mental health nurses, including their understanding of the self-image of psychiatric-mental health nurses.

Considering the likely role of advertisements in the recruitment of nurses in psychiatric-mental health care, it is surprising that these have not previously, to our knowledge, caught the attention of nursing researchers. Increased knowledge of the image of nurses in recruitment advertisements can aid assessment of the current status of professional psychiatric-mental health nursing, as well as inform services dealing with the challenges of nurse recruitment.

Aim

Our aim with this study was to explore descriptions of nurses in psychiatric-mental health care in recruitment advertisements. More specifically, we aimed to describe variations and similarities in the contents of recruitment advertisements and calculate frequencies of content categories.

Methods

This is a descriptive study combining qualitative and quantitative approaches to content analysis (Krippendorff, 2013). The study was carried out by two women and one man, all specialist nurses experienced in psychiatric-mental health care. At the time of the study, two of the authors worked as senior lecturers, and one was pursuing a doctoral degree.

Context

In Sweden, to gain the title specialist nurse in psychiatric-mental health nursing, clinically experienced and bachelor’s degree-qualified registered nurses must complete a postgraduate, post-registration programme in specialist nursing, achieving a graduate diploma and/or a 1-year master’s degree (Swedish Council for Higher Education, 1993). However, a specialist qualification is not a legal requirement for working as a nurse in psychiatric-mental health services in Sweden, and there is no binding distinction made between the roles and responsibilities of general versus specialist nurses. Rather, employers are responsible for arranging staffing that is adequate to ensure patient safety and quality care. In 2019, there were more than two general nurses per specialist nurse, on average, in Swedish psychiatric-mental health inpatient and outpatient care (Uppdrag Psykisk Hälsa, 2020a; 2020b).

Historically, the development of psychiatric-mental health nursing in Sweden has involved a conflict between the nursing profession, which was dominated by well-educated, idealistic, upper-class women, and the mental health carer vocation, dominated by working-class men (Svedberg, 2002). This conflict was essentially resolved in the 1950s through governmental licencing of the nursing profession and allocation of leading positions in psychiatric-mental health care to educated nurses (Svedberg, 2002, p. 121). However, the conflict might still be visible in the unclear division of responsibility between registered nurses and nursing assistants in Swedish psychiatric-mental health care (Gabrielsson et al., 2014; Salberg et al., 2019).

The Swedish healthcare system is decentralised and diversified, encompassing both public and private services (National Board of Health & Welfare, 2021). Public services are managed by local or regional authorities. Staffing agencies provide some temporary staff to healthcare services. Both inpatient and outpatient services provide specialist psychiatric-mental health care (NHS Benchmarking Network, 2019). Social psychiatry services provide community-based daily activities and housing support. Both local authorities and private companies provide long-term treatment facilities. Private services may or may not be contracted by local or regional authorities, and account for approximately 5% of Swedish psychiatric-mental health care (NHS Benchmarking Network, 2019).

In Swedish recruitment advertisements, it is common to construct an ideal applicant ‘through the personal qualities asked for, the benefits promised, and information about the preferred age and sex’ (Helgesson, 2011, p. 319). Helgesson identified the ability to co-operate as one of the most sought-after qualities during the period 1955–2005, although personal drive emerged as the most desirable quality in 2000. Throughout the period, employers described themselves as large, leading and expansive, with a shift towards describing benefits for the employee being identified near the end of the period.

Data collection and sample

Using purposive sampling, we collected all advertisements for registered nurses in psychiatric-mental health care listed in the Swedish Public Employment Services publicly accessible job database Platsbanken (www.platsbanken.se) on February 3 2019. Platsbanken is said to be Sweden’s largest and most visited job database. We downloaded the advertisements and compiled them into a single text file. After removal of two duplicates, 75 recruitment advertisements were included in the study.

For the purpose of this study, the term ‘nurses’ refers to registered nurses with or without specialist qualifications. The term ‘psychiatric-mental health nurses’ refers to registered nurses with specialist qualifications in psychiatric-mental health nursing.

While all included advertisements were listed under the category ‘Registered nurse, psychiatric-mental health care’ (Swedish: ‘Sjuksköterska, psykiatrisk vård’), most employers would accept either nurses or psychiatric-mental health nurses (62.7%). Some specified that the position offered was for psychiatric-mental health nurses (18.7%) or registered nurses (18.7%).

The advertisements represented recruitment efforts on the part of a range of services: inpatient care (45.3%), outpatient care (32.0%), emergency department/crisis response team (9.3%), social psychiatry (8.0%), long-term treatment facilities (6.7%), and higher education institutions (1.3%). Most services targeted adults (86.7%), with some targeting children and adolescents (10.7%). We classified services as public (61.3%), agency (24.0%), or private (14.7%).

Data analysis

Data were analysed using content analysis (Krippendorff, 2013). In line with the contemporary understanding of qualitative content analysis, we took an inductive approach and strived to analyse both manifest and descriptive content, and latent and descriptive content (Graneheim et al., 2017; Graneheim & Lundman, 2004; Lindgren et al., 2020). The text was read as a whole to get an initial understanding of the contents. Based on this reading, analytical questions were formulated that guided the subsequent analysis:

1. What objective qualifications are valued in nurses?

2. What personal attributes are valued in nurses?

3. How is the nature of nurses’ work described?

4. How is the content of nurses’ work described?

5. What offers are made to attract nurses?

Five domains were formulated based on these questions. Content relating to these domains was extracted and analysed separately through coding and categorisation, focussing on describing similarities and variations. For example, the content ‘Planning together with family members, outpatient clinics, the municipality, and primary health care is an important part of the job’ was extracted as Planning with family members, outpatient clinics, the municipality and primary health care, further coded as Interact with other actors in the sector, and finally included in the category Collaborative. The categories and codes generated through the qualitative analysis formed the basis for a descriptive quantitative analysis calculating frequencies. The analysis resulted in 28 categories and one overarching theme. Categories are descriptive and concrete, while overarching themes reflect a higher degree of interpretation and abstraction (Lindgren et al., 2020).

Ethical considerations

As this study was based on non-sensitive and openly available data, no formal ethical approval was required under Swedish law. We have observed principles of confidentiality in presenting our findings.

Results

Our analysis identified one theme and 28 categories describing nurses in psychiatric-mental health care in recruitment advertisements (Table 1).

Table 1. Overview of results describing nurses in psychiatric-mental health care in recruitment advertisements.

Theme	Domain	Category
Willing and able to function in discouraging practice environments	Objective qualifications	Professionally qualified
		Experienced
		Skilled
		Safe
		Underrepresented
	Personal attributes	Dedicated
		Team player
		Suitable
		Adaptable
		Autonomous
	Nature of work	Collaborative
		Autonomous
	Contents of work	Unspecified patient-oriented tasks
		Medical tasks
		Nursing tasks
		Administrative tasks
		Developmental tasks
		Family-oriented tasks
		Psychotherapeutic tasks
		Supervisory tasks
	Incentives offered	Confident employer
		Appealing benefits
		Attractive working conditions
		Inspiring contents of the work
		Competence development
		Agreeable work environment factors
		Support structure for work
		Proficient co-workers

Being willing and able to function in discouraging practice environments

The main feature of recruitment advertisements’ descriptions of nurses was interpreted as focussing on their being willing and able to function in discouraging practice environments. This theme recurred in all domains. While the advertisements did not mention general academic qualifications, they listed specific requirements such as being familiar with certain software for documentation. This suggested a primary interest in nurses being able to adapt to the conditions at hand and hit the ground running, rather than an ambition to support and benefit from nurses’ personal and professional development. This interpretation was further reinforced by many advertisements not insisting on relevant specialist qualifications or experience. For example, an advertisement from an outpatient service stated:

We consider specialisation in psychiatric-mental health nursing, or basic therapeutic training, and/or training in medical yoga, a strong advantage. (Advertisement #39)

The skills specified rarely pertained to nursing or reflected nurses as having a role in leadership or development. Advertisements underlined the need for nurses to be able to adapt and handle existing demands, rather than their being able to take a critical stance and contribute to change. One agency looking for a nurse to work at a psychiatric emergency room stated:

Applicants for this position should be cheerful, positive and flexible. To fit in this role, you should also be solution-focused and service-minded, while at the same time calm and able to handle stress. (Advertisement #53)

The nature of nurses’ work was predominantly described as collaborative and dependent, rather than indicating that nurses would contribute with specific knowledge or assume autonomous responsibility for nursing. One advertisement from a child and adolescent inpatient service stated:

… nurses and nurse assistants work together. The team plans and organises care together with patients, and keeps in touch with next-of-kin and other caregivers. (Advertisement #60)

Rather than framing nurses as independent professionals, the content of nurses’ work was typically presented as a list of tasks that nurses were expected to carry out. An advertisement from an inpatient service stated:

… work includes conventional RN duties within the psychiatric area, for example, nursing care, drawing blood samples, handling medications, talking with family members, keeping a patient journal, telephone counselling, collaborating with other health care services and authorities. (Advertisement #76)

Incentives were generally described in terms of reasonable working conditions and standard economic benefits, rather than detailing a favourable practice environment. For example, an advertisement from an inpatient service stated:

Employees are offered some benefits. Besides a gym, a large restaurant and free health care, there is the possibility to join in joint staff activities like trips and excursions. (Advertisement #4)

Objective qualifications

Aside from basic nursing education and specialisation in psychiatric-mental health nursing, advertisements listed objective qualifications, describing verifiable training and competencies (Table 2).

Table 2. Categories of objective qualifications of nurses in psychiatric-mental health care in recruitment advertisements and the number of advertisements listing each qualification (N = 75).

Categories	Advertisements that list qualification % (n)
Professionally qualified	100.0 (75)
Registered nurse	100.0 (75)
Registered nurse specialised in psychiatric-mental health nursing	81.3 (61)
Registered nurse specialised in paediatric nursing	4.0 (3)
Registered nurse with non-specified nursing specialisation	2.7 (2)
Social worker	1.3 (1)
Experienced	85.3 (64)
Work in psychiatric-mental health services	60.0 (45)
Experience as a nurse	17.3 (13)
Work in addiction services	14.7 (11)
Work with children and adolescents	5.3 (4)
Computers	5.3 (4)
Non-specified experience	4.0 (3)
Specific administrative software	4.0 (3)
Work in somatic care	2.7 (2)
Developmental work	2.7 (2)
Specific services	1.3 (1)
Research	1.3 (1)
Correctional facilities	1.3 (1)
External cooperation	1.3 (1)
Care planning	1.3 (1)
Motivational interviewing	1.3 (1)
Skilled	50.7 (38)
Swedish language	20.0 (15)
Driver’s licence	18.7 (14)
Therapeutic training	8.0 (6)
Specific administrative software	5.3 (4)
Motivational interviewing	4.0 (3)
Non-specified other training	2.7 (2)
CPR	2.7 (2)
English language	1.3 (1)
Medical skills	1.3 (1)
Supervision	1.3 (1)
Relapse prevention	1.3 (1)
Medical yoga	1.3 (1)
Patient and family education	1.3 (1)
Safe	33.8 (26)
No criminal record	34.7 (26)
No drugs	5.3 (4)
No MRSA	4.0 (3)
No piercing	4.0 (3)
Underrepresented	22.1 (17)
Diversity	22.7 (17)
Underrepresented sex	20.0 (15)

Note. Percentages may not total 100%, as advertisements could list more than one category.

All advertisements requested professional qualifications as a registered nurse. Most either valued or required specialisation in psychiatric-mental health nursing, while some valued non-specified or non-psychiatric-mental health nursing specialisations. Most advertisements requested previous experience, most commonly from working in psychiatric-mental health services. Less sought-after experience included, for example, developmental work and research. Half of the advertisements listed specific certifiable skills, such as Swedish language skills, having a driver’s licence, therapeutic training, or being familiar with specific administrative software. One third of the advertisements directly or indirectly listed particular requirements relating to safety, most commonly that applicants should be prepared to provide their criminal record. Some advertisements indicated that they would favour applicants of the underrepresented sex or who would add to the diversity of their workforce.

Personal attributes

Advertisements listed personal attributes, describing positive and desirable personal traits (Table 3).

Table 3. Categories of personal attributes of nurses in psychiatric-mental health care in recruitment advertisements and the number of advertisements listing each attribute (N = 75).

Categories	Advertisements that list attribute % (n)
Dedicated	76.0 (57)
Responsible	34.7 (26)
Committed	32.0 (24)
Genuine interest in people with mental ill-health	21.3 (16)
Wish to develop (practices and services)	20.0 (15)
Patient focus	17.3 (13)
Wish for personal and professional development	14.7 (11)
Genuine interest in psychiatric-mental health care	13.3 (10)
Motivated	5.3 (4)
Enjoys challenges	5.3 (4)
Goal-oriented	5.3 (4)
Curious	5.3 (4)
Innovative	5.3 (4)
Meticulous	5.3 (4)
Creative	2.7 (2)
Climate-smart	1.3 (1)
Patient safety-oriented	1.3 (1)
Team player	72.0 (54)
Cooperative	60.0 (45)
Adds to a positive work environment	20.0 (15)
Communicative	10.7 (8)
Shares knowledge	9.3 (7)
Holistic approach	5.3 (4)
Appreciates others’ competence	1.3 (1)
Extroverted	1.3 (1)
Suitable	61.3 (46)
Personal suitability	54.7 (41)
Shared values	6.7 (5)
Professional approach	6.7 (5)
Personal maturity	5.3 (4)
Reliable	2.7 (2)
Skilled	2.7 (2)
Has self-knowledge	1.3 (1)
Adaptable	56.0 (42)
Flexible	28.0 (21)
Positive	18.7 (14)
Solution-focussed	16.0 (12)
Stress-resistant	10.7 (8)
Appreciates variation	8.0 (6)
Structured	5.3 (4)
Able to engage and connect with service users	5.3 (4)
Service-minded	4.0 (3)
Calm	2.7 (2)
Reflective	1.3 (1)
Able to engage and connect with employers	1.3 (1)
Autonomous	53.3 (40)
Independent	40.0 (30)
Confident	18.7 (14)
Actionable	17.3 (13)
Full of initiative	12.0 (9)
Leader	6.7 (5)

Note. Percentages may not total 100%, as advertisements could list more than one category.

Advertisements typically listed personal attributes relating to nurses being dedicated. These involved, for example, nurses being responsible, committed and motivated, with a focus on the patient and a genuine interest in people with mental ill-health and psychiatric-mental health care. Another frequently mentioned type of subjective qualification pertained to nurses as team players: being able to add to a positive work environment, being communicative, sharing knowledge, and appreciating the competence of others. They should also apply a holistic approach, i.e., be able to see the bigger picture. Often, the advertisements asked for ‘suitable’ nurses, typically described in vague terms like personal suitability. More than half of the advertisements asked for adaptable nurses. For example, nurses should be flexible, appreciate variety, and be solution-focussed and stress-resistant. Half of the advertisements listed personal attributes relating to nurses being autonomous. Desired qualities included being confident, actionable, ready to take initiative, and a leader.

Nature of work

Advertisements described the nature of nurses’ work in regard to nurses as team members, but also stated that the employee was expected to act autonomously (Table 4).

Table 4. Categories of the nature of nurses’ work in psychiatric-mental health care described in recruitment advertisements and the number of advertisements listing each category (N = 75).

Categories	Advertisements that list this nature of work category % (n)
Collaborative	82.5 (47)
Work in teams	42.7 (32)
Interact with others	36.0 (27)
Adapt to shifting circumstances	10.7 (8)
Autonomous	34.7 (26)
Responsible for nursing	12.0 (9)
Planning	12.0 (9)
Lead the team	10.7 (8)
Independent work	9.3 (7)
Be part of the management team	1.3 (1)

Note. Percentages may not total 100%, as advertisements could list more than one category.

Most advertisements described the nature of nurses’ work as collaborative ‒ nurses should engage in teamwork and interaction with others. One third of advertisements described work in autonomous terms. Few advertisements specified nurses’ work as involving responsibility for nursing or planning, leading a team or independent work.

Contents of work

The contents of nurses’ work were described in general terms and as being task-oriented (Table 5).

Table 5. Categories of the content of nurses’ work in psychiatric-mental health care described in recruitment advertisements and the number of advertisements listing each category (N = 75).

Categories	Advertisements that list this content of work category % (n)
Unspecific patient-oriented tasks	78.7 (59)
Unspecified patient work	30.7 (23)
‘Conventional RN duties’	22.3 (17)
Unspecified advisor role	20.0 (15)
Unspecified assessments	18.7 (14)
Unspecified treatments	16.0 (12)
Unspecified counselling	9.3 (7)
Unspecified patient-related responsibilities	8.0 (6)
Strengthening patients	6.7 (5)
Unspecified visits	6.7 (5)
Unspecified diagnostic evaluations	2.7 (2)
Crime processing	1.3 (1)
Medical tasks	53.3 (40)
Handling medications	32.0 (24)
Follow-up of medications	16.0 (12)
Medical assessments	14.7 (11)
Taking blood/urine sampling	12.0 (9)
Medical treatments	9.3 (7)
Medical evaluations	4.0 (3)
Planning with physician	2.7 (2)
Providing medical information	1.3 (1)
Handling PICC line and catheters	1.3 (1)
Somatic observations	1.3 (1)
Nursing tasks	30.7 (23)
Unspecified nursing	10.7 (8)
Assessment of nursing needs	6.7 (5)
Unspecified psychiatric-mental health nursing	5.3 (4)
Planning nursing	5.3 (4)
Supportive counselling	5.3 (4)
Promoting and preserving health	5.3 (4)
Lead nursing	4.0 (3)
Unspecified somatic nursing	4.0 (3)
Somatic nursing	1.3 (1)
Administrative tasks	22.7 (17)
Keeping a patient journal	16.0 (12)
General administration	6.7 (5)
Developmental tasks	17.3 (13)
Developmental work	17.3 (13)
Family-oriented tasks	16.0 (12)
Dialogue with family members	13.3 (10)
Family education	4.0 (3)
Psychotherapeutic tasks	16.0 (12)
Psychoeducation	9.3 (7)
Using specific methods	4.0 (3)
Motivational work	2.7 (2)
Using unspecific methods	2.7 (2)
Supervisory tasks	13.3 (10)
Pedagogical responsibilities	13.3 (10)

Note. Percentages may not total 100%, as advertisements could list more than one category.

The tasks most commonly described in the advertisements were unspecified patient-oriented tasks, including unspecified patient work, conventional RN duties without further specification, advisory work, assessments, and treatments. More than half of the advertisements specified medical tasks as central for nurses. Of these, the most common were handling medications, follow-up of medications, and medical assessments, along with technical medical tasks, such as drawing blood and performing medical treatments. We found that less than a third of the advertisements specified nursing tasks as a responsibility. Nursing tasks described were, for example, unspecified nursing, assessment of patients’ nursing needs, planning nursing, supportive counselling, and promoting and preserving health. Very few advertisements specified lead nursing as a nurse’s responsibility. Close to a quarter of the advertisements described administrative tasks like keeping a patient journal, while developmental tasks were rarely described. Some advertisements described tasks focussing on family members. A few advertisements specified psychotherapeutic tasks or supervisory tasks.

Incentives offered

Advertisements listed appealing factors with regard to the organisation, employment, and workplace, as well as the work itself and future co-workers (Table 6).

Table 6. Categories of what incentives nurses in psychiatric-mental health care are offered in recruitment advertisements and the number of advertisements listing each incentive (N = 75).

Categories and sub-categories	Advertisements that lists incentive, % (n)
Confident employer	56.0 (42)
Supportive leadership	33.3 (25)
Organisation with opportunities	26.7 (20)
Employer with focus and visions	25.3 (19)
Bearable staffing situation	8.0 (6)
Appealing benefits	52.0 (39)
Grants for wellness	25.3 (19)
Job security	20.0 (15)
Collective agreements apply	17.3 (13)
Insurance benefits	16.0 (12)
Pension benefits	14.7 (11)
Accommodation and travels	12.0 (9)
Financial bonus	10.7 (8)
Other benefits	8.0 (6)
Subsidy for work shoes	5.3 (4)
Health care benefits	5.3 (4)
Social benefits	4.0 (3)
Other financial compensation	4.0 (3)
Attractive working conditions	50.7 (38)
Generous salary conditions	22.7 (17)
Flexible working hours	16.0 (12)
Opportunity to adapt schedule	14.7 (11)
Employment characteristics	13.3 (10)
Variation in work	13.3 (10)
Clear working time frameworks	12.0 (9)
Inspiring content of work	48.0 (36)
Interesting and varied tasks	21.3 (16)
Specified working methods	20.0 (15)
Freedom at work	16.0 (12)
Meaningful work	10.7 (8)
Competence-intensive tasks	9.3 (7)
Work in team	8.0 (6)
Work at a fast pace	6.7 (5)
Nursing focus	4.0 (3)
Competence development	48.0 (36)
Professional development opportunities	29.3 (22)
Educational opportunities	16.0 (12)
Positive developmental climate	14.7 (11)
Agreeable work environment factors	44.0 (33)
Positive psychosocial environment	14.7 (11)
Workplace with good sense of community	13.3 (10)
Health-promoting workplace	10.7 (8)
Pleasant physical environment	10.7 (8)
Appealing surroundings	8.0 (6)
Support structure for work	42.7 (32)
Introduction to work	20.0 (15)
Guidance during work	20.0 (15)
Supervision	14.7 (11)
Proficient co-workers	34.7 (26)
College of nurses	14.7 (11)
Competent and diverse working group	13.3 (10)
Positive co-workers	12.0 (9)
Not addressed	8.0 (6)

Note: Percentages may not total 100%, as advertisements could list more than one category.

As seen in the category Confident employer, over half of the advertisements presented some sort of description regarding the employing organisation. These descriptions were predominantly positive, such as there being a supportive leadership. However, the subcategory describing a ‘bearable’ staffing situation hinted at understaffed units. We identified appealing benefits, mainly monetary incentives, in around half of the advertisements. Some appeared to be basic features of Swedish employment contracts, e.g., job security and pension benefits. Others, like financial bonuses and reimbursement for accommodation and travel, could be seen as favourable supplements. Half of the advertisements listed attractive working conditions, while almost half listed inspiring work contents. Notably, a nursing focus was mentioned in only three advertisements. The opportunity for competence development during employment was identified in almost half of the advertisements. Both professional development opportunities and educational opportunities were said to be offered, with organisations described as having a positive developmental climate with continuous improvement and developmental work are present. Agreeable work environment factors, which comprised both psychosocial and physical factors, were mentioned in a large number of advertisements. Regarding the support structure for work, it was often mentioned that the new nurse would receive a thorough introduction to work. Guidance during work after the introduction, for instance in the form of routines, meetings and available medical staff, was described as an aspect of a support structure. Continuous supervision would be offered in various forms. Around a third of the advertisements described co-workers positively, as being proficient. A college of nurses was described as having a close, collegial cooperation with committed colleagues.

Discussion

This study aimed to explore descriptions of nurses in psychiatric-mental health care in recruitment advertisements. We are pleased that our findings did not reinforce the popular image of psychiatric-mental health nurses as ‘sadistic’ (Bladon, 2017). However, they did suggest that nurses in psychiatric-mental health care are ‘assigned only a background role’ (Bladon, 2017, p. 688), as employers seemed to fail to appreciate nurses as nursing experts and professionals. Instead, recruitment advertisements mainly targeted nurses’ willingness and ability to function in discouraging practice environments. The identified descriptions reflected how employers, consciously or unconsciously, devalued nursing education, failing to appreciate the potential contributions of nurses to psychiatric-mental health care. Nurses were cast as ‘autonomous medical assistants’, and the implicit expectation was that nurses in psychiatric-mental health care should consider ordinary working conditions to be extraordinary.

The complete lack of advertisements mentioning general academic qualifications such as a bachelor’s or master’s degree is one of the most remarkable findings in this study. As substantial research has demonstrated that general qualifications are linked to better patient outcomes (e.g. Aiken et al., 2014; Djukic et al., 2019), we must assume that employers are either unaware of—or choose to disregard—these findings. We believe that this devaluation of nursing education is representative of the lack of role clarity (Bladon, 2018; Lakeman & Molloy, 2018; Salberg et al., 2019; Terry, 2020) that plagues psychiatric-mental health nursing.

Our findings portrayed the autonomous aspect of the profession primarily as the ability to act independently as a medical assistant, i.e., to independently function as a physician in the absence of physicians, without actually claiming the status and authority of physicians. It would be difficult for an employee whose major academic qualification is nursing, not medicine, to satisfy such expectations. Nevertheless, nurses might have no choice but to adapt to the system, as research describes nursing in this context as lacking in autonomy (Lakeman & Molloy, 2018). On a historical note, this has been the case for over a century (Dock & Stewart, 1920)—nurses are expected to ‘know their place’ in a context where nursing is subordinate to medicine (Lakeman & Molloy, 2018). If nursing were seen as a profession (Brante, 2013), we would expect that the roles and responsibilities described in the advertisements would have been focussed on the nurses’ main field of study—nursing—rather than on assisting another profession. We would also have expected nurses to be asked to shoulder areas of professional responsibilities rather than being given a list of more or less specified tasks.

In this study, the employing organisation was commonly described in terms of being a confident employer, where supportive leadership was the most frequent subcategory. These results give some hope, being in line with knowledge on the impact of leadership on nurse turnover, although this relates to a later stage of employment (Nei et al., 2015). Our findings also suggested that employers assume nurses are attracted by monetary and other material benefits. Though previous research has identified deprecatory images of nurses, such as them being greedy (Farrow & O'Brien, 2005), monetary factors like salary have been found to be less important when it comes to retention of nurses (Nei et al., 2015). The findings also indicated some awareness among employers of the importance of a positive practice environment to attract nurses, evident in their tendency to portray quite ordinary working conditions as extraordinary. While some advertisements did inform about staff shortages, some of the incentives presented could be interpreted as camouflaging organisational deficiencies. For example, we believe ‘work at a fast pace’ may be an alternative way to describe a high workload. Ultimately, we found little evidence suggesting that employers possessed a deeper knowledge about the conditions and aspects of nurses’ practice environment that would attract competent professionals. Our findings might reflect that many employers were unable to offer attractive practice environments to nurses, or that they lacked awareness on how practice environments might support nurses’ professional practice. This is worrying, as the organisational and professional work satisfaction of nurses is known to impact patient mortality, quality of care and length of stay, as well as nurse turnover, retention and fulfilment (Aiken et al., 2014; Karlsson et al., 2019).

The image described in our findings was representative of the ‘zombification of the mental health nursing workforce’ proposed by Lakeman and Molloy (2018, p. 1009). They argued that while the idea of psychiatric-mental health nursing will live on, psychiatric-mental health nurses are as a rule seen as a subordinate extension of the medical profession, positioned in a psychiatric-mental health care reduced to ‘a set of tasks, procedures, and processes’ (Lakeman & Molloy, 2018, p. 1011). Under such conditions, it is no surprise that employers seek to attract and cultivate a herd of zombies unable or unwilling to think and act independently, rather than reflective and confident nursing experts and leaders enacting professional values that might cause unrest in the organisation. Thus, our findings did not indicate that psychiatric-mental health care employers in Sweden understand nursing as a profession. Despite substantial developments in the education and regulation of nursing, it seems—at least in the case of Swedish psychiatric-mental health nurses and psychiatric-mental health nursing—that nursing is at best stuck in the semi-profession category.

Limitations

Measures were taken to ensure trustworthiness throughout the study. Our pre-understanding was informed by many years’ experience in nursing practice, education and research and likely influenced our perceptions, explanations and interpretations of the descriptions of nurses in psychiatric-mental health care in this study. However, qualitative content analysis is a text-bound method for analysing data (Krippendorff, 2013), which might have limited this influence during the analytical process. Credibility (Lincoln & Guba, 1985) was strengthened by theoretical reasoning about the methodology and having the aim of guidance through a transparent process. To further strengthen credibility, we consulted an HR specialist on the relevance of Platsbanken in contemporary recruitment strategies. We were advised that although other platforms (e.g., LinkedIn) have increased in popularity, advertisements for nurses in Platsbanken were unlikely to differ from those on other platforms. Further, the analysis was carried out by all three authors, strengthening dependability (Patton, 2015). The advertisements used were all collected on the same date. This might have limited the transferability of our findings, as it is reasonable to assume that there are seasonal variations in job vacancies. Further, transferability was taken into account by clearly describing the authors’ pre-understanding. However, transferability to other contexts is left to the reader to determine, following critical reflection (Lincoln & Guba, 1985). To make the results confirmable and strengthen dependability, all steps of the study, as well as contributions, have been described (Patton, 2015).

Implications

Our findings could be used to ensure that advertisements reflect and reinforce an understanding of nurses as professionals. Given that highly educated nursing experts make a much-needed and crucial contribution to quality health care and patient outcomes, this would serve the interests of psychiatric-mental health services as well as those of nurses in psychiatric-mental health care. Nursing managers need to be aware that recruitment advertisements contribute to how the nursing profession is viewed and understood. We suggest that nursing managers perform a systematic analysis of organisational needs with regard to nurses’ professional skills, academic competences and patient safety. Considering the current scientific knowledge regarding the link between patient outcomes and nurses’ general academic qualifications, advertisements should state the academic qualifications required for the vacant position.

Conclusions

This study proves the usefulness of recruitment advertisements as data in nursing research. The description of nurses in psychiatric-mental health care in Swedish nurse recruitment advertisements is a poor match with the ideal of nurses and nursing advocated by the nursing profession and manifested in nursing curricula. It might, however, be a valid representation of the realities of nurses and nursing in Swedish psychiatric-mental health care, at least from the perspective of employers. Thus, our study suggested a need to align the ideals and the realities of the nursing profession. Considering the growing evidence in support of academically qualified nurses’ contribution to quality health care, we believe persons who have mental health problems might be better off if the major adjustments were made on the ‘reality’ side.

Future research should further explore how nursing and nurses are described and how such descriptions contribute to the construction of the nursing profession.

Acknowledgements

We are grateful for the constructive criticism of colleagues near and far.

Funding

This study received no specific funding.