Under Prepared for Practice: A Qualitative Study of Mental Health Nurse Undergraduate Workforce Preparation in Australia

Abstract

Internationally there are both current and looming mental health workforce shortages. Mental health nurses who have received specialist education are a vital component to respond to these challenges. Aim: This qualitative study aimed to better understand the efficacy and product quality of mental health nurse workforce preparation through pre-registration nurse education in Australia. Method: To meet this aim 19 educators representing 13 different universities were qualitatively interviewed. Results: Thematic analysis found four themes (1) Graduates are under-prepared for safe mental health nurse practice; (2) Essential mental health nurse capabilities are missing in graduates; (3) Barriers to graduate preparation, and (4) Negative impacts of inadequate graduate preparation. Discussion: Findings from this study suggest future workforce shortages would be best addressed through direct undergraduate entry for mental health nursing Implications for Practice: All nurse undergraduate training needs significantly enhanced mental health theory and placement within the course.

Background

Internationally there is a significant challenge in recruiting and retaining health workforce, with an expected shortfall of 10 million staff by 2030 (World Health Organization, 2023). The drivers for this are multiple and complex, with gender-based discrimination, workplace violence and staff burnout being prominent. This shortage has triggered international competition for scarce health workforce and increasing migration of workers towards developed countries, necessitating a global code of recruitment practice (World Health Organization, 2010). This wider workforce shortage is particularly challenging within mental health contexts where pre Covid-19 epidemic there was a shortfall of over a million staff in low- and middle-income countries alone (Endale et al., 2020). However, mental health workforce shortages are also critical in advanced countries such as the United States of America (Delaney & Vanderhoef, 2019) and the United Kingdom (Royal College of Psychiatrists, 2021) resulting in unmet mental health needs.

These global challenges are echoed in a current and critical mental health workforce shortage in Australia that is expected to worsen over the short to medium term (Institute for social science research, 2020). This staffing challenge is further heightened in rural, remote and regional settings (Van Spijker et al., 2019). With the Australian Government developing a new National Mental Health Workforce Strategy (Department of Health and Aged Care, 2023) there is an imperative for mental health nurses (MHNs), as a large specialist workforce of 25,000, to position themselves as being integral in responding to these shortages. Importantly, workforce shortages refer not only to workforce volume, but also to the workforce having the necessary skills to meet the mental health needs of diverse populations. Such skills incorporate not only clinical capability, but also the underpinning values and de-stigmatising attitudes that are congruent with recovery and trauma informed principles which guide contemporary mental health care (Isobel et al., 2021).

The very usefulness of the mental health workforce begins and ultimately ends in meeting the needs of those with lived experiences of a mental health diagnosis or mental health service use. Those with complex mental health needs have a life expectancy between 10 and 16 years less than the general population (Australian Institute of Health and Welfare [AIHW], 2022) and will have greater rates of homelessness, poverty and social marginalisation than others in the general population (State of Victoria, 2020). Most people with mental health challenges do not become unwell due to lifestyle choices that lead to the many chronic physical health conditions challenging an overworked heath sector (Crosland et al., 2019). Rather, some 70% of mental health challenges emerge in youth aged 12—24 (Fusar-Poli, 2019), often triggered by traumatic adverse childhood events that were beyond their agency to alter. This is a population needing, and indeed deserving of, skilled and compassionate services.

The importance and value of MHN clinical services and roles in responding to such needs have been well established (Buus et al., 2020; Lakeman et al., 2023). Where these nurses have received specialist mental health training there is strong evidence that they undertake a range of complex and demanding roles with populations significantly exposed to vulnerability (Hurley et al., 2020; Moyo et al., 2022). However, for those students entering nursing wanting to be a MHN in Australia, they confront a protracted and expensive process to gain specialist qualifications. The multi-step process necessitates 5 to 6 years to first gain a pre-registration nursing degree, then become registered as a comprehensive nurse, and then gain mental health clinical experience. Next, if they want a specialist MHN qualification, they must undertake a post graduate diploma or Masters in mental health nursing that enables accreditation with the Australian College of Mental Health Nursing (ACMHN), to become a credentialed MHN (Australian Universities, 2022). Importantly this the shift away from specialist mental health nurse training is an international one. Specialist training in the United Kingdom is under serious threat and similar changes are being considered in the Republic of Ireland, effectively leaving Malta as the only European Union member country with specialist training leading to registration (Mental Health Deserves Better, 2024; Warrender et al., 2023). The impact of generic nursing training in Australia on the reparation of mental health nurses over the past 40 years is an international case example of the outcomes of this approach.

When considering that MHN work is already stigmatised and challenging in nursing (Harrison et al., 2017) such barriers, although surmountable for the deeply committed, further minimise the number of skilled graduates entering the discipline. Those attracted to mental health nursing can enter the workforce through a simpler but less robust pathway. Under current structures in Australia all pre-registration nursing graduates are considered to be comprehensively prepared, capable of working as a registered nurse in any clinical setting including mental health. This preparation can be through a 3-year undergraduate degree or a pre-registration Masters degree. This preference for comprehensive preparation is adopted by the leading nursing body in Australia, the Australian Nursing and Midwifery Accreditation Council (ANMAC), and is uncontested by other nursing groups such as the Council of Deans for Nursing and Midwifery (CDNM). This is despite widespread and longstanding concerns about the preparedness of these graduates to work in specialist mental health settings (Clinton & Hazelton, 2000; Hurley et al., 2023; Stuhlmiller, 2005) and Productivity Commission recommendations for direct entry options to be created (Productivity Commission, 2020).

In the context of significant mental health workforce shortages and the need to train specialist mental health specialists, including nurses, (Institute for Social Science Research, 2020), it is important to understand the current efficacy of undergraduate MHN preparation and, if required, how this preparation could be improved. Consequently, this study aimed to better understand the efficacy and product quality of mental health nurse workforce preparation through pre-registration nurse education in Australia. The experiences, insights and recommendations of MHN educators as a key stakeholder group were sought to meet this aim.

Methods

Study design

This study was undertaken with approval from the Southern Cross University Research Ethics Committee. Data reported here is drawn from a mixed method study with online survey and qualitative interviews, with the quantitative survey findings being reported elsewhere. The current qualitative study utilised a descriptive qualitative design (Doyle et al., 2020) that sought to provide insight and describe deep and contextualised experiences from MHN educators involved with pre-registration nurse education.

Participants

All Australian universities listed by the CDNM (ND) were approached to participate in the wider study in March, 2023. These universities covered all Australian jurisdictions incorporating urban, regional and rural providers. Recruitment for the wider study was undertaken through the Australian College of Mental Health Nurses monthly electronic new letter. Additionally, social media and snowballing recruitment strategies were used. Both strategies included an invitation to participate whereby the individual emailed the research team. Those staff responding to the initial survey represented 25 of the 36 universities listed by the CDNM, who were invited at the end of the survey to take part in qualitative interviews, with 19 agreeing to do so. Of those, nine identified as female and 10 as males, with 13 separate universities being represented in this purposeful sample. The sample was purposeful as all 19 held academic qualifications in mental health nursing ranging from undergraduate/pre-registration degree through to PhD. Their experience as a MHN ranged from 5 years to over 20 years. Two were casual academics and one a Director of Nursing, with the remaining having from 2 to over 20 years’ experience as an academic. All received a participant information sheet and provided written informed consent prior to interview.

Data collection

One to one semi-structured interviews were undertaken by all authors, who were experienced qualitative researchers from May 2023 through to June 2023 utilising Zoom. All interviews were audio recorded with automatic transcription. Transcripts were then checked for accuracy though reading the generated transcripts while listening to the recordings. Interviews ranged between 40 to 60 min, with trigger questions reflecting the aims of the study being used to commence the interviews. These included questions such as:

• In your experience what factors within current undergraduate (pre-registration) nurse training enable and/or inhibit graduates to work effectively in MHN settings?

• Describe in as much detail as you can how the program you are involved in prepares nurses to work effectively with people experiencing mental health problems.

• What do you consider to be the essential skills, knowledge and attributes that a MHN should ideally possess?

  • Which of these, if any, are missing in your graduates?

  • What, if any, vital mental health theory is currently absent from your curriculum?

  • What, if any, vital mental health clinical skills are currently absent from your curriculum?

Data analysis

Descriptive thematic analysis that adopted the approach of Braun and Clarke (2006) was undertaken. Nvivo software was used to manage the data, with initial thematic nodes being generated by simultaneously reading the transcripts and listening to the audio recordings. As deeper perspectives and meanings were identified child thematic nodes were then created. Data saturation was reached after 12 interviews, but analysis continued until all transcripts had been coded in order to gain widespread perspectives across participating universities. The final themes were checked and agreed upon by three of the listed authors. The group met weekly and the Consolidated Criteria for Reporting Qualitative Research Checklist (Tong et al., 2007) was used to enhance robustness of the design and in the reporting of the findings.

Findings

Four themes were identified: (1) Graduates not fit for safe MHN practice; (2) Essential MHN capabilities are missing in graduates; (3) Barriers to graduate preparation, and (4) Negative impacts of inadequate graduate preparation.

Graduates are under-prepared for safe MHN practice

A significant majority of those interviewed identified that their graduates were not adequately prepared to work competently in mental health settings by the end of their undergraduate nurse training due to lacking critical knowledge in both theory and practice:

(RP10) “Sorry, I was laughing there because the answer is no, we can’t make them have it (competence) after one subject. So that week of face to face 30 hours, is a lot on attitude and perspectives and trying to make students look at the person rather than diagnosis. So, I don’t think that it prepares them in terms of skills and knowledge, to be honest”.

This lack of exposure to mental health content that led to graduates being perceived as unfit for MHN practice was expressed by most participants:

(RP12) “I’m going to be very brutal and answer No. I'd say that is a shame, because I would like them to be. I think it comes down to that preparation. I think the time spans that we get with individuals in terms of preparing, far too short. Those nine-week, eight-week blocks of teaching that we get are so limited”.

This perceived lack of competency was identified as being due to inadequate levels of mental health theory and content in pre-registration programs which led to students being unable to recognise the impacts of mental illness or respond to those impacts (RP14) “They’re not going to be competent. They’re not going to recognise what’s going on with a mental illness…., they’re not going to know how to manage that”. There was also concern that graduates unknowingly generate harm through “perpetuating the stigma surrounding mental health”. The risk of inadequately prepared graduate harm was echoed by others in the study; (RP3) “I wouldn’t even say that they are at the point of being a minimal standard safe”.

Participants reported that graduates should not be considered as having the identity of a mental health nurse or having the capabilities to enter the profession without receiving additional specialist education:

(RP1) “So, there’s no way that I would want any of our students to be considered a mental health nurse or go and work straight to an area in mental health where they finished their 3-year undergraduate degree before they go into postgraduate mental health study”.

Missing essential MHN capabilities

Participants identified that essential MHN capabilities were missing in their graduates. These capability gaps most frequently included basic MHN clinical skills including assessment and interpersonal skills nuanced to mental health contexts. The values, attitudes and philosophies that guide MHN practice and identity were also identified by many participants as being absent in current nursing graduates. The gaps in skills and knowledge were also reported as contributing to graduates being aware they were ineffectual in mental health settings; (RP 4) “They feel underprepared. They don’t have the clinical skills or knowledge to be able to feel that they’re an effective team member whilst working on the [mental health] ward environment”.

Clinical skills fundamental to beginning MHN practice were frequently identified by participants as missing in graduates from Australian universities:

(RP 2) “Mental state examination (MSE), it’s obviously a core skill of a mental health nurse. But when a student gets out of this undergrad program it’s not like they go out with a great idea about how to do a MSE. If a new grad wrote a MSE, for me, I'd go ‘Thanks very much for that’, pat them on the shoulder, and then I'd go back and do a proper one”.

This absence of essential and fundamental MHN skills were reported in other areas:

(RP 14) Skills to de-escalate a situation. It’s helpful for conflict, conflict resolution, just general communication. I've been working in academia since 2015. And I've never taught that in any of I've worked in four different universities in the undergraduate curriculums”.

Interpersonal capabilities contextualised to MHN practice were also identified by most participants as missing in graduates (RP 5) “the therapeutic relationship, in some circumstances can be more effective than medication, that drum is not beaten in the undergraduate degrees”. Where graduates had nursing skills pertinent to all nursing practice, they were reported as being unable to translate those into mental health contexts: (RP11) “All they’ve been taught is communication for people who can give you a coherent response, who’s in full control of their faculties, fully compliant, meet society’s norms. When they don’t get that, then they struggle”.

Underpinning MHN philosophies and values that guide clinical practice and interpersonal therapeutic relationships were also frequently identified as missing in graduates (RP 7) “…things like good practice is recovery oriented practise. None of the students know what that is. Therapeutic relationships. None of the students know what that is”. Participants reported that they simply had insufficient time to teach what are complex and inter-related constructs:

(RP 3) “In the classroom and teach them what recovery looks like and teach them what trauma informed care looks like and oh. My gosh, we’re talking 4 hours, to talk about stigma, recovery, and trauma informed care. I mean, that’s just dipping your toe and running away from the ocean. It’s such a ridiculously poor offering”.

Barriers to effective graduate preparation

While a lack of mental health content and appropriate clinical placements were highlighted as barriers by most participants, the disconnect between theory and placement and between areas of content, were also frequently highlighted as significant barriers (RP 12) “we’ve got the minimised amount of content and then, being able to bridge that into practice,….there doesn’t seem to be a willingness for the university to actually bridge that gap, so we struggle. As expressed by this participant, challenges of retaining already minimal content that is then spaced out over time and embedded in generalist content is an ineffectual structure to imbed mental health learning:

(RP2) “I mean, it’s never gonna (sic) be enough to prepare them for, because by the time they get to through the third year, I'm pretty sure a lot of this has been data dumped and they’ve moved on to the next thing, anyway that, with the way that we structure things, we sort of throw a couple of weeks of mental health in amongst these other subjects that are very general focused, that it does get lost in terms of its relevance”.

Clinical placements were identified as having a powerful impact on developing a student’s attachment to nursing generally, and in choosing mental health nursing career in particular (RP16) “undergraduate students tend to be inspired by their exposure to specific mental health placements. If those are inadequate, then they lack the inspiration, …to explore mental health as a career opportunity”. However, the majority of study participants reported non mental health placements being used for the student’s ‘specialist’ mental health placement (RP6) “often people would have to default to, having their mental health clinical in an aged care setting, where it wasn’t specific mental health presentations”. MHN academics reported their institutions adding additional barriers to the current non-mandated need for specialist mental health placements:

(RP13) “We do not have a compulsory clinical placement attached to this programme, which I think is very sad that went out of the curriculum when I first started. Currently, a big barrier is that the students have to actually submit an expression of interest, if they want to go to mental health. And now, that requires writing a mini essay about why they want to go to mental health”.

A large majority of participants identified that stigma and active de-valuing of mental health nursing contributed to these barriers to adequate preparation of a MHN workforce (RP 3) “when you have decision makers who have highly expressed stigma towards mental health, mental illness, people with mental illness, people with lived experience, you have got no chance at all”. Such experiences extended beyond those in leadership positions to many examples that included academic colleagues:

(RP 6) “Within a comprehensive nursing programme, I've actually been in situations where other academics are saying, why would you want to work in mental health? Walking in on conversations where they’re actually dissuading students from ever working in mental health? Why would you want to work there, you’re gonna (sic) lose your skills”.

Impacts of inadequate training

Most participants made connections between the gaps in graduates’ clinical skills and discipline specific and values, and experiences of MHN service delivery;

(RP6) “the current curriculum, it doesn’t prepare people to understand the medications that they’re giving out. I'm seeing that on the ground now, giving out Anticholinergics and not even understanding why the person was complaining of blurred vision”. This participant, who was specialist MHN trained in the United Kingdom, identified that the lack of therapeutic skills of Australian graduates resulted in their scope of practice being restricted to an overreliance on medical treatments:

(RP1) “I was absolutely shocked. I'd come from working with children and young people where it was very much, you worked with carers, you worked with people with a lived experience, and you only put people on medication if you really felt there was no other choice. I came over here (Australia) and the first thing I remember joking to my husband about was that I think they must have shares in some sort of pharmaceutical company. The amount of medication that was being prescribed to children and young people”.

Most participants identified that the lack of graduate therapeutic capability was resulting in consumers receiving less than optimal nursing care (RP15) “there’s just a lot of focus on risk and on assessing people, rather than therapeutically engaging them”. Rather, graduates were described as having skills sets more attuned to a Nightingale model of nursing (RP12) “How do we get them to go use themselves therapeutically, not just in this task focused, very routine, our very medicalised form of care” and that this results in “restraint, the use of medication, relies on the use of detention” and that “things that have been done to the person rather than the person expressing need”.

Industry stakeholder feedback to participants in this study highlighted key workforce implications of under prepared graduates. With graduates lacking confidence to work in mental health and having had greater exposure to generalist nursing settings, they are opting for non-mental health graduate opportunities; (RP13) “…the director of nursing for mental health applicants said, we’ve gone from 25 graduates, to last year, we had five. And she said, we’ve just lost two of those who’ve gone over to med surg (sic). She said, we’ve got no nobody coming in”. The lack of graduate recruitment and retention was also identified as impacting on the levels of experience in the MHN workforce and care provision:

(RP8) “I was talking to a clinical facilitator at the local hospital she said, it’s worse than ever. The most experienced person in the ward at the moment might have three years since graduation, and hardly anybody’s got any postgraduate qualifications, which is astounding to comprehend how they could possibly be providing the sort of care that people need”

Discussion

This study sought to better understand the efficacy and product quality of graduates from pre-registration/undergraduate comprehensive nurse training in Australia to work in mental health settings, by drawing on the experiences of MHN educators. Thematic findings reported here identify that graduate nurses are widely considered to be unfit and or unsafe for MHN practice as a Registered Nurse by the academics who teach them. Additionally, many graduates were reported as lacking basic MHN clinical skills and inter-personal capabilities. This reflects findings by Hooper et al., (2016) in their integrative review of nursing graduates with a focus on Australian contexts. This review also found a lack of adequate graduate preparation from the comprehensive nurse training model, exacerbated by the challenges of working in acute mental health settings and inadequate preceptorship for new graduate nurse. Such concerns have been repeatedly highlighted in the literature for some considerable time (Clinton & Hazelton, 2000; Happell, & Gaskin, 2013), with the importance of clinical placements for workforce recruitment and preparation for the field being specifically raised (Happell, 2008; McCann et al., 2009).

The lack of MHN theoretical content that was reported in this study was compounded by mental health content being delivered in disconnected chunks, that failed to communicate the complexities of good MHN practice. Recovery and trauma informed principles, and the nuanced communication and therapeutic relationship skills of mental health nursing, were widely considered to be unaddressed. The importance of scaffolded discipline-specific undergraduate education is highlighted by Warrender et al., (2023) as being vital to produce effective MHN graduates. Additionally, the priority of consumers and their supporters for MHNs to have undergraduate training in effective relationship building and advanced non-technical work skills was evident in the recent study by Hurley et al., (2023), with a strong preference from these stakeholders for a direct undergraduate entry degree for mental health nursing. These consumers and their supporters wanted empathetic and compassionate MHN experiences of service, rather than the mechanistic, generic, and medically driven practices described in this study. The necessity for graduates to be adequately prepared through undergraduate education, that is then followed up by supportive graduate placements and caring mental health clinical practice, is widely recognised in the international literature as vital for workforce recruitment and retention (Mabala et al., 2019; Slemon et al., 2020). In Australia there is a predicted MHN shortfall of around 18,000 staff by 2030, and along with other mental health disciplines, they are an ageing workforce (Health Workforce Australia, 2014). Ensuring there are sufficient numbers of new nursing graduates with specialist mental health capabilities is essential to meet these workforce challenges. The problem of a mental health nurse workforce shortfall is an international one. In their 2022 report the International Council of Nurses (ICN) identified that mental health nurses are the largest discipline of mental health workforce (44%) in the context of global workforce shortages. The ICN’s recommendations stemming from their review of mental health nursing education globally included the need for specialist training, minimum standards for both clinical placements and theory, as well as the need for mental health nurses to be involved in leadership level decision making (ICN, 2022).

Of concern for building the required future MHN workforce identified in this study is that new graduates are increasingly not taking up MHN positions, often due to a lack of placements. The lack of graduate confidence in mental health settings compared to their familiarity with medical and surgical contexts was in part driving this. Additionally, the worth and importance of MHN work was reported as being actively degraded by generalist nursing academics, with there also being evidence of stigma within the nursing leadership of some Australian universities. Similar workforce challenges are reported by Lakeman et al., (2023) who highlight from their service user and supporter study that there is a need to align services with MHN values and helpful clinical practices to promote recruitment and retention.

Conclusion

Undergraduate education is highly influential in building foundational professional skills, capabilities and values. These can then be further developed as a graduate within specialised settings (Productivity Commission, 2019a; 2019b). Where undergraduate nurses have been exposed to targeted educational interventions designed to build clinical confidence and de-stigmatising attitudes in mental health settings there is solid evidence of improvements (Foster et al., 2019; Patterson et al.2023). This suggests that better undergraduate preparation for a MHN workforce is achievable, where there is willingness, supported specialised placement and targeted mental health content delivered and led by MHN academics.

In the absence of any regulated and mandatory minimum requirements in Australia for such preconditions, there is very limited potential to sustainably replicate such outcomes. Rather, findings in this study indicate widespread failure of the comprehensive nurse training model in Australia to produce a product fit for a future MHN workforce. These findings are supported by a historical record of similar findings. These shortcomings have not been rectified by regulation or policy despite there being opportunity and agency for ANMAC to do so. This unwillingness to act arguably reflects a low regard by domineering generalist nursing bodies such as ANMAC and CDNM towards MHNs, and the work they undertake. This lack of regard towards the work and capabilities of specialist trained MHNs extends to State and Federal policy makers, who steadfastly prioritise other mental health disciplines, even in the context of significant workforce shortages (Hurley, Lakeman, Cashin et al., 2020). Simultaneously, there has been no call of support from Psychiatry who have remained silent on the topic. The lack of agency that MHNs have to better educate nurses and to promote the worth of the discipline connects to being under the same registration as generalist nurses. Within such a generic grouping of nurses competing priorities take precedence, an issue reflected not just in Australia, but across international settings (Stewart et al., 2022). Findings from this paper add to the body of evidence from which to argue the need for better specialised training and form mental health nurses to promote the worth and complexity of the work they undertake.

Relevance for clinical practice

Preparing a MHN workforce to meet the needs of mental health consumers requires early exposure to positive clinical placement, structured mental health content and effective role models (Institute for Social Science Research, 2020). The current preparation approach is a sustained failure that is contributing to inadequate MHN workforce capabilities and potentially unsafe and stigmatising MHN practice. Direct undergraduate entry for MHN education is urgently needed, as are mandatory minimum MHN content and clinical placement in all undergraduate nurse education. These changes need to be led by MHN academic and clinical leaders, working in partnership with consumers and their supporters, as recommended by the ICN (2022). A separate professional registration for MHNs will further enable the successful development of a fit for purpose MHN workforce. These are vital considerations for countries in the United Kingdom and the European Union who are viewing generic or comprehensive nurse training as a future option. The case example of Australia suggests that graduates from generic nurse training models are simply insufficiently prepared for the complexities of safe metal health nursing practice.

Author contributions

All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors, and all authors agree with the manuscript.

Limitations

This study reports qualitative data that is not generalisable across all settings. Additionally, as not all universities participated in the study some views may not have been represented.

• This was an unfunded study.

• No authors have a conflict of interest to declare.

• The study was conducted with the HREC approval from Southern Cross University: 2023/015.

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.