Mental health nurses' perceptions of good work in an acute setting

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    Mental health nurses perceptions of good work inan acute setting

    Michelle Cleary,1 Jan Horsfall,2 Maureen OHara-Aarons,3 Debra Jackson4 andGlenn E. Hunt2,51Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, Singapore; and 2Concord Centre for MentalHealth, Sydney Local Health District, Concord Hospital, 3School of Nursing & Midwifery, University of WesternSydney, 4Faculty of Nursing, Midwifery and Health, University of Technology, and 5Discipline of Psychiatry,University of Sydney, Sydney, New South Wales, Australia

    ABSTRACT: Frequently, research and conference papers explore difficult or problematic areas ofpractice that can inadvertently render daily nursing accomplishments invisible and create the per-ception of a discipline in crisis. In this qualitative study, we explore the views of registered nursesabout achievements in the workplace and good nursing work in an acute inpatient mental healthsetting in Sydney, Australia. Mental health nurses were asked a series of questions about theirexperiences and understanding of what constitutes good nursing work as well as their sense ofoptimism about their work. A total of 40 structured face-to-face interviews were completed. Among theresponses to questions about achievements and good nursing practice, five broad themes were iden-tified: i) teamwork; (ii) interpersonal interactions with patients; (iii) providing practical and holisticsupport to patients; (iv) patients mental health improvements; and (v) optimismpessimism con-tinuum. Findings contribute to a discussion of good nursing work in acute mental health settings, aswell as self-perceptions of optimism and hopefulness, which are important contributors to positive,supportive health-care settings and patient recovery.

    KEY WORDS: achievements, acute mental health, good nursing work, interpersonal interactions inmental health nursing, nursing teamwork, optimism.


    Frequently, research and conference papers explore dif-ficult or problematic areas of practice that can inadvert-ently render daily nursing accomplishments invisible andcreate the perception of a discipline not quite up toscratch (Jackson 2009). In mental health nursing, for

    example, consumer and carer-focused care is not transpir-ing to the degree hoped for by mental health policy-makers and patients (Cleary et al. 2005; Cutcliffe &Happell 2009; Grant & Briscoe 2002; Hall 2004; Hamil-ton & Manias 2008; Woodbridge & Fulford 2004), andthere are many constructive suggestions provided in thepublished literature for improving professional practice inmental health facilities (Deacon et al. 2006; Hughes &Fulford 2005). The nursing literature highlights the frus-tration of nurses being unable to do what they should bedoing (Cleary & Edwards 1999; Cleary et al. 2011c;Ewashen & Lane 2007), being overwhelmed by theauthority of medical practitioners (Taxis 2002; Vuokila-Oikkonen et al. 2004), and the contradictions betweenactual practice in acute inpatient mental health units andmental health ideology (Cleary 2004; Deacon et al. 2006;

    Correspondence: Michelle Cleary, Alice Lee Centre for NursingStudies, Yong Loo Lin School of Medicine, Level 2, Clinical ResearchCentre, Block MD11, 10 Medical Drive, Singapore 117597.

    Michelle Cleary, RN, PhD.Jan Horsfall, PhD.Maureen OHara-Aarons, RN, MN.Debra Jackson, RN, PhD.Glenn E. Hunt, PhD.Accepted December 2011.


    International Journal of Mental Health Nursing (2012) , doi: 10.1111/j.1447-0349.2011.00810.x

    2012 The AuthorsInternational Journal of Mental Health Nursing 2012 Australian College of Mental Health Nurses Inc.

  • Fourie et al. 2005; Horsfall et al. 2011). Controversialaspects of practice have also been highlighted, includinginvoluntary treatment, seclusion, suicidality, boundaryviolations, and patient competence (Cleary et al. 2010;Gabbard & Peltz 2001; Gutheil & Gabbard 1998; Huntet al. 2010; Taxis 2002).

    Claims are made that subtle and complex therapeuticinteractions do not always occur in acute mental healthsettings (e.g. Whittington & McLaughlin 2000). Forexample, the discussion in Grant and Briscoe (2002) oneveryday interactions in acute inpatient mental healthinpatient units shows that well-meaning and experiencedmental health professionals do not always understandthe relevance of patients needs and concerns to theirpresent wellbeing and recovery. It is important for anydiscipline to reflect on the challenging aspects of profes-sional life and practice, and on areas that are problem-atic and require improvement. However, in so doing, itis possible to overlook that which is done well, and isunproblematic. Although it may seem unimportant toconsider what we do well, it is vital to do so to foster asense of professional pride and optimism, and toenhance morale. Indeed, there is very limited publishedliterature on optimism within the nursing profession, oron the awareness and acknowledgment of good nursingwork, both of which are essential to mirror and honournursing achievements and to present a well-roundedoverview of challenges and rewards (Christiansen 2008;Jackson 2009). The limited literature that is availablesuggests that many registered nurses (RN) consider afair and understanding manager to be essential to a sup-portive work environment. Also considered importantare fellow workers and being in a well-coordinated team(Josefsson et al. 2011).

    In a climate characterized by issues in nurse recruit-ment and retention, and increasing challenges within theacute workplace itself, it is important to recognize high-quality nursing work (Cleary et al. 2009; Horsfall et al.2010a; 2011). According to Christiansen (2008), such rec-ognition can encourage nurses to maintain and strengthenthe values and goals of the nursing profession. Potentiallythen, this recognition might have a crucial role in consoli-dating and strengthening professional identity, raisingprofessional pride, enhancing retention, and encouragingRN to consider mental health nursing a worthwhile, inter-esting, and personally and professionally fulfilling special-ization. The aim of the exploratory study from whichthis paper is drawn was to ascertain nurses views aboutgood nursing work in an acute mental health inpatientsetting. We investigated what aspects of their professionallives and achievements mental health nurses selected to

    convey to others, as confirming that they have done goodwork.


    The aim of this project was to develop insights into thenature of good mental health nursing work through theperspectives of mental health nurses in the acute mentalhealth environment. A qualitative interpretive approachwas chosen to guide the development of the project(Borbasi & Jackson 2008), and participants were encour-aged to tell stories about their practice experiences. Thisproject was approved by the Hospital Human ResearchEthics Committee and reciprocal approval was given bythe University Human Research Ethics Committee. Thesetting was four acute inpatient units in a large specialistmental health centre in Sydney, Australia. These unitshave 80 patient beds and approximately 21 nurses workthe day shifts from Monday to Friday in these wards. Thestudy was conducted in June and July 2011. During thisperiod, an experienced mental health researcher, who haspreviously collected research in this setting, completedseveral rounds of interviews in four inpatient units two tothree times per week. The nurse researcher greetednursing staff, stated the purpose of the study, and invitedregistered nurses to participate. The face-to-face inter-view was voluntary and no identifying information waslisted on the pro forma used to note comments verbatim.The interviewer asked registered nurses about their viewson good nursing work. The familiarity of the interviewerwith the routines and procedures in the setting facilitatedminimal disruption on the units and her acceptance bynursing staff seemed to facilitate the collection of highquality and authentic narrative data.

    A series of written questions were provided to RNparticipants before the interview so that they had timeto consider the questions and prepare themselves forthe interview. Interview questions were developed bymembers of the research team to elicit: information aboutwhat the RN considered as positive nursing achievementsor good nursing work; an exemplar of an occasion inwhich participating RN performed what they believed tobe good nursing work; and, where they positioned them-selves to sit along an optimisticpessimistic continuum inrelation to their work. When no data emerged, interview-ing ceased, providing a total of 40 interviews with RN.

    This paper focuses on questions that address goodnursing work and self-perceptions about being positive,optimistic, and hopeful or negative, pessimistic, and burntout. The responses to questions are analysed and dis-cussed. Results from the other interview questions are

    2 M. CLEARY ET AL.

    2012 The AuthorsInternational Journal of Mental Health Nursing 2012 Australian College of Mental Health Nurses Inc.

  • reported elsewhere (Cleary et al. 2012a; 2012b). Thequestions were:

    1 In your workplace, what would you identify as nursingachievements or good nursing work?

    2 Could you tell me about a time on the ward whenyou did what you believe to be good nursing work?Describe a situation, outcome, and whether it wasacknowledged.

    3 Optimism is an element of resilience and when facedwith adversity, resilient people are able to maintaintheir optimism rather than becoming overly negative orcynical. Do you consider yourself to be positive, opti-mistic, hopeful, negative, pessimistic, burnt out, or a bitof them all, about your nursing work in general? Whatdoes this depend on?

    Data were analysed in accordance with the tenetsof thematic analysis. This required close engagementwith the data, and an iterative process of reading andre-reading the narratives (Borbasi & Jackson 2008). Oncewe had developed a clear understanding of the nature ofthe data, key ideas were documented, labelled, catego-rized, grouped by hand, and sorted into a series of themesto reflect the participants views and experiences of goodnursing work in the acute mental health setting. Datawere analysed by two members of the research team tohelp ensure authenticity of findings and that the themesaccurately reflected conveyed meaning (Aronson 1994).The final analysis reveals that major topics articulated byrespondents fell into five themes.


    A total of forty RN interviews were completed. The fol-lowing five themes arising from the data are discussedbelow: (i) teamwork; (ii) interpersonal interactions withpatients; (iii) practical and holistic patient support; (iv)improved patient mental health; and (v) optimismpessimism continuum.

    Theme 1: TeamworkTeamwork was considered the outstanding nursingachievement by the nurse participants. One RN (16)stated that working well within the team with good com-munication, professionalism, fluid transfer of leadership,and initiative throughout the team is an importantachievement. Positive morale and teamwork amongst. . . the multidisciplinary team was also identified as anachievement (RN7). One RN (1) stated: The approach ofthe staff here is really flexible and positive. There is a goodculture of teamwork on this ward. Given the aggressive

    and volatile nature of the patients on this ward, theculture is flexible to the patients needs . . . The senseof teamwork here makes it easy to contribute to thetherapeutic relationship with patients.

    Teamwork is exemplified in RN18s example of goodnursing work, which involved the care of a person witha methamphetamine addiction admitted that day: weworked as a team to manage the aggression by activatinga duress and having enough staff to safely restrainand medicate him. This example emphasizes the dailyworking challenges and that nurses only have themselvesand each other to rely on. Being able to provide patientsand staff with a safe place is really important as a lot ofthese patients are here because they are a risk to them-selves or others and keeping all patients and staff safe isgood nursing work (RN3).

    Even when interviewees were asked to describe theirown good nursing work (the implication within the ques-tion being that an individual example was sought), nineparticipants spoke of teamwork, three more referred tomanaging staff, and two to teaching colleagues. Suchresponses may indicate the level of seniority of the RN, inthat those in charge or with significant clinical experienceare more likely directly involved in organizing and coor-dinating others work for the benefit of all, and teaching,mentoring, or supporting newer staff. Our findingssuggest that these aspects of nursing work were highlyvalued. RN9 commented on how she enjoyed being ableto support and mentor junior and newly employed staff .

    The value of teamwork was not only considered to beimportant from the point of view of enhancing the clinicalenvironment as a workplace, but it was seen to directlyand positively influence patient care. All the staff onthe ward tried to get the patient to see the need formedication, but as a team we spoke each day (RN1), andparticularly with patients with a borderline personalitydisorder, it is important to work with team consistency(RN26). In these and other instances, the idea of team-work involves perseverance, with all nurses being com-mitted to the same intervention or approach, so that thepower of the group is persistently and consistently rein-forced. The aim in these collective efforts is usually toensure that the least restrictive option remains availableto the individual patient.

    Theme 2: Interpersonal interactionsAlmost half of the examples of good nursing work focusedon one-to-one situations where the RN perceived thatshe or he made a breakthrough with a specific patient.The most common situation described was that of offer-ing and negotiating the use of prn (pro re nata, as needed)


    2012 The AuthorsInternational Journal of Mental Health Nursing 2012 Australian College of Mental Health Nurses Inc.

  • medication to prevent further deterioration of thepatients wellbeing. Almost as many examples involvedverbal and interpersonal deescalation of a patientsaggression, sometimes resulting in patient agreement totake medication. For example, There was a patient whowas quite psychotic and refusing all treatments and thera-peutic interventions. The only option was to seclude thepatient as the patient was aggressive and threatening toharm others. I took the patient to the courtyard and spentsome time deescalating the patient one-to-one andoffered the patient prn medication, which he accepted. . . he became cooperative for the rest of the stay on theward (RN2).

    Other examples included a patient over many shiftsbeing coaxed to feel safe enough to talk and provide hername: I can remember a patient who was adm...


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