Views and experiences of mental health nurses working with undergraduate assistants in nursing in an acute mental health setting

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Views and experiences of mental health nursesworking with undergraduate assistants in nursingin an acute mental health setting

Michelle Cleary,1 Jan Horsfall,2 Maureen O’Hara-Aarons,1 Judy Mannix,1 Debra Jackson3

and Glenn E. Hunt2,4

1School of Nursing and Midwifery, University of Western Sydney, 2Concord Centre for Mental Health, Sydney LocalHealth District, Concord Hospital, 3School of Nursing, Midwifery and Health, University of Technology and4Department of Psychiatry, University of Sydney, Sydney, New South Wales, Australia

ABSTRACT: Undergraduate nurses are employed as assistants in nursing (AIN) in inpatient mentalhealth settings; however, there is a paucity of published research exploring registered nurses’ (RN)views about the AIN role in these settings. This qualitative study documents the views and experiencesof RN working with undergraduate AIN. Fifty structured face-to-face interviews were analysed, andthe results are discussed in three sections. The first section outlines RN perceptions of qualities andskills required of AIN in mental health, and the responses primarily focus on communication skills,initiative, and willingness to learn. The second section targets factors in the workplace that mightenhance the interest of AIN in a mental health nursing career; the responses emphasize their need towork with experienced staff. The last section outlines RN expectations of AIN, most of which are metand involve physical observations and technical tasks; less fulfilled activities primarily cluster aroundinteractions with patients. Findings highlight the advantages and disadvantages of drawing on under-graduate nursing students as AIN in mental health settings. Communication skills, personal initiative,safety training to prevent violence, and education to increase knowledge and awareness about mentalillness, diagnosis, and mental status-related skills were all important concerns articulated by RN.

KEY WORDS: assistants in nursing, communication, mental health, safety, skill mix, undergraduatenursing student.

INTRODUCTION

The difficulty in attracting graduates of undergraduatenursing programmes into mental health nursing (MHN)

remains an ongoing challenge for the field, and it is widelyacknowledged that undergraduate nursing students donot always regard MHN favourably as a potential area ofemployment (Cleary et al. 2011). While 12-month transi-tion to practice programmes for registered nurses (RN)commonly aim to recruit MHN staff (Cleary & Happell2005a; Cleary et al. 2009a,b), there has been little explo-ration of the employment of undergraduate Assistants inNursing (AIN) in inpatient mental health settings (Clearyet al. 2012).

AIN in Australia work within various legislative andstatutory requirements under the supervision, guidance,and direction of RN with activities restricted according to

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. Email:[email protected]

Michelle Cleary, RN, PhD.Jan Horsfall, PhD.Maureen O’Hara-Aarons, RN, MN.Judy Mannix, RN, BEd (Nsg), MN (Hons).Debra Jackson, RN, PhD.Glenn E. Hunt, PhD.Accepted September 2011.

International Journal of Mental Health Nursing (2012) 21, 184–190 doi: 10.1111/j.1447-0349.2011.00784.x

© 2011 The AuthorsInternational Journal of Mental Health Nursing © 2011 Australian College of Mental Health Nurses Inc.

the job description (Cleary et al. 2012). Undergraduatenurses employed as AIN in New South Wales (NSW),Australia must possess a Health Services CertificateIII, have equivalent experience, or be in the second orthird year of their Bachelor of Nursing programme(unless other qualifications and/or experience are deemedequivalent) (Department of Health, NSW 2010).

It is not known whether a positive clinical experienceworking as an AIN is a successful strategy for influencingthe attitudes of nursing students towards a more favour-able perception of MHN (Cleary et al. 2012). Researchshows that clinical experience in mental health settings islimited in Australian undergraduate nursing programmes(Happell 2008). Clinical experience in the mental healthfield as an AIN not only provides undergraduate nursingstudents with opportunities for extended clinical exposure(Happell & Gough 2007), but is also a feasible recruit-ment strategy through increasing undergraduate nursingstudents’ knowledge of and confidence in the field.

To date, research has emphasized strategies topromote positive clinical experiences for undergraduatenursing students (Cleary & Happell 2005b), but not nec-essarily for undergraduates working as AIN. To maximizethe benefits of AIN programmes for undergraduatenursing students, evaluation of exposure to clinical set-tings is crucial to determine how such programmes can beimproved. Furthermore, with a MHN workforce in crisisand an absence of speciality-trained mental health staff, itis likely that the use of AIN will increase. It is against thisbackground that the current exploratory study was devel-oped. The aim of this exploratory study is to ascertain theviews of RN in mental health inpatient settings who haveworked with AIN undergraduate nursing students in themental health workplace. Although we acknowledge thatthe views of AIN are important, so too are the views ofRN. This is particularly so because although AIN getsome choice and have autonomy over whether or not theywill become AIN in the mental health environment; RNhave little choice over whether they work with AIN or not.

METHOD

This project was approved by the hospital HumanResearch Ethics Committee, and reciprocal approval wasgiven by the university Human Research Ethics Commit-tee. The setting was a large, specialist mental healthcentre in Sydney, Australia that has acute units, and arecovery and an extended recovery unit. The study wasconducted in May 2011.

Over a 4-week period, an experienced mental healthnurse with previous employment experience of the Area

Mental Health Service visited inpatient units two to threetimes per week to explain the purpose of the study andinvite RN to participate. As a skilled interviewer familiarwith routines and procedures in the setting, her presencecaused minimal disruption in the busy inpatient units.Participation in the face-to-face interview was voluntary,and no identifying information or demographics wereincluded on the schedule used to document the verbatimresponses of the RN. Written questions were providedbeforehand to allow the RN time to consider and reflecton the topics, and prepare for the interview.

The 10 structured interview questions focused on RNexperiences of working with AIN; the skills they preferredin an AIN; their views on contributions that AIN actuallymake to clinical care; activities they expect an AIN toparticipate in; the personal qualities that make an AINuseful in mental health; what orientation or training AINshould receive before entering the hospital units; in situsupports that would benefit AINs, patients, and otherstaff; what would assist AIN to specialize in MHN; andwhat satisfactions, challenges, difficulties, or privilegeswould RN convey to an AIN anticipating a MHN career.RN were also asked to discuss any further AIN-relatedissues they considered important, but were notadequately addressed by previous questions. When ideasreached ‘saturation’, interviewing stopped; a total of 50interviews were completed with RN.

In keeping with the tenants of thematic analysis, tran-scripts of the responses to the questions were read andreread to gain an overview of the nature of issues raised byrespondents (Aronson 1994). Each response was consid-ered to determine recurring ideas and concerns. Regard-less of the terminological differences, congruence ofmeaning was sought. Responses were listed and priori-tized by frequency. The main responses were then clus-tered together to form groups that related to each otherwithin and across questions. The last phase of analysisreveals that major topics articulated by respondents fellinto three categories.

RESULTS

Major topics articulated by RN were grouped into threecategories. The first group addressed issues around quali-ties and skills necessary to work effectively in inpatientmental health settings, and these related to orientationrequirements. The second topic focused on career poten-tial, and considered supports for AIN, a MHN trajectory,and the RN perceptions of mental health as a specialty.The third category targeted RN expectations versus actualAIN work; these led to responses to the open question,

WORKING WITH NURSING UNDERGRADUATES 185


wherein RN primarily summarized concerns about theirexperience of working with AIN.

Fifty interviews were completed with RN who workedacross admission, acute recovery, and extended recoveryunits, thus providing a good spread of respondents acrossthe range of inpatient mental health settings. Thirtythree of the RN worked in acute admission units. Effectsof the actual work area on responses (e.g. admissionsvs recovery units) were considered during analysis, andthe responses showed no difference between theseunits.

Qualities and skills deemed necessary to work inmental health settingsThe data discussed in this section arise from questionstargeting the qualities and personal skills required for anAIN to be useful in inpatient mental health units, as wellas RN expectations of orientation-training programmecontent. The following outlines the main responses tothese questions in order of frequency.

Communication and interpersonal skills were the mostcommonly nominated and emphasized qualities. Giventhat the AIN can spend considerable time interacting withpatients, it is essential that they do so with appropriateskill and sensitivity. The expected communications skillsflow in all directions, as one RN pointed out: ‘I do expectan AIN to report anything, even minor things to me’(RN39). Some RN noted that written communicationsare also important in these settings.

Responses highlighting the need for personal initia-tive and autonomous action were almost equivalent inimportance and frequency as communication skills. Thisrelates to the requirement that AIN are under RNinstruction, but clearly, if the employee waits for specificorders or frequently seeks instruction, then the workloadof RN becomes onerous. A few RN commented thatsome AIN spent too much time in the office, and oneRN stated that if s/he has to keep telling AIN to carryout designated activities, s/he may as well do them(RN31).

‘Willingness to learn’ and ‘keenness to work’ featureprominently. One respondent summarized these expecta-tions as: ‘patience and willingness to learn, to be coopera-tive and a team player; to know how to work as a teammember’ (RN28). As well as these, many respondentshoped that AIN would be friendly, approachable, caring,and have the potential to develop rapport with patients.At the personal and interpersonal level, one intervieweestated: ‘I believe empathy, sensitivity, and emotionalcontrol are all important’ (RN8). One nurse summarizedthis cluster of personal qualities:

They should be approachable, have good communicationskills, be open-minded, be eager to learn, and be willingto work as part of a team. (RN14)

Within responses regarding their expectations of ori-entation or pre-employment training, safety emerged asthe key issue. The shorthand term that the RN used tocover this multifaceted concern was the CIPO (criticalincident positive outcome) training programme. Forexample, if an AIN leaves a kitchen door open when itshould be locked, this has the potential to endangerpatients and staff in the unit; or if an AIN does not rec-ognize and respond appropriately to an agitated patient’sspatial needs or inability to concentrate on words, s/hemight inadvertently behave intrusively and upset thatpatient, which can have a domino effect in the unit:

Just like a good psych nurse, they need CIPO training,good communication skills, and willingness to learn andask; a genuine interest in the mental health field, not justlooking at this role as just a job. (RN12)

Other expectations of pre-entry training included anunderstanding of ward routines from the most obvious –‘They should not be lazy, and they need to know what todo and what is expected of them; for example, answer thedoorbell if it rings, rather than waiting to be asked’(RN31) – to the most subtle or sophisticated ‘empathy,sensitivity, and emotional control’ (RN8), which havebeen developed to facilitate effective overall unitfunctioning.

The third significant concern is that AIN shouldunderstand the nature of mental illness; have an idea ofpossibilities and limits of patient accessibility andresponsiveness, depending on psychiatric diagnosis; andmost importantly, have good verbal, audio, and activity-level observations skills to recognize behavioural changesthat warrant reporting to an RN or the nursing unitmanager. This concern permeates everything that RNdo, as one respondent simply stated: ‘their knowledgeof mental health and self-awareness and awareness ofworking with a team’ (RN20) is an integral aspect of wholeunit functioning.

MHN career possibilities for AINIf supports (Q7) are not provided for AIN, there areobvious negative consequences. The most frequentresponse to the question about necessary supports forAIN was that they should have experienced staff workingwith them at all times on every shift, and some RNbelieved a designated supervisor or preceptor should beallocated:

186 M. CLEARY ET AL.


AIN should take a patient load on each shift and shouldhave a preceptor or supervisor, but the problem is wehave new graduates who also need that support, and theremight not be enough senior staff for all the roles. (RN3)

Some respondents suggest that the AIN, althoughemployed casually, should be utilized in the one area allthe time:

I would be happy if they had a preceptor, but this is notpossible, as they are not permanent in one setting. Theyshould be working with senior staff on every shift and beable to ask questions. They do need lots of supportbecause of their lack of knowledge. (RN4)

The issue of support comes full circle when the ques-tion of an AIN career in mental health is addressed. Thetwo most common responses are that for AIN to considerMHN as a career, the staff who work with them should besupportive and friendly, and that the experiences of AINshould be positive and worthwhile:

Welcome them to the unit and have a proper induction;they should be kept busy and let them see things thathappen on the ward, even if they can’t participate ineverything. Include them in team conversations, giveclear expectations, and teach them, even if they don’talways ask. (RN20)

A few respondents perceived that as MHN is peopleoriented, AIN who develop an enthusiasm for its intrinsicchallenges and rewards are more likely to take it up as aspecialty in the future, along with those who appreciateworking as part of a close-knit team:

I think that when I was an AIN that I came back to mentalhealth as an RN because the staff were nice and support-ive. A good experience in mental health helps, and theyneed to be well educated while they are here working asAIN on the ward. (RN11)

When discussing MHN as a future prospect with AIN,RN would emphasize satisfactions (n = 25), challenges(n = 19), and difficulties (n = 5), with one nominating aprivilege. The satisfactions the RN nominated involvedworking with patients whose well-being can actually beseen to improve. Some appreciated the diversity of indi-viduals and variety of work, and the flexibility and inter-personal challenges that emanate from unpredictability inthe settings. Others valued the opportunity to work withthis particularly vulnerable and often neglected cohort.

The challenges nominated returned to the respon-dents’ emphasis on communication skills, in that experi-enced RN continued to broach communication andrelational impediments with some patients that involve

delicate negotiations backed up by solid foundationalcommunication principles. One respondent pointed out:

Mental health is often challenging—and emotionallychallenging—so they (AIN) have to stay calm and work inthose situations. (RN6)

Nominated difficulties, as highlighted by the researchparticipants, indicated verbal and physical aggression as apermanent possibility and an occasional occurrence,regardless of positive intentions and good nursing care,given the fear experienced by many hospitalized patients,along with distress or anger related to their presentpredicaments:

You can be verbally abused by patients for no reason, andit is important to be able to debrief and work it out withcolleagues. (RN10)

Practical concerns of RN regardingAIN employeesIn this section, the data discussed mainly arise from ques-tions addressing RN expectations of AIN contributions tothe workload (Q4) and the activities that AIN actuallyfulfil (Q3). These practical expectations also relate to thebulk of responses to the open question (Q10), in whichthe interviewer sought further comments about theemployment of AIN in inpatient mental health settings.

The majority of respondents’ expectations wereadequately fulfilled, and these are outlined in order ofsatisfaction. The greatest contribution AIN make is that ofphysical observations of patients, where more than threetimes as many respondents noted their satisfaction in thisregard, in comparison to those who actually named this asan expectation. The requirement to closely observe somepatients (prescribed close observation/care levels) werenot commented upon nearly as frequently, but again,there were three times as many satisfied respondents asthere were who nominated this activity as an expectation:

Observations, BSL, care level 2 rounds; I would like themto talk to the patient. They are not students, so I expectthem to contribute as much as they can. (RN50)

Bed making was the third highest named activity thatAIN fulfilled. This might be associated with high patientturnover and acuity of admission in these wards:

I would expect them to do bed making. They can’t go topharmacy to collect orders and they do not attend duresssituations. AIN do answer the door to locked units, butsometimes have let the wrong people in. For example, wehad a patient here on the ward with substance abuseissues and the AIN let the patient’s boyfriend in the wardwhen he wasn’t allowed; this resulted in an incident



where staff had to ask him to leave and he refused. Secu-rity had to be called because he became aggressive. (RN3)

Although bed making is not specialist or unique toMHN, contributing to the provision of a safe and cleanenvironment while still engaging with clients, and beingable to observe expert mental health nurses go about theirduties with clients was viewed as useful for the AIN andhelpful to their gaining a realistic perspective of MHN.Taking blood sugar levels was as commonly appreciated asbed making, indicating the physical health monitoringneeds of many acutely mentally unwell patients:

I make a list for the AIN at the start of each shift and writedown what patient physical observations are due on theshift as well as BSL. They should help make beds andclean rooms when patients are discharged. (RN4)

Along similar lines, many respondents considered AINvery helpful in assisting patients with activities of dailyliving (ADL), even though nobody nominated ADL intheir expectations. The sixth most fulfilled expectation,where fulfilment responses exactly matched expectations,was that of participating in group activities.

There are three domains where RN expectations havenot been adequately fulfilled: these relate to interactingwith patients, writing up patient notes, and gauging themental status of patients. The view that the main work ofAIN is to interact with patients relates to communication,initiative, and personal confidence issues associated withpre-entry training and preparation, which emerged inresponse to other questions. Many RN expected AIN towrite progress notes on patients they have worked withthroughout the shift, as the RN have often put muchthought into allocating these patients to the AIN on thegrounds that they are comparatively ‘settled’, and there-fore, easier to get to know and less likely to behave unpre-dictably. At least one respondent said that AIN couldwrite draft patient summaries and show them to the RNwho must countersign them when they are put into thereport:

I expect them to do some progress notes, but RN need tocountersign them. . . . I would get the AIN to write thenotes on settled patients, and if there are any incidents, Ido those progress notes myself. (RN38)

The final domain where expectations of AIN were notat all fulfilled was that of gauging the mental status ofpatients and reporting back to the RN if there was behav-ioural change or evidence of patient difficulties.

In response to the open question, the most commonresponses concerned skill mix and extra work for RN inminimally-staffed acute units. Skill mix and extra RN

burdens feed into the second most common area ofconcern: safety in wards when RN are overworked andunderstaffed. The single most commented upon issuearising from the last question was the need for aggressionmanagement training for each AIN to prevent dangeroussituations and enable RN to know that the casualemployee had at least been through this training and hadsome level of awareness of the fragility of interpersonalsituations in acute inpatient units.

The third domain mentioned nearly as often was thatof medication, which relates back to skill mix and extrawork for RN. Respondents who nominated this area as aconcern also considered that AIN need to be aware of theside-effects of commonly-used psychotropics, especiallywhen a patient has changed medication, had another drugadded, or had the dose significantly increased.

DISCUSSION

This research draws attention to the clear advantages anddisadvantages of recruiting undergraduate nursing stu-dents as casual staff in mental health inpatient units. Theadvantages are ‘an extra pair of hands’ to carry out physi-cal observations and work, such as bed making. However,the complexity of the work in the units, which involvesinterpersonal skills and subtle observations of patientbehavioural changes, means that the personal qualitiesand life experience of the AIN are important. Thus com-munication is the most frequently articulated theme, fol-lowed by personal initiative. This is not surprising, givencommunication and interpersonal skills are emphasizedqualities for support workers (Moran et al. 2011). AINcommunication skills, personal initiative, and willingnessto learn, along with a personable and open approach topatients, against a background of unit-wide concern forinterpersonal safety, were deemed the collective respon-sibility of the nursing staff. This ‘willingness to learn’ and‘keenness to work’ corresponds to the ability of the AIN toextrapolate from one type of instruction, remember keypoints about what to do and what not to do, and appreci-ate patient subtleties and the precariousness of the mentalstate and well-being of patients. That is, the importancethat RN place on ‘keenness to work’ relates to the poten-tial that each AIN has to be a contributor to the team,rather than an extra burden, given the multiplicity ofconcerns implicit in being responsible for patients with anacute serious mental illness.

The next most common responses emerged from thequestion on pre-entry orientation, and focused on thenecessity of AIN safety training to prevent violence, andeducation to increase knowledge and awareness about



mental illness, diagnosis, and mental status-related skills.Prudent employment of AIN in the acute mental healthservice clearly has the potential to improve the quality ofcare provided to people with acute mentally illnesses,particularly those with poor general health, comorbidities,or self-care deficits. It is clear, however, from the resultsthat RN require fellow workers of any designation to becaring, communicative, person-oriented people who areable to quickly learn a repertoire of understandings andskills on the job in a milieu characterized by unpredict-ability. Furthermore, AIN employment can provideimportant support to RN in the sector, and continuededucation of these workers would only increase theirpotential, both as providers of care to people with acutementally illnesses and support to RN.

If supports are not provided for AIN, there are obviousnegative consequences for RN, patients, and AIN, ingeneral. Some RN believe that a designated supervisor orpreceptor should be specifically allocated (Happell 2008;McCann et al. 2009; Meek 1998) to each AIN. Groups ledby other team members might also provide opportunitiesfor AIN to observe experts at their craft and learn fromthem, as well as developing skills of observing patientbehaviours in a different environment. Participation ingroups also allows AIN to engage with patients in non-routine ways when the focus is on the group activities.This would address the complex awareness and skillsrequired of an AIN to work effectively within a given unitenvironment, rather than creating apprehension and vigi-lance among other staff vis-à-vis the AIN because of theirneophyte and unknown status.

That some RN consider that AIN do not interact suf-ficiently with patients nor gauge the mental state ofpatients and report back is not a simple mismatch issue, asthey are undergraduate students with limited mentalhealth knowledge who might be fearful and anxious in theclinical setting (Fisher 2002). From an RN perspective, itis easy to see why this skill would be hoped for, as it is partof the collective awareness at the unit level necessary toassess patient changes and pre-empt problems. From acomparatively untrained AIN position, a mental statusexamination is too complex. However, pre-entry trainingabout psychiatric diagnoses and behavioural manifesta-tions of internal difficulties and distress could begin toaddress this knowledge awareness gap.

It seems to be common practice that AIN areemployed when RN are unavailable, and many respon-dents interpret this as a misunderstanding of their multi-faceted work and responsibilities. As a result of adding anAIN (who is likely to not have worked in that settingbefore), the understaffed RN actually have more respon-

sibilities associated with the presence of a worker withunknown levels of commonsense, interpersonal aware-ness, and limited or no experience with patients who havea mental illness and are hospitalized.

Clearly, AIN should not be allowed to administermedication, but there is a cluster of responsibilities sur-rounding medication beyond actual administration, suchas being aware of the side-effects of medication. As well asregular medication, many patients have pro re nata (PRN)medication prescribed as needed (Baker et al. 2007). It isup to the nursing staff to be aware of the patient’s mentalstatus, and to discern when their well-being is deteriorat-ing, or to act promptly when the patient requests PRNmedication (Baker et al. 2008; Duxbury et al. 2010).

The major limitation of this study is that data werecollected from a single health service and ascertained RNviews only. Therefore, it is not clear whether these find-ings would reflect the situation across the sector. Thestrengths of this study include the sample size, which islarge for a qualitative study, and the fact that all respon-dents were currently in the acute mental health sector andhad current experience working with AIN. Futureresearch should study how the benefits of undergraduateAIN employment can be maximized through the evalua-tion of exposure to clinical settings and the perceptiongaps between AIN and RN in mental health settings, andif there are any.

CONCLUSION

In conclusion, the findings of this study suggest that AINprovide valuable assistance to RN in this acute mentalhealth setting. While initially, at least, the AIN might havelacked specific mental health skills, they were able toassist patients with ADL, which helped to ensure optimalclinical care for people with acute mentally illnesses. TheAIN were able to assist with routine nursing care, such asbed making, observations, monitoring of BSL, and ADL.This meant that the expert mental health nurses werebetter able to focus their time on the provision of MHNskills. However, in order to optimize the potential of theseAIN, there is a need to ensure they have access to appro-priate orientation and training that should occur immedi-ately on appointment, with opportunities for continuedskill development. This would mean that these AIN wouldbe able to improve their knowledge and skills in relationto acute care MHN. The provision of such educationcould have both short- and long-term benefits in the clini-cal area, particularly if the AIN later becomes a mentalhealth nurse upon completion of the undergraduatedegree.



ACKNOWLEDGEMENTS

The project was partially funded by the School of Nursingand Midwifery, University of Western Sydney.

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Documents

Views and experiences of mental health nurses working with undergraduate assistants in nursing in an acute mental health setting