Accepted: 13 April 2017

DOI: 10.1111/jpm.12392

ORIGINAL ARTICLE

Breaking down the stigma of mental health nursing: A

qualitative study reflecting opinions from western australian
nurses

Carole A. Harrison RN, RMN, BSc(HONS) Psych, GradDipEd, MSc Psych, former Principle Officer
Intergovernmental Relations1,2,3 |Yvonne Hauck BScN, MSc (Nursing), PhD, Professor4,5|
Rebekah Ashby RN, MSc (Nursing), Mental Health Team Leader6

1
Office of The Chief Psychiatrist, Perth, WA,
Australia
2
North Metropolitan Health Service Mental
Health, Perth, WA, Australia
3
School of Psychiatry and Clinical
Neurosciences,University of Western
Australia, Perth, WA, Australia
4
School of Nursing, Midwifery and
Paramedicine,Curtin University, Perth, WA,
Australia
5
Department Nursing Midwifery Education
and Research,King Edward Memorial
Hospital, Perth, WA, Australia
6 Previous research has focused on why mental health nurses leave the profession
Rockingham Kwinana Mental Health
Service,South Metropolitan Health Service,
Perth, WA, Australia
Correspondence
Carole A. Harrison, Office of The Chief
Psychiatrist, Mental Health Commission,
Perth, WA, Australia.
Email: carole.harrison1@gmail.com
Accessible summary
What is known on the subject?
The rate of mental illness in the general population is ever increasing
Mental health nurses are ageing, and this is not a preferred career for new gradu-
ates; thus, recruitment and retention of mental health nurses is declining
Stigma is attached to the view of mental illness and the role of a mental health
nurse. If this stigma can be reduced, it may provide an opportunity for the profes-
sion to become more popular and assist recruitment in this area
What the paper adds to existing knowledge?
which has not provided successful results
This study adopts a new way of working whereby we gathered opinions from cur-
rent mental health nurses focusing on why they originally wanted to work in mental
health
What are the implications for practice?
New findings presented in this paper will guide improvements in nurse training,
policy development for mental health services and improve recruitment of the next
generation of mental health nurses
The findings provide a strong message that in order to entice others to work in
mental health, we need to first address breaking down the stigma related to mental
health nursing
Abstract
Introduction: A lack of understanding surrounding the role of mental health nursing is
associated with recruitment and retention challenges. Additional complexities include
stigma related to the role, an ageing workforce and dearth of graduates keen to pursue
this career.
Scientific Rational: Previous research has focused on why nurses leave the profession
which has not provided necessary solutions. There is a need to instead explore why
nurses originally chose a career in mental health.

J Psychiatr Ment Health Nurs. 2017;24:513522. 2017 John Wiley & Sons Ltd | 513
wileyonlinelibrary.com/journal/jpm
 |
514 HARRISON etal.

Aim of study: This qualitative study focused on opinions and experiences of existing
mental health nurses to determine what could be performed to entice nurses to choose
mental health.
Methods: A cross-sectional design involving a brief interview was conducted with 192
Western Australian nurses from one public mental health service.
Results: Thematic analysis revealed an overarching theme breaking down stigma and
additional themes of: visibility of mental health nursing and growing mental health
nursing. Subthemes under visibility included self-promotion plus industry and uni-
versity promotion, whereas subthemes related to growing focused upon improving
the student experience. Finally, recognizing the mental health specialty was identi-
fied for an attractive career pathway.
Discussion: This study adds to international evidence and showcases unique insights
from mental health nurses into why they chose a career in mental health whilst previ-
ously replicated research focused on why nurses chose to leave.
Implications for practice: Findings suggest that before we can entice nurses to choose
mental health, there is urgency to reduce stigma related to the role. Breaking down stigma
will allow the role to become more visible and be represented in a more positive authentic
manner. New findings in this paper will drive improvements of future nurse education,
policy planning and recruitment design for the next generation of mental health nurses.

KEYWORDS
cross-sectional design, mental health nursing, recruitment, retention, stigma

1| INTRODUCTION
There appears to be a fundamental lack of understanding surrounding
the role of mental health nursing and why it merits being described as
a distinct specialty within nursing. Hercelinskyj, Cruickshank, Brown,
and Phillips (2012) have described this dearth as resulting from a
weakly defined professional identity, which is intrinsically linked to the
unpopularity of the specialty (Happell & Gaskin, 2013).
Traditionally, mental health nursing has been inextricably linked
with psychiatry in that the role was medically driven and built on di-
agnostic classification and labelling (Martyr, 2010). Diagnostic labelling
has long been recognized as the catalyst for stigma and may also be re-
garded as a barrier to developing and sustaining the nurse patient part-
nership (Farley-Toombs, 2012). Furthermore, Gouthro (2009) proposes
the public perception of mental illness can be largely negative which
has consequentially impacted the popularity of mental health nursing
due to stigma by association (Halter, 2008). Stigmatizing attitudes are
evident from other peer healthcare professionals (Halter, 2008). Sercu,
Ayala, and Bracke (2015) suggest that due to this associated stigma,
mental health nursing is impacted significantly by decreased visibility
and a declining growth in those attracted to this specialty area.
The perception of mental health as one of the least attractive dis-
ciplines for nurses has adversely affected sustainability of the mental
health nursing workforce. As a global concern, this has been debated
in the literature (Halter, 2008; Happell & Gaskin, 2013; Humble &
Cross, 2010; Hunter, Weber, Shattell, & Harris, 2015; Stevens, Browne,
& Graham, 2013). Key factors surrounding the reluctance of nurses to
choose mental health are commonly identified as negative clinical ex-
periences (Gouthro, 2009; Hayman-White & Happell, 2005; Humble
& Cross, 2010) and the lack of awareness surrounding mental illness
(Gyllensten etal., 2011). Whilst clinical experiences are intended to pro-
vide essential practical experience, this often translates negatively due
to the lack of preparation of student nurses in the mental health area
(Hunter etal., 2015; Moxham, McCann, Usher, Farrell, & Crookes, 2011).
Adding to these recruitment and retention complexities is the age-
ing workforce within mental health nursing. In Australia, the average
age of a mental health nurse in 2014 was 47years (Australian Institute
of Health and Welfare, 2016). The proportion of nurses aged 55years
and over was 31% in 2014, which is in sharp contrast to registered
psychologists whose workforce profile shows 73% are younger than
55years. With an ageing workforce, and difficulties in attracting gradu-
ates, Australia is experiencing a critical mental health nursing workforce
shortage, which is projected to continue into the future. Without inno-
vation and the application of informed recruitment and retention strat-
egies, sustainability of the mental health nursing profession is uncertain.
Recruitment and retention strategies for the mental health nursing
workforce are regularly debated in the literature (Happell & Gaskin,
2013; Hercelinskyj etal., 2012; Scott, 1996; Stevens etal., 2013).
As well, a significant proportion of the research has focused on the
reasons why nurses choose to leave the profession (Flinkman, Leino-
Kilpi, & Salanter, 2010; Heinen etal., 2013; Rhaume, Clment, &
Lebel, 2011; Tummers, Groeneveld, & Lankhaar, 2013), which for all
HARRISON etal.
intents and purpose should be considered a valuable factor to assist
future recruitment and retention planning. However, responses to this
question are simply not providing the necessary solutions. There is
a distinct dearth of research which specifically explores why nurses
choose to become a mental health nurses. It is evident that a unique,
more innovative approach is called for in this quest for the Holy Grail.
There should be more investment in exploring the reasons why nurses
choose a career in mental health nursing and harnessing their sugges-
tions of how to attract a future workforce, if we are to pave the way
for a future sustainable workforce. For our study, we chose to employ
a powerful method of gathering stories to do just this, using a mental
health nurse to survey other mental health nurses in a collegial, non-
threatening environment thus promoting valuable discussion.
The aim of this paper was to explore how mental health nursing
could be promoted as a sustainable career option. A qualitative ap-
proach has been adopted because of our focus on the opinion and
experience of existing mental health nurses from a Western Australian
public mental health service perspective.
2|METHODS
2.1|Design
Two open-ended questions were posed in this cross-sectional study
with a qualitative exploratory approach, which reflects the opinions of
Western Australian mental health nurses employed in one public met-
ropolitan health service at a single point in time (January to May 2013)
(Laimputtong, 2013). Cross-sectional studies traditionally use surveys to
gather information from a convenience sample (Schneider, Whitehead,
LoBiondo-Wood, & Haber, 2013), whereas this exploratory study used
an interview strategy to facilitate nurses responses and investigate their
opinions around enhancing the sustainability of mental health nursing.
2.2|Setting and participants
The sample was drawn from all nurses employed within one public
mental health service in Western Australia. In 2013, the population
consisted of 853 mental health nurses employed in adult inpatient,
older adult inpatient, adult forensic inpatient, adult community, older
adult community or education and research. Senior nursing staff in
the service facilitated the dissemination of information of the study
to all nurses through global emails and fliers distributed at key nursing
meetings and also posted on notice boards.
2.3|Data collection
The principal researcher, an experienced senior nurse researcher
with registered nursing qualifications gained overseas in both men-
tal health and general, conducted all interviews with nursing staff in
private. She was available to staff during designated dates and times
within all clinical settings, as advertised on fliers. Nurses who were
interested after being informed of the study were able to approach
the researcher within the clinical setting to participate in a brief
|
515
face-to-face interview. Arrangements were also made for telephone
interviews for those who could not attend a face-to-face interview.
Informed verbal consent was obtained from nurses prior to commenc-
ing interviews, which lasted between 10 and 20minutes.
The two questions asked of each nurse were as follows: (i) Was there
something specifically in your nurse education that encouraged you to
decide to work in mental health nursing and (ii) in your opinion what
could be done to entice nurses to choose to work in mental health?
Responses to the questions were recorded manually, and the nurses
were asked to read and amend the written responses as required to
accurately reflect their opinion. Data collection was consistent as one
researcher collected and transcribed all data prior to the team analysis.
Demographic data were also collected prior to the interview to provide
a profile of the participants, which included age, sex, current nursing
registration, country where mental health nursing education was ob-
tained, current work setting and years practicing in mental health.
2.4|Data analysis
Data saturation, whereby new data provide redundant informa-
tion was reached (Fusch & Ness, 2015) around the 150th interview
but we felt it was ethical to continue conducting interviews with all
participants who contacted us and expressed a desire to share their
thoughts and opinions. Thematic analysis was used to analyse nurses
opinions of what could be done to entice nurses to choose to work
in mental health: the premise being that themes would capture the
essence of the data and represent a patterned response in relation
to the research question (Braun & Clarke, 2006). A team of three re-
searchers: two mental health nurses and one non-mental health nurse
conducted the analysis. The analysis was conducted by a team of re-
searchers to minimize the possibility of bias in interpretation.
We utilized Braun and Clarke (2006) phases of thematic analysis as
follows: (i) familiarizing yourself with your data: the team of research-
ers became familiar with the data by reading and re-reading and noting
down preliminary ideas, (ii) individual team members coded features of
the data and then collated all data relevant to a specific code, (iii) codes
were collated into potential themes, and relevant data were gathered
for each potential theme, (iv) the team together interpreted themes
in relation to coded extracts and developed a thematic map of the
analysis which included identification and relative strength of major
and minor themes, (v) further analysis of themes continued until clear
definitions and names for each were agreed upon and (vi) a final report
was produced. The research team conducted a number of presenta-
tions to share study findings at nursing forums, committee meetings
and in the clinical setting. Study participants were contacted and in-
vited to attend in order to provide essential feedback related to the
themes in order to confirm the researchers analysis and interpretation.
2.5|Ethics
The Human Research Ethics Committee of the North Metropolitan
Health Service Mental Health granted quality improvement exemp-
tion from ethical review for this study in January 2014. The study
 |
516 HARRISON etal.

was undertaken with the consent of the participants and the institu- was not only vital for the individual practitioner but also required a
tion involved. The activity did not impose an additional risk of harm, system approach.
discomfort or burden on participants beyond that to which they may
already be exposed. The interviews transcripts were anonymous, and We as an organization dont do enough to de-stigmatize
no private information of any participant was identifiable. mental health nurses are stigmatized by working in mental
health
(1).
3| FINDINGS

Of all nurses who agreed to participate in this study, no one withdrew.

One hundred and ninety-two mental health nurses participated in the
study: 58.9% (n=113) were female and 41.1% (n=79) were male.
The majority of nurses were over 50years of age (48.4%, n=93)
with 24.5% (n=47) being 41 to 50years, 17.7% (n=34) being 31
to 40years and the smallest number 9.4% (n=18) being less than
30years. Years practicing in mental health ranged from 1 to 49years
(mean of 22.7years; mode 30 and median 25). Registered nurses
dominated the sample (93.8%, n=180) with 6.3% (n=12) being
registered as an enrolled nurse. The majority were educated in Western
Australia (46.9%, n=90) with the United Kingdom representing the
second highest group (35.4%, n=68) and smaller numbers from other
Australian states (9.4%, n=18) and other countries (8.3%, n=16).
The clinical settings where participants were employed included
adult inpatient (30.2%, n=58), older adult inpatient (20.8%, n=40),
adult community (16.1%, n=31), forensic inpatient (14.6%, n=28),
older adult community (4.2%, n=8) and other (4.7%, n=9). Nurses
employed in mental health settings in Australia are not required
to have a specific mental health nursing qualification due to the
curriculum in comprehensive university programmes addressing
the standard of maintenance of health and prevention of illness for
individuals with physical or mental illness (Australian Nursing and
Midwifery Accreditation Council (ANMAC), 2012).
An overarching theme breaking down stigma emerged in re-
sponse to how participants felt nurses could be enticed to choose to
work in mental health. Two themes were captured under this overar-
ching theme: visibility of mental health nursing and growing men-
tal health nursing. Seven corresponding subthemes, definitions and
supporting quotes are summarized in Table1. To support our findings,
direct quotes are offered from the participants in italics along with a
code (1 to 192) assigned to each nurse.
3.1.1|Visibility of mental health nursing
Nurses felt that the visibility of mental health nursing needed to be
improved.
If the profile is heightened then people will be attracted
to work here
(18).
Three subthemes around how promotion was needed to enhance
visibility were captured under three subthemes: self-promotion, indus-
try promotion and university promotion. Promotion at all levels was
deemed essential so a clear understanding of the role of a mental health
nurse was being portrayed. Due to concerns around lack of awareness
and misinformation about this nursing role, participants shared how the
appeal of this speciality to prospective nurses had been compromised.
Mental health nursing is the red-headed step-child of nurs-
ing careers
(152).
3.1.2|Self-promotion
The mental health nurses acknowledged that as a profession they
needed to improve their own self-promotion as it was recognized
that motivated staff would attract new staff (70). Taking ownership in
how individuals demonstrated pride and promoted their profession was
accepted as an important strategy. With regard to the sustainability of
future mental health services, providing student nurses the opportunity
and access to positive role models was viewed as a means to entice
nurses to consider mental health nursing as a rewarding career.

3.1|Overarching theme: Breaking down stigma

The stigma associated with mental illness that can affect patients was
felt by nurses to have a wider impact beyond consumers and also in-
fluence the context of mental health care and its practitioners.
Mental health nursing needs to be de-stigmatized and
normalized
(51).
In fact, nurses felt they had a role to play in combating stigma. We
need to break down the stigma (57). The responsibility to oppose stigma
[Nurses] need to be made aware that their negativity is im-
pacting on the service recruitment and that they dont actively
encourage students to go into mental health nursing. We as a
group of mental health nurses need to take ownership
(161).
3.1.3|Industry promotion
Industry was also seen to have an important role in the promotion of
mental health nursing. Participants shared that the variety of clinical
settings where nurses are able to practice should be used to entice
HARRISON etal.
T A B L E 1 Encouraging and enticing nurses to choose to work in mental health: themes, subthemes, definitions and supporting quotes
Overarching theme:Breaking down stigma
Theme: Visibility of mental health nursing
Participants felt the visibility of mental health nursing needed to be improved
and responsibilities of this specialty better articulated in order to demystify the
role.
Self-promotion
Nurses felt they needed to improve their own self-promotion and that taking
ownership by demonstrating pride was acknowledged as an important strategy.
Industry promotion
Nurses working in clinical settings can also promote the profession by being a
role model to inspire others
University promotion
Dedicated and committed mental health nurses with a passion with their
profession were recognized as key instruments to get nursing students to
consider a career in mental health.
Theme: Growing mental health nursing
In order to make mental health nursing more enticing, participants felt that
growth was required by improving the student experience, promoting
professional development opportunities for existing nurses, recognizing that
mental health was a specialty and demonstrating that staff were valued.
Improving the student experience
The timing and exposure to mental health content and dedicated clinicians was
recognized as an issue. Mental health nurses within the university sector can
be more strategic in introducing this career option. Extended time in the clinical
area was suggested with better access to supportive staff.
Professional development opportunities
The participants shared concerns around the attention and value demonstrated
to sustain the existing workforce. Improving opportunities for professional
development were regarded as essential such as preceptor education and
support. This aligns with the nurses reflections around the importance of the
student experience.
Recognizing the mental health specialty
Nurses felt that mental health nursing needed to be recognized as a specialty
within nursing. Although the comprehensive nursing programs prepare nurses
for mental health issues within general nursing settings, the preparation and
recognition for those nurses who want to work in designated psychiatric
clinical areas was felt to be inadequate.
Valuing staff
Suggestions included improvements to physical conditions for patients in
clinical settings. Another commonly shared concern was safety of staff and
managing patient aggression. Developing clear and attractive career pathways
for mental health nurses was recommended.
people into mental health nursing by showing the career option in a more
diverse way. Lots of different avenuesforensic, triage, CAMHS [child and
adolescent mental health services], elderly (9).
Marketing strategies within industry could be used to promote
graduates and existing nurses working in other clinical settings to
consider a career in mental health. One participant shared how
positive promotion could not only increase the workforce but
also at the same time address the concerns around stigma:
The whole mental health nursing industry is portrayed
badly. There should be staff representatives to give talks at
|
517
There is a huge problem marketing mental health nursing as a
viable career option. People just dont understand what we do
(103).
Have good role models on the wardsreward this and promote
this with colleagues (38).
Spread the word that mental health nursing is the future career
for our skilled workforce. Stop the stigma (120).
There should be more mental health trained lecturers who act
as advocates for mental health nursing. Students have told me
that their lecturers have told them not to come into mental
health and this stigmatizes it (45).
We need to improve the experience that students get from our
workplace. We need preceptors to be people who want to
actually be with the students as they should be providing the
experience (117).
We need better quality staff development. The executive have
undervalued us as mental health nurses by removing our staff
development unit and not adequately providing the staff
needed for good professional development (141).
There should be more preceptor coursesthese courses are the
tools of the trade (123).
Mental health nursing is supposed to be a specialty and should
be better associated with an appraisal system (127).
The wards should be made into safer environments for
staffwhich would also assist in retaining people as well as help
with recruiting new nurses. Better staff training regarding
aggression management (152).
Increase the career pathway for mental health nurses and
include good promotional positions Promote the variation of
specialties to graduatesI dont think half of them know what
goes on in mental health (38).
[educational institutions]. This would change the attitudes
towards the students. It would also promote mental health
nursing as a great field to work in
(114).
3.1.4|University promotion
The final area of promotion was within the university sector.
Employing committed mental health nurses with a passion for their
profession was recognized as crucial to get nursing students to con-
sider a career in mental health. Exposure to positive role models
518 |
needs to commence early during students educational experience.
Enticement needs to be carried out at university. Promoting mental
health as a career optionneed to be advertised a lot better in mental
health. There are many diverse jobs in mental health and you dont get to
hear about them (6).
Without the influence of passionate mental health nurses within
the university sector, the risks and impact of stigma will continue. Two
nurses shared that: universities need to start to encourage people to work
in mental health instead of discouraging them (71) and universities should
be challenged about the damage they are doing to mental health (73).
The value of timely access to a supportive role model cannot be
underestimated:
The lecturer at university encouraged me to go into mental
health nursing. She told stories about her time in mental
health and they were really interesting and caught my
attention. This encouraged me to start working in mental
health. She was so passionate about it (11).
3.1.5|Growing mental health nursing
The second theme builds upon promotion to focus on growing men-
tal health nursing. Nurses shared how this growth must address sub-
themes such the student experience, professional development for
existing staff, recognition of mental health as a specialty and valuing
staff.
3.1.6|Improving the student experience
To improve the student experience, timing and exposure to mental
health content and dedicated clinicians was regarded as imperative
by these participants. Specialized mental health content within the
Australian university curriculum traditionally involves one designed
unit of study followed by a limited clinical placement experience.
Earlier exposure and greater depth in content was suggested as useful
to inform and entice nurses and make them more curious and interested
in mental health (34). Extended opportunities for clinical practice were
also advocated:
There needs to be longer clinical practice in the training.
Possibly two practice placementsone at the beginning
and one towards the end (50).
It was proposed that mental health nurses within the university sec-
tor could be more strategic in introducing this career option. Clinicians
need to talk to university students at the beginning of the degree; that
would help in encouraging people at a stage before they finally choose a
graduate program (111).
Nurses generally felt that improvements to the student experience
were a priority:
Everybody comes to mental health with preconceived
ideas and they just get a lick and a promise instead of a
HARRISON etal.
proper experience. There should be a designated precep-
tor to have time to spend with the students or graduates.
They [preceptors] should be relieved of part of their clinical
load so that they have time to spend instead of rushing off
doing clinical work (25).
Recommendations were made regarding the content of mental health
within nursing education in addition to the quality and amount of clinical
experience. The curriculum at university has to change and include a lot
more mental health into it. The clinical exposure in mental health needs to
be greater as the short time that is currently spent here10daysis not
enough (34).
Extended time in the clinical area must also be accompanied by ac-
cess to supportive mentors. There also need to be positive mentorsnot
people who have been forced to take on students. There should be more
of a culture of learning within mental health nursing (43).
Participants felt the quality of the clinical experience could be im-
proved through the use of preceptors identified for the reason of being
excellent clinicians and wanting to work with students (129) and the effort
to provide planned experiences on the wards and community placements
so they [students] will value it more as a place to come and work (46).
3.1.7|Professional development opportunities
The second subtheme under promoting growth applies to professional
development opportunities for staff. Participants shared concerns
around the attention and value demonstrated to the professional de-
velopment of the existing workforce. There should be better staff devel-
opment for the mental health nurses working in the services. How can we
help students if nobody helps us? (143).
Improving opportunities were regarded as critical, whereas
limitations to recent educational offerings were seen to under-
minethedesire for professional development valued by the partici-
pants. There should be better staff development for the staff in the clinical
areas and professional development should be carried out much more reg-
ularly (131).
A key concept acknowledged within improving professional
development was preceptor education and support, which aligns with
the nurses reflections around the importance of the student experi-
ence. There should be preceptor courses. We should be looking after the
students better and if we do that they will want to return and work here.
They are our futureour succession plan (166).
The aspiration for a positive student experience relies upon existing
staff having the opportunity for growth in developing their preceptor
skills. Students should be assigned to a trained preceptor who wants to
be with them and remain on their shifts throughout their placement (10).
3.1.8|Recognizing the mental health specialty
Although improving the student experience and enhancing pro-
fessional development opportunities were regarded as important
to decrease stigma associated with mental health and raise the
profile of mental health nursing, two additional subthemes were
HARRISON etal.
raised: recognizing that mental health is a specialty and approaches
to demonstrate how staff are valued. Study participants felt that
mental health nursing needed to be recognized as a specialty within
nursing. There should also be recognition of mental health as a specialty
in nursing (191).
Although comprehensive tertiary nursing programmes prepare
nurses for mental health issues within general nursing settings, the
preparation and recognition for those nurses who want to work
in designated psychiatric clinical areas was felt to be inadequate.
Comments reflected a concern for patients, the future of this role
and how well nurses are supported in working in these settings. Make
mental health a proper specialty. It certainly isnt taught well on the
wards. When the mental health nurses all retire there will be no specialist
nurses left (188).
3.1.9|Valuing staff
The final subtheme valuing staff included ideas and suggestions
participants felt would increase the desirability of mental health
nursing as a potential career as well as address some concerns
around stigma. Specific suggestions to improve the conditions for
patients and staff included attention to physical facilities in clinical
settings. Improve facilities that mentally ill people have to stay in and
mental health nurses have to work in (101).
Another commonly shared concern was around the safety of staff
and their preparation in managing aggression:
There should be a zero tolerance for all types of aggres-
sion and management should support this. If wards were
redesigned to allow better patient orientated spaces, quiet
rooms, reading rooms and a nicer environment this would
assist with de-escalation and help lessen the aggression
(74).
Finally, developing clear and attractive career pathways for mental
health nurses was recommended. We need a career pathway. There are
so many areas in mental health nursing; not many people know about this
diversity. Its not advertised well. People need to be aware and perhaps
they would find mental health more interesting (7).
Transparency as well as active promotion of these pathways to stu-
dents and existing nurses was seen to be a positive step forward. Spread
the word that mental health nursing is the future career for our skilled
workforce. Stop the stigma (122).
4|DISCUSSION
Findings from this study reveal the overarching theme as breaking
down stigma, which has highlighted the urgent need for action in
order to entice nurses to choose to work in mental health nursing. The
two major themes characterized under this banner are again appeals
for action: visibility of mental health nursing and growing mental
health nursing. The subthemes belonging to the theme visibility
|
519
can be interpreted as crucial prompts for the profession, for example
self-promotion, industry promotion and university promotion.
Subthemes of the theme growing also present themselves in a simi-
lar way, for example improving the student experience, professional
development opportunities, recognizing the mental health specialty
and valuing staff.
Mental health nursing is not highly regarded within the broader
nursing profession as the technological skills of the general nurse are
prized, whereas the dominance of the therapeutic framework (Sercu
etal., 2015) in mental health nursing is not. Halter (2008) proposes
this lack of acknowledgement is due to stigma by association, which
may in fact be perpetuated by a need for mental health nursing to be
demystified for both general nurses and the public (Happell & Gaskin,
2013; Hercelinskyj etal., 2012). In better defining the identity and as
well highlighting the work of mental health nurses, this may ensure
this specialty of nursing is seen as a viable career option. Stigmatizing
beliefs held by health professionals may seem unlikely in todays world
of contemporary patient-centred health care, nevertheless, the liter-
ature reports otherwise (Ahmedani, 2011; Mrtensson, Jacobsson, &
Engstrm, 2014). Resolving stigma for mental health nurses is often
reported as a personal motivation (Sercu etal., 2015), which is made
more complex by the challenging relationship with the medical model
of care. This notion is strongly emphasized in our findings under the
themes of visibility of mental health nursing and growing mental
health nursing.
If mental health nursing can be positively represented, then this
may begin to enhance visibility and promote mental health nursing.
For example, the media and television can portray nursing and/or mid-
wifery in positive ways through televised drama series such as Call
the Midwife and All Saints. However, there are television series that
portray mental illness as stigmatizing and frightening for the general
public such as Law and Order, which regularly stereotypes those
living with mental illness in a negative way as aggressors. Recently,
a British mental health documentary series, Bedlam, was acclaimed
(Baggaley, 2014) for positively raising public awareness of the role of
mental health nurses and psychiatrists. Nurses should be urged to ac-
tively promote and engage with similar opportunities in the Australian
media both written and digital. This would also include responding
assertively to negative media to counteract or correct this misinfor-
mation. The responsibility for this advocacy role would lie with each
individual mental health nurse in addition to the professional bodies
such as Australian College of Mental Health Nursing and the American
Psychiatric Nurses Association.
Further subthemes of our research highlight the importance of
raising the profile of mental health nursing in self-promotion and in-
dustry/university promotion. There is no specific evidence to support
the notion that changing students attitudes would result in more newly
qualified nurses choosing to work in mental health nursing (Happell &
Gaskin, 2013). It may be that mental health clinicians hold the key to
promoting this specialist area of nursing as a desirable career option,
coupled with better mental health theoretical preparation and clinical
placement preparation and support (Happell & McAllister, 2014). If
university and industry work together to develop stronger collegiate
 |
520
links, as our research indicates, this may facilitate the promotion of
mental health nursing as a more attractive career option.
Additional subthemes emphasize the significance of professional
development opportunities, recognizing the mental health specialty
and valuing staff when enticing nurses to choose to work in men-
tal health. There have been challenges associated with encouraging
mental health nurses to return to postgraduate study. Happell and
McAllister (2014) suggest that numerous recruitment strategies
have not been successful. Postgraduate nursing courses (Australian
Education Network, 2015) are usually considered more for career ad-
vancement than for initial employment opportunities as there is no
requirement for nurses to have additional mental health specific skills
as a basic requirement for employment. Nationally, there are four
categories of registration under the Nursing and Midwifery Board of
Australia (Nursing and Midwifery Board of Australia (NMBA), 2017):
enrolled nurse, registered nurse, nurse practitioner and midwife, with
no distinct mental health nurse registration. This is not consistent with
the United Kingdom where there is recognition of a specialist regis-
tered mental health nurse qualification and a number of other record-
able specialist qualifications (Nursing and Midwifery Council, 2017).
Marketing of the many varied career pathways in the mental
health nursing profession such as Nurse Practitioners in acute care
and community, management and leadership roles, education and
research is an essential component of acknowledging this profes-
sion. Although there are eighteen Nurse Practitioner higher degree
courses in Australia registered under Australian Health Practitioner
Regulation Agency (Australian Health Practitioner Regulation Agency,
2017), only one is identified as a mental health specialty. This chal-
lenge was identified within our study findings which specifically em-
phasized that we as mental health nurses do not publicize our craft
as well as we should.
Onsite professional development is often readily accessible in
many healthcare settings to ensure appropriate nursing skills are main-
tained for patient safety purposes, whereas within the mental health
area, this is not always the case due to funding shortages and lack
of staff resources to provide education. However, a registered nurse
with a comprehensive nursing degree in Australia receives very lim-
ited education on mental illness, in accordance with the Registered
Nurse Accreditation Standards (Australian Nursing and Midwifery
Accreditation Council (ANMAC), 2012). This limited exposure to men-
tal health curricula is considered adequate preparation in caring for
patients with a chronic medical condition and comorbidities of de-
pression and anxiety on a general medical or surgical ward. Would this
same nurse be adequately prepared and safe to practice in caring for
a patient suffering an acute psychotic episode or expressing suicidal
ideation in a psychiatric unit? In fact, this nurse would most likely not
be employed in an acute mental health unit without prior experience,
which raises questions as to where health services will find suitable
mental health nurses for the future? These are critical issues which are
reflected in our research findings.
Improving the student experience, a subtheme identified within
this study, was recognized as vital for the profession with a focus on
timing and exposure of students and dedicated clinicians. Lfmark,
HARRISON etal.
Thorkildsen, Rholm, and Natvig (2012) suggest that clinical precep-
tors and academics are an invaluable resource in preparing students
for the role of the graduate nurse. In the same way that clinicians must
ensure they are suitably prepared to preceptor students, the nursing
academics should adequately prepare their students where they have
the ability to reflect on their own knowledge and skills as noted in our
findings. Further findings from our research have alleged that a mi-
nority of general nursing academics have actively discouraged students
from pursuing careers in mental health. This may be an indication that
there is an additional need for mental health nurses to include their
fellow nursing colleagues in their promotional activities and better as-
sist them to recognize and advocate for this area of specialty nursing.
Taylor and Harrison (2010) articulate the need for a formal recog-
nition of clinical supervision in mental health nursing. They put for-
ward that staff should actively participate in their own professional
development for reflection and growth. Reflective practice as the
key component of clinical supervision could assist students and be-
ginning practitioners to develop an awareness of their own thoughts
and feelings and as well stigmatizing beliefs (Buck & Lysaker, 2010).
The newly released Registered Nurse Standards for Practice (Nursing
and Midwifery Board of Australia (NMBA), 2017) stresses that self-
assessment through reflection is a key component of determining an
individuals competence. This reflection would also be incorporated
into a clinical supervision model to enhance and strengthen the pre-
ceptor relationship and is echoed in the findings of this study.
More often than not, when critical matters such as recruitment
and retention issues are raised within health services, a committee
is assembled with a representative for each area having membership
and responsibility to contribute on behalf of others. This study ad-
opted an alternative approach whereby all mental health nurses in one
health service were encouraged to participate and contribute their
uncensored account of ideas and opinions that could entice nurses to
choose to work in mental health. The findings presented in this paper
are both powerful and unique and represent an authoritative source,
that is, current mental health nurses.
5|LIMITATIONS OF THE STUDY
A limitation of this study is that it is not generalizable as the findings
reflect the perceptions of nurses in one public mental health service in
Western Australia at one point in time. However, rich description has
been provided to allow the reader to assess whether transferability
of the findings can be considered for other contexts (Braun & Clarke,
2006; Graneheim & Lundman, 2004).
6|WHAT THE STUDY ADDS TO THE
INTERNATIONAL EVIDENCE
The traditional focus of addressing nursing shortages has been to ask
why nurses choose to leave the profession (Flinkman etal., 2010;
Heinen etal., 2013; Rhaume etal., 2011; Tummers etal., 2013),
HARRISON etal.
when the discontent is already in situ. This has not been efficacious
in that we continue to face the same issues that have been the focus
of debate over the last two decades (Happell & Gaskin, 2013; Scott,
1996; Stevens etal., 2013). This study provides a necessary devia-
tion and break in tradition by targeting current nurses and listening to
their stories. This study adds to the international research evidence
in that it has demonstrated a new way of working, which is uniquely
focused on the reasons why nurses remain working in mental health
and the guidance those nurses have shared for recruitment of the fu-
ture workforce.
7|IMPLICATIONS FOR PRACTICE
This research study has provided many new insights into how we can
attract nurses into mental health and how we can retain our current
workforce. The novel approach employed by the researchers in listen-
ing to the personal experiences and opinions of current mental health
nurses has made it possible to generate a richer, more powerful under-
standing of the specialist role of the mental health nurse.
The overarching theme of breaking down stigma which emerged
in the new findings specifically emphasizes what urgently needs to
occur if we are to entice nurses to choose mental health as their fu-
ture career path. Our findings also suggest that the current mental
health nursing is strongly motivated to put an end to stigma (Sercu
etal., 2015), and as such is reflected under the themes of visibility of
mental health nursing and growing mental health nursing. If there is
a serious attempt made to stamp out stigma, then this will go a long
way to making mental health nursing a more desirable profession for
new graduates and more experienced nurses seeking a career change.
It will also allow the mental health nursings role to be demystified and
therefore represented in a more positive and authentic way (Happell &
Gaskin, 2013; Hercelinskyj etal., 2012).
The findings from this study suggest that the collective voice and
opinions of mental health nurses needs to be listened to with essen-
tial ideas incorporated into the development of policy and strate-
gic planning, together with education in tertiary environments and
mental health services recruitment of the next generation of mental
health nurses into the workforce. More specifically, if we apply the
three main themes within recruitment and retention strategies to en-
tice nurses to choose mental health nursing then we would be guar-
anteed a more reliable outcome. For example, the use of the main
theme titles, such as visibility of mental health nursing, growing
mental health nursing, could be used as focal points in marketing,
policy and strategic planning for our future mental health services.
Such strategies would contribute to breaking down stigma of the
nursing role and improving the sustainability of mental health nursing
based on a positive and more authentic representation of the role.
Our themes and their associated subthemes provide essential
confirmation that we need to work differently, and also harder and
smarter, when preparing and supporting our nurses to have the moti-
vation, confidence and ambition to be positive role models for the next
generation of mental health nurses.
|
521
8|RELEVANCE STATEMENT
This paper presents a qualitative study employing thematic analysis
to examine current mental health nurses opinions of how to entice
nurses to choose to work in mental health. Previous replicated re-
search has focused on why nurses leave the profession whilst this
paper utilizes a new way of working focusing on why nurses chose
mental health as their career path. New findings offer a unique insight
into the mental health nurses role illustrating how we can break down
stigma, demystify and better represent the mental health nurses role
in a more positive authentic way thus ensuring we have a successful
workforce into the future.
AC KNOW L ED G M ENTS
The authors wish to thank Ms Rosemary Hoffman for her and support
of the project. There has been no financial support accepted in the
process of developing this manuscript.
CO NFL I C T O F I NT ER ES T
There are no relationships that may pose a conflict of interest.
AU T HO R S CO NT R I B U T I O N
All authors listed meet the authorship criteria according to the latest
guidelines of the International Committee of Medical Journal Editors,
and all authors are in agreement with the manuscript. The work
has not been published and is not being considered for publication
elsewhere.
REFERENCES
Ahmedani, B. K. (2011). Mental health stigma: society, individuals, and the
profession. Journal of Social Work Values Ethics, 4(1), 416.
Australian Education Network (2015). Study postgraduate nursing courses in
Australia. http://www.australianuniversities.com.au/courses/australia/
postgraduate/nursing/campus/c/d/pg-nursing/ Accessed: 11 March
2017.
Australian Health Practitioner Regulation Agency (2017). Approved
Programs of Study. http://www.ahpra.gov.au/Education/Approved-
Programs-of-Study.aspx Accessed: 11 January 2017.
Australian Institute of Health and Welfare (2016). Who Are Nurses and
Midwives?. Canberra: AIHW.
Australian Nursing and Midwifery Accreditation Council (ANMAC) (2012).
Registered Nurse Accreditation Standards. Canberra, ACT: ANMAC.
Baggaley, M. (2014). Channel 4s Bedlam series got people talking about
mental illness. http://www.theguardian.com/healthcare-network/2014/
jun/30/channel-4-bedlam-mental-illness Accessed: 11 March 2017.
Braun, V., & Clarke, V.. (2006). Using thematic analysis in psychology.
Qualitative Research in Psychology, 3(2), 77101.
Buck, K. D., & Lysaker, P. H. (2010). Clinical supervision for the treatment of
adults with severe mental illness: Pertinent issues when assisting grad-
uate nursing students. Perspectives in Psychiatric Care, 46(3), 23443.
Farley-Toombs, C. (2012). The stigma of a psychiatric diagnosis: Prevalence,
implications and nursing interventions in clinical care settings. Critical
Care Nursing Clinics of North America, 24(1), 14956.
 |
522
Flinkman, M., Leino-Kilpi, H., & Salanter, S. (2010). Nurses intention to
leave the profession: Integrative review. Journal of Advanced Nursing,
66(7), 142234.
Fusch, P. I., & Ness, L. R. (2015). Are we there yet? Data saturation in quali-
tative research. The Qualitative Report, 20(9), 14081416.
Gouthro, T. J. (2009). Recognising and addressing the stigma associated
with mental health nursing: A critical perspective. Issues in Mental
Health Nursing, 30(11), 669676.
Graneheim, U., & Lundman, B. (2004). Qualitative content analysis in nurs-
ing research: concepts, procedures and measures to achieve trustwor-
thiness. Nursing Education Today, 24, 105112.
Gyllensten, A. L., Svensson, B., Bjorkman, T., Hansson, L., Leufstadius, C.,
Bejerholm, U., Markstrom, U., Ostman, M., Eklund, M., Brunt, D., &
Sandlund, M. (2011). Attitudes in healthcare students towards mental
illness A pre-and post-multicentre university program survey. Journal
of Allied Health Sciences & Practice, 9(3), 18.
Halter, M. J. (2008). Perceived characteristics of psychiatric nurses: Stigma
by association. Archives of Psychiatric Nursing, 22, 2226.
Happell, B., & Gaskin, C. J. (2013). The attitudes of undergraduate nursing
towards mental health nursing: A systematic review. Journal of Clinical
Nursing, 22, 148158.
Happell, B., & McAllister, M. (2014). Perspectives of Australian nursing
directors regarding educational preparation for mental health nursing
practice. Issues in Mental Health Nursing, 35(11), 8917.
Hayman-White, K., & Happell, B. (2005). Nursing students attitudes to-
wards mental health nursing and consumers: Psychometric properties
of a self-report scale. Archives of Psychiatric Nursing, 19(4), 184193.
Heinen, M. M., van Achterberg, T., Schwendimann, R., Zander, B.,
Matthews, A., Kozha, M., Ensio, A., Sjetne, I. S., Moreno Casbas, T., Ball,
J., & Schoonhoven, L. (2013). Nurses intention to leave their profes-
sion: A cross sectional observational study in 10 European countries.
International Journal of Nursing Studies, 50(2), 17484.
Hercelinskyj, G., Cruickshank, M., Brown, P., & Phillips, B. (2012).
Perceptions from the front line: Professional identity in mental health
nursing. International Journal of Mental Health Nursing, 23(1), 2432.
Humble, F., & Cross, W. (2010). Being different: A phenomenological explo-
ration of a group of veteran psychiatric nurses. International Journal of
Mental Health Nursing, 19, 128136.
Hunter, L., Weber, T., Shattell, M., & Harris, B. (2015). Nursing students at-
titudes about psychiatric mental health nursing. Issues in Mental Health
Nursing, 36(1), 2934.
Laimputtong, P. (Ed). (2013). Research methods in health: Foundations for ev-
idence-based practice. (2nd ed.) South Melbourne, VIC: Victoria Oxford
University Press.
Lfmark, A., Thorkildsen, K., Rholm, M. B., & Natvig, G. K. (2012). Nursing
students satisfaction with supervision from preceptors and teachers
during clinical practice. Nurse Education in Practice, 12(3), 1649.
HARRISON etal.
Mrtensson, G., Jacobsson, J. W., & Engstrm, M. (2014). Mental health
nursing staffs attitudes towards mental illness: An analysis of re-
lated factors. Journal of Psychiatric and Mental Health Nursing, 21(9),
782788.
Martyr, P. (2010). A lesson in vigilance? Mental health nursing training in
Western Australia, 1903-1958. Issues in Mental Health Nursing, 31(11),
72330.
Moxham, L., McCann, T., Usher, K., Farrell, G., & Crookes, P. (2011). Mental
health nursing education in preregistration nursing curricula: A national
report. International Journal of Mental Health Nursing, 20(4), 2326.
Nursing and Midwifery Board of Australia (NMBA) (2017). Registered Nurse
Standards for Practice. Retrieved: 11 March 2017. http://www.nursing-
midwiferyboard.gov.au/News/2016-02-01-revised-standards.aspx
Nursing and Midwifery Council (2017). Registration, Staying on the register,
Adding qualifications. Retrieved: 11 March 2017. https://www.nmc.org.
uk/registration/staying-on-the-register/adding-qualifications/
Rhaume, A., Clment, L., & Lebel, N. (2011). Understanding intention
to leave amongst new graduate Canadian nurses: A repeated cross
sectional survey. International Journal of Nursing Studies, 48(4), 490500.
Schneider, Z., Whitehead, D., LoBiondo-Wood, G., & Haber, J. (2013).
Nursing and midwifery research: Methods and appraisal for evidence-based
practice, 4th ed.. Sydney: Mosby.
Scott, H. (1996). Nursing shortages: Why are nurses leaving the NHS?
British Journal of Nursing, 5(18), 1098.
Sercu, C., Ayala, R. A., & Bracke, P. (2015). How does stigma influence men-
tal health nursing identities? An ethnographic study of the meaning of
stigma for nursing role identities in two Belgian Psychiatric Hospitals.
International Journal of Nursing Studies, 52, 307316.
Stevens, J., Browne, G., & Graham, I. (2013). Career in mental health still
an unlikely career choice for nursing graduates: A replicated longitudi-
nal study. International Journal of Mental Health Nursing, 22, 213220.
Taylor, M., & Harrison, C. A. (2010). Introducing clinical supervision across
Western Australian public mental health services. International Journal
of Mental Health Nursing, 19, 287293.
Tummers, L. G., Groeneveld, S. M., & Lankhaar, M. (2013). Why do nurses
intend to leave their organization? A large-scale analysis in long-term
care. Journal of Advanced Nursing, 69(12), 282638.
How to cite this article: Harrison CA, Hauck Y, Ashby R.
Breaking down the stigma of mental health nursing: A
qualitative study reflecting opinions from western australian
nurses. J Psychiatr Ment Health Nurs. 2017;24:513522.
https://doi.org/10.1111/jpm.12392