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.

    INTRODUCTION

    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. Email:michelle_cleary@nuhs.edu.sg

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

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    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.

    METHOD

    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

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  • 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.

    RESULTS

    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)

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  • 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 admitted whowould not tell anyone her name so essentially we didntknow who she was. She rarely spoke to anyone and it wasdifficult then to diagnose and treat her. I spent a lot oftime with this patient to build trust and rapport overseveral shifts and then managed to convince her to tell usher name. She began to talk more and treatment was ableto be provided. My peers acknowledged my effort andpatience (RN15).

    RN12 gave the following example: A patient on theward who was very vulnerable and upset throughout hisadmission, he wanted someone to listen to his problemsand issues and I listened to him each shift. This helpedhim to be more settled on the ward and this was a goodoutcome. I was acknowledged by this patient when hesent me a card to say thank you. Other staff rememberedthis so I think they too acknowledged my efforts. Therewere many others examples provided: for example, aninterviewee listened to and comforted a man sharing hisdistress at hospitalization; another kept talking on thephone with a woman who was suicidal until an ambulancearrived to bring her into hospital: Counselling an anxiousclient in the community with suicidal thoughts [and] theability to keep her on the line. I called the ambulance. . . I was able to follow her up when she arrived at theemergency department (RN19).

    Interestingly, the six interviewees who did not offera specific example of good nursing work all spoke ofinteractive principles, such as listening, being non-judgemental, building rapport, reiterating clear informa-tion to demanding patients, aiming for them tounderstand limits placed on them and staff, or deescalat-ing violence: I think really just listening to the patientsand having empathy . . . not judging someone becausethey have a mental illness and making them feel OK aboutbeing in hospital (RN40).

    Theme 3: Providing practical and holisticsupport to patientsThe third most common theme arising from the questionabout nursing achievements involves the acute mentalhealth nurses supporting broader aspects of patientslives than those relating directly to their here-and-nowmental illness or physical safety. These achievementscovered practical aspects of patients lives, such asimproving daily living skills, supporting autonomy asmuch as possible at a given point in time, encouragingpeople to be more active in the community, giving posi-tive feedback to patients for their accomplishments,improving knowledge about medication and side effects,teaching with the aim of empowerment, and advocatingfor patient concerns and rights (especially leave and dis-charge planning) to senior nurses, staff on the next shift,and medical personnel.

    Responses to the good nursing question that fitted withthis more holistic approach to the patients wellbeinginclude the following: I noticed many patients had chil-dren visitors especially on the weekend. Family support isreally important so having them visit helps the patients. Iestablished a room called the family room with toys andspace for visitors, patients, and children to make it safe forthem to visit their relatives in an acute admission ward.Other staff acknowledged my efforts (RN3). Anotherinterviewee spoke of a person whom s/he assisted withfinancial matters, accommodation, and community sup-ports to improve his post-discharge circumstances. Some-times, physical health problems are recognized and oneRN pointed out such a problem to the patients primarynurse so that s/he would receive better physical healthcare. Another respondent spoke of managing post-ECTpatients attentively and carefully in ways that are appre-ciated by both patients and medical staff.

    Theme 4: Mental health improvementThis theme emerged from a question targeting nursingachievements in mental health settings. The mentalhealth improvement category includes observing patientsimprove and get better, assessing mental status thor-oughly on each shift, ensuring continuity of care . . . tomaintain relationships, maintaining patient rights and. . . safety, stabilizing patients mental wellbeing, encour-aging patients to develop strategies for coping and gettingwell, encouraging patients to take positive activities intheir lives and engaging supportive efforts in the commu-nity, evidence of greater patient insight, and, receivingpatient feedback about their perception and experienceof improvement.

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  • These examples are really a re-statement of the ratio-nale for the existence of such facilities. Patients are admit-ted in a disturbed, distressed, and/or chaotic state and,through combined efforts, their psychotic symptomsabate, their capacity to engage with others improves, andthey are discharged into the community, sometimes withbetter supports in place. Good work is clearly exemplifiedby a patients improvement in physical and mental healthand social and emotional wellbeing, and nursing achieve-ments are evidenced by these, regardless of the presenceor absence of explicit acknowledgement of the nursescentral contribution by the patients themselves.

    Theme 5: Optimismpessimism continuumGiven the preponderance of team and interpersonalanswers to questions about nursing achievements andgood nursing work, responses to a later interview questionabout RN experience of optimism are congruent withinteractional themes. A total of 18 responses indicate thatthe interviewees level of optimism was dependent onenvironmental factors, 16 related their position on thiscontinuum to their personality, and 11 answers involvedbeing optimistic at times and pessimistic on other occa-sions. Some of those whose perspective was influenced byothers conveyed the sense of a roller coaster ride. Forexample, RN4 stated that she felt: positive when every-thing goes well; optimistic and hopeful when I seeimprovement in a patient; negative when a patient isacutely unwell and verbally or physically aggressive; andpessimistic when I see a patient re-admitted severaltimes.

    Of the respondents who explicitly outlined their deter-minants of optimism-pessimism, nine nominated otherstaff and team members most often, six targeted the skillmix (pointing to insufficient numbers of RN on the shift),five considered the nurse unit manager or managementper se to be implicated, and four referred to overwork.Only four interviewees in our study mentioned patient-related factors, such as poor mental state, difficult behav-iours, or frequent re-admissions as determinants ofoptimism or pessimism.

    The skill mix, management, and overwork are likely tobe intertwined, with each category impinging on theothers. Other interviewees considered the bigger pictureas well as the future: I am more pessimistic aboutthe outlook of the profession of mental health nurs-ing . . . The skill mix and staffing levels as well as the sheervolume of patients when we dont have the beds means Icant give the care I would like to . . . its a shame (RN15).However, some participants highlighted the capacity forchange: this team is very good and we have a good NUM

    [nursing unit manager] so I am positive and optimistic,although I have been burnt out when I have worked in award with no supportive NUM and negative colleagues(RN17).

    DISCUSSION

    The non-consenting, involuntary patient legal status fun-damentally shapes the nursing work of acute inpatientnurses. Dangerousness to self or others, assessment andobservation for diagnostic purposes, and treatment bymedication, particularly to ameliorate positive psychoticsymptoms, are common reasons as to why patients areadmitted to these facilities (Bowers 2005). Thus, withinthe acute mental health environment, nurses tread a linebetween caring for the health of patients/clients, protect-ing their safety, and respecting their right to autonomyand self-determination. At times, it may seem very diffi-cult to achieve safety and optimal functioning, while stillrespecting autonomy and, indeed, numerous ethicalissues and dilemmas are a feature of the everyday workinglives of acute inpatient mental health nurses. These ten-sions are reflected in some of the participant responsesand provide a window into how nurses manage and con-struct these ethical dilemmas. Some of the respondentnarratives contained descriptions that could be viewed aspatient-blaming, and may not be viewed as good work bypatients/clients or even other nurses. However, they arevaluable, as they reveal how the nurses were able to makemeaning from some of the more difficult aspects of theirwork and so we have chosen to present them in this paper.

    It is clear that safety concerns are important activities,and from nurses accounts, patients have seriously mentalillnesses, and the work nurses do is pivotal to the transi-tion from acute psychotic experiences to re-entering thecommunity (Cleary 2003; Deacon et al. 2006; Hamilton &Manias 2008). Participants emphasized the challengesthat confront them on a daily basis and reinforced thefundamental fact that they only have themselves and eachother to rely on to successfully manage a range of patientswith extreme behaviours, with the ultimate aim ofimproving patients wellbeing and keeping everyone safe(Cleary 2004; Cleary et al. 2010). To some extent, this is inaccordance with national policy agendas for acute inpa-tient units, which advocate short hospital stays, rapidpatient improvement, and an ethos of least restrictive care(Bowers & Flood 2008; Delaney & Johnson 2006), whichundoubtedly contributes to the perception that mentalnursing work is reactive. This invariably results in tensionbetween the ideals and the reality of ones work; thistension is important to recognise when and how good

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  • work manifests itself . . . [which] may also serve as asource of consciousness raising for professional andethical guidelines at the workplace (Christiansen 2008; p.1651).

    According to three-quarters of the respondents, team-work and interpersonal interactions are the most signifi-cant factors that feed into perceptions of good nursingand a sense of achievement. It may seem surprising thatteamwork was identified as the primary category fornursing achievement in mental health settings, particu-larly within a workplace culture that rewards and admiresindividual accomplishments (Horsfall et al. 2010b). Fur-thermore, respondents did not make reference to riskmanagement as contributing at all to good nursing work,which contrasts with the current focus in health care.However, managing aggression and safety was a dominantnursing activity that fell within the constructs of thenursing team rather than as a distinct and separate factor/theme.

    Teamwork may provide the necessary support toenable the hour-by-hour work with newly-arrived and/orpatients who are acutely distressed to be achieved with abasic level of safety for all and at times when interpersonalsituations become unmanageable or dangerous. Given thepotential for danger in acute inpatient units (Bowers et al.2006; Deacon et al. 2006; Kindy et al. 2005), and the factthat mental health nurses are continuous front-lineworkers, teamwork is especially important to newly-registered nurses (Cleary et al. 2011b). The significanceof teamwork, however, has been noted in other mentalhealth nursing research in acute settings (Cleary et al.2011c; Deacon & Fairhurst 2008), and may well be thehallmark of successful nursing in most contemporaryheath-care settings (Christiansen 2008; Josefsson et al.2011). Furthermore, in this study, it is evident thatthe nurses greatly valued feeling recognized for theirefforts by their peers, and this recognition and collegialvalidation was an important aspect of positive, effectiveteamwork for these participants. This resonates withChristiansens (2008) study of good nursing work, whichreported supportive peer feedback to be a motivationalfactor that provided nurses with confirmation of compe-tencies. Christiansens (2008) study focused on a younggroup of nurses from various general settings. In ourstudy, the focus on nurses from the acute mental healthinpatient sector meant that much of their perceived goodwork was around managing aggression, a known and par-ticularly challenging aspect of mental health nursingwork. Particular skills are needed to appropriately manageaggression in the clinical setting, and the crucial role ofpeer feedback in developing these skills is made visible

    through the narratives of these nurses. Where our studyfurther extends Christiansens (2008) earlier work is inhighlighting the reflective processes through which thenurses were able to conceptualize their own role inachieving mental health improvements, and the waysthat this assisted them in having a sense of professionaloptimism.

    Providing holistic and practical care to acute patientsin mental health units as well as signs that patients mentalwellbeing is improving were also important to the partici-pants perception of doing good work. This supports find-ings by Christiansen (2008; p. 1650), who states that goodwork implies ensuring that the work is done on the wardand that patients are receiving the care they need and arebeing treated well. Descriptions of good nursing workarising also included one-on-one situations, teamwork,generic interactional principles, coordinating and manag-ing nursing staff, physical health interventions, practicalinterventions, and teaching and supporting colleagues.

    Interpersonal interactions within mental healthnursing have traditionally been deemed central (Horsfallet al. 2011) and the centrality of interpersonal skills andqualities when interacting with patients and colleagueswere reflected in these findings. Similar situationsdescribing interpersonal skills in the context of deescala-tion, sometimes in crisis situations, are evident in theliterature (Deacon et al. 2006; Delaney et al. 2001; Hem& Heggen 2003). In this current study, the importance oflistening, empathy, and recognition of the centrality of thepatient experience were among the interpersonal skillsconsidered by the nurses to be associated with goodnursing work. Furthermore, these findings reveal hownurses had a range of interpersonal skills that could bedrawn on to meet the variant needs of particular patientswith their own particular issues. The use of gentle per-suasion was highlighted in this way, with nurses feelingsatisfied when able to enhance a patients health status bygently persuading them to accept treatment without theneed for coercive intervention. Coaxing was also used toencourage patients to reveal information. These interper-sonal strategies required establishment of a therapeuticrelationship between nurse and patient, and took consid-erable one-on-one time to achieve, yet what these find-ings reveal is that these mental health nurses derivedconsiderable professional satisfaction and optimism fromthe unremarkable: the everyday and commonplace out-comes that can be achieved through good nursing work inthe acute mental health sector.

    Other researchers have documented interventionssimilar to those highlighted in our study, showing hownurses often continue day after day with interventions

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  • that involve patience, implicit empathy, respect, andunderstanding (Bjorkdahl et al. 2010; Chiovitti 2008;Delaney & Johnson 2006). Routine provision of informa-tion or re-explaining the purpose and effects of prn medi-cation, behavioural rules, or property access protocolsmight sound unremarkable, but in some circumstancesthey help an agitated, distressed or edgy patient under-stand their circumstances better, enabling them to gain anenhanced sense of security, and, thus, become calmer(Chiovitti 2008; Cleary 2003; Fourie et al. 2005). Many ofthese interpersonal skills arise as much from the personalcharacteristics and qualities of nurses as they do from rolemodels, education, or training (Cleary et al. 2011a; Smith& Godfrey 2002).

    Answers to the question targeting optimism and pessi-mism and their causes resulted in responses indicatingthat hopefulness is contingent on circumstances and otherpeople. Situational interpersonal factors included: teammembers, management, skill mix, overwork, and patientaggression. Given that more than half of the intervieweesconsidered their sense of optimismpessimism to bedetermined by their work environment, this project con-tributes to a discussion of the important contributors tosupportive health-care settings and, ultimately, to patientrecovery.

    This study is not without limitations. Data were col-lected from a single health service and ascertained RNviews in Sydney, Australia only. Furthermore, interviewswere not audio recorded, so the data were notes taken atinterview. Some caution is also warranted about RN per-ceptions or accounts of good work, as this method couldengender self-satisfaction without substance. Strengths,however, include the relatively large sample size of nurseswho are currently working in the acute mental healthinpatient services. We are not making a case for the gen-eralizability of findings, but it would be interesting tocompare our findings to other international acute inpa-tient mental health settings. Future research mightinclude patients views of good nursing work, so that thesemight be compared against the views of nurses.

    NURSING IMPLICATIONS

    It is important that managers and senior nurses developinsights into the aspects of the nursing workplace that areconsidered positive. Such understandings will allow forthe facilitation of opportunities to highlight and celebratepositive nursing work. It could also go some way inhelping maintain morale in acute care mental healthnurses, who must sometimes become demoralizedbecause of the relentless, challenging, and often thankless

    nature of nursing work. Additional research to ascertainthe relationship (if any) between a sense of being able tocontribute to good nursing work and professional opti-mism would be very useful in providing information thatcould assist in enhancing optimism in the acute mentalhealth workplace.

    CONCLUSION

    This paper reports on a study of acute mental healthnurses views on what constitutes good nursing workand how optimistic they considered themselves. Clearly,professional interactions and relationships with both col-leagues and patients were central to participants experi-ences of good nursing work. It is important to developinsights into the aspects of clinical work that providemental health nurses with a sense of fulfilment and pro-fessional satisfaction. Enhanced understanding of suchfactors can make an important and unique contribution tothe knowledge base that aims to improve and optimize theclinical work environment for acute mental health nurses.

    ACKNOWLEDGEMENTS

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

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