Rapid changes bring a shift in mental health nurses’ perceived identity: Q&A

Mental health care in Australia has undergone a dramatic transformation since the 1980s.

Old-fashioned institutions where patients received psychological care in hospital wards made way for flexible, community-based environments with an individual-focused approach.

Mental health nurses were compelled to adjust to these rapid changes but often encountered significant barriers.

And as we know today, the nursing profession is still facing many challenges such as a lack of staff and recourses.

During Professor Michael Roche's recent public lecture, he said society's perception that the mental health sector is not a great place to work is still held by some today and is affecting the staff and patient care.

He's advocating for a change; not only in mental health education but also in the nursing work environment.

"It takes courage to overcome our fear of change and the inertia of organisations – but the time to do so is now," he said.

Nursing Review had a conversation with Michael, the Clinical Chair of Mental Health Nursing at the University of Canberra, on how their role has shifted over the past decades and what barriers the profession is currently facing.

NR: In your lecture as part of the university's Research Week, you pointed out that the mental health profession has seen drastic changes since the '80s, which changed how nurses perceive themselves in their roles. 

What were those changes and how did they affect the current mental health profession?

MR: Two things happened at a very similar time. First, in the 80s and 90s, mental health services were, up until that time, traditionally institutionalised and based in large old-style hospitals. Then, those services moved out into a more community-oriented and mainstream environment. That shift meant that many mental health units moved out of wards of old institutions into public hospitals.

While that was a positive change, it also created a significant disruption. It altered how mental health nurses practise their profession because they transferred from a somewhat static environment to a much more flexible one. 

Teaching nursing in Australia also moved from a hospital-based model to education at colleges and universities. And that transformed the nature of nursing education from attaining a psychiatric nursing qualification and working in a psychiatric hospital ward to a comprehensive education where mental health has a postgraduate approach, and someone can obtain a master's degree in mental health nursing.

These changes were essential but also created an enormous amount of disruption, with the focus of nursing care moving to an unfamiliar and much more dynamic environment, and a lag in developing accessible postgraduate mental health nursing to replace the previous system

It wasn't unique to the mental health sector because there were many other times in health care that change occurred. However, it was significant in mental health nurses' experience because it resulted in a loss of their perceived identity in their role.

It actually took us a long time to realise how that change impacted mental health nursing and what we could do about it. For example, there were a lot of nurses doing fantastic work in setting up community services and establishing mainstream mental health services, but at the same time, those nurses were struggling to adapt.

Sometimes, they couldn't adjust simply because of the magnitude of the change. So, it significantly impacted the way people worked and lived their lives.

While there was a perceived loss of role and identity, it also resulted in significant growth in other professions, such as psychology and social work groups, which altered how some teams work and collaborate. 

Although it was disruptive and confusing, it also had major benefits. Probably the best thing of all was that the voice of people with experience in mental health was getting heard, which became even stronger as it progressed. Plus, services started to consider personal recovery, not necessarily only the alleviation of the symptoms, but to the extent that the patient was satisfied and felt the service was productive.

There was also a shift in philosophy. Where nursing used to have a very biomedical approach, which is still the case sometimes, there became an emphasis on services with a personal focus. And that meant that in addition to the structural change, the care focus changed to a personal recovery service. So it said, 'rather than we are providing care to you, we are working with you towards your personal recovery'.

Those things inspired and changed the role and the identity of mental health nurses. It took a long time for those processes to become established – to get a universal and consistent view of mental health services across the country.

And we're still facing challenges; this is not a done deal. And as we learn and move further down the track, we must continue that cycle of learning to work with people.

So, while change is still ongoing, are most processes now well established?

If we had the opportunity to study every mental health service in this country, we would find wonderful services, nurses and other professionals providing care in Australia. I've worked with many of those nurses and mental health professionals, and it's evident that people have gained experience, are fully engaged in this service and have partners and support in their care delivery.

But I'm sure there are also services out there that are not operating in their business model and are still making that transition, which is unfortunate.

But I don't want to paint too bleak a picture. We must simply move into this and look at the best way to approach these challenges in the future. Change has to be ongoing, and we have to learn from evidence.

One of the most pressing issues at the moment is how to address the workforce shortages in healthcare. How do you suggest we work on retaining and attracting mental health nurses?

Well, it's a broad basket issue with a long history. First, we need to grow the mental health workforce in nursing and across psychiatry, psychology, social work and occupational therapy in the country. We've had a long COVID tail, so there will be an ongoing need for all mental health professionals across Australia.

To do that, we need to enhance the pathway to grow the number of nurses entering mental health nursing. We need to sustain – and I use the term sustain rather than retain – those nurses in the profession. But we also need to sustain nurses already working in the occupation. 

The average age of mental health nursing in Australia is slightly older than other nurses, who are a few years shy of their mid-40s. Therefore, a high proportion of the older age groups are closer to retirement. So, many nurses in this area can't stay in the workforce unless we properly sustain them.

At the moment, we're not providing them with the skills and opportunities to look after themselves adequately, and that's organisational rather than personal. 

There are several techniques we can apply to sustain nurses. Not just in the way of retention – retaining people who are not working to their optimum is not ideal, and we want people to work at their best level. We need to sustain them, so they're psychologically well and supported, at their optimum, and provide the proper health care.

Recently, the Fair Work Commission lifted minimum hourly wages. Do you think this increase will help retain nurses in any way?

There are different schedules for salary changes across other jurisdictions in the mental health sector. Unfortunately, mental health nurses happen to be at the wrong end of the curve. It's a minimal increase. 

And to be honest, I'm also not sure whether it's entirely about salary for them. Yes, I think there's a valid justification for well-paid health workers across the board and to hold onto many of those salaries for many years. But I think it's more about the work environment and, most importantly, health professionals' ability to conduct the care they're trying to deliver. 

That means it's about better and more flexible staffing so that they can perform their work to the highest possible standard. There's ample evidence to suggest that if we give people the opportunity to practise at a higher standard, they will. That's what drives health professionals and mental health nurses.

We need to develop a system so people can deliver better care to keep people in the profession and ensure they practise to a higher standard. Those are the key things that need to change aside from the appropriate salary.

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