Mental health nurses' attitudes towards mental illness and recovery-oriented practice in acute inpatient psychiatric units: a non-participant observation study International Journal of Mental Health Nursing, doi: 10.1111/inm.13152

We were very pleased to see your study (Sreeram et al., 2023) exploring mental health nurses' attitudes towards mental illness and recovery-oriented practice in acute inpatient units by observing the interactions between consumers and nurses. We found your publication timely to provide more supporting research evidence that mental health nurses are confident to use recovery-focused care in acute inpatient units. Specifically, we were delighted to see that the findings of your study echoed that of our previous study (Lim et al., 2021), that mental health nurses are using recovery-focused care in acute inpatient units. While there seems to be a ‘natural fit’ for mental health nurses to use recovery-focused care given to their continuous presence in the consumers' recovery process (Caldwell et al., 2010; Santangelo et al., 2018), previous studies that have used traditional research methods and explored mental health nurses' beliefs, attitudes, knowledge and skills grappled with the evidence that they generated on how mental health nurses used recovery-focused care in acute mental health (Cleary et al., 2013; Hardy et al., 2022; Kidd et al., 2015; McKenna et al., 2014). This may be due to the uniqueness of every consumers' phases of mental illness when admitted to acute mental health units that required mental health nurses to use different approaches to contribute positively to the individual's recovery and to be actively engaged in the management of their illness (Lim et al., 2021). As such, there is a need for nursing researchers to consider novel research methods to examine this phenomenon of interest (Lim et al., 2021). Your choice of using non-participation observation method is novel in mental health nursing research to capture the micro-affirmations (Topor et al., 2018) when meeting the consumer's personal needs. The use of micro-affirmations in acute inpatient settings are important for supporting the consumers to experience more meaningful conversations that foster strengths, hope, optimisms and regain their confidence to assume control of own lives after experiencing a mental health crisis (Jacob et al., 2015; Xie et al., 2015). The use of micro-affirmation is also important for supporting consumers to experience self-determination, shared-decision making and be empowered to participate actively in co-production of their care and treatment (Laitila et al., 2018; Park et al., 2014; Slade et al., 2014; Wyder et al., 2017). These nurse-consumer interactions are moments where mental health nurses may be using recovery-focused care but could easily be overshadowed by their conflicting and competing roles of working in acute mental health settings (Lim et al., 2019). Indeed, the mental health nursing profession has been blamed or scapegoated for the organizational failure to achieve a recovery-oriented culture in acute mental health settings (McKeown et al., 2019). As such, the caveat is placed on improving the attitudes, knowledge and skills of mental health nurses to use recovery-focused care. This may have inevitably led to mental health nurses being stereotyped as being unskilled and unknowledgeable to use recovery-focused care (Sercu et al., 2015). Consequently, there is a lack of organizational investment to support mental health nurses with adequate staffing and time (McKeown et al., 2019), and support consumers to achieve self-management of their psychiatric symptoms and risks (Lim et al., 2021). For this reason, mental health nurses are spending most of their clinical time on risk management as an integral part of mental health nursing in acute mental health settings (Paradis-Gagné et al., 2021). Yet, this should not reflect mental health nurses' attitudes towards the use of recovery-focused care, even though they may in some situations use restrictive practices as ‘the last resort’ to manage the person's level of risk or potential for aggression (Wilson et al., 2017). As highlighted in the results of your observations in the intensive care area, recovery-focused care can be used by maintaining dignity and respect, non-judgmental communication and facilitating choices for consumers in all aspects of care (Sreeram et al., 2023). With the increasing research evidence that mental health nurses are using recovery-focused care in acute mental health settings, we believed that there is a need to advocate for more systemic-level changes in acute mental health care. For example, the current policies and procedures may need to adopt a more recovery-focused perspective towards consumers with an acute mental illness, and move away from the traditional risk-averse perspective to promote a safe and therapeutic environment (Fletcher et al., 2018). Ashcraft and Anthony (2008) highlighted that the consumers' inherent strengths and resources to self-regulate continue to be overlooked or underutilized when hospitalized when the dominating model of care is driven by the reduction of psychiatric symptoms. As such, consumers were often considered to be incapable of achieving self-management of their mental illnesses and subjected to strict regimes prescribed by the treating team in acute mental health settings (Serin et al., 2016). If all healthcare professionals adopt a more recovery-focused perspective towards consumers with an acute mental illness, this will significantly help to drive clinical practice and initiatives in acute mental health settings to support mental health nurses to use recovery-focused care. Secondly, there may be a need to incorporate relationship-building and supporting the consumer's personal recovery is as a key performance indicator of mental health nursing in acute mental health settings (Santangelo et al., 2018). The Australian College of Mental Health Nurses (2010) affirmed that mental health nurses are registered nurses who have specialist knowledge in mental health nursing to provide holistic care and can work collaboratively with the service users towards recovery as defined by the individual. Yet, the communications between mental health nurses and the interdisciplinary team continues to be centred on consumers' clinical recovery. The lack of communications regarding the importance of consumers' personal recovery can significantly discount the importance of mental health nurses using recovery-focused care in acute mental health settings. Lastly, with the integration of mental health nursing curriculum into the comprehensive nursing programs, there is a reduction in clinical placements for nursing students to acquire the clinical experience to care for consumers that are acutely unwell (Happell et al., 2015). Hardy et al. (2022) examined the factors affecting knowledge of recovery-oriented practice amongst mental health nursing and medical staff working on acute mental health settings highlighted that their total mental health experiences was an important predictor of higher recovery knowledge and attitudes. Similarly, your observations in the intensive care area identified that junior nursing staff are more likely to experience some level of anxiety when compared to senior staff to use recovery-focused care (Sreeram et al., 2023). As such, the responsibility may now lie with the respective mental health services to support junior nursing staff to develop specialist mental health knowledge and skills, for example through mandatory clinical supervision and acquisition of professional nursing qualifications that allows them to be credentialing as a mental health nurse with The Australian College of Mental Health Nurses to practice confidently in acute mental health settings. This is important for the mental health service to build mental health nursing workforce that can consistently use recovery-focused care to care for consumers in all areas of mental health delivery. Contributions to conception and writing: Eric Lim. Writing of the article, reviewing and revising for improving intellectual content: Dianne Wynaden, Karen Heslop. None. Open access publishing facilitated by Curtin University, as part of the Wiley - Curtin University agreement via the Council of Australian University Librarians. There is no funding. Emeritus Professor Dianne Wynaden is an Editorial Board Member of International Journal of Mental Health Nursing. Dr Eric Lim and Associate Professor Karen Heslop declare that there is no conflict of interest or funding. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.