INTRODUCTION

Mental health nurses struggle to provide person-centred, recovery-oriented care in inpatient services, but such efforts are counteracted by conflicting demands and a lack of supportive practice environments (Gabrielsson et al. 2016; Molin et al. 2016; Moreno-Poyato et al. 2021). From the perspective of young people, child and adolescent psychiatric (CAP) inpatient care can support recovery when staff engage young people and allow them to feel listened to, believed in and safe (Wallström et al. 2021). The focus of this study was the nursing staff’s perspective on working in CAP inpatient care.

BACKGROUND

Nurses in CAP inpatient care operate in a space between care expectations and the reality of practice environments (Ellilä et al. 2007; Hayes et al. 2019b; Rasmussen et al. 2017). Nurses in CAP care are expected to ensure the physical and emotional safety of children in a proactive manner that minimizes the use of coercion (Delaney 2018). Further, nurses employ their clinical judgement and critical reflection to provide structure adapted to the children’s individual needs. Nurses provide support while balancing the need to uphold ward structure with the need to respect children’s autonomy, and engage in approaches and interventions that foster self-management (Delaney 2018). Yet, nursing in CAP inpatient care is believed to lack an evidence base and to instead build on implicit knowledge and routines that are neither challenged nor questioned (Rasmussen et al. 2017). Many non-medical interventions in CAP inpatient care lack clarity and consistency (Hayes et al. 2019b). CAP ward managers fail to relate nursing ideology to nursing models, theories, and ethics (Ellilä et al. 2007). Upholding and developing the nursing profession is problematic, and nurses have difficulties formulating the distinct contribution of nursing in CAP inpatient care (Rasmussen et al. 2017). In striving to improve care and reduce the use of restrictive measures, nurses in CAP inpatient care face ethical dilemmas and experience moral distress (Regan 2010).

To the best of our knowledge, only a few studies have focused on staff’s experiences of child and adolescent psychiatric inpatient care (Dean et al. 2010; Hayes et al. 2019a; Matthews & Williamson, 2016; Rasmussen et al. 2014). Dean et al. (2010) interviewed 33 staff in an Australian CAP inpatient unit about their experiences of aggressive behaviour. Staff saw dealing with aggressive behaviour as a natural part of work, although the level of aggression in the ward was considered unacceptable. Aggression was believed to have a negative impact on staff’s emotional well-being and the therapeutic relationship with patients. They also believed the effective management of aggressive situations could lessen negative consequences.

Rasmussen et al. (2014) interviewed 19 staff at an Australian CAP inpatient unit to explore nurses’ work in inpatient care, and from these data they developed a conceptual framework for nurses’ knowledge and knowledge development. Hayes et al. (2019a) interviewed 10 clinicians in a private adolescent inpatient unit in Australia to explore their perceptions of a dialectical behaviour therapy model of care. Matthews and Williamson (2016) collected diary entries from 10 health care assistants working in two female adolescent wards in England, and interviewed five of them, to explore the effect of the CAP inpatient environment on their health and well-being. Participants described being torn between a personal moral responsibility towards empathy and support and organizational demand for emotional distancing and control. They experienced CAP inpatient care as focused on medical and psychological perspectives rather than taking a holistic approach towards young people. Arguably, this might lead to nursing staff lacking autonomy in work (Matthews & Williamson 2016).

Rationale

Research aimed at gathering staff perspectives on CAP care has been targeted at specific issues. Less is known of the broader views of staff around their work with CAP inpatient care. In addition, the role of nurses and nursing in CAP inpatient care is unclear, and nurses are at risk of moral distress from having to deal with complex demands while lacking organizational support. A better insight into the content and conditions for nursing in CAP inpatient care from the perspective of nurses and assistant nurses is necessary to further understand how nursing can make a sustainable contribution to child and adolescent mental health.

Aim

This study aimed to describe nurses’ and assistant nurses’ experiences working in child and adolescent psychiatric inpatient care.

METHODS

We employed a qualitative descriptive design for this study. This is useful for obtaining rich data and understanding a phenomenon (Kim et al. 2017). All authors, one man and two women, are registered nurses specialized in psychiatric care. At the time of the study, authors two and three worked as assistant professors in nursing. Author one was a lecturer in nursing. This study is reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) (Tong et al. 2007).

Setting

Data for this study were collected in conjunction with a project designed to evaluate the feasibility of a recovery-focused intervention in a Swedish CAP inpatient ward. Authors two and three were responsible for implementing and evaluating the intervention. The ward was a six-bed, 24-hour inpatient service that accepted acute admissions. Besides nurses and assistant nurses, the ward employed psychiatrists, a psychologist, a counsellor, and a ward manager.

Context

Swedish health care is decentralized and diversified (National Board of Health & Welfare 2021). Nursing staff in Swedish CAP inpatient care mainly consists of registered nurses and assistant nurses. Registered nurses can be generalist nurses with a three-year, bachelor-level university education or specialist nurses with an additional one-year, post-registration, master’s-level education. Assistant nurses typically have one to three years of education on a high school level. In this paper, we use the term nurses in reference to registered nurses, while nursing staff refers to both registered nurses and assistant nurses. While ‘nurse’ (Swedish: ‘Sjuksköterska’) is a protected title that may only be used by registered nurses, the roles and responsibilities of nurses in Swedish psychiatric care are unclear and contested (Gabrielsson et al. 2021; Salberg et al. 2019). This ambiguity involves a historical conflict between the nursing profession and the mental health carer vocation that might still resonate in the relationship between nurses and assistant nurses (Swedish: ‘Undersköterska’). While national professional bodies have established professional competencies and responsibilities for health care professionals, these declarations do not carry legal status. Swedish law mainly regulates how health care tasks should be carried out, not by whom. Thus, there is no formal requirement to employ registered nurses, specialist nurses or nurse managers in psychiatric inpatient care. Instead, it is up to the local head of department to specify the necessary qualifications for different tasks.

Participants and procedure

This study used a purposive sample (Higginbottom 2004) seeking to include nurses and assistant nurses experienced in CAP inpatient care. All staff members working at a CAP inpatient unit were invited to participate in semi-structured interviews prior to taking part in a recovery-focused intervention in the ward. The purpose of the interviews was to describe staff members’ experiences of working in CAP inpatient care. These interviews were intended to inform the design and evaluation of the intervention. However, staff were also informed that with their consent, the interview would be audio-recorded for a research study. The third author provided potential participants written and oral information about this additional use of the interview data, the purpose of the study, and its voluntary and confidential nature. A total of 18 staff members who participated in interviews to develop the recovery-focused intervention gave their informed consent to participate in this research study. For the purpose of this specific paper, we excluded interviews with non-nursing staff (n = 3) from the analysis.

Eight nurses and seven assistant nurses, 10 women and five men with an average age of 43, gave their written informed consent and participated in research interviews. Three of the nurses were specialized in psychiatric care. Participants’ length of experience working in CAP care ranged between one week and 37 years, with an average length of 4.1 years. Participants’ experience working at the specific ward ranged between one week and 14 years, with an average of 3.6 years.

Interviews

The third author conducted individual, semi-structured, responsive interviews (Rubin & Rubin, 2004) at the participants’ workplace in September and October 2019. Interviews were audio-recorded and transcribed verbatim. Interviews lasted between 19 and 57 min (average 35 min). No one else was present during the interviews. The authors developed an interview guide with questions that focused on participants’ work experiences and perceptions. For example, ‘How do you perceive your professional role’?, ‘How do you like it here’?, ‘What are your most important duties’?, ‘What are the strengths of this ward’?, ‘What are the weaknesses of this ward’?

To prompt participants to share their experiences and perceptions of everyday care in the ward, participants were also asked to reflect on the following scenario: ‘A patient has received a negative decision and reacts by shouting out loud and pounding on the walls in the hallway’. Participants were asked how they themselves would react in this type of situation, how they thought other staff would react, how participants wished staff would react and how that could be achieved.

Finally, participants were asked to reflect on a set of opposing statements inspired by Looi et al. (2014): ‘In a challenging situation, the most important priority is to observe and interpret the patient’s behaviour vs listen and try to understand the patient’s experience’, ‘In a challenging situation, the most important priority is to adapt to the situation at hand vs following ward rules and protocols’, ‘In a challenging situation, the most important priority is to get the patient to change his/her behaviour vs make sure the situation is resolved in a way that empowers the patient’, ‘In a challenging situation, the most important priority is to meet the patients’ needs vs see to staff’s needs’. Participants were asked to consider both their own perceptions and the predominant perceptions at their place of work.

Analysis

Transcribed interviews were analysed using qualitative content analysis, a systematic method for analysing written and verbal communication and making replicable and valid inferences from texts (Krippendorff 2013). Following Graneheim and Lundman (2004), the text was considered as a whole, read repeatedly, and then divided into meaning units. Meaning units were coded and categorized in several steps. For example, the meaning unit ‘helping all children and youth to feel better, to stabilize and stop hurting themselves… well to get more structure in their life… that is so complicated, it’s so much and so different things that different people need’ was coded as ‘Meeting the patient as an individual’, first categorized as ‘The importance of understanding the person and the persons needs’, and then as ‘Striving to be there for children and parents’. Finally, an overarching theme was formulated that, together with the categories, describes nurses and assistant nurses’ experiences. In qualitative content analysis, themes are considered abstract and interpretative, while categories are concrete and descriptive (Lindgren et al. 2020). The first author was responsible for the formal analysis, and all authors discussed each step. Codes, categories, and theme were developed and revised following joint reflection. Transcripts were not returned to participants for comments, and participants did not provide feedback on the findings.

Ethical considerations

This study adhered to ethical principles of informed consent and confidentiality. Approval was granted by the Regional Ethics Board in Umeå (2018/264-31) and the Swedish Ethical Review Authority (2019-04128).

RESULTS

The results describe nurse’s and assistant nurses’ experiences of CAP inpatient care in one theme: Constrained nursing, and four categories: Striving to be there for children and parents; Finding a way to manage work; Depending on others; and Lacking nursing leadership. In the following, the theme and categories are presented with illustrative quotes.

Constrained nursing

We identified the constraining and hindering of nursing as a recurring theme throughout categories. Most nursing staff described how they strived for, and to some extent, engaged in good mental health nursing practice in terms of seeing the person, meeting unique needs, doing good, being flexible, and going the extra mile when needed. However, in everyday life on the ward, this work seemed to go unnoticed and unarticulated. During rounds and in documentation, nursing perspectives took a subordinate role to medical and psychotherapeutic perspectives. This was partly due to a lack of professional nursing vocabulary as nurses had difficulties verbalizing nursing practice. As described below, a lack of nursing leadership meant that all professions and vocations on the ward could claim nursing as their domain, resulting in nursing being everyone’s and nobody’s responsibility. Nursing staff described being stuck in old routines and generic approaches to care, while longing for a more reflective nursing practice focusing on patient’s individual needs. Experiences of being questioned and criticized by other team members led to feelings of uncertainty and a fear of doing things differently.

Striving to be there for children and their parents In our analysis of nursing staff’s descriptions, we identified striving to be there for children and their parents as a category of nurses’ and assistant nurses’ work in CAP inpatient care. Being there involved engaging children and parents and being present, listening, and developing trusting relationships that allowed them to understand the patients’ needs. Many nursing staff described possessing personal skills in this area, and they valued the ability of staff to remain calm, humble, and receptive. Nursing staff spoke of the importance of also engaging parents with confidence and trust. The presence of parents on the ward was considered valuable, and nursing staff also regarded parents’ needs as their responsibility. Nursing staff described understanding the person and their needs as an important part of work, which required them to listen to patients and establish relationships. This could mean going beyond what was formally expected, for example, by staying in touch with discharged patients:

She was doing much better at home and just to be able to write was helpful for her… because she’s feeling better and can keep on doing her stuff and doesn’t need to come to the hospital… it doesn’t hurt me, it wasn’t stressful… (Participant N)

However, being there also involved challenges. Nursing staff sometimes hesitated to approach a person due to the severity of the patient’s condition or feeling uncertain about the preferred approach. Participants attributed staff choosing not to engage patients to a lack of knowledge and skills and to prejudice or a personal desire to maintain a distance. Being there also became difficult when staff failed to follow up on agreements and prioritize patient’s wishes, as this would result in patients developing a lack of trust towards staff. Emotional engagement was considered straining but also one aspect of being there. For example, participants described being emotionally overwhelmed by taking part of patients’ traumatic experiences. One assistant nurse described how it was hard to get around certain barriers for being there:

For quite a long time we have had a lot of girls who have experienced sexual abuse, and as a guy, I am unable to get very close… (Participant I)

Nursing staff described how all patients were offered psychoeducative information sessions and weekly schedules in order to provide structure, regardless of their actual needs. The use of these kinds of generic measures was considered a failure to acknowledge and engage the person. One nurse explained:

… and then it’s like medication and sleep; there are too many lists being made just because they should be made… and they keep asking for it… and I don’t always understand what is this… you don’t see the person, the individual, perhaps… but you make lists, weekly schedules, and they keep asking for it… (Participant D)

Likewise, ward rules and routines, for example, restricting patients’ use of mobile phones or access to showers, also made it hard for staff to engage patients. A lack of flexibility also meant that patients who needed it were denied the opportunity to do things outside the ward. Nursing staff also saw denying patients information or involvement in their care as problematic. One assistant nurse described:

I think it’s really annoying because some who come here with, for example, ADHD, they can’t go to sleep without listening to music… Shouldn’t they be allowed to (listen to music) just because we have decided that they can’t… (Participant I)

Finding a way to manage work

We also identified the category finding a way to manage work, describing a prominent aspect of nurses’ and assistant nurses’ work in CAP inpatient care. Experiences in this category further add to the main theme, constrained nursing, as they involved having to deal with a lack of clarity in roles and responsibilities. Nursing staff describe the significance of finding a way to feel confident in their ability to manage various situations but also being able to articulate practice and state their views. Such confidence could be rooted in both experience and training.

Feeling hope and being able to appreciate positive outcomes from work contributed to nursing staff being able to comprehend their work and their satisfaction with work. When nursing staff could see that they made a difference and were able to help, they found working with children and adolescents important, interesting, and challenging. Feelings of hope could also be related to the organization – they saw that change was possible and that there was a potential for development. As opposed to these positive aspects of work, nursing staff also described feeling inadequate, frustrated, and powerless, and the strain of seeing children and adolescents in distress.

The need to find a way to manage work was rooted in a sense of ambiguity around many aspects of their role. Nursing staff described a sense of insecurity related to unclear roles and responsibilities. This involved not knowing one’s professional role, lacking the necessary knowledge and skills to deal with work tasks, unclear ward rules and procedures, and having to adapt to expectations from different physicians. One assistant nurse reflected on having to deal with role ambiguity:

It’s hard… and you don’t always feel that you will be able to manage in the long run… (Participant I)

Nursing staff described that the workgroup was good at discussion and reasoning and perceived this as a part of everyday work, allowing the team to learn from experience and understand what could be done differently. At the same time, they expressed a need to develop their ability to reflect together and adopt more of a long-term perspective on patients. They also wanted to have more of a common ground for their work and be able to question ward rules and procedures with unclear aims. Nursing staff wanted the team to be able to talk about what was really important even when this made people uneasy. One assistant nurse explained:

I believe that we might not be very good at questioning why we have these rules… why we do these things… why everybody must have a schedule… why we do things just because we have always done them? I think sometimes we are not very good at reflecting on why we do stuff… (Participant N)

Depending on others

We identified depending on others as a prominent category in nurses’ and assistant nurses’ experiences, which further added to the theme constrained nursing by obstructing autonomous nursing practice. Nursing staff described intra- and interprofessional teamwork as something positive, where they all helped each other and contributed different experiences and competencies. Both longer and shorter work experience were described as valuable, as those with shorter experience could contribute new perspectives and ideas. Getting to know each other was considered important for successful teamwork. Nursing staff described feeling safe with each other, being able to communicate and solve problems together, and offering each other support when needed. But while nursing staff appreciated positive aspects of teamwork, they also described negative experiences of depending on others.

When it came to interprofessional collaboration, nursing staff described being ‘run over’ by members of other professions, not having their knowledge valued, lack of trust in their competencies, and severe communication deficiencies where information got lost and agreements were broken. They felt reprimanded and questioned. These negative experiences were partly related to professions and to specific persons. One nurse gave this example:

… not being included in a conversation… who attended the conversation… well, it was the physician and the psychologist… well, I was also there, but that is ignored, and then you are not really a part of it but a sidekick… (Participant B)

Nursing staff also described difficulties in collaboration amongst nurses and assistant nurses. Nursing staff explained how they had to relate to personal and professional conflicts between nursing staff members stirring under a pleasant surface, and how professional conflicts tended to evolve into personal conflict. They experienced a lack of patient focus amongst colleagues and that the comfort of staff was a priority over patients’ needs. However, calling this out evoked negative attitudes and being excluded from the group. Like other professions, nurses and assistant nurses questioned each other, and nursing staff described how staff formed different subgroups. One assistant nurse explained the willingness to work in a flexible and person-centred manner as a source of conflict:

We don’t always do things the same way, and sometimes you would get… some… well… criticism for not being properly rigid and rule-bound… (Participant N)

The significance of being dependent on others became clear in violent and potentially violent patient-related situations. Nursing staff described feeling confident that they could handle these types of situations due to their experience and training. Staff being able to defuse conflict situations and avoid violence and coercive measures were deemed a strength of the unit. However, nursing staff also described potentially violent situations as a negative aspect of work and a source of distress and fear. They also shared experiences of being left alone in dangerous situations when colleagues locked themselves in offices out of fear. Nursing staff described facing expectations, sometimes related to gender, that they should be the ones managing these types of situations. At times, nursing staff felt criticized by other team members for not using coercive measures to manage behaviours deemed intolerable. One assistant nurse said:

He felt that it wasn’t our job to fight with patients but that we should call security at once… and if we had the situation would have exploded and he [the patient] would be strapped to something… and that’s not what we should be doing… (Participant I)

Being dependent on others also involved being reliant on the support of management and the organization. However, nursing staff experienced a lack of clarity and structure on the ward. Nursing staff needed time, both to engage patients and to catch up on information and knowledge developments. A clear structuring of work was important, as it allowed for continuity and proactive care. Nursing staff stressed that structure must allow for flexibility and should not impede on the relationship with the individual patient. Nursing staff also wished for lower staff turnaround and support from other units in violent situations. They wanted leadership to have a clear focus on patients’ needs and development. They feared being stuck in old ways of doing things if they did not have a clear structure for the development and implementation of new knowledge.

Lacking nursing leadership Further adding to the main theme of constrained nursing, this category describes how nursing staff experienced a lack of nursing leadership. Nursing staff explained that registered nurses and assistant nurses alike shared the responsibilities of nursing. This involved engaging and talking with patients, psychoeducation, conducting rounds, attending physicians’ meetings with patients, supporting parents, and coordinating with external parties. This lack of differentiation between registered nurses and assistant nurses was mainly described in neutral or positive terms as ‘helping out’ and a ‘lack of hierarchy’. A few tasks were considered more nurse-specific; documentation, telephone advice, and handling medications, although assistant nurses were deemed equally qualified to handle medications and telephone advice in practice. One assistant nurse described:

… that’s what’s so good about this place, that there is very little difference… we basically do the same things; it’s just the medical bit that differs… nurses of course have more of a documentation responsibility but other than that, we do exactly the same things… (Participant K)

Nursing staff rarely mentioned nursing leadership. Rather, they described leadership as a personal attribute not related to one’s profession or vocation. However, nurses were expected to take the lead in acute situations, delegate tasks, and contact physicians. One nurse explained:

You have some kind of leader function… maybe not in nursing because here we have not really defined what nursing is… so you have some kind of almost medical responsibility… (Participant B)

The staff noticed the lack of clear nursing leadership in that physicians ordered nursing-oriented tasks. Nursing staff experienced this as frustrating, as such interventions became generic and not adapted to individual patients. Nursing staff also described difficulties in communicating nursing practice as it related to nursing being undefined and hard to verbalize. They believed nursing care plans were useful if they were appropriate and kept alive. However, physicians substituted these nursing care plans with general care plans. It was unclear if nursing care plans were required, and if they were made, they were not necessarily used. One assistant nurse explained why care plans were meaningless:

‘I think it’s a waste of time… it’s like you document everything several times… let’s say you have a patient with an eating disorder, then I am supposed to write down goals… gaining weight, eat and all those things… it takes quite some time, and everybody knows the goal is that they should get well and gain weight…’ (Participant H)

DISCUSSION

Our results describe nurses’ and assistant nurses’ experiences working in child and adolescent psychiatric inpatient care in one theme, Constrained nursing, and four categories: Striving to be there for children and parents; Finding a way to manage work; Depending on others; Lacking nursing leadership. Overall, our findings add to previous research describing a duality of inpatient mental health nursing in general (Gabrielsson et al. 2016; Graneheim et al. 2014; Molin et al. 2016) and CAP inpatient care in specific (Matthews and Williamsson, 2015), where the ideals and realities of care differ. They are consistent with previous research describing the uncertain status of nursing in CAP inpatient care (Ellilä et al. 2007; Hayes et al. 2019b; Rasmussen et al. 2017) and how ward management fails to relate nursing ideology to nursing models, theories, and ethics (Ellilä et al. 2007).

Our results describe staff’s experiences of working in CAP inpatient care as striving to be there for children and parents and emphasizes the significance of acknowledging the person, being present, building caring relationships, and tending to the individual needs of patients. This aligns with conceptualizations of mental health nursing as person-centred, recovery-oriented, and caring (Gabrielsson et al. 2020). We conclude that participants in this study saw good nursing practice as their responsibility. However, results also describe difficulties in articulating and achieving this. Previous research also describes a lack of shared visions of roles, values, and goals amongst nursing staff in psychiatric inpatient care (Salberg et al. 2019).

While our results thus suggest that mental health nursing is practiced in the CAP inpatient context, it is obscured by a lack of clarity in roles and responsibilities, forcing staff to find a way to deal with work. The complexity of the nursing role in acute inpatient settings involves balancing multiple and sometimes conflicting perspectives (Wyder et al. 2017). For nurses to be able to support recovery, they need support in dealing with the complexities of their role (Santangelo et al. 2018). It is important for staff to develop an understanding of their work to be able to communicate their knowledge (Terry 2020). Reflective practices might increase self-awareness and clarify roles (Wyder et al. 2017). Thus, our results suggest a need for nurses and assistant nurses to articulate their practice, and a need for support in doing so.

Our results in the category depending on others describe difficulties in establishing an autonomous nursing practice in relation to non-nursing staff and for nurses to assume nursing leadership. This adds to previous research describing how a dominant medical focus in psychiatric inpatient care might counteract nurses’ ambitions to deliver recovery-oriented nursing care and lead to moral distress (Wyder et al. 2017). Known sources of moral distress for nurses in psychiatric inpatient care involve experiences of substandard care, conflicts between ideals and realities and letting patients down (Jansen et al. 2020). Nurses who experience moral distress might add to the devaluing of good nursing practice, as they might respond by distancing themselves from patients and redefining their responsibilities (Gabrielsson et al. 2016; Jansen et al. 2020; Molin et al. 2016). To escape the limitations of the medical perspective (Moreno-Poyato et al. 2021; Santangelo et al. 2018), it seems crucial that nurses are allowed to assume leadership and develop an autonomous nursing practice. Mental health nursing needs to break free and contribute to quality CAP inpatient care. Arguably, the support of medical professionals is important for autonomous nursing practice (Cusack et al. 2017). Our results highlight the importance of developing intra- and interprofessional trust and communication for this to happen. Such a professional practice environment involves common goals and values as well as interprofessional respect, support, and dialogue (Jansen et al. 2020).

Our results also describe how nurses and assistant nurses working in CAP inpatient care experience a lack of nursing leadership, adding to the constraining of nursing in CAP inpatient care. Strong leadership is important for nurses to feel secure when their role is unclear (Cusack et al. 2017; Wyder et al. 2017). Weak nursing leadership might be due to nurses being assigned the role of coordinators filling the gap between other professions (Terry, 2020) or being reduced to administrative or medical assistants (Karlowicz & Ternus 2009) rather than assuming the role of independent professionals and nurse leaders. Arguably, nurses’ leadership in psychiatric care should involve, for example, acting as a role model, inspiring nursing staff to work towards common goals, ensuring evidence-based care, and upholding ethical principles (Ennis et al. 2015; Gustafsson & Stenberg, 2017).

To support youth mental health recovery, psychiatric-mental health nurses need to contribute to developing inpatient care (Wallström et al. 2021). Nurses are expected to take the lead in the development of person-centred, recovery-oriented psychiatric care (Cleary et al. 2017; Gabrielsson et al. 2020). However, the absence of nurse leadership in psychiatric care has been described as the ‘zombification’ of mental health nursing, suggesting that while the ideal of mental health nursing lives on, in reality, it is made subordinate to the medical profession and reduced to a set of tasks and procedures (Lakeman & Molloy, 2018). This aligns with our finding, which details how nursing practice in CAP inpatient care remains unarticulated and underdeveloped due to a lack of support, clarity, and leadership.

STUDY LIMITATIONS

All participants were recruited from the same inpatient ward. It is possible that the inclusion of nurses and assistant nurses from other CAP inpatient services would have resulted in more varied and nuanced descriptions. Also, we chose to include participants with limited experience of working in CAP inpatient care. Following Graneheim and Lundman (2004), we believe the inclusion of staff with various length of experience might have ‘contributed to a richer variation of the phenomena under study’ (2004, p.110). However, the consistency of our findings with previous research in mental health nursing suggests that our findings, following critical reflection, are transferable to other settings.

CONCLUSIONS

This study provides new detail to the nursing practice environment in CAP inpatient care from the perspective of nursing staff. Good, person-centred, and recovery-oriented nursing practice can exist but remain unrecognized and lacking in support. Due to unclear roles and responsibilities and lack of leadership, nurses and assistant nurses working in CAP inpatient care practice constrained nursing – mental health nursing that remains unrecognized, unarticulated, unappreciated, and unsupported.

RELEVANCE FOR CLINICAL PRACTICE

CAP services need to acknowledge the contribution of nursing and nursing staff in delivering quality care and ensure supportive nurse practice environments. Nurses in CAP inpatient care need to claim the role of nursing experts and leaders. In doing so, they need a clear mandate to assume positions as independent professionals.

Funding information

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgements

The authors would like to thank the study participants for sharing their time and experiences.

References

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