Abstract
Background
Forensic mental health nursing is a specialised practice area. Graduate programs are essential for recruitment and retention. There have, however, been very few studies exploring forensic mental health graduate programs.
Aim
The aim of this study was to explore the experience of graduate nurses who completed a 2-year graduate program in a forensic mental health service in the state of Victoria Australia, and the nurses who support the graduates in the program.
Methods
An exploratory study was conducted gathering data via one-to-one interviews, with purposive sample of 20 forensic mental health nurses.
Findings
Analysis resulted in the interpretation of two themes; essential ingredients and ‘hitting hurdles’.
Discussion
Graduate nurses commence with limited knowledge, experience challenges, and organisational pressures.
Conclusion
Transition to practice was enhanced with consistent support, university education, and program structure.
Keywords
Summary of relevance
Problem or Issue
There have been very few studies examining graduate programs specifically designed for graduate nurses entering forensic mental health nursing.
What is already known
Graduate nurses experience a range of challenges when entering the workforce due to limited knowledge and experience coupled with organisational pressures.
What this paper adds
Graduate nurses entering forensic mental health nursing can be supported by ensuring they are provided with consistent support from on-site clinical educators and nursing staff at the unit level as well as supplementing their learning with a graduate nursing diploma and a structured in-house program.
1. Introduction
Undergraduate nursing education programs in many countries, such as Australia, Canada, New Zealand, and the United Kingdom (UK), transferred from hospital based education to the university sector in the 1980s (
Clinton and Hazelton, 2008
; Institute of Medicine, 2011
). Some countries, such as the UK, offer specialised undergraduate courses for general nursing, learning disability and mental health nursing. Other countries, such as Australia and New Zealand, offer generic nursing courses toward registration. These undergraduate courses cover a wide range of nursing practice areas, including medical and surgical nursing, older persons' health, child and family healthcare, primary health, and mental health nursing. Therefore, specialisation occurs after graduation (Happell, 2003
; - Happell B.
Comprehensive nursing education in Victoria: rhetoric or reality?.
Journal of Psychiatric and Mental Health Nursing. 2003; 8: 507-516https://doi.org/10.1046/j.1365-2850.2001.00418.x
Hemingway et al., 2016
).- Hemingway S.
- Clifton A.
- Edward K-L.
The future of mental health nursing education in the United Kingdom: reflections on the Australian and New Zealand experience.
Journal of Psychiatric and Mental Health Nursing. 2016; 23: 331-337https://doi.org/10.1111/jpm.12312
In countries with specialised undergraduate education, the mental health speciality courses experience poor student enrolment compared with other specialised programs (
Sørensen et al., 2018
). In countries with generic undergraduate nursing, curricula have been criticised by mental health nursing academics for placing the mental health nursing profession at a disadvantage, as there is limited mental health content, and insufficient opportunities for undergraduate nursing students to gain clinical experience in mental health nursing (- Sørensen T.
- Tingleff E.B.
- Gildberg F.A.
Feeling safe and taking on responsibilities: newly graduated nurses' perceptions and evaluations of their transition into a forensic mental health inpatient setting.
Journal of Forensic Nursing. 2018; 14 (PMID: 29601414): 126-134https://doi.org/10.1097/JFN.0000000000000190
Edward et al., 2015
; - Edward K.l.
- Warelow .
- Hemingway .
- et al.
Motivations of nursing students regarding their educational preparation for mental health nursing in Australia and the United Kingdom: a survey evaluation.
BMC Nursing. 2015; 14https://doi.org/10.1186/s12912-015-0084-8
Happell, 2010
). The lack of education and limited clinical placements results in many graduate nurses entering their career with limited knowledge and exposure to mental health nursing (Proctor et al., 2011
). It is suggested that it takes about a year for new graduate nurses entering the nursing workforce at a novice level, to become proficient practitioners (- Proctor N.
- Beutel J.
- Deuter K.
- Curren D.
- de Crespigny C.
- Simon M.
The developing role of transition to practice programs for newly graduated mental health nurses.
International Journal of Nursing Practice. 2011; 17: 254-261https://doi.org/10.1111/j.1440-172X.2011.01932.x
Clinton and Hazelton, 2008
; Cowley et al., 2016
).Services have responded by providing support and developing nursing programs in the first and sometimes second year after undergraduate training (
Clinton and Hazelton, 2008
). Graduate nursing programs have three main aims; ensuring the graduate nurse successfully transitions to practice; ensuring relevant nursing competencies and standards of practice are met, and recruiting and retaining suitably skilled nurses (Martin et al., 2007
). Forensic mental health services offering graduate programs also need to ensure graduates are able to transition in a subspecialised area of practice, within the specialty of mental health nursing, with additional skills and knowledge requirements (- Martin T.
- Donley M.
- Parkes J.
- Wilkin C.F.
Evaluation of a forensic psychiatric setting to provide a graduate nurse programme.
International Journal of Mental Health Nursing. 2007; 16: 28-34https://doi.org/10.1111/j.1447-0349.2006.00441.x
Barr et al., 2019
; Martin et al., 2012
). While there has been limited investigation into nursing graduate programs in forensic mental health, a recent study (Sørensen et al., 2018
) highlighted the importance of graduate nurses feeling safe during their transition, in order to effectively engage in the clinical responsibilities required of them.- Sørensen T.
- Tingleff E.B.
- Gildberg F.A.
Feeling safe and taking on responsibilities: newly graduated nurses' perceptions and evaluations of their transition into a forensic mental health inpatient setting.
Journal of Forensic Nursing. 2018; 14 (PMID: 29601414): 126-134https://doi.org/10.1097/JFN.0000000000000190
1.1 Background of this study-Forensicare
The setting for this study is Forensicare, the state wide forensic mental health service in Victoria, Australia, that provides specialist services for a population of approximately 6.6 million people (
Australian Bureau of Statistics 2021
). Forensicare delivers a range of recovery-oriented mental health services across the state. Services are tailored to different stages of recovery and range from assessment, early intervention and prevention, secure inpatient acute care and rehabilitation, and community integration support. Consumers, who come into contact with the service, are individuals with a mental illness at risk of, or involved in the criminal justice system; individuals who have committed a criminal offence, but found not guilty or unfit to be tried; and individuals in the community at risk of offending who pose a risk to themselves or others (Australian Bureau of Statistics. (2021). National state and territory population.Canberra: Australian Bureau of Statistics. Retrieved 31 August 2021 Available from: https://www.abs.gov.au/statistics/people/population/national-state-and-territory-population/latest-release.
Victorian Institute of Forensic Mental Health 2020
). Covering a variety of services allows Forensicare to offer a range of placements for graduates across the service in courts, prisons, secure inpatient services and the community.1.2 Graduate program and structure
The graduate nurse program at Forensicare commenced in 1994. The initial program was based in the secure hospital, the graduates were enrolled in a mental health nursing graduate certificate course, and there was no formal structure other than fortnightly group supervision. Over time, the program has evolved, and now the program includes a combination of tertiary education and clinical experience. Graduates complete a Graduate Diploma in Mental Health Nursing at a university specified by Forensicare, comprised of seven modules. The service requires the graduates to complete a specific elective, a course on forensic mental health nursing which is undertaken through, (Swinburne University of Technology), and is completed in their final semester of the program. Within the service, graduates are allocated a preceptor in the first year and a mentor in the second year for each placement, where they will have four placements over the two years, and some graduates will also have the opportunity to have placements in prison services and in the community. Graduates are required to develop clinical objectives for each placement, and complete formal assessments of clinical competencies, assessed by their coordinator preceptor/mentor, and Nurse Unit Manager (NUM).
All of the course requirements are contained in a learning manual. They also attend regular meetings as a group, and in-house lectures provided by nursing staff at Forensicare. The program is coordinated by Clinical Nurse Educators (CNEs) employed by Forensicare, with one CNE specifically dedicated to year one, and another for year two of the program (see Table 1 for description of year one and two of the program).
Table 1Components of the graduate program.
| Graduate year | One | Two |
|---|---|---|
| Competencies | Leave escorting | Primary nursing |
| Medication | Clinical risk and management | |
| Pre-leave competency | Quality improvement project | |
| Group facilitation | ||
| Dynamic Appraisal of Situation Aggression | ||
| Modules | Mental health histories and mental state examination | Challenging behaviour |
| Biopsychosocial factors | The therapeutic relationship | |
| Working with people who have borderline personality disorder | Offence issues | |
| Trauma and mental health | ||
| University requirements | Commence graduate diploma inmental health nursing | Complete diploma including elective-forensic mental health nursing |
| Local support | Graduate coordinator and assigned a preceptor | Graduate coordinator and assigned a mentor |
| Meetings | Objectives meeting | Objectives meeting |
| Mid placement meeting | Mid-placement meeting | |
| Final evaluation meeting | Final evaluation meeting | |
| In-house lectures | MSE and applying to practice | Role of a primary nurse: |
| Mental illness | Running groups | |
| Mediation | Completing quality improvement activities | |
| Documentation | Therapeutic relationships | |
| Patient observation and engagement | Offence issues | |
| Risk assessment and management | Risk management | |
| Relational security | Reducing and eliminating seclusion and restraint | |
| Nursing process | Understanding relational security | |
| Legislation | Managing personal stress | |
| Mental illness and offending | Clinical supervision | |
| Consumer consultants | ||
| Family and carers | ||
| Care planning | ||
| Primary nursing | ||
| Preceptoring and nentoring | ||
| Safewards | ||
| Trauma informed care | ||
| Cultural responsiveness | ||
| Dual diagnosis | ||
| Therapeutic groups | ||
| Evaluation |
Over the last five years in particular, Forensicare has experienced considerable growth, with staff almost doubling (with the majority of the increase in nursing), and expansion in service delivery (
Victorian Public Sector Commission 2020
). Forensicare now employs approximately 500 nurses across three directorates (hospital, community, and prisons). The expansion of the service has seen the intake of the graduate program increase, resulting in additional options for graduate nurses to have clinical placements in the courts, community and prison services. Against this background, the overall aim of this qualitative study was to explore the experiences and perspectives of nurses, who have recently completed the graduate nursing program, and the experience of the nurses who support the graduates in the program. Exploration of the nurse's experiences is important to enable Forensicare to develop, and enhance the program to ensure it is meeting the needs of the graduates and the organisation. The intent is to also assist the development of such programs in other jurisdictions.2. Method
2.1 Research design
This qualitative, descriptive, exploratory study involved the collection of data through semistructured interviews conducted across the three directorates at Forensicare. This type of approach allowed an in-depth exploration of the nurses’ learning in the program detailed through their own unique experience. The study was reported using EQUATOR network recommendations for qualitative research (COREQ;
Tong et al., 2007
). The study research design received approval from the (Forensicare). The current study was approved by the relevant HREC (SHR Project number SHREC: 20205405-5748). Data were collected from February 2021 to June 2021.2.2 Participants
A purposive sampling strategy was used to recruit participants for this study. A purposive sample can be used to create an understanding of issues of central importance to a research question, as the process seeks to recruit information-rich participants
Palinkas et al., 2015
. Therefore, the inclusion criteria were (i) nurses who had completed the graduate nurse program in either 2019 or 2020, who were still working in Forensicare, and (ii) nurses at Forensicare who support the program either as a graduate coordinator, CNE, NUM, preceptor or mentor. The recruitment of the purposive sample of graduates occurred via emails to those graduates on the coordinator's enrolment list. Staff participant recruitment methods were information flyers, emails, and presenting the study in various internal meetings.2.3 Data collection
All participants provided informed voluntary written consent to a one-off, semistructured interview. Interviews were conducted either face-to-face in a location external to the work place; or via an online platform or over the phone, during COVID-19 lockdown periods, at a time that suited the participants. Two researchers external to the graduate program and the Swinburne Forensic Mental Health Nursing subject interviewed the graduate nurses, who are both academic staff. Researchers TM and DM interviewed the nurses who support the program, and had no line management responsibility to the nurses. All interviews were audio-recorded and lasted between 40 minutes to 1 hour. Field notes were taken by the researchers during the interviews. An interview guide was used to provide some structure to the interviews, and the guide was based on the study objectives. The interview questions focused on the perceived level of support in the program, opportunities to practice clinical skills, the graduate learning manual, completion of the Graduate Diploma and the Swinburne forensic mental health nursing subject forensic mental health nursing subject, and the in house lectures. Confidentiality of participants was maintained by de‐identifying the data and assigning a unique subject number. The letter ‘N’ was used for the support nurses in this study, and the letters ‘GN’ were used for the graduate nurses in this study.
2.4 Data analysis
The interview data were analysed using the six‐stage Reflexive Thematic Approach proposed by
Braun and Clarke, 2019
, which is a method about how the researcher is reflective and has thoughtful engagement with the data, and how they are reflexive and thoughtful engaged with the analytic process (- Braun V.
- Clarke V.
Reflecting on reflexive thematic analysis.
Qualitative Research in Sport Exercise and Health. 2019; 11: 589-597https://doi.org/10.1080/2159676X.2019.1628806
Braun et al., 2018
). The reflexive thematic analysis was largely conducted by authors * and *, and the additional authors *, * and * were engaged to audit the reflexive analytical process, verify ideas and explore assumptions and interpretations of the data in order to approach achieve generalisability of the concepts described by the participants in this study.After transcription of the interview data verbatim and field notes, the first author listened to every interview in full, and checked all transcripts for accuracy against the audio file. The interview transcripts for the graduate nurses were subject to analysis by researchers TM and DM and the support nurses TM, RL and MN. Following familiarisation of the data, initial codes were generated using open-coding, whereby similar statements were identified and allocated codes.
The collation of codes into potential themes then occurred, using an Excel spreadsheet. The themes were then reviewed in relation to the coded extracts, followed by the entire dataset. In phase five, the research team met again to discuss the final themes as a whole, resulting in the interpretation of two themes. The themes were defined and named. The final phase, writing up, was in the form of writing this article. All members of the research team have either qualitative analysis experience, or experience in working as a forensic mental health nurse.
3. Findings
3.1 Sample description
A total of 20 nurses participated, five nurses who had completed the graduate program in either 2019 or 2020, and 15 nurses who supported the nurses in the graduate program (see Table 2). The graduate nurses who participated all had placements at the secure hospital, and some had completed clinical rotations in the community and prison services. The nurses who supported the program were also from various locations from across the service, and had supported the graduate nurses as a CNE, NUM, or preceptor/mentor.
Table 2Participant characteristics.
| N | (%) | ||
|---|---|---|---|
| Graduate nurses | |||
| Gender | Male | 2 | 40 |
| Female | 3 | 60 | |
| Clinical rotations | Inpatient | 5 | 100 |
| Prisons | 2 | 40 | |
| Community | 2 | 40 | |
| Nurses supporting the graduate program | |||
| Gender | Male | 3 | 20 |
| Female | 12 | 80 | |
| Location | Inpatient | 8 | 53 |
| Prisons | 4 | 27 | |
| Community | 3 | 20 | |
| Role | CNE | 5 | 33 |
| NUM | 5 | 33 | |
| Preceptor/Mentor | 5 | 33 |
4. Themes
Analysis resulted in the interpretation of two themes from the data; (i) essential ingredients, and (ii) hitting hurdles, and six subthemes linked to the themes (see Table 3).
Table 3Themes and subthemes.
| Theme | Subtheme |
|---|---|
| Essential ingredients | Support |
| Education | |
| Structure | |
| Hitting hurdles | Educational hurdles |
| Unit hurdles | |
| Organisational hurdles |
4.1 Theme one: Essential ingredients
This theme describes the elements of the graduate program that participants considered key in supporting the learning and practice development of the graduate nurses. Participants identified that when graduate nurses commence, they need to be orientated to the environment, a range of policies and procedures, and settle into the professional role, in order to consolidate and further develop the knowledge and skills learnt in their undergraduate training. There are three subthemes that describe the essential ingredients which are support, education, and structure.
4.2 Support: ‘High on people's radars’
The views of the graduates highlighted the importance of the support they received from a range of staff including the CNE's, NUMs, preceptors, mentors, and unit staff.
“..I was paired with good people. I think obviously that makes a huge difference if you feel like you can approach them for support, because it's a whole new world. You don't know anything when you start this job, so you need that person to go to. I found any member of the team would help you and the educators were amazing. You could e-mail them, or call them...it was a nice and warm and fuzzy kind of support, which I think is necessary when you're a baby nurse.” GN3
There was also a sense that the unit staff was acutely aware of the needs of graduate nurses, and would step in to assist when needed.
"I have seen staff really pitch in with the grads[graduates], and if they see that people are struggling, they will approach them. They are quite high on people's radars.” N8
Support was provided not only from the nurses working on the unit with the graduates, but also through debriefing and graduate meetings, which were described as supportive places, where issues and challenges could be discussed as a group.
“I did find them (graduate meetings) quite useful. If you had issues and things that we were not really understanding, discussions about why we did such things are really good.” GN5
“Whether it is consolidating what they already know, or unpacking the different perspectives they may not have considered otherwise, it gives them a safe space to explore situations.” N2
While the program focuses on the provision of support from allocated preceptors, mentors and the CNEs, the graduates described support from their peers. While peer support is not necessarily intent of the program, the graduates viewed this as an important part of their journey.
“As a grad group as well, we were a good group and helped each other debrief and what not.” GN3
4.3 Education
Undertaking the Graduate Diploma of Mental Health Nursing was considered to be important in assisting the transition to practice. The participants identified firsthand clinical experiences, where there was limited understanding of the clinical reasoning behind the practice. This is where the theory and evidenced based practice covered in the diploma complements the clinical experience.
“You have got the clinical bit, which is where you learn the most because you are on the job, but you also need the theory as to why you are doing things.” GN5
Furthermore, because the graduate nurses were all working in a forensic mental health setting, the requirement to undertake the Forensicare Forensic Mental Health Nursing subject was seen as essential to equip them with knowledge and skills relevant for working with consumers, and necessary due to the specialised nature of practice in this field.
“When you do undergraduate nursing, you come out as a general nurse. So that specialised knowledge, skills and education in mental health nursing, and the forensic subject that we did, provided the skills and knowledge that we need to then work within our current environment.” GN4
“Mental health is a speciality, forensic mental health is an even more special form of mental health nursing...forensic mental health nursing as a separate subject is very worthwhile." N14
"...the forensic subject is really important because it is a subspecialty, and there is a lot that we need to understand about risk and offending issues that's probably very different if you were just in an area mental health service.” N9
4.4 Structure
The final essential ingredient was the structure of the program. The structure in the program facilitated feedback at key times during each rotation (objectives meetings, mid placement meetings, and final evaluation meetings), and provided direction for learning and the skills graduate nurses were expected to achieve. The structure also provided opportunity to address any problems early on in the clinical placements (for example, difficulties meeting objectives). The learning manuals are in essence the key document that details the structure of the program and were seen to assist in goal setting, and facilitating feedback, hence facilitating learning in a structured manner.
“The manual is pretty good. The first one's more competencies, and it was good to just know what we're going to be able to do…knowing what you should be looking out for and having them included in the manual, and listing of everything off.” GN5
“The manual directs the learning…it's good to have the direction of the things you need to focus on in this year of your learning." GN2
"The manual gives structure about how to work with them, and what skills they are required to achieve." N13
“(The manual) assisted in giving feedback on any area we might want them to work on or explore, and if there were any issues, we want to be addressing them fairly early on and not leaving it to the end." N2
The view from the participants highlights the need to provide graduates with support on the unit, theoretical knowledge related to mental health and forensic mental health nursing, in a structured manner, to enhance the graduate experience and maximise learning opportunities.
4.5 Theme two: Hitting hurdles
While all participants spoke positively overall about the program, there were also a number of ‘hurdles’ that graduates came up against during the course of the program. These hurdles came under three subthemes, knowledge on entry to the program, challenges on the unit, and organisational pressures.
4.6 Knowledge on entry to program
The forensic mental health setting can be a demanding environment, and the nurses in the study related how graduates needed to have a certain level of knowledge in mental health nursing to work effectively in the setting. Participants in this study acknowledged that limited exposure to mental health care before commencing employment, coupled often with limited mental health knowledge was a challenge, especially in the early part of the program.
“I also found that there were some duties that were required of me that I had not really any prior knowledge of.” GN4
“Often they don't come to us with that level of understanding around mental health and because there is so little that's actually taught at a university level (mental health).” N8
"Although they have had their mental health placement, one, two if they are lucky…Sometimes I am worried that they are unconsciously incompetent, they don't know what they don't know.” N12
Graduate nurses also identified that it was at times hard to see the relevance of what was being taught in the host Graduate Diploma of Mental Health Nursing course, where the content is more directed toward generic mental health nursing (as compared to the module on forensic mental health nursing) in their everyday practice. Although integrating and consolidating what is learnt in university into everyday practice can prove challenging at times, on reflection some of the participants appreciated the need for more generic mental health nursing knowledge in the application of their specific forensic mental health nursing practice.
"There is always the conundrum of applying what you have learnt to practice. Often it doesn't flow freely.” N9
“It's difficult to put that theory into practice when you don't really understand what you're doing at work as well… it just was confusing and it didn't feel relevant at the time..I feel like you learn a lot more on the job.” GN3
“At the time, doing it (the host university modules of learning) when you first started work, then it's difficult to see the relevance. Upon reflection, I could see the relevance.” GN4
The participant views represent the initial hurdles of entering the workforce with limited knowledge and exposure and the ongoing challenge of applying theory to practice.
4.7 Challenges on the unit
There were also a range of hurdles experienced at the unit level. Several of the graduates spoke about the limited time they had on the units to spend with staff. Reasons cited for lack of time included delays in being assigned a preceptor and/or mentor and not being rostered on together, which contributed to feelings of being unsupported.
“The unit manager was not as supportive. It took me about two months to get a mentor there.” GN1
“My rosters never aligned with my mentor’s.” GN2
The engagement and willingness of the preceptor/mentor was also considered to be important in determining the experience of the graduate nurse. Several nurses identified staffing shortages resulting in fewer people being available to assist the graduates, and where some people may have been assigned the role of preceptor/mentor out of necessity, rather than a true desire to want to work with a graduate. When there was reluctance from the assigned preceptor/mentor, this was reported to impact on the graduate's experience, confidence, willingness to seek assistance, and at times their relationship with the preceptor/mentor.
"One of them [staff member on the unit] said to a graduate, “I don't like students, or I don't like graduates’, and making these outward comments that makes them [graduates] feel very uncomfortable." N4
"There are clearly some preceptors and mentors that don't want to be a preceptor or mentor, and this can do more damage." N11
"Some of them don't want to do it (be a preceptor) and they get told there is no one else and they have to do it, so they will begrudgingly do it, and I think that ruins the relationship.” N2
“On some units you could ask other people for help, but I didn't always feel comfortable…. Not everyone was able to have the confidence to bring up questions and talk to other staff about issues.” GN2
Working in a specialist area, such as forensic mental health, also requires graduate nurses to work towards specific competencies in forensic mental health nursing. There was a sense that at times the competencies might test some of the preceptors, which may have resulted in competencies being signed off without being complete. In such instances, more support was needed from the clinical educators to ensure the competencies were achieved.
"...the grads have a contemporary knowledge base, they are at uni, they are being taught, so they are coming with all this knowledge and I think it really tests the preceptors...it's a little embarrassing when there is a competency that you need to sign off and you don't know too much about it, so it's much easier to sign it off than to say I have got no idea what that means." N2”
“I got the sense that it is across the board, not specific to any location, and again I think it really came down to the fact that the unit staff didn't have the knowledge so it (the competencies) was signed off." N4
4.8 Organisational pressures
Several changes to the program coordinators resulted in cancellation of some of the in-house lectures, or these sessions being replaced with unstructured debriefings. This highlights the importance of consistency in the program, and the need for these in house lectures to enhance the learning experience, and the sense of support garnered for the program from the service in general.
“Most of our education sessions were just debriefs. There was a lot of structure to begin with, but then it sort of dropped off pretty rapidly, and then when we were getting various coordinators, I don't think we had a graduate meeting, due to the fact that the coordinators just kept changing. We definitely didn't cover all the topics that we were meant to.” GN3
Furthermore, changes to graduate coordinators meant nurses coming into the position needed to orientate them into a new role. The frequent changes may have resulted in the coordinators not always being able to be as responsive as the graduates needed. There was also a sense that while at times the debriefings were helpful, they were not helpful when there were not structured, to ensure these sessions focused on the actions and thought processes involved in clinical care.
“We ended up having three or four coordinators in the second year, which made it really difficult. Any time we would direct a question to someone, they would sort of just palm it off to someone else, or they wouldn't be in that role anymore. It made it really difficult for us to get any solid answers to our questions.” GN1
“The education sessions turn into like a bit of a like a de-brief…..in a way it was helpful to hear everyone's experiences, but it could get a bit out of hand at times.” (GN1)
5. Discussion
This is the first study to report the experiences and perceptions of graduate nurses, and the nurses who support them, in a bespoke forensic mental health nursing graduate program. This study has emphasised the need for a program that can assist newly graduated nurses in their transition into clinical practice in a forensic mental health setting. Three key ingredients of support, education, and structure are required to scaffold the learning and skill development of the graduates. This study has also highlighted obstacles graduates face during the course of their journey, related to the limited knowledge they have when commencing the program, challenges experienced at the unit level and organisational pressures.
Entering the workforce can be a stressful and challenging time, where newly graduated nurses may commence with limited knowledge and exposure to mental health (
Clinton and Hazelton, 2008
; Wing et al., 2015
), which can influence their confidence and competence (Hayman-White et al., 2007
). To support new nurses, graduate programs are designed to offer support in the clinical context to assist the application of theory and enhance recruitment and retention in the workforce (Proctor et al., 2011
).- Proctor N.
- Beutel J.
- Deuter K.
- Curren D.
- de Crespigny C.
- Simon M.
The developing role of transition to practice programs for newly graduated mental health nurses.
International Journal of Nursing Practice. 2011; 17: 254-261https://doi.org/10.1111/j.1440-172X.2011.01932.x
Participants in this current study valued the support they received during the program from the CNEs, NUMs, unit staff, as well as the support they received from their peer group. However, there were several factors around the structure of the program and access to support that impacted on the graduate's confidence and consistency of the program. The perception of support wavered when there were multiple changes to the coordination of the program, unstructured debriefs in place of educational sessions, limited time with preceptors and mentors, and reluctance to work with graduates.
These findings are consistent with a previous study exploring graduate nurses during their introductory period in forensic mental health. In this study, when staff on the unit were less willing to offer support, graduates experienced confusion related to inconsistency of values and rules on the unit, whereas compassion from unit staff was considered pivotal to graduates feeling safe (
Sørensen et al., 2018
). The development of positive relationships is the foundation of nursing, and providing care is characterised by sensitivity and close working relationships, which requires the clinical setting to be conducive to carrying out this work (- Sørensen T.
- Tingleff E.B.
- Gildberg F.A.
Feeling safe and taking on responsibilities: newly graduated nurses' perceptions and evaluations of their transition into a forensic mental health inpatient setting.
Journal of Forensic Nursing. 2018; 14 (PMID: 29601414): 126-134https://doi.org/10.1097/JFN.0000000000000190
Finfgeld-Connett, 2008
; Wright et al., 2011
). With projected workforce shortages (Phillips and Miltner, 2015
), there lies a responsibility for the nursing profession to encourage new nurses to ensure they feel welcome, safe, and supported in the workplace (Hawkins et al., 2019
). Nurses who are able to adequately support new graduate nurses, play an important role in serving as positive role models and creating an environment that encourages development and growth, and in assisting new nurses to settle into the workplace environment (- Hawkins N.
- Jeong S.
- Smith T.
New graduate registered nurses’ exposure to negative workplace behaviour in the acute care setting: an integrative review.
International Journal of Nursing Studies. 2019; 93: 41-54https://doi.org/10.1016/j.ijnurstu.2018.09.020
Proctor et al., 2011
). Coaching roles such as the preceptor/mentor roles need to be valued, sustained, and protected as part of a healthy workplace culture that explicitly values engagement with students and graduate nurses.- Proctor N.
- Beutel J.
- Deuter K.
- Curren D.
- de Crespigny C.
- Simon M.
The developing role of transition to practice programs for newly graduated mental health nurses.
International Journal of Nursing Practice. 2011; 17: 254-261https://doi.org/10.1111/j.1440-172X.2011.01932.x
There was some suggestion from the participants in this study that the competencies required of the graduate nurses may have tested some of the preceptors. While newly graduated nurses expect appropriate training and education to assist their transition, for nurses in their mid- to late-career, ongoing learning is essential for maintaining competency, providing quality care to consumers, and for enhancing nursing career opportunities (
Price and Reichert, 2017
). Taking on the role as a preceptor can provide nurses the opportunity to enhance their professional development and confidence, but this does require nurses to maintain a high level of knowledge and skill (Happell, 2010
), and the role requires active support from people in positions such as NUMs, to ensure those providing preceptorship have the necessary time and skills to effectively undertake the role (Mooney, 2007
; Whitehead et al., 2013
). It also requires the organisational structure to meet the targeted staff development needs in such roles as preceptors/mentors and Nurse Unit Manger.The forensic mental health setting also comes with the need for additional skills and training (
Barr et al., 2019
) related to inherent security requirements (Martin et al., 2007
), requirements to address additional needs such as violence risk assessment and management, and offending behaviour (- Martin T.
- Donley M.
- Parkes J.
- Wilkin C.F.
Evaluation of a forensic psychiatric setting to provide a graduate nurse programme.
International Journal of Mental Health Nursing. 2007; 16: 28-34https://doi.org/10.1111/j.1447-0349.2006.00441.x
Maguire et al., 2021
; - Maguire T.
- Carroll A.
- McKenna B.
- Dunn C.
- Daffern D.
The model for understanding inpatient aggression: a version for mental health nurses working in prisons.
Issues in Mental Health Nursing. 2021; https://doi.org/10.1080/01612840.2020.1871134
Maguire et al., 2012
), and an additional set of nursing standards (Forensic Mental Health Nursing Standards of Practice; - Maguire T.
- Young R.
- Martin T.
Seclusion reduction in a forensic mental health setting.
Journal of Psychiatric and Mental Health Nursing. 2012; 19: 97-106https://doi.org/10.1111/j.1365-2850.2011.01753.x
Martin et al., 2012
). While some may argue that it may not be realistic to prepare graduate nurses specifically for forensic mental health nursing, given the specialised area of practice (Sørensen et al., 2018
), findings from this study suggest that the addition of a specific forensic mental health nursing subject, was important in assisting the transition to practice in a specialised environment. The newly graduated nurses in this study identified the specialised nature of the work, and the nurses who supported them believed that additional knowledge and skills are required to work as a forensic mental health nurse. Furthermore, acknowledging the complexities of nursing within the forensic mental health setting, coupled with supervision, can assist nurses in the delivery of care and the development and maintenance of therapeutic relationships (- Sørensen T.
- Tingleff E.B.
- Gildberg F.A.
Feeling safe and taking on responsibilities: newly graduated nurses' perceptions and evaluations of their transition into a forensic mental health inpatient setting.
Journal of Forensic Nursing. 2018; 14 (PMID: 29601414): 126-134https://doi.org/10.1097/JFN.0000000000000190
Feerick et al., 2021
). While participants found debriefings helpful, findings from this study stress the importance of maintaining a clinical focus to ensure graduate nurses are able to reflect on clinical care and issues encountered in the workplace, and have the opportunity to link theory to practice in a safe space with peers.5.1 Limitations
This study was conducted at one forensic mental health service, which may also limit the generalisability of the findings to other services. Some of the data collection in this study occurred during a period of lockdown due to the COVID-19 pandemic. As a result, online interviewing was required in some situations, which was less than ideal. At times, there were connection issues when using the online platforms, which may have impacted the flow of the interviews.
The pandemic also impacted staff working on the units providing direct patient care, which meant often more junior nurses, such as the graduate nurses in this study, were not able to leave the unit to participate in interviews. Whereas, nurses who support the graduates were more likely to be working from home, or have their own office and computer, which may have contributed to recruitment of more support nurses than graduate nurses. While only five graduate nurses were in the sample, nine of the support nurse cohort, had previously been through the graduate program at the service.
6. Conclusion
The transition from nursing student to registered nurse can be a stressful time, where newly graduated nurses need to adjust to their new work environment, undertake graduate studies, and work to consolidate their skills over the course of the program. The specialised nature of forensic mental health nursing also requires additional knowledge and skills. This study identified support from staff; mental health and forensic mental health nursing education; and structure in the program, as essential ingredients in supporting newly graduated nurses. Conversely lack of support from staff, lack of consistency and limited time with preceptors and mentors can negatively influence the experience of graduate nurses.
Support from preceptors is crucial, as a positive working relationship can assist the newly graduated nurse to settle into the workplace, develop their skills, and translate their theoretical knowledge into the practice setting. The role of the preceptor can also be professionally rewarding, however, it requires a high level of knowledge, skill, and organisational support. Despite the challenges, nurses in this study appreciated the support they received from staff who were attuned to their needs, and appreciated the addition of specific education to work in the unique speciality, that is forensic mental health nursing.
Authorship contribution statement
Tessa Maguire: Conceptualisation, Methodology, data collection, analysis, and writing. Jo Ryan: Conceptualisation and data collection. Rebecca Lofts: Data collection and analysis. Daveena Mawren: data collection, analysis and editing. Margaret Nixon: Conceptualisation, methodology, and editing. Brian McKenna: Conceptualisation, Methodology, data collection, analysis, and editing.
Ethical statement
The submitted manuscript involved human research. Ethical Approval was granted for the Study as a scientific research study. - The name of the ethics committee: Swinburne University Human Research Ethics Committee - The approval number: SHREC: 20205405-5748 - The date of approval 18/01/2021.
Conflict of interest
None.
Acknowledgements
The authors would like to thank Dr Trentham Furness for his helpful comments in an earlier draft of this paper. There has been no financial assistance with this project.
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Article info
Publication history
Published online: July 26, 2022
Accepted:
July 11,
2022
Received in revised form:
July 11,
2022
Received:
January 19,
2022
Identification
Copyright
© 2022 Australian College of Nursing Ltd. Published by Elsevier Ltd.
