Purpose of this study

Many previous studies have adopted quantitative methods to examine stress in mental health nursing students, but there are a number of limitations with this approach. For example, when constructing their instruments, investigators often assume they know which stressors they should assess (Ravazi, 2001; Beiske, 2002). However, this approach may lead to researchers ignoring a wide variety of variables

that are meaningful for the population being investigated (Creswell, 2003; Ritchie et al., 2004). Therefore, to complement the quantitative research, qualitative research is required.

5.3 Methods

5.3.1 Participants

Semi-structured one-to-one interviews were conducted with a sample of mental health nursing students (n = 12) enrolled on a three-year pre-registration nursing undergraduate degree at Cardiff University. The students were all aiming for BN (Hons) in Mental Health Nursing, with registration in the mental health nursing field. Demographic details for the sample are provided in table 5.1.

Sex Age range

(mean) Year of training (n) Ethnicity (n) Females = 8 Males = 4 19-39 (M = 25.58) Year 1 (n = 2) Year 2 (n = 4) Year 3 (n = 6) White British (n = 12)

Table 5.1 The participants demographic information.

Interviews lasted around 45 to 60 min and were audio recorded. The participants gave informed consent, were made aware that they could refrain from answering any questions they did not feel comfortable answering, and could withdraw from the study at any time. At the end of the interview, participants were debriefed and provided with contact details for the university support services should they be required.

5.3.2 Procedure

Before interviews began, a meeting with a newly qualified mental health nurse who had just completed the course was arranged. This individual discussed some of the main issues they came across during their education and, using this information as a guide, the questions to be asked to participants were developed. The list of

questions is available in table 5.2. After the interviews, transcripts were prepared, rendered anonymous, read and coded. The participants were made aware that while confidentiality is protected, this protection had its limits. If any disclosures were made that indicated an intention to harm themselves or others, then the researcher would have to breach confidentiality and report these disclosures to others. This included any disclosures of malpractice or suboptimal care of clients.

Introductory questions

1. What made you want to become a mental health nurse? 2. What made you choose this career path?

3. At what point did you realise you wanted to become a mental health nurse? 4. Were there any other career paths you considered?

Questions related to experiences on the course

5. How was/is your first year of training? 6. How were the placements during this year?

7. How was the academic side of the course during this year? 8. How was/is your second year of training? (if applicable) 9. Repeat questions 6 and 7 here.

10. How was/is your third year of training? (if applicable) 11. Repeat questions 6 and 7 here.

12. Is there anything specific about the stage of training you are currently at which is particularly stressful?

13. Is the training harder or easier than you expected so far? 14. Overall, do you feel like you belong or ‘fit in’ on the course? 15. Overall, do you feel like you fit in academically?

16. Overall, do you feel like you fit in on placements?

17. Have the academic aspects of the course coincided with the clinical aspects? 18. Have you ever been asked to do something that you didn’t feel comfortable doing

on placement?

19. Have you ever been close to giving up on your training? If so, why were you thinking of giving up? What made you stay?

20. How is your work/life balance?

21. Do you think the training has impacted your personal life? Or, the other way round, has your personal life interfered with the course in any way?

22. How are the support systems on the course? Have you used any? If so, how did you find these experiences?

23. Do you feel like you have changed in any way since commencing training? 24. Do you feel like any of your experiences have been particularly important in

shaping the person you have become? 25. What coping strategies do you use?

26. Is there anything that hasn’t been mentioned, related to nurse training or anything else, which you think might be relevant to the topic of this study? Specifically, to do with the topic of stress?

The consolidated criteria for reporting qualitative research (COREQ; Tong et al., 2007) were followed to structure the qualitative chapters in this thesis (i.e. chapters 5 and 7). These guidelines propose that background information of the researcher should be described (Tong et al., 2007). The interviewer (John Galvin; JG) is a male Psychology PhD student with experience of carrying out qualitative research for dissertation projects during his academic career. He also has previous experience of publishing a qualitative paper in a peer-review journal. The fact that JG’s academic background is not associated with the nursing department has advantages and disadvantages. An advantage is that participants might answer more honestly to questions from an ‘outsider’. For example, if the interviewer was an academic member staff in the nursing department then participants might be less likely to raise concerns with this person. A disadvantage is that a lack of mental health nursing experience may hinder the author’s interpretation of the data. However, attempts were made to address this limitation, as will be described later in the analysis section of this paper.

5.3.3 Analysis

Thematic analysis (Braun & Clarke, 2006) was the analysis strategy employed. The flexibility of thematic analysis allows data to be analysed under a number of different qualitative frameworks and, for this study, the framework chosen was grounded theory (Strauss & Corbin, 1998). Therefore, theoretical developments were made in a bottom up manner in order to be anchored to the data. As interviews progressed, the responses to questions given in earlier interviews informed new questions to be asked in future interviews. An inductive approach to analysis was chosen as the most appropriate, as this kind of analysis is data-driven, and allows for unexpected themes to be identified (Braun & Clarke, 2006). The increasing popularity of this approach to data analysis in health research (e.g. Crawford et al., 2008) is

largely due to researchers wanting to extract themes from data without having to subscribe to the theoretical commitments of a ‘full-fat’ grounded theory (Braun & Clarke, 2006).

In their paper, Braun and Clarke (2006) described a step-by-step guide to conducting a good thematic analysis. First, the researcher should familiarise themselves with the data through transcription, and by reading and re-reading the data while making notes about their initial interpretations. The researcher should then generate initial codes, and collate the data relevant to each code in a systematic fashion. Next, the codes should be collated into potential themes and these themes should be reviewed by checking they are logical in relation to the extracts and the entire data set. The themes should then be named and defined.

The analysis strategy involved JG and three other research assistants analysing the data separately, with each of them following the Braun and Clarke (2006) recommendations. Then, all four researchers met for an analysis session, which involved discussing the themes generated by each of them. Importantly, none of the themes were discussed between the researchers before this point, as a general consensus would strengthen the trustworthiness of the findings.

During the analysis session JG first asked each research assistant to present their findings individually. The key concepts and ideas reported were mapped out on a whiteboard during this initial stage. When agreement was found between the researchers, the concepts and ideas that were agreed upon were moved forward to the next stage of the analysis. When agreement was not reached, the researchers engaged in further discussion to reach a conclusion. In the second stage of the analysis, the initial concepts and ideas were moved around and links were made

between them to form more structured sub-themes. These sub-themes were then organised into higher order themes.

During the analysis session, it became clear that the researchers’ individual interpretations of the transcripts were very similar, this gave the researchers confidence that their interpretations of the data were indeed trustworthy. Further reviews of the data were carried out to confirm these interpretations were traceable. This involved the researchers re-reading the transcripts after the themes were established to further validate the findings. In addition to this, an experienced mental health nursing educator later read over the themes to consider the feasibility of the findings. All the steps taken in the analysis are summarised in table 5.3.

Table 5.3. The five phases in the analysis and a description of the processes involved.

Phase Description of process

1. The lead researcher and three research assistants followed Braun and Clarke’s (2006) recommendations:

Each researcher read and re-read the transcripts, made notes on their initial interpretations, generated codes, collated codes into potential themes, reviewed the themes and defined and named the themes. This was all done by working separately from one another.

2. The researchers met for an analysis session to consider the codes and themes generated by each author:

A meeting was set up and the researchers described their interpretations of the data individually. Findings were compared and contrasted with each other and discussions took place regarding any differences that occurred. The final themes were agreed upon.

3. Final reviews of the data to further validate the findings:

Each researcher then read through the transcripts again to ensure the final themes were truly reflective of the data. 4. The report was produced: Each theme was written up into a report

and data extracts were selected to be used as examples when describing each theme.

5. Validation from a mental health nurse educator:

A mental health nursing educator read over the themes and considered the credibility of the findings.

5.4 Results

Three superordinate themes emerged; demands/control/support, attitudes towards students and stress and coping.