Exploring Mental Health Nurses' Perspectives on the Australian Stepped Care Model in Primary Mental Health Services

ABSTRACT

Primary healthcare remains an essential aspect of mental health service delivery in most developed nations worldwide. Mental health nurses (MHNs) play an important role in the delivery of mental health care within primary health care settings. This study, a subset of a broader study, explores MHNs’ experiences of the stepped care model (SCM) in Australian primary mental healthcare. Through semistructured interviews, the exploratory descriptive inquiry study explores the perspectives of eight MHNs on the implementation and effectiveness of the SCM across diverse settings, delving into their roles, motivations, approaches to care, experiences and the challenges encountered. Five themes were identified: the diverse roles of MHNs in the SCM, motivation to work in SCM, a consumer‐centred approach, challenges of the SCM and ‘it is great if you can get it’. Findings reveal diverse roles, from delivering psychotherapy to consumers presenting with mild to moderate needs to coordinating care for individuals presenting with severe and complex challenges. MHNs working in the SCM are driven by a desire to provide flexible, recovery‐focused care. They prioritise consumer‐centred approaches and tailored care to meet individual needs. They experience challenges, including professional isolation in some cases, resource constraints, limited session availability for the consumers they work with and administrative burdens. The study underscores the need for structural enhancements to optimise the SCM's effectiveness and meet diverse consumer needs. These insights from MHNs are relevant to policymakers, Primary Health Networks (PHNs), service providers and clinicians. Future research could expand the scope to include perspectives from various disciplines involved in the model, as well as consumers and carers accessing SCM services. Overall, this paper contributes valuable insights to the discourse on the effectiveness of the SCM through the lens of MHNs delivering care within the model.

1. Background

Australia's primary health system is at the forefront of addressing the nation's health challenges and meeting the evolving needs of its diverse population (Department of Health ²⁰¹⁹). In this light, as the need for mental health services continues to rise, Australia's primary mental healthcare system iterations are pivotal in ensuring accessible, efficient and cost‐effective services (Anderson et al. 2020). Such ongoing transformation and adjustments in primary mental healthcare are crucial for ensuring that individuals from all backgrounds can access the mental health support they need.

Australian mental health care operates across primary and tertiary levels, supporting varying needs. Generally funded by the Australian Government, primary mental health care focuses on early intervention, prevention and treatment of common mental health conditions while also supporting individuals transitioning from tertiary services (Australian Institute of Health and Welfare ²⁰²⁴). General practitioners often serve as patients' first point of contact in primary care, playing a pivotal role in care coordination and management (Department of Health ²⁰¹⁹). Tertiary services, generally funded by state and territory governments, support consumers with higher acuity levels through specialised, hospital‐based programmes. These include community mental health teams, acute inpatient units and subacute facilities such as Prevention and Recovery Care (PARC) units, which are designed to support recovery and transition into the community (Australian Institute of Health and Welfare ²⁰²⁴).

In Australia's primary mental healthcare system, the stepped care model (SCM) has emerged as a crucial framework guiding the delivery of primary mental health services (Department of Health ²⁰¹⁹; Henderson et al. ²⁰¹⁹). The model is a framework designed to provide a continuum of mental health services tailored to an individual's specific needs. The model organises mental health care into different levels of intensity, allowing consumers to receive the appropriate level of care based on the severity and complexity of their presenting needs (Department of Health ²⁰¹⁹). The model shows promise, with better outcomes noted compared to other preexisting primary mental health models, in addressing the diverse challenges that individuals who grapple with mental health issues face. This includes quicker responses to treatment and sustained well‐being after accessing SCM care (Muntingh et al. 2014; Oosterbaan et al. ²⁰¹³).

The Australian SCM in primary mental healthcare originated from the establishment of Primary Health Networks (PHNs), which oversee its implementation (Henderson et al. 2019). Since July 1, 2015, the creation of 31 PHNs nationwide aims to increase the effectiveness and accessibility of primary health services, especially for vulnerable populations such as Aboriginal and Torres Strait Islander people, people in rural and regional areas, culturally and linguistic diverse groups and individuals with mental health and comorbid conditions (Department of Health ²⁰¹⁹). PHNs play a crucial role in allocating resources across primary care areas, aligning funding with local needs assessments and government directives (Olasoji et al. 2020). The SCM is a primary mental health service modality commissioned by PHNs.

Mental health nurses (MHNs) are one of the largest health professional groups in the Australian mental health system (Hurley et al. ^2020a), playing a vital role in implementing the SCM. As primary care clinicians and advocates for individuals with mental health challenges, MHNs bring extensive knowledge, expertise and hands‐on experience to delivering care (Browne et al. 2014; Kenwright et al. ²⁰²⁴). Their duties range from conducting assessments and developing care plans to delivering therapeutic interventions and providing ongoing support for consumers and their families (Lakeman et al. 2023). MHNs also act as intermediaries between consumers and other healthcare professionals, ensuring holistic, person‐centred care that responds to the diverse needs of individuals in the community (Olasoji et al. 2020). In the Australian healthcare system, MHNs play an imperative role in promoting mental health, preventing and managing mental illness and facilitating recovery (Browne et al. 2014). They work across diverse settings, including community teams, inpatient units, primary care and specialised services, offering care to individuals with varied mental health concerns (Lakeman 2014). Trained in various interventions, MHNs assess and deliver care interventions for mental health conditions and provide psychosocial support, counselling, therapy and psychoeducation (McLeod and Simpson ²⁰¹⁷; Lakeman et al. ²⁰²⁰; Olasoji et al. ²⁰²⁰). At the core of MHN practice is the adoption of recovery‐focused practices, where MHNs focus on empowering individuals in their recovery process and achieve their personal goals (Santangelo et al. 2018). By adopting a recovery‐oriented approach, MHNs support consumers in their journey towards autonomy and self‐determination and ensure that care is person‐centred and holistic (McLeod and Simpson ²⁰¹⁷). This focus on recovery‐oriented practice is critical in delivering mental health services that meet consumer needs, enabling MHNs to play a vital role in fostering sustained well‐being in those they care for (McLeod and Simpson ²⁰¹⁷; Olasoji et al. ²⁰²⁰).

Despite MHNs being the second largest group in Australia's mental health workforce, their representation in primary mental health settings is disproportionately low primarily due to various factors, including limited funding under the universal health insurance Medicare Benefits Scheme, resulting in minimal presence compared to other mental health disciplines such as psychologists, social workers and occupational therapists (Hurley et al. ^{2020a, 2020b}). Other factors contributing to this low representation of MHNs include a lack of pathways to transition to primary care, limited employment opportunities and inadequate systemic support (Hurley et al. ^2020b, 2022).

Within the Australian SCM, the model consists of five levels of mental health intervention (Department of Health ²⁰¹⁹). Level 1 focuses on self‐management and prevention, while Level 2 offers low‐intensity, brief interventions for mild to moderate mental illness. Level 3 provides moderate‐intensity, structured care for mild to moderate mental illness. Level 4 delivers high‐intensity, multidisciplinary support for consumers presenting with severe and complex, persistent or episodic mental illness. Level 5 involves specialist tertiary mental health services for severe and complex, episodic or persistent presentations (Department of Health ²⁰¹⁹). In Australian primary care, MHNs' work spans Levels 2–3, mild to moderate and Level 4 severe and complex steps (Hurley et al. ^2020b; Olasoji et al. ²⁰²⁰).

Despite the SCM's growing prominence in Australia, there is a notable gap in understanding primary care–based MHN's perspectives on its implementation and efficacy (Olasoji et al. 2020). These perspectives are paramount for grasping the practical realities, challenges and opportunities in delivering primary mental health services. By exploring MHNs' experiences, this study aims to illuminate critical aspects such as SCM's effectiveness, the integration of evidence‐based practices, implementation challenges and potential areas for improvement.

Through qualitative inquiry, this study offers nuanced insights into MHNs' perspectives of the SCM for policymakers, healthcare administrators and clinicians aiming to improve the delivery of primary mental health services in Australia. Ultimately, the study aims to contribute to refining the SCM, ensuring its responsiveness to evolving mental health needs while recognising the indispensable role of MHNs in shaping mental healthcare delivery.

2. Methods

2.1. Study Design

The study adopted an exploratory, descriptive enquiry approach using semistructured interviews to gather insights and experiences of MHNs about their perspectives on the implementation and effectiveness of the SCM in Australian primary mental healthcare.

2.2. Participants

The study was conducted with MHNs based in various metropolitan and regional Australian locations. Eight MHNs were interviewed and had all been in the SCM for over 3 years. The MHNs had experience in primary mental healthcare, specifically PHN‐funded SCM services. They worked across the mild to moderate and severe and complex steps of the model.

A convenience sample of MHNs working in primary care was accessed using three methods. First, invitations were emailed to the executives of several organisations that deliver SCM services. These executives were asked to circulate the invitation among their workforce. A participant information consent form, which detailed information about the study, risks, benefits and intended outcomes accompanied the invites. Second, MHNs who were listed on the Australian College of Mental Health Nurses and who indicated that they worked in the PHN‐funded programmes were emailed. Third, snowballing led to more participants as interviewed nurses passed on study information to interested colleagues.

On average, participants had been working in mental health services for 25 years. Their professional mental health experience spanned diverse settings, including triage teams, crisis assessment teams, inpatient units, forensic mental health services, clinical leadership within hospitals, academia and policy roles. All participants held postgraduate qualifications in mental health nursing, alongside additional relevant qualifications such as psychotherapeutic modalities, research and management. The MHNs were trained primarily in New Zealand, the United Kingdom, Australia and Taiwan.

To protect participant identities, their profiles were simplified in the demographic table below (see Table 1).

TABLE 1.

Demographic information of participants.

Demographic characteristics	Participant
	(n = 8)
Age
25–34	1
35–44	4
45–54	1
55–64	2
Gender
Female	3
Male	5
SCM level
Mild to moderate	2
Severe and complex	2
Mild to moderate and severe, and complex	4
State/territory
New South Wales	1
Queensland	1
Victoria	6

2.3. Data Collection

Data for this study were collected through semistructured interviews conducted via Microsoft Teams. The interview schedule was developed from prior literature (Olasoji et al. 2020), input from experienced mental health nurse researchers and academics, experienced mental health clinicians in primary care and a lived experience leader with significant experience across primary care.

Eight individual online interviews were conducted, and audio recorded. Each interview lasted approximately 40 min. Notes and reflections accompanied each interview, which added richness to the collected data. Data saturation was achieved with a sample size of 8, as no new themes or insights emerged from the data. Consequently, further interviews were deemed unnecessary. The interview questions are listed in Table 2.

TABLE 2.

Schedule of interview questions.

Interview questions
Could you please tell me about your professional background?
2Can you describe your role in the SCM to me?
3Can you describe your current scope of practice under the SCM at your organisation?
4What is your experience of the multidisciplinary approach within the SCM?
5What is your overall view of the SCM model?
6Finally, do you have any other information or comments about the SCM that we have not already covered?

2.4. Ethics

Ethics approval was obtained from the Federation University's Human Research Ethics Committee (Approval reference: 2023/060). A rigorous protocol established to protect privacy and confidentiality included the development of a data management plan for removing identifiable data, securing storage, appropriately disposing of sensitive information and disseminating only nonidentifiable data.

All participants were informed that the study formed part of the first author's PhD research project. Consent was obtained before conducting interviews, ensuring that participants fully agreed to participate in the study.

2.5. Data Analysis

Data analysis was conducted using the Reflexive Thematic Analysis method by Braun and Clarke (2022). The first author transcribed the interviews verbatim, fostering a deep familiarity with the data. A systematic coding process was then undertaken using NVivo software. Through an in‐depth interpretation of the findings, all four authors collaboratively generated initial codes. These codes were subsequently used to identify and review emerging themes. Several meetings were held among all authors to determine the significance of themes and reach a consensus on the themes. Finally, the themes were named and documented.

3. Results

Data analysis of the semistructured interviews revealed five themes, which are presented in Figure 1 and discussed in the following subsections.

FIGURE 1.

Categories representing the perspectives of mental health nurses on the Australian stepped care model in primary mental health services.

3.1. Diverse Roles of MHNs in the SCM

All MHNs provided a comprehensive and intricate description of their roles within the SCM. Their perspectives offered a holistic understanding, clarifying contributions' extensive scope and profound significance within the primary mental health space.

MHNs who worked in the mild to moderate step of the SCM described their roles as delivering psychotherapy to consumers, as exemplified in the following quotes.

I utilise counselling and psychotherapy to support consumers with mild to moderate needs. These people may be able to function relatively well but experience mental health issues which impact their ability to manage day‐to‐day life stresses. (P1)

The sessions generally consist of interventions, such as cognitive behavioural therapy (CBT), acceptance and commitment therapy (ACT) and motivational interviewing (MI), to support them and ideally help build their skills so they can utilise and practice the strategies at home. (P4)

I call myself a mental health nurse psychotherapist. It involves both my nursing and my training as a psychotherapist. (P6)

MHNs working in the context of the severe and complex step provided a clear and practical depiction of their roles. These roles are tailored to meet the increased level of need and severity representative of consumers accessing services within this step. Their narrative seamlessly aligned with the heightened complexity and intensity inherent to individuals grappling with severe and complex mental health challenges that, in general, significantly impact other areas of their lives.

My role is direct consumer engagement, which includes providing therapeutic services and nursing coordination. So it is, really, working with people with complex needs and essentially people that have been diagnosed with severe mental illness that might have different social determinants that need to be met, alongside obviously their mental health needs. (P7)

So, my role is to bring that clinical mental health aspect to somebody's care outside of the hospital. To build a robust safety net for each consumer so that they can go on and live their best life. (P8)

In the discourse surrounding their roles, MHNs working in the severe and complex step recurrently emphasised the significance of care coordination within their role. They articulated a commitment to providing a comprehensive role aimed at discerning and adequately addressing the varied needs of consumers. This encompassed identifying, documenting and facilitating appropriate support measures to align with individual requirements.

I am more of a care coordinator. I do an initial comprehensive assessment to determine the level of needs for the individual and a care pathway to determine if this is helpful for them… then we determine what I can do to assist the individual, or do I need to link them up with another service? (P3)

3.2. Unveiling the Passion: Motivation to Work in SCM

This theme offers valuable insights into the motivations underpinning MHNs' decisions to practise in the SCM. Through detailed reflections, MHNs articulated a profound and deeply rooted motivation driving their deliberate choice to practise within the SCM.

The thing about this work is that the needs of the consumer guide you, and you are using your skills to find out where exactly the consumer's needs are and then utilising your skills to help them achieve their goals. (P1)

I like the freedom it gives me as a clinician and the consumers I work with… I like that, you know, I can see people in the park, I can see people in coffee shops, I can see people at their home, depending on what works for them… it allows me to be the recovery focus clinician I want to be. (P3)

MHNs conveyed a notable aspiration to transition away from conventional and confining care settings. This became a pivotal factor in their deliberate preference to work in the SCM.

Within tertiary settings, MHNs are somewhat restrictive in their approach, … so the main reason was to be able to really use the full extent of my skills and work with people therapeutically, not in a custodial or paternalistic way. (P7)

Against the backdrop of reports of considerable strain within the tertiary healthcare system, MHNs emphasised this challenge as a compelling catalyst for their decision to work in the SCM. Within the SCM, MHNs identified an opportune platform enabling them to harness and fully deploy their skills and expertise.

I choose to do it in this sector outside of hospitals; you can do the job properly… MHNs working in the tertiary are under immense pressure. It is just a pressure cooker. Outside of the hospital system, you can do the stuff that we do well. (P8)

Finally, MHNs also emphasised the role of acknowledgement and recognition, especially within primary mental health sector, regarding the depth of their professional competencies and expertise. This recognition is deemed crucial for validating the specialised contributions of MHNs and fostering collaborative relationships among diverse mental health professions.

As mental health nurses, we have much knowledge… our skills cover a broader spectrum. It is just a shame that there is not much help and support for mental health nurses to transition from tertiary services to primary mental health. (P2)

Once I knew of the opportunity, I really wanted to be able to harness that and demonstrate that mental health nurses are a valued part of primary care. (P7)

3.3. A Consumer‐Centred Approach

This thematic exploration offered MHNs invaluable insights into their approaches when engaging with consumers in the SCM. MHNs articulated their approach to care as centred around the individualised needs of consumers. Leveraging their extensive repertoire of competencies, MHNs adeptly adapt their strategies to align with each consumer's unique requirements, thus facilitating optimal care outcomes.

I approach my work from the point of view of getting to know the consumers and to wholly understand them and, together, understanding who they are and how they work… well how do we both see the development of this disorder or difficulty in their life, how do we both understand that, and so then together we can look at how we can together find solutions for it. (P4)

In deploying a consumer‐centred approach, MHNs exhibited a disposition to adopt a comprehensive approach, extending their support beyond the immediate consumer to incorporate and activate the natural support systems available.

So, I would usually use those sessions to run family sessions, to educate family, get others to support whether there be family or friends, to see how everyone can best support the consumer, but also link up or hold professional meetings with other services, getting round tables again, just getting more wrap‐around services for the consumers. (P4)

I am working with them, their parents, and their families. It is a very dynamic space that you end up having to be in. (P7)

I am always encouraging and having discussions with the young person about whether they would like their family to be involved; I am very big on getting consent to having their family involved. (P7)

In adopting a consumer‐centred approach, MHNs ensured that consumers were linked with ongoing support after their episode of care within the SCM.

A lot of the consumers that I worked with met criteria (for the NDIS), so generally I would support them to apply and get through so they can get adequate support. (P4)

There's one stage I was starting to do National Disability Insurance Scheme (NDIS) applications. It is not my primary role, but that is what the consumers needed. (P6)

3.4. Challenges of the SCM

This theme delves into the intricate landscape of challenges MHNs encounter in their SCM work. Their experiences offer a comprehension of the various obstacles, constraints and barriers that MHNs navigate in their daily practice, shedding light on the nuanced dynamics of mental health service delivery and the ongoing quest for the best possible care delivery in this evolving space.

The adopted commissioning model of the SCM significantly impacted the experiences of the MHNs. MHNs who had direct individual contracts with PHNs, thereby assuming autonomous roles, encountered distinct challenges in their daily professional practice, particularly when attending to consumers with heightened levels of need in the severe and complex step.

One of the biggest challenges for me is that I am not having a team that's around me in terms of when I'm delivering services. (P1)

I suppose I am working within the SCM; I am very isolated; I am normally working on my own. (P2)

I would want a more robust and assertive approach… but obviously, you can't do that as a solo clinician when you're seeing people with complex needs. (P7)

In addition, MHNs also highlighted the shortcomings of the current SCM service structure, particularly the limited number of sessions available to consumers. This issue is exacerbated by the fact that PHN mental health services mainly target individuals who are already experiencing significant disadvantages, thus ideally requiring more sustained and, at times, longer term support.

Unfortunately… we've had to discharge consumers prematurely, and unfortunately, they deteriorated and ended up within the public mental health system. (P3)

I could tell you that six sessions are grossly insufficient; it can be damaging and dangerous to give somebody with a history of complex trauma who has been bouncing around this system four or five sessions, and then it's all over, and you can wait till next year. (P5)

Realistically, you have to ask: what is six sessions for this consumer group?… some of our consumers could use up 29 sessions in the first month. (P8)

MHNs also emphasised broader structural challenges encountered in the SCM and queried whether a standardised approach would be the answer.

It would be potentially helpful to get a standardised tool that all referrers need to complete so that the information we receive is comprehensive. (P3)

Everyone is not on the same page, and again, rather than having multiple forms and multiple systems, a really streamlined, simple method of moving consumers between the steps would be great. (P4)

So, there is no universally agreed way of operationalising SCM… which is a huge challenge. (P5)

The administrative burden and various key performance indicators (KPIs) set by the provider organisations and the PHNs were highlighted as some of the challenges the MHNs were experiencing. The MHNs reported that the funding structure covers only the face‐to‐face sessions with the consumer, with minimal acknowledgement of the extensive administrative work required to support the consumer.

I was thinking about giving it up because they're starting to bring in all these additional reporting requirements and KPIs, and I do not know if I had the capacity to do all that. (P6)

Overall, the sentiments among MHNs were evident that while the SCM had the potential to improve consumer outcomes, substantial groundwork remains imperative to adequately align it with the diverse array of needs and expectations encompassed within its purview.

I think it is a good model… but as you know, people do not always fit into boxes as such, and I think it is always hard to have a system where you have rigid parameters for each level of intensity. (P1)

So, I think the overall premise, everything about the idea and the concept, is great … however, you know this.… there are things that could be done better. (P4)

3.5. It Is Great, if You Can Get It

This theme summarises the sentiments conveyed by MHNs regarding the successes and positive outcomes they have encountered and observed in the SCM. In conveying favourable experiences within the SCM, MHNs accentuated various consumer success stories demonstrating commendable performance, despite the challenges outlined earlier.

I have found that a lot of the people that we have worked with have benefited from the services and have been grateful. (P3)

There's one woman I've been working with … we've been able to get right down into the core sense of perception that she has about herself and the reasons why, and it is all coming together for her… it's been an absolutely fabulous journey for her. (P6)

And you know, here's a woman who's in her mid‐40s with two kids, fleeing family violence and has had an extremely tough 2 years with mental health challenges, who now has got some hope. It's amazing, I tell you!… she is a good example of somebody who steps up and down in this model. (P8)

In summary, MHNs emphasised that individuals who present themselves for the provided support and receive prompt assistance within the allocated sessions successfully navigate the barriers associated with access and referral processes. Moreover, those fortunate enough to present when clinicians have the capacity to accept their referrals tend to experience a notably satisfactory engagement and attain favourable outcomes.

So, is it helpful (the SCM)?… I would say, yes… for the lucky ones who get it, it is. (P8)

Well, I would say the headline here is, it's great if you can get it. (P5)

4. Discussion

The study explores MHNs' perspectives on the Australian SCM in primary mental health services. MHNs delved into their diverse roles, motivations for working in this model, approach to working with consumers, challenges encountered and successes observed within the SCM.

This study adds knowledge to understanding the experiences of MHNs in Australia's primary mental health SCM services, a relatively new area that is not well known (Olasoji et al. 2020). The findings reveal the diverse roles MHNs undertake within the SCM, serving individuals across mild, moderate and severe and complex SCM categories. Consistent with numerous studies, these findings underscore the extensive skillset that MHNs possess despite somewhat limited opportunities to showcase them (Hurley et al. 2022; Lakeman ²⁰¹⁴; Lakeman et al. ²⁰²⁰). MHNs in the mild to moderate SCM steps primarily focus on delivering psychotherapy and providing psychological interventions to consumers. This finding supports assertions emphasising MHNs’ role as psychotherapists and showcasing their ability and capability in this regard (Hurley et al. ^2020b; Lakeman et al. ²⁰²⁰). These MHNs emphasise employing approaches such as CBT, ACT and MI to equip individuals with skills to manage day‐to‐day stressors effectively.

In addition, MHNs in the severe and complex SCM step adopt a multifaceted role involving direct consumer engagement, therapeutic service provision and nursing coordination. These roles are customised to meet the heightened needs and complexities of consumers accessing services in this step. This emphasises that primary care not only equips MHNs with the necessary skills but also offers a platform to showcase their expertise as they support varying consumer needs while providing them with the flexibility to spend adequate time with consumers, a significant contrast to the experiences of MHNs in tertiary service (Olasoji et al. 2020).

Overall, the findings highlight the complexity of combining MHNs' diverse roles and professional identity into a concise framework, given their range of responsibilities across various settings (Hurley et al. 2022). These roles span across the mild to moderate, and severe and complex steps of the SCM.

MHNs were eager to engage in the SCM, highlighting the prospects it offers to work with consumers. Based on the historical backdrop of the asylum‐based care paradigm, MHNs' functions are often perceived as being primarily custodial and rudimentary in their professional enactment (Hurley et al. 2022). Findings from this study offer an alternative to the widely held misconceptions that have predominantly highlighted MHNs' roles in more traditional and restrictive care settings (Lakeman et al. 2020). In this study, MHNs emphasised thriving in the opportunity to depart from historical and some contemporary care frameworks to instead harness their expertise therapeutic practice in a recovery‐oriented manner.

Paradoxically, although they comprise the second‐largest group of mental health professionals in Australia (Hurley et al. ^2020a), MHNs have mainly been confined to tertiary care services, notably in inpatient facilities (Hurley et al. 2022). These tertiary services are generally characterised by traumatic instead of recovery care, often to the detriment of consumers (State of Victoria ²⁰²¹). According to this source, pressures on tertiary mental health services often lead to crisis‐oriented care, which diverges from consumer preferences and results in experiences marked by isolation and disempowerment, where consumer voices are marginalised. These practices strongly contrast with the principles of recovery‐oriented care.

The findings of this study reinforce these perspectives, with MHNs articulating their motivation towards the optimal use of their skill sets in environments that mitigate harm and foster trauma‐informed, recovery‐focused care delivery (Olasoji et al. 2020). This provides another point of contrast to widely held misconceptions that often portray MHNs as only capable of operating primarily within crisis‐driven and acute services confined roles (Lakeman et al. 2020).

MHNs in this study adopted a consumer‐centred approach in the SCM, emphasising individualised care to meet each consumer's unique needs. They used their diverse skills to adapt strategies and achieve optimal care outcomes. Furthermore, MHNs extended support beyond the immediate consumer, incorporating available support systems to foster holistic care provision. This aligns with the core principles and values of MHN therapeutic practice (Lakeman et al. 2020). According to these authors, MHNs adopted an approach to understand the consumer holistically. Such an approach addresses physical, emotional, relational and existential issues for healing, growth and transformation. This comprehensive approach is a notable shift from previous models that often failed to comprehensively address the broader needs of consumers (McLeod and Simpson ²⁰¹⁷).

By considering a consumer's entire well‐being and by employing a holistic treatment approach, MHNs facilitate access to necessary support systems for consumers, such as the NDIS. This approach ensures that consumers are empowered to lead fulfilling lives despite their mental health challenges. Moreover, by addressing not only their mental health needs but also effectively managing any comorbid conditions, MHNs enhance satisfaction with mental health services, fostering improved outcomes for consumers (McLeod and Simpson ²⁰¹⁷).

MHNs displayed key attributes that consumers and carers seek in MHNs, such as combining therapeutic skills and creating conditions that can resolve crises and realise consumers' recovery (Lakeman et al. 2023). They employed a flexible approach to accommodate consumers' needs, for example, by offering choices for important and routine activities like appointment venues and times.

Overall, MHNs emphasised the significance of fostering therapeutic relationships with consumers, establishing authentic alliances fundamental for effective care provision and attaining optimal consumer outcomes. These findings contrast with earlier research that often highlighted medicalised, transactional and legalised coercion as a common feature of mental health nursing services (Browne et al. 2014).

Despite MHNs recognising the potential benefits of the SCM (Muntingh et al. 2014; Oosterbaan et al. ²⁰¹³), participants in this study reported various challenges in their daily professional work. Specifically, MHNs highlighted the impact of commissioning models, implemented by PHNs, on their practice. MHNs engaging with PHNs and operating in solo settings frequently grappled with obstacles such as professional isolation and resource constraints. Such observations appear incongruent with the ideals outlined by the Department of Health (2019), which advocates for an optimally functioning SCM service characterised by multidisciplinary collaboration, where various healthcare professionals operate in proximity and facilitate seamless access to one another's expertise. These challenges are consistent with prior studies that have also noted similar issues in the implementation of SCM services (Meurk et al. 2018).

The cost analysis of services is inevitable when assessing the implementation of the SCM (Department of Health ²⁰¹⁹). According to MHNs, the restricted number of sessions available to consumers is a significant inadequacy in the SCM due to funding constraints. Given that consumers supported by MHNs often face multiple challenges already, a limited number of sessions would generally not be helpful. This aligns with evidence from other studies suggesting that the Australian‐adopted SCM approach may be generally more suited for consumers presenting with mild to moderate symptoms and highlights a service gap that exists in supporting those in the severe and complex category who may require prolonged support (Henderson et al. 2019).

Escalated administrative burdens and the imposition of KPIs by provider organisations and PHNs have compounded the challenges, potentially exerting adverse effects on the provided quality of care. Although administrative aspects were highlighted as a critical component in the commissioning of the SCM services (Meurk et al. 2018), MHNs in this study contemplated their ongoing role in the SCM due to the increased administrative burden. MHNs found these aspects significantly taxing and necessitating some using their personal time outside work. These administrative challenges create disincentives and are a point of divergence from MHNs' primary motivation to transition to primary care settings (Olasoji et al. 2020).

Overall, MHNs expressed mixed feelings about the SCM. They recognised its considerable potential, especially for individuals receiving customised services. This perspective resonates with scholars noting the SCM's contribution to improved consumer outcomes (Anderson et al. 2020; Muntingh et al. ²⁰¹⁴; Oosterbaan et al. ²⁰¹³). MHNs also highlighted positive outcomes and consumer engagement in the SCM, stressing the crucial role of timely assistance and support provision. However, MHNs acknowledged the need to improve the SCM to meet the consumer service's support needs effectively. Key recommendations included implementing more sessions, enhancing accessibility and integrating with the broader mental health systems. These sentiments align with scholars who argue for critical adjustments to optimise SCM's efficacy (Anderson et al. 2020). These calls for improvements are another point of distinction from earlier studies that predominantly focused on the theoretical benefits of the SCM without extensively addressing practical implementation challenges (Muntingh et al. 2014; Oosterbaan et al. ²⁰¹³).

5. Limitations

This study is subject to limitations typical of translational research approaches. First, the small sample size and the fact that most of the participants were based in the state of Victoria limits the generalisability of the findings, potentially limiting the broader applicability of the results. Second, the perspectives captured in the results may be influenced by the self‐selection bias inherent in voluntary participation in research, thereby possibly skewing the representation of MHNs in Australia's SCM. Moreover, as this paper concentrates on MHNs, the absence of other critical viewpoints such as consumers, carers and other disciplines working within the SCM in the study group poses a limitation, as divergent viewpoints and insights from them could yield markedly different findings, potentially enriching the understanding of the subject matter.

6. Conclusions

This study explores mental health service delivery within the Australian primary mental healthcare SCM from MHNs' perspectives, unveiling their diverse roles, motivations, consumer‐centred approaches, challenges and overall sentiments. Despite acknowledging the SCM's potential benefits, MHNs encounter obstacles such as professional isolation, resource constraints and administrative burdens that hinder optimal service delivery. Nonetheless, MHNs remain motivated by the opportunities SCM presents for recovery‐focused, individualised care outside traditional hospital settings.

The study highlights the importance of ongoing efforts to address structural shortcomings and promote a consumer‐centred approach throughout the SCM. Embracing continuous improvement can enhance mental health interventions and outcomes for individuals in Australia's primary healthcare. This study suggests that the Australian SCM can lead to improved outcomes, with MHNs significantly contributing to this (Lakeman 2021).

7. Relevance to Practice

This study offers valuable insights for primary mental healthcare stakeholders, including policymakers, PHNs, service providers and clinicians. The findings provide a foundation for refining SCM approaches to meet consumers' needs better. MHNs’ perspectives highlight successful aspects of the SCM and areas needing improvement. In addition, the call for further research aligns with a commitment to recovery‐focused, evidence‐based, consumer‐centred care, which is crucial amidst rising global demands for mental health services. Embracing continuous improvement within the SCM can lead to more effective interventions, improved outcomes and a better service experience for those facing mental health challenges and their support. The findings contribute to providing strategic direction for stakeholders in primary mental healthcare to address identified areas for improvement and foster a culture of continuous enhancement, ensuring care that is evidence based, consumer centred and effective.

Author Contributions

S.M. led the idea conception and project design, conducted the literature search, collected and transcribed the data, performed data analysis and led the manuscript writing. M.O. provided project oversight, participated in the literature search, contributed to data coding, theme identification and naming, reported results, reviewed the manuscript and contributed to discussions. L.Z. contributed to the manuscript review and participated in the literature search, data coding, theme identification and naming and discussions. M.C.W. participated in the manuscript review, literature search, data coding, theme identification and naming and discussions. All authors involved in this manuscript have met the authorship criteria and have unanimously consented to the final version.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.