Victorian Mental Health Nurses' Experiences of Mental Health Reform: A Qualitative Descriptive Study

ABSTRACT

The state of Victoria, Australia is currently in a period of mental health reform, spurred on by a recent damning Royal Commission and updates to legislation. New legislation promotes the choices and rights of consumers in the mental health system, including recommendations to eliminate seclusion by 2030. While much of this reform has been met with enthusiasm by consumer groups and nurses alike, there remains uncertainty. The aim of this paper is to describe the experiences and perceptions of mental health nurses on mental health reform in the State of Victoria, Australia. Adopting a qualitative descriptive method, mental health nurses (n = 14) working in public mental health services in Victoria undertook individual interviews, with data thematically analysed. After analysis, three themes were identified: Navigating the new Act: Overcoming Managing challenges faced by mental health nurses, Defusing the storm: Mental health nurses' safety concerns under the new Act, and Workforce strain and organisational value: The impact on mental health nurses. Nurses described distress at working in a system with increasing occupational pressures and expressed concern that the goal to eliminate seclusion by 2030 may not be achievable due to current system constraints and deficits. They also highlighted legislative barriers that prioritised consumer preferences over clinical judgement, which they perceived as contributing to a decline in consumer wellbeing and, in some cases, serious adverse outcomes. While mental health reform is essential to improving care, it must also consider the practical and emotional demands placed on clinicians within evolving legislative frameworks. This study identified that the implementation of mental health reform requires a consistent approach by health services and government that promotes the needs of consumers whilst also balancing the significant workplace stressors that nurses encounter. Plans to eliminate restrictive practices need to adopt a consistent, collaborative approach that recognises the complexity of current challenges and the importance of thoughtfully addressing the underlying factors, rather than simply removing existing responses.

1. Introduction

Mental health reform can be described as systemic changes and improvements to policy, law, and services to improve the outcomes for people experiencing a mental health issue (Gorton and Greenfield 2024). Mental health reform aims to create a system which is accessible, recovery‐oriented, trauma‐informed, and person‐centred. Some of the key components of mental health reform include a shift to a rights‐based approach, which prioritises lived experience, expanding community‐based care, facilitating an integrated system that promotes holistic care, suicide prevention, a reduction in coercive practices, and an emphasis on prevention and early intervention (Department of Health 2024a, 2024b, 2025a). Australian mental health service delivery, in a process of reform, has historically sought improved models of practice (e.g., trauma‐informed care and the recovery framework), developments in treatment and understanding of aetiology of mental illness, and a greater consumer and peer voice (World Health Organisation [WHO] 2018). This approach is consistent with that of other developed countries where there has been a shift from inpatient care to primary care in a community setting (Cohen et al. 2020). Additionally, there has been a move to improve human rights for people experiencing mental health issues, and to reduce restrictive interventions (WHO 2018) and coercive practices such as involuntary admission and seclusion and restraint (Sashidharan et al. 2019). This reform requires a multipronged approach, including changes to legislation, workforce practices, and enhancing responsibility structures and governance (Department of Health 2025a). Additionally, a greater inclusion of consumer voice and experience is paramount to accomplishing this (WHO 2024). In the State of Victoria, the implementation of Safewards has been pivotal in reform. Safewards is a model of practice which aims to promote consumer and clinician safety through a process of reducing restrictive interventions such as seclusion and restraint (Department of Health 2023). In order to achieve reform, the mental health system needs to be dynamic and responsive but also needs to provide a system that is safe and effective for both consumers accessing it and staff working within it.

2. Background

In 2019, the Victorian Government called for a Royal Commission into the mental health system after finally recognising that the current arrangement was unable to meet the needs of people living with mental health issues (Department of Health 2025a). There was a total of 65 recommendations from the Royal Commission report ranging from increased access to services, greater training for mental health clinicians, and a reduction of restrictive interventions and compulsory treatment (Royal Commission into Victoria's Mental Health System 2021). The current mental health system in Australia is additionally impacted by Government propensity to provide more hospital beds in response to healthcare needs (Hickie and Rosenberg 2024). This approach, however, has failed to keep up with mental health reform which actively pushes for community‐based treatment, and as such, community‐based services are often inadequately resourced to fund this approach (Hickie and Rosenberg 2024). Around the same time as the Royal Commission, the State of Victoria began the implementation of a new Mental Health and Wellbeing Act (Vic)2022 (referred to hereafter as, The Act), largely driven by the recommendations from the Royal Commission. The Act aims to foster a diverse, responsive, and compassionate mental health and wellbeing system in Victoria, as outlined within the Royal Commission's recommendations. The Act was developed with a specific focus on human rights and dignity and ensuring that consumers are afforded greater control and decision making responsibilities regarding their treatment, supporting the dignity and autonomy of individuals experiencing mental illness, providing greater consumer involvement in treatment decisions while recognising the importance of families, carers, and significant others, and ensuring that the service system addresses the varied needs of the Victorian population (Department of Health 2025b; Mental Health and Wellbeing Act 2022 (Vic)). The introduction of The Act has brought to the forefront the crucial balance between individual rights, the demands of care, and safety. With critique, however, the new Act may not fully address these concerns, particularly in reference to a person's rights as defined by international human rights law; in addition, the absence of consumer representation in the Royal Commission process neglected key issues, such as the complete cessation of restrictive practices (Maylea 2023). As a result, some opinion exists that rather than being an effort to reform a ‘broken’ mental health system, the final result of the Royal Commission process was to reduce current harms occurring within mental healthcare.

The premise of reducing restrictive practices is not new. Over the years, several models of care have been implemented to improve the outcomes of people living with severe mental health issues who intersect with the public health system. Safewards is a model of care which seeks to support mental health clinicians to minimise restrictive practices and improve therapeutic engagement (Safer Care Victoria 2025). Since the Royal Commission, there have been several other initiatives in Victoria, underpinned by a six‐billion‐dollar investment into mental health service delivery; of this investment, $600 million has been invested in workforce reforms, including new mental health and lived experience roles, and greater sustainability of staffing through additional mental health nurse and allied health graduate roles. Prevention has been a focus with the establishment of 15 new Mental Health and Wellbeing Local services across Victoria, mental health Hospital in the Home services, and Mental Health and Alcohol and Other Drug Emergency Department Hubs. In the context of these initiatives, the Mental Health and Wellbeing Act (2022) is described as a means to ‘… [provide] more contemporary legislation that facilitates a diverse, responsive and compassionate mental health and wellbeing system for all Victorians’, (Victoria State Government 2024, 28).

Mental health nurses comprise most healthcare professionals working in the mental health sector in Australia (Australian Institute of Health and Welfare [AIHW] 2024). Although key aims of both the Royal Commission and The Act are to reduce and eliminate restrictive interventions, these practices are always a last resort in contemporary mental health care settings. Despite evidence of workplace violence and aggression against mental health nurses (Cranage and Foster 2022; Gerace and Muir‐Cochrane 2018), evidence suggests they are acutely cognisant of the impact restrictive interventions place on consumers and their therapeutic alliance with them (Gerace and Muir‐Cochrane 2018). Over the past 10 years, there has been a decline in the use of seclusion in Australia by almost 7%; yet Victoria's seclusion rates remain higher than the national average (AIHW 2023). While the mental health act reform has been welcomed by consumers, clinicians, and advocates, it is not without some concerns. One of the overwhelming reasons mental health nurses cite for their intention to leave the specialty is workplace violence and aggression (Adams et al. 2021). To ensure that our mental health system is dynamic and responsive to the needs of consumers and the workforce, consideration of the impacts of any reform must be analysed. Therefore, this study aims to describe the experiences and perceptions of mental health nurses on the implementation of a new Mental Health and Wellbeing Act in the State of Victoria, Australia.

3. Methods & Design

3.1. Design

Qualitative description is the overarching methodology for this study. Qualitative description is a low inference qualitative design, with the aim of providing a description of events under examination in the participant's own language (Neergaard et al. 2009; Sandelowski 2010). Semi‐structured interviews were conducted with 14 nurses across Victoria, that worked in settings including inpatient units and community mental health services, and the resulting data were analysed using Braun and Clarke's (2006) method of thematic analysis. This study has deliberately focused solely on capturing the experiences of mental health nurses following recent legislative reform. We did not explore the complexities of aggression and violence or the experience of consumers, as our intent was not to present a balance of all perspectives but rather to highlight the specific viewpoints of mental health nurses.

3.2. Data Collection

This study used a purposive sampling method to recruit participants who were registered nurses working in Victorian mental health services. We used a purposive sampling method to ensure that participants met these criteria and were able to inform the findings of the study through their experience of implementation of The Act (Campbell et al. 2020). Recruitment for this study took place by advertising for participants to volunteer for an interview via the Australian College of Mental Health Nurses newsletter and Victorian Branch, with the snowballing technique bringing in additional interested participants (Noy 2008). Interested participants were able to click a link in the recruitment materials, which took them to a Qualtrics survey where they were able to access the Participant Information Sheet and leave their contact details (email) for researchers to contact them to arrange an interview time. All interviews were conducted by Zoom and recorded using the Zoom platform, then deleted from the server once transcription was complete. Fourteen potential participants expressed their interest to take part in an interview, with all 14 responding to the request to schedule an interview and completing the semi‐structured interview process.

The semi‐structured interview guide (see Table 1) was developed following a scan of the literature and industry feedback around the implementation of the new Mental Health Act, with an experienced mental health service director providing feedback on the guide. Interviews were conducted by the first and third authors, both with significant experience in qualitative interviews, between May 2024 and August 2024. To ensure that the interview format was consistent, regular meetings were held between the interviewers to discuss interview conduct and progress; other research team members also reviewed interviews from both interviewers to establish consistency.

TABLE 1.

Semi‐structured interview guide questions.

Topic	Interview question
Experience under the new Act	Describe your experience as a mental health nurse since the new Mental Health Act came into effect.
Preparedness for the new Act	How prepared did you feel to work under the new Act when it was implemented?
	What training and support did you receive from your health service regarding the new Act?
Positive & negative experiences	What have been the key positive and negative experiences you have encountered since the implementation of the new Act?

Interview length ranged between 28:32 and 58:54 min, with a mean interview duration of 45 min (SD 9.99). Interviews were recorded verbatim and transcribed by Zoom, then re‐examined for consistency by the researcher who conducted the interview. All transcripts were sent to participants to verify, with two participants making updates to their transcript. Recordings were then removed from the Zoom platform and transferred to a secure research storage site to comply with ethical data requirements.

3.3. Analysis

Data analysis was performed by all members of the research team using Braun and Clarke's (2006) six‐step method of thematic analysis: (1) familiarisation with the data, (2) generating initial codes, (3) combining codes into themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the report. The first two steps of this process were completed by authors independently prior to jointly reviewing themes to ensure coding accuracy. From this point forward, themes were refined and coded jointly, with any disagreement being resolved using the method described by Hemmler et al. (2022), where authors were required to justify their coding decisions, and consensus was reached between the group before coding continued to ensure interrater reliability. Data were analysed until saturation was reached at 14 participants, which is consistent with Guest et al. (2006) who noted that qualitative research usually achieves saturation at 12 participants.

3.4. Ethical Considerations

This project received ethical approval from the relevant university Human Research Ethics Committee as a low‐risk qualitative study (HEAG‐H 41_2024). Participants provided consent on several occasions: after reading the participant information sheet which was embedded in the Qualtrics survey where they nominated their interest, then again when they were sent a consent form prior to the interview. Finally, participants provided verbal consent during the recording. Participants were informed that they could skip a question or stop the recording at any stage and were able to withdraw their consent in writing up to one week after their transcript was sent to them for verification. Participants were informed that the recording would be destroyed after it had been transcribed, deidentified and stored on a secured, password protected server. After the interview process commenced, no requests to cease the interview or to withdraw data once an interview was completed were received from participants. The conduct and reporting of this study was guided by the Consolidated Criteria for Reporting Qualitative Research (CORE‐Q) (Tong et al. 2007).

4. Results

Demographic data are shown in Table 2. Of the 14 participants, most worked in hospital mental health settings, such as inpatient units, emergency psychiatry, and consultation liaison (n = 10, 71.4%), with four working in community mental health settings (28.6%) and one working in a ‘program‐wide’ role that encompassed both inpatient and community settings. There were n = 4 males and n = 10 females, and the average years of experience was 12.7 years.

TABLE 2.

Participant demographics.

Demographics	N (%)
Years working as a mental health nurse
1–5	4 (28.6)
6–10	2 (14.2)
11–15	4 (28.6)
16+	4 (28.6)
Gender
Female	10 (71.4)
Male	4 (28.6)
Other	0 (0)
Mental health setting
Inpatient unit (includes adult, older adult, and AOD settings)	4 (28.6)
Community continuing care teams (includes adult, and older adult)	3 (21.4)
Crisis and emergency mental health (Crisis assessment and treatment, emergency psychiatry, psychiatric triage, consultation‐liaison)	6 (42.9)
Other (program‐wide, includes both IPU and community)	1 (7.1)
Position/Role
Registered nurse (RN)	9 (64.3)
Nurse practitioner candidate	2 (14.3)
Nurse educator	2 (14.3)
Other (clinical and/or project lead)	1 (7.1)

Three themes were identified after analysis of transcripts: (1) Navigating the new Act: Managing challenges faced by mental health nurses; (2) Defusing the storm: Mental health nurses' safety concerns under the new Act; and (3) Workforce strain and organisational value: The impact on mental health nurses.

4.1. Theme 1: Navigating the New Act: Managing Challenges Faced by Mental Health Nurses

This theme explored how individual health services and the Health Department prepared staff to work safely and effectively under the new legislative changes. It also highlighted the complexities of The Act, with many nurses noting that its ambiguity further complicated implementation and increased the documentation burden. Nurse's experiences of their preparation for the new Act were significantly varied with some nurses describing adequate and supported processes, while others described a distinct and worrying lack of preparation entirely: ‘People were practising under the old Mental Health Act with old documentation for at least two months’ (RN3). This nurse went on to describe how paperwork was ‘backdated’ to fulfil legal obligations. Another noted ‘the training was delivered on the day of the rollout’ (RN12) and ‘the timing was exceptionally poor’ (RN10). The degree to which nurses felt supported and confident in implementing the new Act was heavily influenced by their health services roll out of support. Several noted that they had a nominated person to seek support and advice from, and were required to undertake learning modules, and these implementations were directly correlated with a more positive experience of change in nurses: ‘…we had a person whose role was the implementation of The Act…and she did a great job’ (RN5). This however was not a consistent experience, several nurses described having no training whatsoever, and that this was particularly burdensome for part time and casual nurses ¹ ‘…we were not prepared at all. All of us were scared and apprehensive about that (the new Act)’ (RN2) and ‘…regulars (staff) got the professional development…but casuals didn't’ (RN1). This was viewed by some nurses as starting off on the backfoot: ‘there was a lack of information and people were really unprepared and that really sets people up to fail’ (RN3).

Additionally, while several participants described their health service being well prepared, they noted that the Health Department's lack of clear communication caused issues for those responsible for the dissemination of information. These experiences were exacerbated by perceived ambiguity in the language used in The Act, particularly around admission criteria which resulted in nurses becoming creative to have a consumer admitted: ‘So it's a bit like, I wouldn't say cooking the books but maximising your resources and opportunities and the parameters’ (RN4) and ‘…The previous Acts were more prescriptive…much clearer (RN11)’. While most nurses noted that the new Act was consumer centric and had good intentions, many noted that this was not helpful when it was so obstruse: ‘The Act is well intentioned until you have a mental health tribunal, and they are literal and they have three people who are scrutinising, and there's no ambiguity then’ (RN10). Additionally while this nurse saw the importance and necessity of advanced statements, the lack of communication between health services meant that locating details during emergency situations was problematic: ‘We don't have a central medical records place so if advanced statements are held with the GP…often emergencies and crisis occurs out of hours…sometimes it's difficult to locate nominated people… (and it can be hard) to involve them (family/carer)’ (RN9).

The burden of documentation was discussed by several nurses. This was described in response to the volume of new documentation, the complexity of interpreting it and navigating the ambiguity of The Act. These documentation requirements were noted to have increased significantly, and several nurses described this increased burden was something which detracted them from therapeutic time spent with consumers: ‘…it (The Act) added more paperwork in terms of admission…so it takes more time now’ (RN7) and ‘there is a lot of time spent trying to figure out which is the right form…I do feel like it did take away from clinical contact’ (RN11). One nurse noted that paperwork was ‘… always done incorrectly…and what I constantly hear back from staff is that they don't spend any therapeutic time with consumers’ (RN3). While another nurse who worked in psychiatric triage stated that despite already being ‘short staffed’, their intake assessment notes took as long as they spent talking to the consumer: ‘…1.5 to 2 h of notes…so how many patients can you clear in one day? Definitely not more than three’ (RN1).

4.2. Theme 2: Defusing the Storm: Mental Health Nurses' Safety Concerns Under the New Act

This theme described the sense of moral distress nurses felt about their role under the new Mental Health Act. Additionally, safety was a consistent topic for participants, including concern over the removal of seclusion and restraint, and the fear nurses felt of litigation.

Overwhelmingly nurses described feeling unsafe in their role, with most nurses interviewed discussing safety and workplace violence aspects of their role as worrying, with one senior nurse noting: ‘There has been a marked increase in violence within clinical settings within our hospital, I can say there has been a sharp increase in code blacks and violence towards healthcare staff…and file reviews…have seen an increase in aggression and reduction in the use of sedation’ (RN10). This includes an example of a nurse being ‘punched in the face’ because a demand for a pizza was not able to be accommodated, yet the consumer was permitted to remain as a voluntary admission because they had nowhere else to go: ‘…patient care (was) prioritised over staff safety’ (RN10). Another nurse noted: ‘I've been here for 16 years. This is the most violent year of my career and more code blacks, more code greys than I've ever seen before’ (RN11).

While all nurses interviewed were able to agree that the new Act had the best of intentions, they also expressed significant concern about the approaching deadline for the removal of seclusion in Victoria. At the time of these interviews, that was less than 6 years away. One described how a seclusion room was closed and turned into a sensory room that no one uses: ‘we (staff) don't feel safe anymore’ (RN2) and ‘…they're working toward removing two seclusion rooms…and we're seeing more aggression and a need to use restrictive practises as a necessary evil…we're not eliminating aggression. We're not eliminating danger. We're eliminating the way we manage it’ (RN10). One nurse described disappointment regarding the emphasis on reducing restrictive practices; that there is a suggestion that this is not something that nurses have been doing under all Acts:

…to be honest even before this Mental Health and Wellbeing Act came, we know and it's been drummed into us, that restraint and seclusion are the last option. When all the other options are exhausted, we go for that so still the same at the moment right? We all know even before that there was a lot of paperwork. We don't like to put anyone in seclusion or restrain them. Firstly, it's inhuman. We all know that. Secondly a lot of paperwork there, I'm not sure what they're trying to create with this (Act) because I think we have been doing this before. (RN2)

Additionally, nurses described that the elimination of restrictive practice requirements were not supported by effective ways of managing violence when it occurred:

I think the elimination of restrictive practices with providing no other alternative or options…there is not even a state‐wide agreed upon standard for aggression management in Victoria. Every health service included their own…so when there is a state‐wide determination that eliminating (restrictive) practices, and no guidance about how to manage aggression…I think it's irresponsible. (RN10)

Some nurses noted their health service had responded to staff risk of violence and aggression after closing seclusion beds by posting security guards permanently on mental health units. The irony of this is not lost on some nurses: ‘…bring more security in! They do aggression management training but they're just big, boofy boys who like a fight!’ (RN5) and ‘…there's a gaggle of them, a team of security. And that's another reason the police are called. You're going so heavy handed…’ (RN8).

Many nurses felt that this sharp increase in violence was attributed to the new Acts propensity of avoiding assertive treatment and that this resulted in a lack of opportunity for early intervention and subsequent decline in mental state and functioning. This necessitated crisis admissions which increased both consumer distress and risks: ‘…not enough early intervention, so they end up getting really down and then taking a longer time to recover from that acute deterioration’ (RN6) and ‘…there has been a marked increase in levels of aggression and I think that is largely due to people being significantly more unwell by the time I get to see them’ (RN11). This inability to respond before a crisis was distressing for some nurses: ‘you're walking into a lion's den’ (RN2). Additionally, some nurses noted, this hesitancy resulted in the treating team erring on the consumers right to a least restrictive intervention as absolute priority, despite their level of risk often being extremely high and, even when they knew a consumer well and could see their relapse signature unfolding before their very eyes. This point is highlighted by the following quote:

…it feels like we are being actively stopped…or prevented from being able to help people who are…at real risk of clinical aggression… it just seems like there are enormous hurdles that you have to overcome to be able to act assertively for management of these (violent) situations…we cannot do anything to hurt these people but we also can't allow people that are clearly acutely unwell to hurt anyone else. It's like they hand you this problem and expect you to fix it with nothing other than your words and abilities as a person. (RN12)

This created a level of moral distress and frustration in nurses and was at times fuelled by a perception of future litigation. Nurses frequently described fearing potential litigation and noted that the ambiguity of The Act compounded this issue significantly: ‘…there are a lot of staff who are very fearful that they are going to be accused of doing something incorrectly because of changes’ (RN10) and ‘…I think there is a real sense of defensive practice…practising from a place where this person will accuse you of doing all the wrong things (and) your health service will rake you over the coals…and all these things contribute to a mentally fragile workforce’ (RN12). This culminated in changes to practise for some nurses with one describing the changes to The Act as being untested: ‘…a lot of The Act isn't tried, and the only way it's going to be tested would be if something goes wrong…someone gets caught in the crosshairs and then get beaten up by either the coronial or legal system’ (RN5). This nurse went on to describe feelings of ‘coronoia’ a term they coined to describe the paranoia of ending up in the coroner's court. Despite the humorous term, there was a very real expression of worry and concern about litigation from several participants.

4.3. Theme 3: Workforce Strain and Organisational Value: The Impact on Mental Health Nurses

This theme described the impacts of working under the new Act on mental health nurses' own wellbeing, including how valued they felt by consumers and their health service. Additionally, this theme also explored the impacts of staffing and workforce shortages.

Most nurses identified the difficulty of working in mental health, and the impacts this job had on their own mental health and wellbeing. Several senior nurses described being grateful that they were no longer client‐facing, and others described that they could not imagine working in this environment for many more years. Overwhelmingly the negative impacts were a result of violence and aggression and removal of ways to manage these situations safely (e.g., the removal of restrictive practices). Nurses described that the significant impact of substance‐affected consumers should not be the remit of a mental health service that has no means of managing violence safely; that recommendations from the Royal Commission into Mental Health meant they were promised dedicated detox services equipped to manage, for example methamphetamine intoxication: ‘There were going to be sobering centres…and hubs for detoxing and facilities…and we're not seeing them, they're definitely not in our area….methamphetamine is the largest problem we are facing…that's a contributing factor to our workload and adds to the risk profile staff are facing’ (RN10). One participant described their distress at The Act entire focus being on the rights of consumers:

…there we are watching our back all the time, on our toes walking around on eggshells not comfortable at all. The stress level is like through the roof. I thought the Mental Health and Wellbeing Act was supposed to help, but forget about us nurses or staff forget about stress and the danger that we face. (RN2)

The gravity of these situations and their impact to nurses' mental health was expressed by several nurses who described how the changes to The Act resulted in an inability to assertively treat consumers: ‘We actually can't intervene…we're going to have to wait. And then there's definitely been times where that's resulted in family violence. And then we bring that person in (eventually), and the family doesn't necessarily blame us for that, but it takes a toll on the clinician, definitely. We feel terrible about that’ (RN11). This nurse went on to discuss how this inability to assertively treat consumers has resulted in suicide ‘I can think of three (suicides) that I would…I probably would have (been able to admit prior to the new Act)…it's really hard on the staff’ (RN 11). One nurse described several colleagues leaving nursing entirely ‘…three nurses have left the whole profession because of trauma’ (RN2).

Additionally senior nurses expressed concern around the rapid promotion of early career nurses with little experience because they simply could not find people willing to work incharge, including graduates with 6 months of total nursing experience, in charge of an acute inpatient unit: ‘They have no choice…because there is no one (else)…very dangerous’ (RN2) and ‘…I think a lot of people (early career nurses) don't know that they're too inexperienced and they're not thorough enough in their assessment or their understanding’ (RN5). This perception of poor understanding of their lack of expertise was also very evident in our discussion with several early career nurses. Two graduate nurses were working incharge in inpatient units during their graduate year, and both believed that they were chosen because of their ability and skills, not because there was a shortage of available senior nurses: ‘They told me I'm doing well…I know everything on the ward’ (RN7) and ‘…no there's plenty of experienced staff…my NUM is a big advocate for nurses straight out of their graduate (year) to…tick boxes…step up and take the responsibility…carry the weight of the ward’ (RN14). This disparity between senior and early career nurses was also evident in their experiences of how The Act had impacted practice. Because early career nurses had nothing to compare to, they were often more positive about The Act and how it was good for consumers: ‘If I was a consumer, I would love it (The Act)’ (RN7). In contrast, senior nurses identified that early promotion was fuelled by workforce shortages, often resulting from nurses leaving mental health because of the increases in violence and aggression and a lack of being able to manage it safely and effectively. One community nurse described having early career nurses working in their community team (which is traditionally only staffed with more experienced clinicians): ‘We've lost a lot of experience in our team, and we have got a lot of newer, younger nurses. We've got transition‐to‐practice enrolled nurses and RNs and people that haven't worked in an in‐patient unit…we added it up…we've lost over 200 years of (mental health nursing) experience in two years’ (RN6).

Staff shortages and issues with retention were additionally raised by nurses: ‘I think the greatest despair as a nurse generally is the number of nurses leaving the profession’ (RN4) and ‘we're haemorrhaging staff…we're really up against it’ (RN11). Most nurses interviewed knew someone who had left because of trauma: ‘two or three nurses actually left the nursing profession because of the trauma; my best friend she still gets nightmares you know’ (RN2).

Overwhelmingly nurses described feeling valued by consumers and carers: ‘I think were valued. I think I really do believe we're valued in the health profession as well as amongst our colleagues’ (RN9). Unsurprisingly some nurses identified that during acute episodes of illness some consumers struggled to see that they were trying to help them, this however eased when they began their recovery. These elements of their position made their role easier to manage and there was a clear message from nurses that they felt the intentions of the new Act were well meaning: ‘I can appreciate the values driving it…the philosophy driving it…but I think it's misplaced…I don't think it's having the outcome they intended’ (RN11) and ‘…in terms of recognising consumer rights and carer rights…there is lots of really interesting progressive steps forward…quite trauma informed and quite seismic in terms of the changes’ (RN12). With regards to how supported they felt by management, most nurses were less positive with these experiences and some described feeling like they would be blamed and not supported in the event of a sentinel event. ‘I think they (management) pay a lot of lip service’ (RN13). One participant described a complete lack of alarm for staff assault:

I've sat in meetings with the (Health) Department…when there's been a complaint made anonymously from a consumer claiming that a staff member assaulted someone…they witnessed an assault on the ward…the response was that we should have called the police…in the same meeting where a nurse was physically assaulted, they just moved onto the next item…there was no discussion… we're a disposable entity…within the workforce…we're replaceable. (RN10)

5. Discussion

This is the first paper to report the experiences of mental health nurses working in Victoria under the new Act. Several nurses in our study identified increases in occupational violence and aggression and demonstrated concerns about their inability to provide early intervention, resulting in serious outcomes such as completed suicides, since the introduction of The Act. Additionally, some nurses felt that The Act is ambiguous and difficult to categorically and confidently use. With the implementation of any new Act comes a period of change and transition. This often translates to increases in workload to accommodate the policy changes and expectations, such as attending tribunal hearings, increased incentives for discharge pre‐28‐days, satisfying compliance in contacting nominated persons, and stricter monitoring and documentation requirements (Cross et al. 2014). Farmanova et al. (2018) also note that for an organisation to successfully implement change, this often requires years of preparation, and importantly, support from leadership, key stakeholders and acknowledgement and recognition of the importance of organisational cultural readiness to change. Participants in our study identified a further increase in documentation requirements and the subsequent impact on their capacity to provide optimal care. They noted that these issues were further complicated by the need to understand the complexities of documentation changes and how to apply them in practice. Many nurses spoke to the engrained phrase from their undergraduate training: ‘if it was not documented, it did not happen’ (Gesner et al. 2022). This increase in documentation burden has a significant correlation with clinician burnout syndrome, particularly in the domains of emotional exhaustion and depersonalisation (Gesner et al. 2022), further exacerbating the workforce challenges in retaining mental health nurses (Adams et al. 2021; Cranage and Foster 2022).

These concerns were echoed many times by participants in our study, who noted the number of nurses leaving mental health because of trauma and retirement had affected their skill mix. Participants shared their experiences of the additional strain caused by the migration of senior nurses leaving the profession, further compounded following the COVID‐19 pandemic, and the burden of successfully implementing a new Act whilst feeling that they did not have the workforce capacity in place to do so. The premature deployment of junior staff into incharge positions without the support of senior staff to scaffold their transition can result in additional stress on the system, breakdowns in care due to changes in skill mix, and the loss of future potential leaders (Ting et al. 2024). In an era where recruitment and retention of mental health nurses are challenging (Adams et al. 2021) and predicted to worsen (Australian Government Productivity Commission 2020), factors that increase this burden should be cautiously implemented.

The significance of early intervention in mental health treatment is well established (Correll et al. 2018; Knapp and Wong 2020), yet participants from our study experienced existing legislation as often mandating a reactive approach that waits until an individual's condition has significantly deteriorated. This delay not only prolongs recovery but is also directly linked to poorer outcomes for those affected (Correll et al. 2018), as well as potential increases in violence (Biswas et al. 2018). The benefit to consumers is clear, but early intervention also saves governments significant money as such interventions are either cost‐effective or cost‐saving (Le et al. 2021). These issues of moral distress brought about by an inability to intervene early, burnout, and defensive practice are all factors that have the potential to deplete the mental health workforce prematurely, and this will have likely negative impacts on consumers.

Mental health reform is an integral part of improving the outcomes in mental healthcare, and legislation plays an important part in maintaining and upholding the rights of our most vulnerable communities. However, it is important to note that the core principles of The Act do not explicitly address the needs of the mental health workforce, which are essential for enabling them to practice within this framework and deliver care that meets the requirements of the new Act. Maylea (2023) further deconstructs the changes in the new Act, noting the lack of ability for the mental healthcare system to enforce these new principles and objectives. Changes in legislation often also result in additional needs; for example, modifications to infrastructure in an inpatient unit (Snipe and Searby 2023), creating a financial burden that is not achievable and therefore unable to be implemented. Participants in our study also identified additional barriers that prohibited service innovation and the ability to meet reform requirements. For example, in some services, there was no dedicated Act staff member overseeing its implementation, while others noted that dedicated alcohol and other drug (AOD) hubs which were promised as part of the state‐wide response to the Act were not provided, significantly impacting the ability to manage violence amongst substance‐affected consumers on wards that were not equipped to manage them without leaning on restrictive interventions.

Substance intoxication has been associated with greater incidents of violence (Kalk et al. 2022) and restrictive practices (McKenna et al. 2017), resulting in a cohort likely to inflate restrictive practice statistics, and requiring a different approach to management. As such, the implementation of any new policy stipulating a closure or reduction of seclusion rooms must be coupled with resources to support substance intoxication. Participants in our study also noted that in response to violence, security guards had been posted. To that point, restrictive practice cannot be eliminated by replacing seclusion with security presence, and to date there are no studies identifying a correlation between security presence and a reduction in violent episodes (Muir‐Cochrane et al. 2018). In fact, Oostermeijer et al. (2021) found that features such as gardens, recreational facilities, and a reduction in overcrowding were more aligned to reducing restrictive interventions. These are, however, design features that cost significantly more than posted security guards, requiring a significant long‐term financial investment from government. Security staff themselves are often confused about their role, expressing a lack of understanding regarding their duty of care and their legal position, as well as poor communication from clinical staff regarding the complexity of presentations, all of which impacts their ability to respond and support clinicians (Wand et al. 2020). Security staff also do not have the clinical expertise to respond in a trauma‐informed, positive risk‐taking way; and these are the philosophical approaches needed to ensure that seclusion is not required (Muir‐Cochrane et al. 2018). Additionally, security guards own mental health has been reported as poor because of their role (Talas et al. 2021) and as key members of the healthcare workforce support in hospitals, this should not be ignored. One legislative Act cannot change structures overnight (Wand et al. 2020) and as reinforced by Snipe and Searby (2023), without viable alternatives, the elimination of restrictive practices cannot be achieved, let alone sustained.

Participants in our study expressed concern about escalating violence within their health services. This is consistent with evidence reporting 83% of the Victorian mental health workforce have been exposed to at least one form of violence in the previous year (Muir‐Cochrane et al. 2018; Tonso et al. 2016). According to Safe Work Australia (2024a, 2024b) female nurses comprise the largest proponent of occupational violence and aggression compensation claims, and that male patients are the likely perpetrators of such incidents. Compensation claims are also highly associated with both experiencing and observing occupational violence and aggression incidents, indicating the significant individual and financial impacts of vicarious trauma. The recent Safe Work NSW (2021) report, which explored occupational violence and aggression in healthcare, noted that mental state was a significant factor in healthcare occupational violence and aggression. The report also noted the obvious disconnect between mental health legislation and work safety practices, resulting in staff responding to situations of occupational violence and aggression that contravene their workplace safety. For example, mental health legislation does not consider the Work Health and Safety Act (2011) which states that workplaces have a duty to prevent or eliminate causes of risk to employees. This is understandably a complex issue that cannot preference the risks of one population at the expense of another, but one that will not be resolved with blanket bans that do not take into consideration current high rates and experiencers of occupational violence and aggression. Occupational violence and aggression are impacted by several complex factors, not just staff and policy which can be changed, and as such require investment beyond mandates in legislation; this investment includes the built environment and the workforce (Snipe and Searby 2023).

Participants in our study reported that legislative changes have failed to address the risk of occupational violence and aggression and impacts of substance misuse in a way that enables nurses to keep themselves and consumers safe. Of concern, the closure of seclusion rooms as part of addressing Royal Commission recommendations was a key concern for participants in this study. Closing seclusion rooms does not always end in a reduction in containment practice (Muir‐Cochrane et al. 2018), as it can in fact lead to increases in other forms of restrictive practice, such as chemical restraint, which are not as easily captured and readily documented. While the closure of seclusion rooms is an important component of reform and a reduction in restrictive practices, this must be balanced with a consistent approach to how occupational violence and aggression are managed. Participants in our study expressed concern that there was no uniform approach to managing occupational violence and aggression, yet there are ‘blanket’ requirements to remove seclusion without regard to the nuances of both the services they provide and the acuity of their clientele. This is echoed in Jenkin et al. (2022) who found seclusion episodes were beyond mere management of diagnostic characteristics but rather were significantly impacted by improper infrastructure and bureaucratic organisational factors; factors that are unlikely to be addressed through legislative mandates. Additionally, any efforts to understand occupational violence and aggression must also address extended wait times (Timmins et al. 2023), locked doors confinement, and sterile and untherapeutic environments (Wand et al. 2020; Weber et al. 2022).

Despite these challenges, updates to The Act are commonplace in mental health legislation. In exploring updates between Mental Health Acts, Vine and Judd (2019) noted the lack of clinical growth and funding in the mental health system in Victoria as accurately proportionate to the population growth and demand. Grace et al. (2015) found that mental health nurses stipulated that the successes of the 2014 Act update and rollout were unfortunately eclipsed by the failure of successful implementation of promised reforms. The nurses interviewed in our study have shared similar experiences to those of prior rollouts, suggesting there has been little, if any, consideration of the mental health nurse perspective in this experience. Also, there is concern that the important and necessary changes of The Act to align with the United Nations guidance on human rights in legislation (Maylea 2023) as a positive and progressive improvement have been lost in the rollout due to the poor implementation in areas of the state. Unfortunately, the disjointed implementation does not seem to have been adequate to support nurses in making the required practice changes, reinforced by the work of Slemon et al. (2017) where nurses in their study demonstrated feelings of being beholden to a health system that expects a certain level of mental health care yet fails to provide the resources for this care to be enacted. The dynamic role of mental health nursing requires nurses to walk the fine line between practising according to The Act and providing person‐centred care, as well as the core responsibility of maintaining safety for all people involved in a consumer's care, that may not always be possible to achieve (Delaney and Johnson 2008; Muir‐Cochrane et al. 2018).

Staffing and workforce shortages were an additional area of concern raised by nurses in our study. Nurses make up 44% of the global mental health workforce (International Council of Nurses [ICN] 2023) and Australia currently has a 32% shortfall in mental health workers, with this shortfall expected to grow to 42% by 2030 if action is not taken to address recruitment and retention (Australian Government Productivity Commission 2020). Both Adams et al. (2021) and Cranage and Foster (2022) report that job satisfaction for mental health nurses is at the lowest level it has ever been, with many nurses emotionally and physically exhausted. These cumulative experiences have been reported as factors that can result in mental health nurses leaving the profession (Adams et al. 2021; ICN 2023). Participants in our study highlighted concerns with the workforce, including early career nurses being promoted to positions of leadership without adequate clinical experience. This is supported by data which notes the largest group of mental health nurses in Australia belongs to the 20–34‐year age group (AIHW 2024). This suggests that the youngest and least experienced of our mental health nursing workforce provide the majority of care to consumers.

The impacts of consumers experiencing mental state deterioration often lead to increased use of restrictive interventions, and create challenges in managing unpredictability, risk of injuries, impact on staff morale, and poor job satisfaction (Morphet et al. 2018) with mental health nursing being one of the higher risk areas that a nurse will experience moral distress (Alimoradi et al. 2023). Muir‐Cochrane et al. (2018) found that nurses have significant fear and concerns with restrictive practice elimination due to a feeling of blame at both initiating and not initiating restrictive practices, resulting in moral distress. Consistent with the experiences of nurses in our study, Snipe and Searby (2023) also identified that nurses themselves experience trauma and emotional distress at applying restrictive interventions and would prefer to use other options where possible. Restraint elimination practices can, and do, work, but they need to be implemented safely for everyone (Smith et al. 2015). The impact of this moral distress is not insignificant, with post‐traumatic stress disorder rates in mental health nurses reported as high as 17% (Woo et al. 2024). Several nurses in our study indicated that colleagues had left the profession after experiencing trauma. Worryingly, an increase in levels of moral distress in mental health nurses can also cause an increase in compassion fatigue and burnout levels (Kaya and Molu 2023) which can further exacerbate a cycle of poor care for the consumer. With increases in burnout reported in mental health nurses (Alimoradi et al. 2023), further exacerbating the workforce issues in retaining experienced mental health staff, urgent action is needed by both Federal and State governments.

6. Limitations

This study reports findings from a small sample of registered nurses working in Victoria and may not be transferable to other settings, especially as a qualitative methodology. This study did not focus on one specific area of mental health care delivery; instead, the sample included a number of nurses working in broad areas of mental health care including inpatient settings, crisis, emergency mental health, as well as representation from community‐based services. This broad sample may affect the results obtained. Additionally, mental health nurses employed in private settings were not included, as they typically work adjacent to the Mental Health and Wellbeing Act. Demographic details such as age, years of experience, cultural background, and geographic location (e.g., rural vs. metropolitan) were not deeply explored, limiting the ability to understand how diverse backgrounds may shape perspectives. Finally, whilst the absence of the consumer voice in this study was intentional to ensure a sole focus on understanding mental health nurses' experiences, this remains a noteworthy limitation to acknowledge.

7. Recommendations

While Vine and Judd (2019) noted that exploring the impacts of occupational violence and aggression, seclusion rates and suicide in any new Act are important, this is inherently challenging. Nurses in our study have made claims about greater incidents of occupational violence and aggression and suicide deaths that warrant further investigation. Additionally, as echoed by nurses in our study, a unified and consistent approach to managing and reporting the impacts of occupational violence and aggression is necessary. This approach needs to acknowledge the role mental health clinicians and consumers play in occupational violence and aggression. An approach that only addresses staff perspective is unlikely to address the real issues. While a state‐based de‐escalation and management of aggression approach is warranted, this also needs to be nuanced to the individual needs of services and consumers. Legislative reform needs to consider the documentation burden that drives nurses away from consumer engagement and keeps them behind a desk. Finally, ensuring adequate representation of client‐facing nurses in legislation is an important part of system reform. Nurses have an important message, and their voices need to be heard.

8. Relevance for Clinical Practice

Understanding the impacts of legislation rollout on nurses is important in ensuring that this process is improved for future iterations of reform. Mental health nurses in our study described varied experiences of rollout, but largely when they were well informed and prepared, their experiences were much better. Occupational violence and aggression is a significant issue in mental health and plays an important role in nurses' willingness to remain in the profession. Reform that seeks to remove restrictive interventions must be balanced with alternatives to safely respond to occupational violence and aggression. This must be funded and supported by adequate infrastructure acknowledging the nuances of individual health services.

9. Conclusions

The time for mental health reform is long overdue in Victoria but this reform must encompass the mental health system entirely, not mere fractions of it. A reduction in restrictive practices needs to adopt a collective approach that addresses the serious issues caused by inadequate infrastructure, poor staffing profiles, and an inclination for consumer choice over expert clinical decision making. In a time when mental health nurses are leaving the profession in droves, we cannot rest on this issue much longer. To recruit, retain, and sustain our mental health nursing workforce, nurses must be safe and feel that their clinical decision making is valued and safe from litigation. Unsurprisingly, overarching the voice from the nurses in our study was that they find using restrictive practices distressing, that they always practice within a least restrictive framework, but that sometimes they do not have any other alternatives to maintain safety. Mental health nurses are part of the solution, not the problem in mental health reform, but they must be consulted, respected, and trusted to do this.

Author Contributions

Each author certifies that their contribution to this work meets the standards of the International Committee of Medical Journal Editors.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Data S1: inm70127‐sup‐0001‐Supinfo1.pdf.

Alexander, L. , Searby A., Mills C., James R., and Johnson W.. 2025. “Victorian Mental Health Nurses' Experiences of Mental Health Reform: A Qualitative Descriptive Study.” International Journal of Mental Health Nursing 34, no. 4: e70127. 10.1111/inm.70127.

Data Availability Statement

Research data are not shared.