Mental health nursing students’ experiences of stress during training: a thematic analysis of qualitative interviews

Introduction: Previous studies investigating stress in nursing students focus on general nursing students or adopt quantitative measures. Purpose of study: A qualitative study focusing speciﬁcally on mental health nursing students is required. Method: One-to-one interviews were carried out with mental health nursing students ( n = 12). Data were thematically analysed. Results: Participants reported unreasonable demands during clinical blocks, and described how control/support is lowest on

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Accessible summary
What is known on the subject?
• Stress can impact students on mental health nurse training. This can have implications at the individual level (e.g. their own mental health) and at the level of the organization (e.g. sickness absence and attrition).
What this paper adds to existing knowledge?
• We interviewed 12 mental health nursing students regarding the stress they experienced during training. Participants described how the academic demands can at times be unbearable during clinical placements. There were also issues with 'being a student' on some placements, with participants describing negative attitudes towards them from staff.
• The younger participants reported feeling overwhelmed on their initial placements and described some of the main challenges of mental health work for them. Raising concerns about the quality of care on wards was also described as particularly challenging for the students.
What are the implications for practice?
• This paper can be useful to help training providers support mental health nursing students. Recommendations include reducing academic demands during clinical placements and extending and promoting existing support services beyond normal 9am-5pm working hours, even if these services are limited. Younger students could be better supported by being allocated to the more well-resourced placements in the early stages of their training.

Introduction
Research focusing on nurses has commonly found that this population reports high levels of stress (Edwards et al. 2000, Dickinson & Wright 2008. Lazarus & Folkman (1984) defined stress as a 'particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or wellbeing ' (p.19). In other words, stress occurs when the individual appraises an event as threatening and lacks the appropriate coping resources to deal with it. High levels of stress can impact on learning and memory, affect concentration and cause deficits in problem-solving abilities (Kaplan & Sadock 2000, Kuoppala et al. 2008. Stress is therefore an important area for further investigation, particularly in educational settings, where it has the potential to interfere with student learning and functioning. Furthermore, stress may lead to higher levels of attrition (Deary et al. 2003), which is a major problem for nursing programmes worldwide (Gaynor et al. 2006, Brown & Marshall 2008, Cameron et al. 2010.

Stress in nursing students
Nursing students have received a deserved amount of attention by stress researchers internationally (Burnard et al. 2008, Pulido-Martos et al. 2012, Wolf et al. 2015. A longitudinal study by Burnard et al. (2008) compared levels and sources of stress among nursing students in five different countries and found that, while retaining individual cultural features, students from across the globe reported very similar experiences of stress. Most of the available research suggests that the clinical component of the course is particularly stressful (Moscaritolo 2009, Chernomas & Shapiro 2013, with the highest levels of stress being reported around the time of the first clinical placement (Jones & Johnston 1997, Sheu et al. 2002. Commonly reported clinical stressors include issues with placements, fear of making mistakes and interactions with other members of staff (Alzayyat & Al-Gamal 2014). Academic stressors include workload, examinations and fear of failure (Tully 2004, Gibbons et al. 2008, and personal and social sources of stress include family issues, financial concerns and a lack of time for leisure activities (Pryjmachuk & Richards 2007a).

Stress in mental health nursing students
Research suggests that mental health nursing students are particularly vulnerable to stress and may be struggling to cope (Tully 2004, Nolan & Ryan 2008. Recent survey data from mental health nursing students in the United Kingdom (UK) suggested that this group engaged in more emotion-focused coping and less problem-focused coping strategies than other similar groups in training, and these findings were associated with higher levels of stress (Galvin & Smith 2015). Furthermore, higher levels of substance abuse were also found in this study. Jordaan et al. (2007) reported similar findings in other groups of mental health professionals, and concluded that an alarmingly high number of mental health workers may fail to adopt positive coping strategies to manage their own stress.

Stress in the National Health Service
The National Health Service (NHS) is the publicly funded healthcare system in the UK, in which mental health nursing students learn the clinical skills required for the profession. Undergoing placements in the NHS may be an inherently challenging aspect of training, as this working environment is renowned for being stressful. In the NHS Staff Survey (2013), for example, 39% of staff reported feeling ill due to work-related stress. More mental health nurses reported work-related stress (46%), when compared with learning disabilities nurses (40%), adult nurses (39%) and child nurses (39%). This suggests that NHS mental health workplaces might be particularly stressful environments. Furthermore, only 44% of all the staff surveyed believed that their organization takes positive action on health and well-being. It is therefore essential that research investigates stress in UK mental health nursing students, as they are often exposed to these high-stress work environments when on placements.

Purpose of this study
Many previous studies have adopted quantitative methods to examine stress in nursing students, but there are a number of limitations with this approach. For example, when constructing their instruments, investigators often assume that they know which stressors they should assess (Ravazi 2001, Beiske 2002. However, this approach may lead to researchers ignoring a wide variety of variables that are meaningful for the population being investigated (Creswell 2003, Ritchie et al. 2004. Therefore, to complement the quantitative research, qualitative research is required. Additionally, many studies have considered stress in nursing students in general, but very few qualitative studies have focused specifically on stress in mental health nursing students. This is important, as there are likely to be important differences between the specialties (Pryjmachuk & Richards 2007b). Indeed, findings related to one branch of nursing do not necessarily reflect other branches, despite many studies tending to pool participants under the same general term 'the student nurse'. This study therefore focuses on stress in UK mental health nursing students using qualitative research methods.

Participants
Semi-structured one-to-one interviews were conducted with mental health nursing students enrolled on a 3-year pre-registration undergraduate degree at Cardiff University, UK. The students recruited in this study were all aiming for BN (Hons) in Mental Health Nursing, with registration in the mental health nursing field. Recruitment involved purposive sampling, with the students being invited to interview via their university e-mail accounts. In keeping with the principles of data saturation in qualitative research, interviews were terminated after n = 12 interviews as the collection of new data did not provide any more useful information. Demographic details for the sample are provided in Table 1.

Procedure
Ethical approval was given from the School of Psychology Research Ethics Committee. The Healthcare REC honoured the Psychology REC and granted permission to access the students. Before taking part, the participants were made aware that if, during their interview, they were to disclose information that indicated an intention to harm themselves or others, or if they disclosed malpractice or suboptimal care of clients, then the researcher may have to breach confidentiality and report these disclosures to others. Any such disclosures of malpractice would be reported to the Programme Director. The consolidated criteria for reporting qualitative research (COREQ) were followed to structure this write up (Tong et al. 2007). Author JG carried out all the interviews, which lasted around 30 to 45 min and were audio recorded. JG is a male Psychology PhD student with experience of carrying out qualitative research for dissertation projects during his academic career. He also has previous experience of publishing a qualitative paper in a peerreview journal. The fact that the author's academic background is not associated with the nursing department has advantages and disadvantages. An advantage is that participants might answer more honestly to questions from an 'outsider'. For example, if the interviewer was an academic member of staff, it might be less likely that the participants would raise concerns with this person. A disadvantage is that a lack of mental health nursing experience may hinder the author's interpretation of the data. However, attempts were made by the authors to address this limitation, as is described later in the analysis section of this paper.
Open-ended questions relating to the students' experiences on their nursing degree programme were asked. Upon completion of the interviews, transcripts were prepared and rendered anonymous. The topic guide was generated by Author JG who arranged a meeting with a newly qualified mental health nurse who had just completed the course. This individual discussed some of the main issues they came across during their mental health nursing Year 1 (2) Year 2 (4) Year 3 (6) White British (12) education and, using this information as a guide, the questions to be asked to participants were developed.

Analysis
Thematic analysis was chosen as appropriate because it is a commonly used method for describing, analyzing, and reporting themes and patterns in data (Braun & Clarke 2006). The flexibility of thematic analysis allows the data to be analysed under a number of qualitative frameworks, and in this instance, the framework was grounded theory (Strauss & Corbin 1998). Using this approach, theoretical developments were made in a bottom-up manner in order to be anchored to the data. As interviews progressed, the responses to the questions given in earlier interviews informed new questions to be asked in future interviews. An inductive analysis was chosen as the most appropriate, as this allowed for unexpected themes to be identified (Braun & Clarke 2006). In their paper, Braun & Clarke (2006) described a stepby-step guide to conducting a good thematic analysis. First, the researchers should familiarize themselves with their data through transcription, and by reading and rereading the data while making notes about their initial interpretations. The researchers should then generate initial codes, and collate the data relevant to each code in a systematic fashion. Next, authors should collate codes into potential themes and review these themes by checking they are logical in relation to the extracts and the entire data set. Authors should then define and name the themes.
The analysis strategy in the present research involved the first four authors analysing the data separately, with each of them following the Braun & Clarke (2006) recommendations. Then these authors met for an analysis session, which involved discussing the themes generated by each author. Importantly, none of the themes was discussed between the authors before this point, as a general consensus would strengthen the trustworthiness of the findings.
During the analysis session, it was clear that the authors' individual interpretations of the transcripts were very similar, providing convincing evidence that the interpretation of the data was indeed trustworthy. Any differences that did occur were resolved by discussion. Further reviews of the data were carried out to confirm that the researchers' interpretations were identifiable. This involved the authors rereading the transcripts after the themes were established to further validate the findings. To address any concerns over the authors' lack of experience in mental health nursing, an experienced mental health nursing educator read over the themes to consider the feasibility of the findings. The steps taken in the analysis are summarized in Table 2.

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

Theme 1: Demands/control/support
Theme 1 described the demands that are placed on the students, the level of control they feel in their work and the support systems available to them. In regard to demands, participants described how in comparison with other students, the demands of nursing courses were much higher.
Participant 6: The actual amount of work they put on us alongside the placement is quite a lot . . . I mean the hardest thing is seeing other students being able to get all the time off, and doing what they want all the time and we're always in.
Contact hours were frequently mentioned and participants described how other people do not understand how stressful that can be.

Table 2
The five phases in the analysis and a description of the processes involved

Phase
Description of process 1. Each of the first four authors followed Braun & Clarke's (2006) recommendations.
Each author read and reread the transcripts, made notes on their initial interpretations, generated codes, collated codes into potential themes, reviewed the themes, and defined and named the themes. This was all done with the authors working separately from one another. 2. Authors met together for an analysis session to consider the codes and themes generated by each author.
A meeting was set up and the authors described their interpretations of the data individually. Findings were compared and contrasted with each other and discussions took place regarding any differences that occurred. The final themes were agreed upon. 3. Final reviews of the data to further validate the findings Each author then read through the transcripts again to ensure the final themes were truly reflective of the data. 4. The report was produced.
Each theme was written up into a report and data extracts were selected to be used as examples when describing each theme. 5. Validation from a mental health nurse educator A mental health nursing educator read over the themes and considered the credibility of the findings. More specifically to mental health nursing, participants described how the nature of mental health work can be emotionally demanding.
Participant 12: I've found the emotional side of some placements quite difficult to deal with. Like, seeing patients who are really unwell and patients who need quite a lot from you in terms of support. I mean, obviously that's what I'm there to do, to support them, help them through it. But the listening side of things can be quite mentally exhausting and after a long shift I just shut down and tend to try and avoid talking to anybody! However, for many participants, the academic side of the course 'gets in the way' and the most enjoyable aspect has been the clinical work.
Participant 11: I've found the academic aspects of it quite hard to deal with and I'm struggling to cope with that in some ways and getting it all done and to be on top of deadlines and things. But the actual placement itself has been really good and it's definitely the thing I'm here for, always you want to be on placement, you don't want to be doing the academic stuff. I can definitely see why people say that.
Many participants have to take up paid work to stay on top of finances, which added further to the demands.
Participant 10: At the moment the work/life balance is not so good. I work weekends as a support worker, just so I get enough money. So, when I'm on placement I'll work, like, 40-50 h and then I've got assignments. It really takes it out of me.
Home life demands were also very common. Many participants described issues related to their own or family members' mental health problems. Staffing problems on placements led the students to feel a lack of control. Many described how they felt vulnerable on placements with staff shortages.
Participant 10: There was a patient who at the time was walking around with a pair of scissors and looked quite nasty, and just kind of wanted to kill someone and it, it was things like that made me think 'I'm on this ward, like, there aren't enough staff here, there are loads of really quite upset patients, and they can't really manage these patients because there are so many of them and there aren't enough staff' . . . So, yeah, everyday I felt particularly vulnerable on that placement and there was always an instance everyday.
This participant went on to discuss one incident that caused particular distress, and how there was a lack of support available for them. The student had not followed correct procedures but was then not debriefed about the situation appropriately.
Participant 10: There was one particular day where two large guys were fighting with each other and there was nobody else intervening. They had three female nurses on the ward and that was it, and they were trying to pull the guys apart and I got involved with that. I knew I shouldn't have because the nurses told me before that I shouldn't have, but I didn't see that there was any other way to resolve that situation without me intervening. Then one of the nurses actually stepped in afterwards and said I should've pulled the alarm, which I forgot to do. But what I didn't like after that particular incident was that nobody really debriefed me about it, so I found that quite stressful. The whole incident I found stressful, but nobody actually came up to me, and said 'are you okay?', like 'how did that go for you?', and I felt that I couldn't say to someone 'that was a bit emotional' because everybody was so busy all the time.
Participants described how they felt restricted on some wards as to the things they can and cannot do. For example, participants discussed how not being able to get involved in restraining patients actually made them feel more vulnerable.
Participant 2: Because I've already worked in the mental health field, I'm obviously already trained in restraints and stuff, but we're not allowed to carry them out on placements as students, so it's more, how do you stop something from happening without actually getting in there if you know what I mean? There was one time where two nurses had to restrain a patient but there was only me and another nurse in there and obviously I was trying not to do anything but also trying to stop him hitting the nurse waiting for another member of staff to come in. It's a strange situation, when the unqualified staff members can restrain patients but students who are meant to be learning to be a nurse, can't, and it does make me feel quite unsafe.
Students believed that some placements were not suitable for the level of clinical expertise they had. This made them feel a lack of control in these placements. The level of support the students received was described as being important to help them cope with the demands of the course. The importance of having a good clinical mentor was acknowledged by the students. Participants described good and bad experiences.
Participant 6: If you've got good mentors then I think it's alright, if you've got someone who will show you the ropes or whatever, and give you that support, then it isn't too bad. While many were happy with their relationship with their personal tutors, a number of participants suggested that they would like to receive more support from them.
Participant 4: I would like to think that if I was somebody's personal tutor that I knew was going through a really crap time, I would like to think that I would be like 'do you want to have a chat?' But that was never offered.
The students reported a lack of support from the university for healthcare students in general. For example, participants described how they struggled to gain access to counselling services.
Participant 12: I wanted to speak to someone about some issues and I found that they're not very accommodating for healthcare students. The counselling support services work 9-5 and when I'm in lectures 9-4 I can't get around to speak to anyone, and then when I'm in placement I find that there's not an opportunity for me to go and do that, so I feel like maybe from that aspect I've been a little bit let down support wise from the uni.

Theme 2: Attitude towards students
The second theme highlighted the students' experiences on placements and how attitudes towards students from some staff members impacted on their experience. These experiences were often expressed as a source of stress. Students described how at times they were made to feel unwelcomed by others in the team.
Participant 8: I turned up to placement one time and I was sat in the waiting room. I looked a bit young and they didn't realise I was a student and my mentor was there and actually said 'oh no not another student, I really don't want them' and then got introduced to me, so that was nice . . . The whole placement they just didn't want me to be there so at the end of the placement she actually said to me do I mind giving them bad feedback so they don't need to have students any longer, so that wasn't very nice. I felt very unwelcome and, I think probably because the wards are so busy, and most of them have a lack of staff, they don't want students straight away and so it takes a couple of weeks to be welcomed. But once you've got stuck in they tend to want you there if that makes sense. However, mainly at the beginning I haven't felt welcome in lots of placements.
The feeling of being unwelcomed was often seen as a barrier to receiving appropriate support.
Participant 10: I've had a couple of placements where I felt like the nurses really couldn't care less whether I was there or not, and one particular placement where my mentor just didn't interact with me at all. I find that a really negative experience because there was just no support for me there . . . They just don't have enough time, or resources, or patience for the students.
Mental health nursing students on this degree programme are required to gain some experience in other nursing specialities on offer at the university (in adult and child nursing). When working in these settings, students described how there was at times discrimination from staff towards mental health nursing students and their clients.
Participant 5: My adult ward were not very welcoming of me. I had a lot of comments of 'oh, now you're here you can do some proper nursing'. It's just like little comments like that and 'ah you go and work with all the crazy people' and all this and, I had one person there who was saying to me that they don't see depression and schizophrenia as being a mental illness because they bring it on themselves. It's just sort of like, you have no idea! And these people are supposed to be nurses, they are qualified nurses that just don't work in mental health, but you're thinking that's really not a good attitude to have.
Participants described how being a student restricted the tasks they could perform on placement and this often caused issues with other members of staff. Participant 3: They will quite often ask you to escort patients on your own who are under section, and we're not allowed to do that as a student . . . So I've had quite a few difficulties with that.
The students also described the difficulties of raising concerns as a student, and how they have been marginalized when they expressed concerns about quality of care. Participant 6: I had a few issues with the staff because I brought up things where I thought there wasn't proper behaviour by the staff. They were a really close group and just having a go at me for that and saying I wasn't in any place to tell them what to do because I'm a student.

Theme 3: Stress and coping
A number of participants reported feeling high levels of stress because of the course, with many describing how they have themselves developed mental health problems. This was particularly prevalent in third year students.
Participant 8: This is going to sound dramatic, but I feel kind of burnt out already and I'm only in my third year of training. I'm going to have a bit of a break before I go into work because I'm a bit concerned, I feel absolutely shattered from the course.
Age and experience appeared to buffer against stress, with mature students and students with more experience reporting that they are coping well with the course.
Participant 7: I'm not sure I'm ever that stressed anymore, to be honest . . . I think that with my age I've realised that I don't need to be as stressed as I've made myself in the past.
However, students who started the course at a younger age reported struggling to manage.
Participant 8: In the first year, I was 18, I was turning up, but a lot of people commented that 18 wasn't really mature enough, and I do feel in agreement to be fair, you do need a bit more experience. Looking back, it was too young, only because I'd had no experience before, so it was a shock, it was tough. I'm not an immature person, but I don't think 18 and having to get stuck in like I did, especially in mental health, it's a bit too young. You need to get a bit more experience to be mature enough to be able to deal with that. Nonetheless, despite her young age, this participant felt that she had developed resilience, and this could help her in her future career.
Participant 8: Stresswise, because it's been so stressful, I have managed to get through it. So hopefully when I start working I'll cope with the stress well. One of my placements was really hard and I went through that, and yeah, I think that'll help me. What I am trying to say here, is that because I've seen certain things and just had to get on with it, it's helped me do things by myself more.
With the high demands of the course, many reported how they would often be too tired to engage in positive coping strategies.
Participant 8: I like to go the gym to release the stress and that makes me feel so much better, but when I'm on placement and things I really don't get the time, I'm just so exhausted all the time.
Alcohol was seen as a release for many, although many recognized this as being a negative coping strategy.
Participant 5: I do think I drink a lot more when I've had a stressful week. So when I go out with my friends, I know I drink a lot more than if I wasn't stressed.

Discussion
This study provides an insight into the experiences of stress in mental health nursing students and adds to the existing literature in this area. To help consider the implications of these findings, suggestions are made to allow nurse educators to reflect on their practice and consider ways they can help students cope with the stress of training. Additionally, the findings are considered in relation to the stress and nursing literature.

Demands/control/support
The Demand-Control-Support (D-C-S) model (Johnson & Hall 1988) could be used to define one of the themes. This model is an extension of Karasek's (1979) Demand-Control (D-C) model, in which jobs with high demands and low control are considered 'high strain jobs'. Johnson & Hall (1988) added the support element to the model, and this D-C-S model proposed that the adverse effect of demands on outcomes is buffered when both control and social support are high.
In terms of demands, participant responses in the present study are similar to findings elsewhere on nursing students, with mental health nursing students reporting an unreasonable workload (Tully 2004, Pryjmachuk & Richards 2007a, Gibbons et al. 2008. Educators must therefore ensure that the amount of academic work is achievable when students are out on placement. Overworking students during these periods can have an impact on the students' stress levels, their engagement and enthusiasm while on the placement and, ultimately, the quality of care their patients receive. To help students feel a sense of control over their environment, it is important to ensure that the placement is suitable for their level of clinical expertise. Knowing which placements are suitable at different stages of the students degree is important, and educators should therefore continually review the placements and the students being sent to them (Nolan & Ryan 2008). It is also necessary that feedback is taken on board from both the placement and the student, and that any discrepancies between the students' clinical expertise and the suitability of the placement are learned from. This may be particularly important in mental health placements, due to the psychological nature of the work and the potential impact a lack of appropriate skills may have on students in these settings.
A lack of control on placement was often attributed to staffing levels. Indeed, in the current NHS environment it is likely that students will end up in workplaces that are short of staff (Scott 2014, Kmietowicz 2015. Trying to care for mental health patients in these environments can be challenging, and students will inevitably feel vulnerable in these settings. If students made mistakes on placements with staff shortages, they reported a lack of debriefing and appropriate support. It is the duty of staff on placements to ensure that any mistakes are discussed with the student and how they might approach similar situations in the future is explored. Additionally, regulators should continually review the suitability and safety of placements with staffing problems. In terms of support, previous research suggests that many mental health nursing students will avoid turning to counselling or other types of professional support to help deal with stress (Cankaya & Duman 2010). Indeed, Galbraith et al. (2014) found that nursing students reported a preference to disclose stress to friends and family rather than to colleagues or professional institutions. Goff (2011) suggested that this reluctance to seek professional support could be due to students perceiving accessing such services as a sign of weakness, or a sign that they cannot cope with the stressors inherent to the job. In the present study, there were further barriers to accessing professional support. Participants described how they struggled to gain access to university counselling services due to opening hours clashing with clinical placements. Arrangements should therefore be made to help allow the students to access other services outside of placement hours, even if these are limited in scope. A drop in facility could be particularly helpful here. Information on support services for students beyond normal working hours should also be more readily available. For example, helpline support services such as the student-run Nightline programme can be helpful for students during busy times.

Attitudes towards students
Expressing concerns about quality of care on placement was another difficulty described by participants in this study. In a recent review into raising concerns commissioned by the UK government (Francis 2015), it was noted that students can play an important role in ensuring acceptable levels of patient care in the NHS. It is essential that these recommendations are implemented in NHS workplaces taking on students to help protect students who speak up. The report recommends that in placements that do not have clear policies in place, the regulator should consider removing its validation from the course (Francis 2015).
In addition to this, policies at university institutions should be reviewed to help protect students who speak up. This protection should include the possibility of the student changing placement if need be, without the fear of penalty regarding their progress on the course. It could also be beneficial for students to be educated on the issues surrounding raising concerns in health care at an early stage of their nursing education. Awareness around such issues can help the students understand the need for open and transparent practices on placements, the protection they should expect to receive should they raise a concern and go some way to encouraging the future generation of nurses to speak out at work without fear.
It should be noted, however, that it can be difficult for students to judge whether correct procedures are being followed on placements and a lack of experience may contribute to them jumping to the wrong conclusions. One way to help with these issues is to encourage students to ask enquiring questions when in doubt. For example, asking questions such as 'I thought you were meant to do it this way, why is it this way?' and talking it through with the staff members concerned can help clarify to the students why they are doing a particular task in a certain way. This may resolve the issue, or confirm to the student that incorrect procedures are being followed. Either way, approaching such situations in a manner that suggests they are trying to learn, rather than complaining, can help them avoid conflict. Educating students about raising concerns should therefore be a key learning outcome in nursing programmes moving forward. A small group seminar might be the best way to achieve this, as such informal settings can encourage student involvement in discussions around sensitive issues (Dennick & Exley 2004).
Due to the increasing number of students in nursing education, it is important that staff members are frequently reminded of the value students can bring to the workplace. Participants described how being a student restricted the tasks they could perform on placement and this would often cause issues with other members of staff: 'they will quite often ask you to escort patients on your own who are under section, and we're not allowed to do that as a student'. This highlights the necessity of staff being aware of what tasks can and cannot be delegated to students. The communication of this information is the responsibility of the management team on wards that take on students, and they should ensure that any new members of staff are properly informed. Making staff aware of the boundaries for students will decrease the likelihood of difficult situations arising, and taking these steps can help improve relations between students and staff.

Stress and coping
In line with other research on mental health nursing students (Tully 2004, Nolan & Ryan 2008, many participants disclosed feeling highly stressed, with negative consequences for their mental health. This was more common in younger participants with less experience, who described the high levels of stress they experienced during placements. We suggest that courses pay particular attention to the allocation of placements early on, with priority given to the younger students who may be best suited to the more established placements with higher resources available. This would ensure appropriate support is given in those early placements for these students. Once more experience is gained, however, and beyond first year, no such concessions need to exist. It is important that students of all ages develop resilience against the nature of mental health work. However, a more balanced and considerate approach to the younger population of mental health nursing students when allocating those early placements could be helpful. It is important to investigate the coping strategies used by mental health nursing students to help them cope with the training course. Galvin and Smith (2015) found that alcohol consumption was highly prevalent in a sample of UK mental health nursing students. However, this finding could merely be reflective of being an undergraduate population, a group known for high alcohol consumption (Gill 2002). Nonetheless, many participants in this study described how alcohol was used to reduce stress of the course, suggesting that this could be a particularly important coping strategy for them. Health promotion and prevention efforts with a specific focus on alcohol could be considered by training providers. More simple changes, such as reduced alcohol marketing around the university campus and not selling alcohol on site, can also help. Furthermore, enabling easier access to other facilities, such as the possibility of institutions offering discounts on university gym memberships, can encourage students to engage in positive coping strategies.

What the study adds to the international evidence
As the stressors identified in this study are consistent with international findings, this paper can also be useful for nurse educators and clinical practitioners in other countries. For example, Hamdan-Mansour et al. (2011) examined the experiences of Jordanian mental health nurses and found that conflict with other professionals was one of the most frequently reported stressors for this group.
The recommendations we have given here in relation to improving relations between staff and students are therefore clearly applicable and potentially useful for educators in other countries. This is also the case for many of the other recommendations in this paper. For example, a lack of staff in placement settings (George et al. 2012, Ebadi & Khalili 2014, barriers to accessing support (Reeve et al. 2013, Harris et al. 2015 and expressing concerns (Jackson et al. 2014) are all issues faced by countries across the world.

Implications for practice
• Educators should ensure that the academic demands placed on students are appropriate during clinical placement blocks to avoid overwhelming the students. • It is essential that students have the skill set needed to work in the placement in which they are allocated; this is particularly important in mental health settings. • Due to the nature of mental health work, more consideration for the placement allocation of younger students at the beginning of their training programme could be particularly helpful for these students. • Counselling services should be available to students outside of normal working hours. Educators should ensure that information on support services beyond these working hours is readily available to the students. • Educating the students about raising concerns should be considered a key learning outcome on training courses. This will help the governments drive for a more open and transparent NHS.

Limitations
The nature and size of the sample in this study meant that analysis was focused on individual perceptions of training, rather than providing a broader social-structural analysis. Generalization is therefore difficult. However, we do claim a broader relevance for this study, as a number of the findings reported here are consistent with other research focusing on nursing students.

Conclusions
This paper described the experiences of mental health nursing students and identifies issues faced by these students. The data presented here can feed into the effective management of mental health nurse training and hopefully give training providers some food for thought.