Perceptions of Saudi psychiatric mental health nurses ’ roles in the inpatient mental health care setting

Purpose – The aim of this study is to investigate the roles of psychiatric mental health nurses during their work experiences in inpatient clinical settings. Design/methodology/approach – A focus group of 10 graduate psychiatric nurses with more than two years ’ practice in inpatient psychiatric settings reflected on their last six months ’ work placements and continuous employment. The transcripts and field notes were analyzed through thematic analysis of inductive data. Findings – Two main themes emerged: management roles and clinical roles. The participants reflected on caring activities and obstacles encountered in fulfilling their professional roles. Originality/value – Multiple practice issues emerged. The participants perceived that psychiatric nurse specialists are required to perform more caring functions than practicable in the inpatient setting due to an excess of noncaring duties, structural minimization of the caring role and inadequate training. They felt that many of the functions performed were not within their expectations of the caring role of a psychiatric nurse specialist and believed that changes in nurse education and attention to clarification of nurses ’ roles might enhance the role they play in patient care.


Introduction
Psychiatric mental health (MH) nursing emerged in the 18th and 19th centuries (Jones & Beauvais, 2022). Over time, those involved in this field have undertaken the roles of attendant, MH nurse, psychiatric nurse and nurse psychotherapist. This transition has culminated in the emergence of modern MH nurses (Hayes, 2022). The role played by psychiatric mental health nurses (PMHNs) has altered over the last three decades, trending toward psychosocial practices being incorporated into a largely biomedical model (Van Belle et al., 2020). Specifically, PMHNs have achieved greater independence regarding how they allocate their time to different areas of patient care toward contemporary PMHNs having more autonomy in how they allocate their activities and time and the type of care given to patients (Martinelli et al., 2022).

Background
The role of nursing, including psychiatric care, has recently been re-examined and modified in some quarters from a mainly biomedical model to include increased recognition of the interpersonal aspect of care. However, this trend is not uniform between institutions and practitioners in re-focusing the role of nursing toward patient-centered, more holistic care (Jaiswal & Mumba, 2022). Hence, this dissonance between the caring and medical models has effected changes in caring practices and professional preparation, which are quite varied (Van Belle et al., 2020).
The blurred boundaries between these approaches have implications for the evolution of high-fidelity nursing care and are indicative of a core problem of nurse education at all levels. The National League for Nursing (USA) (2022) has spoken to this need for clarity in expressing the core values of caring, diversity, ethics, holism, integrity and patientcenteredness in the practice of nursing including introduction of specific course content in nursing education in ways that implement these concepts (Ghane & Esmaeili, 2019). Hall (2023) points out that there is considerable ongoing research into the role of PMHNs. Various studies indicate that MH nursing is multifaceted and tend to elude precise definitions. Nevertheless, Sunnqvist et al. (2022) and Jang, Kim, and Lee (2022) seek to demonstrate clarity in this role. Tirkkonen (2023) stress the importance of physical care in nursing and propose that nurses should possess basic knowledge of neuroanatomy, molecular genetics and brain imaging techniques. This view agrees with Langeland and Vinje (2022), who suggest that MH nursing appears to accord more closely with a medical model. However, this preference for a medical model may not allow PMHNs to fulfill their caring role because it might assign them to being therapeutic assistants for psychiatrists (Skudlik et al., 2023) or attendants for medical staff (Hayes, 2022). Salberg, Backstrom, Roing and Oster (2019) endeavored to describe the role of PMHNs. They assert that for PMHNs to be successful in their caring activities, the way the nursing role is understood by nurses and patients is essential. Having clear role definitions, values and goals assist nurse managers in the provision of nursing interventions such as dialog, psychoeducation, support in normal daily routines, sincere listening and provision of a safe environment. Al-shlool et al. (2022) propose that MH nursing encompasses multiple functions related to patient safety and welfare, not least of which are interpersonal interactions between nurses and patients. Maguire et al. (2022) and Maguire, Garvey, Ryan, Willetts and Olasoji (2022) points to the historic roots of PMHNs aligning their nursing roles in psychiatric inpatient settings as being dominated by psychiatrists and evolving as being subservient to their needs rather than those of the patient.

Mental health care in Saudi Arabia
Saudi Arabia has a population of 33 million people comprising about two thirds of local residents and one third of guest workers. It is a young population: 67% of its residents are aged 34 years or younger. Spending on MH care accounts for 4% of total health care expenditures, with 10.7 MH nurses per 100,000 population, compared with 23.2 in Europe (Al-Subaie, Al-Habeeb, & Altwaijri, 2020).
The Saudi Arabian Ministry of Health offers health care throughout the kingdom through primary care health centers situated in local communities and aims to provide comprehensive health care for all citizens, residents and visitors free of charge, including medication. These centers are the gateway to the health system and are staffed by generalist health care workers, including physicians, nurses and pharmacists, who address all health concerns presented by attendees, with authorization to refer patients to specialist care when appropriate (Al-Subaie et al., 2020).
The dimensions of MH need in Saudi Arabia based on data from evidence-based research are unclear. The Saudi National Mental Health Survey conducted in 2010 was intended to be the first comprehensive report regarding mental disorders in the kingdom. It reported that 34% of the Saudi population would require MH care during their lifetime. However, access to this care may not occur, since this study suggested that 13% would seek care, while 80% would not (Al-Subaie et al., 2020) because of the extensive stigma attached to MH disorders among the general population (Alattar, Felton, & Stickley, 2021). This survey additionally reported that 34.5% of Saudi adults had experienced a diagnosable mental disorder, 6% had suffered a major depressive disorder and 20% of the sample had suffered from an active episode of mental disorder at some time in the 12 months before the survey (Al-Subaie et al., 2020). However, the sampling method, sample sources and size and other aspects of rigor used for the supporting research were not addressed in the final report which may jeopardize the potential usefulness of the data.

Professional nursing in Saudi Arabia
Nursing in Saudi Arabia is undergoing rapid change. Although nurse education and training in Saudi Arabia is well-established and available to qualified applicants at all levels of study from a Bachelor of Nursing Science to a PhD, participation in the nursing sector by Saudi youth has been unpopular. Thus, 50% of the nursing workforce comprises Saudi nationals and permanent residents (of which 75% are diplomat generalists), with the balance being recruited from a variety of other nations (Al-Subaie et al., 2020). Specialized nurse roles are becoming developed as fields of practice, although currently these constitute only 5% of the total nursing workforce (Alluhidan et al., 2020). However, the goals of modernizing Saudi Arabia's institutions including health careknown as Vision 2030include far-reaching goals to improve nursing education and continuing education programs, establishment of clear practice guidelines and appropriate definition and acceptance of nursing roles aimed at realizing a cadre of indigenous professional nurses prepared to meet national needs (Alqahtani et al., 2022).

Theoretical considerations
Travelbee developed the human-to-human relationship model based on concepts of existentialism (Wayne, 2022). This model proposes that the nursing role is an interpersonal process used to help and support individuals, families and communities through choices and conflicts (Travelbee & Doona, 1979). It proposes that the nursing role is aimed toward prevention of suffering through empathy and sympathy found in human relationships, beginning with the original encounter with patients and providing support to them and helping them and their families to find meaning, hope and healing in their life experiences (Petiprin, 2020).

Aim
A review of literature on how practicing PMHNs perceive their role indicates that this area requires additional research. Happell, O'Donovan, Sharrock, Warner and Gordon (2022) discussed the PMHN role based on observations from Australia and New Zealand, noting that political and economic influences are the most important considerations in the revision of nurse education. Although international standards for nurse preparation provide standards and bases, local influences may temper the path of nursing education and training in various locales worldwide. Research into PMHNs' perceptions of their appropriate role in inpatient psychiatric care in Saudi Arabia or other areas of the Middle East is scarce and therefore requires in-depth exploration.
Toward this goal, questions were devised to explore participants' experiences of care delivery (Hirose & Creswell, 2023) and address the research question: How do PMHNs perceive the clinical role of MH nurses in psychiatric inpatient settings?

Research design
The paradigm that provides the basis for this study is a constructivist shared understanding of the PMHN role (Alzailai, Barriball, Alkhatib, & Xyrichis, 2022). Built on this outlook, symbolic interactionism suggests that exchanges between individuals take place within organized systems in society. Therefore, to explore behavior, it is necessary to be aware of participants' perspectives in relation to their society and in relation to themselves as they perform their various roles. Evaluation of the interaction between society and social role expectations and definitions permits the self-construction and reconstruction of social processes (Liu & Sammons, 2022).
The research question pertains to the participants' need to examine their role as experienced as practicing PMHNs. Therefore, this study explored participants' perspectives, elucidations and connotations of their experiences in practice. Peterson (2019) suggests that exploration of topics in which previous evidence-based research is lacking may appropriately employ qualitative strategies because they illuminate participant perceptions and perspectives. Qualitative data from focus groups are induced and guided by introducing initial questions pertaining to the topic of interest. Using emerging inductive data, the researcher engages in theoretical sampling, thereby permitting participants to consider and fully express their own experiences (John et al., 2022).

Sample and setting
The recruitment post required an inclusion limit of one year of inpatient psychiatric care experience. The sample consisted of 10 practicing MHNs aged from 25 to 35 years, and selfreported that each had worked in an inpatient setting for at least two years and were presently employed in those settings, while pursuing an advanced graduate degree in psychiatric-MH nursing. Graduates constituted a sample based of the depth and breadth of their PMHN practice experience. The participants were recruited via posting in the College of Nursing of King Saud University, and this group was supplemented by snowball recruitment provided by the initial participants. A focus group meeting was conducted in the MH department of the College of Nursing.

Data collection
The focus group format employed a digitally recorded semi-structured interview, wherein methods were employed to initiate horizontal relationships between the participants, and all input had equal value. This permitted the establishment of a collective learning process in which experiences and perspectives could be articulated (Ramos, Cattaneo, de Jong, & Espadeiro, 2022).
The participants were encouraged to reflect on their personal experiences of MH nursing and their familiarity with the relevant literature.
The discussion involved open-ended questions, which were intended to prompt an open discussion.
The themes explored in the focus group discussions included perceptions of the role of PMHNs, their experiences of clinical placements, significant events during placements and the perceived influence of nurse education and training.
Pineda, Villanueva and Tolentino (2022) recommend focus groups as a data collection method because use of this technique may enrich discussion among participants, thus increasing the range of aspects of the phenomenon under study through member interaction.
The duration of the focus group interview was approximately 90 minutes. The participants were asked open-ended probes intended to explore their beliefs and thoughts regarding their roles in caring for patients with MH problems. For example, "can you explain what your role is in the setting of your practice? How did you see your work in relation to your colleagues, members of the multidisciplinary psychiatric care group, patients, and their families? Are you satisfied with your role?" Theoretical sampling based on responses to these probes was employed to extract additional data on the themes that emerged. Further probes concerned personal worries, perceptions of obstacles and personal feelings experienced in the MH setting. Other questions related to illuminating perspectives regarding clinical experiences and factors associated with the MH environment.
According to Meyer and Mayrhofer (2022), theoretical sampling should persist until saturation is achieved. This point was signaled when the discussion ceased to produce additional new inductive codes from the research participants. Achievement of this parameter was reached within about 90 minutes of the initiation of the meeting. Member checking was employed at that time to give the participants an opportunity to correct or add additional data.
The group session was digitally recorded and transcribed into a Word document and printed. The audit trail was preserved by storing a flash memory drive containing the focus group interviews, transcripts, field notes and informed consent forms in a secure location.

Ethical considerations
The recruits for the focus group were assured that their personal information would remain confidential. All information that identified the participants, MH settings and staff or patients where the participants had worked was removed. Individual participants were not identified during the recording, which preserved their anonymity.
The participants were advised that they could withdraw at any time. None of the 10 participants expressed any objection to their participation and all the participants recruited provided their written and verbal informed consent.

Data analysis
NVivo.14 software (Par e & Trainer, 2020) assisted the researchers in extracting emergent themes from the data. Pertinent data were divided into several units: phrases, sentences and extracts. The resulting codes were reviewed by the principal investigators and induced to form axial codes, which resulted in the formation of central and sub-themes. Each unit was then grouped into categories or themes and provided with a descriptive title.

Methodological rigor
Two researchers independently reviewed the data, codes and categories before meeting and deciding upon the agreed meaning and significance of the analyzed data. The depth of experiences described by the participants directly impacted transferability and dependability. Data, codes and classifications were also evaluated by two peer researchers to examine the sense, precision and significance of the emergent data. Credibility was enhanced by member checking of mutual understanding of the phenomenon explored.

Results
Analysis of the interview transcripts produced tow main-themes and sub-themes pertaining to the role of PMHNs: management roles, and clinical roles and clinical challenges.
Theme one: management role The participants' perception of this role was that PMHNs acted as ward managers. In this role, they were responsible for all the administrative work of the ward.
Sub-theme one: administrative. All the participants reported that nurses manage all the day-to-day needs of their units and viewed this as part of their role. In addition to routine administrative work, they also considered that their role encompasses evaluation of patient safety provisions, organization of day center visits and securing hospital appointments for patients who needed to be seen by specialists, not least for older patients with multiple physical problems. This was expressed by several participants as part of their role in providing comprehensive care for their patients.
We took on all the administrative details of ward operation, no matter how trivial. There was no one else there to do it. (P5, age 31) We organized orientation in different health care centers and settings to recognize good follow-up within a multidisciplinary team caring for users. (P8, age 25) Although forensic cases involving substance abuse or crime are cared for in separate facilities and are not part of the inpatient population, there were patients who were involuntary admissions.
We have to consider caring for all patient types. In particular, older people with multiple diseases and problems should be considered. (P3, age 27) Sub-theme two: record keeping and documentation. Record keeping and documentation were identified by all the participants as essential aspects of the PMHN role. However, most of them regarded it as time-consuming and deleterious to nurse-patient interactions. The participants reported that their one-to-one contact with patients was limited, especially during early shifts: Particularly in the early morning, we have to record everything, and we are wholly occupied with office work, so we don't have much time with the patients. (P1, age 35) Record-keeping and documentation were considered to have high priority for the participants and the setting where they practiced. Consequently, they reported spending a lot of time on it. However, at least two participants felt that some nurses would use documentation as an excuse to remain in the office: Sometimes we are busy in the office. I'm not sure I can successfully stay with patients. I feel I would not be able to manage those problems. I like to stay in the office. (P9, age 35) Theme two: clinical roles and clinical challenges PMHNs perform clinical and nonclinical duties with their caring role. The participants reflected on what they classified as their various clinical roles.
Sub-theme one: clinical role. Most participants described clinical duties as encompassing observation and care including attending to hygiene and nutritional needs, monitoring threats to patient safety including suicide watch and control of patient self-harm or aggression to other patients or staff was considered to be a highly important aspect of the clinical role.
The nutritional and hygiene needs of the patients were attended to by the PMHN when the patients could not do it for themselves. (P3, age 27) I think we need a lot of skills to improve our role and intervention in clinical skills that we must do proficiently as PMHNs. (P6, age 29).
Medication Management: Drug administration was unanimously regarded as a crucial aspect of the role of PMHNs. The participants discussed dependence on medication as a treatment modality due to nurses' fear of exploring nonpharmaceutical therapies, which are unfamiliar to them and they are not confident using. One participant also reported the following: Medication was not only perceived as necessary but also as the most time-consuming of all nursing activities, and it is crucial how PMHNs deal with it. (P1, age 35) Other responsibilities for PMHNs related to the administration of drugs included monitoring the effects and side effects of the drugs, ordering and storing drugs. This is time-consuming intense work. (P9, age 35) Training: All the members of the group concurred that additional training was required in order to make them confident in medication administration.
We need a lot of knowledge of drugs in psychiatric nursing. Hence, it requires intensive and demanding continuing training courses. (P4, age 33) Sub-theme two: nonclinical role. Nonclinical activities were defined by several participants including domestic and escort duties. On some wards, PMHNs were obliged to perform domestic tasks. Escort duties included accompanying forensically detained patients for walks in the grounds and escorting patients to other hospitals for specialist appointments. Some participants felt that escorting patients was a clinical role due to their therapeutic value. However, student nurses or health assistants tended to be assigned these duties because of the inadequate time available to the PMHNs.
Qualified mental health nurses would only escort patients when there is a shortage of unqualified staff, such as students or health assistants. (P5, age 31) Health care assistants are not mental health nurses. However, they are in short supply, so sometimes we have to provide care for patients. We help them within the grounds and take them to other hospitals for appointments with specialists. (P6, age 29) Liaison Role: PMHNs are viewed as personal links between patients and other health care team members. The participants all felt that this is a highly important role in multidisciplinary meetings and handovers, where information is shared between nursing teams at the beginning and end of each shift and PMHNs advocate on behalf of their patients: We had to present our patient's case and situation and discuss it with the multidisciplinary team during the morning handover. (P8, age 25) During ward rounds, consultant psychiatrists and multidisciplinary team members discuss patient situations, responses to medication and planning for care. When patients had different psychiatrists, the daily ward rounds placed pressure on the nurses' time. Nevertheless, ward rounds were viewed as an essential aspect of the care delivery role: Inside the inpatient ward, the morning round is demanding and places us under pressure. It is essential to discuss the care plan for our patients with the team. (P7, age 32) Patient Support: PMHNs are regarded as a source of patient support because they represent and advocate for patients during ward rounds. Specifically, patient support is how nurses saw their role to speak on behalf of patients who cannot speak for themselves. One participant explained that when patients have undesirable reactions to their medication, nurses typically share this information with the multidisciplinary team.
We are the prominent voice of our patients. We can report what they accept and refuse. We must share that information within the team to make good decisions about patient care. (P9, age 35) Inclusion: The participants felt that principal clinical interventions provided by nurses should include spending time with patients in a therapeutically caring way, as reflected in human-to-human models of patient care. They felt that these encounters should be part of their role as PMHNs, but opportunities were unavailable because of the pressure of administrative duties.
All the PMHNs felt that they were used for administrative and custodial duties rather than being included as a provider of therapeutic caring activities.
We are disappointed that other sorts of therapeutic activities, including art therapy, drama therapy, family therapy, and individual work, are the responsibility of the multidisciplinary team. If you are a very senior nurse, you might have the opportunity to become involved in these therapies. (P4, age 33) Thus, the PMHNs' role was defined mainly as part of the medical model, with little emphasis on psychosocial aspects. Where patients' psychosocial needs were addressed, these were not seen as part of the PMHN's responsibility and were largely unplanned, incidental and unrecognized by managers and policy-makers.

Discussion
This research explored the question, "How do MH nurses perceive their role?" Ten PMHNs described their clinical work experiences. The evaluation indicates that participant PMHNs considered multiple activities to be included in their role in inpatient care: management and administrative roles, clinical roles, medication administration and clinical challenges. Martinelli et al. (2022) and Romeu-Labayen, Tort-Nasarre, Rigol Cuadra, Giralt Palou, & Galbany-Estragu es (2022) stress the ability of nurses to establish therapeutic relationships with patients. In other words, nurses employ their personas to promote their patients' psychological progress, personal development and independence. Abas et al. (2022) suggests that patient outcomes might benefit from allowing MH nurses working on inpatient units to have scheduled 50-min talking sessions with five patients for three days per week, demonstrating that she regards PMHNs as talking therapists. Lin, Yen, Hou, Liao, and Lin (2022) discuss the need to facilitate the provision of time for talking with patients. Liu and Sammons (2022) contend that scheduled time with patients promotes effective relationships between patients and nurses, which may be utilized to promote healthy coping patterns (Martinelli et al., 2022).

Psychosocial orientation
In examining the patient-centered caring role of PMHNs in the Saudi psychiatric inpatient setting, similar concerns were voiced by the participants, who cited staff shortages as a principal contributor to their inability to give this kind of care. The need to focus on patient safety, record keeping and other administrative duties limited the time available to implement therapeutic interventions, reflecting similar concerns in other locales (Baker, Canvin, & Berzins, 2019).

Administration
The PMHNs discussed the presence of diverse roles in accordance with their work environments. As shown in the results of this study, the management and administrative role occupies a large portion of the total PMHN role in this setting.
Although roles reported in the studies conducted by Kohn et al. (2022), Audas (2022) and Horgan et al. (2021) have different labels, and they indicate similarities in the burden of PMHNs' work weighing heavily toward the management side of their overall duties in the Saudi setting.

Documentation
Documentation may be used to demonstrate professional accountability and be utilized in the evaluation of the unit by managers and planners at the institutional level ( € Ozt€ urk & Hiçdurmaz, 2022). It may also be useful for evidence-based research using secondary data (Hamilton, Cole, Bostwick, & Ngune, 2023). However, € Ozt€ urk and Hiçdurmaz (2022) found that the documentation tool employed in psychiatric inpatient record keeping failed to focus on care measures related to holistic and recovery care content, putting the therapeutic value of this activity in doubt.

Clinical care
A review of related research indicates that the PMHN role is increasingly psychotherapeutic (Gerolamo et al., 2022). The present study found that some nurses prioritized contact with patients, whereas others were unwilling to talk to them because they were concerned that they would not be able to manage any needs that emerged, and they did not have much time to do so. The dominant method of meeting therapeutic care needs in the present study was referral to other members of the multidisciplinary team, thereby deferring the caring role to others.
However, Eldal et al. (2019) regard interactions between nurses and patients as pivotal. Many participants viewed one-to-one interactions as an essential therapeutic duty, indicating that patient expectations for caring activities are related to the role of PMHNs. This increasingly psychological orientation may be due to the increasing diversity, recognition and acceptance of psychological approaches to nursing (Meyer & Mayrhofer, 2022;Maguire et al., 2022;Maguire, Garvey, Ryan, Willetts et al., 2022).
PMHNs appear to have progressed little in their therapeutic role because of the pressure of management duties. The current research indicates that extreme demands arising from the insufficient resources available to nurses and the bureaucratic nature of their role exacerbates the physical distance between nurses and patients, which is in line with the research conducted by Lockertsen et al. (2023), which reported that PMHNs spent only 6.75% of their time in one-to-one interactions. However, Son et al.'s (2019) research concluded that PMHNs do provide various therapies, such as relaxation, aromatherapy and counseling.
However, while PMHNs might value psychosocial interventions (Skudlik et al., 2023), they are often incapable of implementing these practices due to a lack of time or training.
Nevertheless, the participants in the current research felt that some PMHNs used their administrative duties as a coping mechanism to distance themselves from stressful confrontations with patients (Al-Qadi, 2021). Inadequate training in psychosocial care principles may prompt some nurses to shun psychological interventions.

Medication management
In their clinical care role, nurses are vital for monitoring and reporting patient responses to medication. Pharmacovigilance in reporting adverse medication reactions can improve pharmaceutical care and patient safety (De Baetselier et al., 2022). Uniform mandatory regulations requiring appropriate training of health care providers coupled with specialized formularies based on certified levels of skill may improve patient care, interprofessional communication, cooperation and organized distribution of responsibilities (Haefner & Filter, 2022;Song, Jung, Park, Hasnain, & Gruss, 2023).
The participants felt that nurses advocate for patients in their relationships with doctors and other members of the multidisciplinary team in respect of medication administration, which was perceived as a highly valuable role. Maguire et al. (2022) and Maguire, Garvey, Ryan, Willetts et al. (2022) suggest that nurses perceive themselves as pivotal to pharmaceutical intervention. Although prescribing is not part of their official role, as in some Council of Europe nations (De Baetselier et al., 2021), collaboration between PMHNs and attending physicians was seen by the nurses as an important part of their role of providing holistic care, since they are responsible for reporting patient responses to prescribed medication to personnel who are certified to prescribe. Most participants in the current research felt that PMHNs should have a significant role in drug administration due to their confidence and familiarity with a variety of medications, although it was often considered time-consuming.
However, the PMHNs expressed a need to build more confidence and knowledge to fulfill this role through better undergraduate education and continuing education opportunities during employment. Increased training in specialized pharmaceutical care through continuing education opportunities for nurses, pharmacists and physicians has been found to provide improved care outcomes for patients and their families (Pham, Moles, O'Reilly, Carrillo, & El-Den, 2022).

Training and orientation
The World Health Organization has put forth basic competencies for nurses and midwives. In addition to adherence to ethical standards, use of evidence, cultural competence, critical and analytical thinking, the ability to practice safely and effectively, skills in patient advocacy and multidisciplinary communication, leadership ability and continual professional development constitute some of these competencies (McKenna Lawson, 2022).
Enhancement or initiation of specific features of practice may require advanced training and orientation for PMHNs to benefit their patients and their own welfare (Maguire et al., 2022;Maguire, Garvey, Ryan, Willetts et al., 2022;Kohn et al., 2022).
This may require improvement in undergraduate curricula and continuing education opportunities for nurses already in practice. The use of direct practice instructional methods for Saudi nursing students is supported by evidence-based research. Enhancement of patient safety competencies was found to have significantly improved when third-and fourth-level undergraduate nursing students were compared with those in their internships in several Saudi hospitals, suggesting that entry into the actual working environment bolsters knowledge and skills (Alquwez et al., 2019).
Liaison, orientation and support These roles were viewed by the participants as essential for providing good quality and continuity in patient care and seen by the PMHNs as a major contribution to the provision of beneficence. The role of liaison between shifts at handover and between members of the multidisciplinary team was viewed by the participants as an administrative function but recognized as a major contribution to the welfare of their patients, which agrees with various studies that note that this process is highly important in mediating quality of care (Maguire et al., 2022;Maguire, Garvey, Ryan, Willetts et al., 2022;Galehouse, Peterson, Kwasky, & Raphel, 2022).

Limitations of the study
There are several limitations in the current research, not least the use of qualitative research methods. The research may not be representative of all PMHNs in Saudi Arabia, since it only included 10 participants. The participants had diverse levels of experience, making it challenging to apply the findings to a general audience. However, the focus group was able to generate practical and experiential information.
To enhance the applicability of the results to a broader audience, the researcher sought to moderate this limitation by including all eligible volunteers. This group had the benefit of extensive experience in multiple settings and included nurses of different ages.

Conclusion
The intricate nature of the PMHN's role cannot justify the avoidance of any clarification of the role of psychiatric nurses in practice settings and nursing education. This paper has indicated multiple obstacles to nurses in the provision of high-quality inpatient psychiatric nursing care. Among these are nurses' feelings of having received inadequate training in nursing skills and use of drugs and alternative treatment options, overload of documentation and administrative duties, a lack of shared vision between nurses and members of the multidisciplinary team of what constitutes holistic and appropriate psychiatric care based on best practice and evidence-based research and unclear role definition resulting in underutilization of professional nursing skills. Improved training in pharmaceutical and alternative care options and clinical care based on evidence-based research were of general concern to the participants. Based on these findings, there is a need for further role development and appropriate utilization of trained PMHNs and improved development of psychosocial care skills aimed toward fostering person-centered holistic care in inpatient psychiatric settings.