problem statement for research in mental health nursing

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• Table of Contents
• Volume 23 - 2018
• Number 2: May 2018
• Evidence Psychiatric Mental Health Interventions

Evidence for Psychiatric and Mental Health Nursing Interventions: An Update (2011 through 2015)

Dr. Bekhet is an Associate Professor at Marquette University College of Nursing in Milwaukee, WI. She received aBSN and MSN from Alexandria University in Alexandria, Egypt. She received a PhD from Case Western Reserve University (CWRU) in Cleveland, OH. Her clinical experience in psychiatric nursing is with persons having schizophrenia, bipolar disorders, obsessive-compulsive disorders, and depressive disorders. She has taught psychiatric mental health nursing to undergraduate and direct entry students. She has also advised PhD students. Dr. Bekhet’s program of research focuses on the effects of positive cognitions and resourcefulness in overcoming adversity in vulnerable populations. Her research has been funded by Sigma Theta Tau International; American Psychiatric Nursing Foundation; International Society of Psychiatric Mental Health Nurses; and Marquette University. She is a past recipient of a Midwest Nursing Research Society Mentorship Grant Award, and has received the Award for Excellence from the CWRU Nursing Alumni Association in 2011 and the Way-Klinger Young Scholar Award from Marquette University in 2012. More recently, she was awarded the 2014 research award from the International Society of Psychiatric Mental Health Nurses. Dr. Bekhet has published numerous articles and presented numerous papers and posters at regional, national, and international conferences.

Dr. Zauszniewski is the Kate Hanna Harvey Professor in Community Health Nursing, and Director of the PhD in Nursing Program at the Case Western Reserve University (CWRU), Cleveland, OH. She received a PhD and MSN from CWRU, Cleveland, OH; a MA in Counseling and Human Services from John Carroll University, Cleveland, OH; a BA in psychology from Cleveland State University, Cleveland, OH; and a diploma in nursing from St. Alexis Hospital School of Nursing, Cleveland, OH. She has practiced nursing for 42 years, including 33 years in the field of psychiatric-mental health nursing; she has experience as a staff nurse, clinical preceptor, head nurse, supervisor, patient care coordinator, nurse educator, and nurse researcher, and is board certified by the American Nurses Credentialing Center (ANCC). Her program of research focuses on the identification of factors and strategies to prevent depression and to preserve healthy functioning across the lifespan. She is best known for her research examining the development and testing of nursing interventions to teach resourcefulness skills to family caregivers. She has received research funding from the National Institutes of Nursing Research and Aging; the National Institutes of Health; Sigma Theta Tau International; the American Nurses Foundation; Midwest Nursing Research Society; and the State of Ohio Board of Regents.

Denise Matel-Anderson is a doctoral student at Marquette University College of Nursing in Milwaukee, WI. She holds an Advanced Practice Nurse Prescriber license, and is currently working on a PhD in nursing with a focus on mental health. She has three publications in mental health nursing journals. Ms. Matel-Anderson currently lectures at Carroll University, Waukesha, WI, in the undergraduate mental health nursing theory course, and serves as a nurse practitioner on the medical team at an acute mental health facility.

Jane Suresky is an Adjunct Assistant Professor at the Frances Payne Bolton School of Nursing of Case Western Reserve University (CWRU) in Cleveland, OH. She has received DNP and MSN degrees from CWRU, and a BSN degree from Cleveland State University, Cleveland, OH. Her clinical experience in psychiatric nursing covers the areas of psychobiological research, adolescent dual diagnosis, and mood disorders. She has taught psychiatric mental health nursing to undergraduate and graduate students. In addition, she has been involved in nursing research that focuses on the stress of the female family members of the severely mentally ill.

Mallory Stonehouse recently graduated with a Master of Science in Nursing degree from Marquette University in Milwaukee, WI, where she completed the adult-older adult, primary care, nurse practitioner program. She is a registered nurse at Froedtert Community Memorial Hospital in Wisconsin, where she works on the Behavioral Health Unit. Ms. Stonehouse holds a Bachelor of Arts degree in psychology.

• Figures/Tables

This state-of-the-evidence review summarizes characteristics of intervention studies published from January 2011 through December 2015, in five psychiatric nursing journals. Of the 115 intervention studies, 23 tested interventions for mental health staff, while 92 focused on interventions to promote the well-being of clients. Analysis of published intervention studies revealed 92 intervention studies from 2011 through 2015, compared with 71 from 2006 through 2010, and 77 from 2000 through 2005. This systematic review identified a somewhat lower number of studies from outside the United States; a slightly greater focus on studies of mental health professionals compared with clients; and a continued trend for testing interventions capturing more than one dimension. Though substantial progress has been made through these years, room to grow remains. In this article, the authors discuss the background and significance of tracking the progress of intervention research disseminated within the specialty journals, present the study methods used , share their findings , describe the intervention domains and nature of the studies , discuss their findings , consider the implications of these studies , and conclude that continued track of psychiatric and mental health nursing intervention research is essential.

Key Words: best practices, evidence-based practice, psychiatric nursing journals, psychiatric nursing research, published research, research dissemination, research utilization, systematic review, tradition, intervention research

Implementation science is concerned with the translation of research into practice... The past five years have seen a rapidly growing interest in the field of implementation science ( Sorensen & Kosten, 2011 ). Implementation science is concerned with the translation of research into practice; it involves the examination of the challenges and the opportunities for successful, evidence-based changes in practice ( Nilsen, 2015 ). Translating research into practice depends heavily on the dissemination of findings from intervention research to those most likely to use those findings in clinical or community settings. In contrast to implementation, dissemination involves the spread of information about an intervention, for example, through publication of the intervention in professional journals. Dissemination strategies that are actively targeted toward spreading evidence-based findings concerning an intervention may prompt future implementation in clinical practice ( Proctor et al., 2009 ).

Translating research into practice depends heavily on the dissemination of findings from intervention research... Important for psychiatric and mental health nurses, it is critical that implementation of evidence-based findings occurs across multiple settings (i.e., beyond specialty mental healthcare units) to medical settings, such as primary care areas in which mental health services are provided, and to non-specialized settings, such as criminal justice and school systems and community social service agencies, where mental healthcare is delivered (Proctor et al., 2009). However, before implementation can happen, dissemination of findings from well-designed intervention studies that can inform psychiatric and mental health nursing practice is needed.

One of the best mediums for disseminating evidence-based findings in psychiatric and mental health nursing is the professional nursing journals that are most available to practicing psychiatric and mental health nurses. Nursing journals that are specifically designed a specialty are more likely to be read by persons in the given specialty area than are other nursing research journals. Nurses in practice settings, including those at an advanced practice level, may not have access to scientific research journals or may choose not to read them if the research does not appear meaningful for their practice. The goal of this review was to describe the findings from intervention studies disseminated through publication in one of the five psychiatric and mental health nursing specialty journals published from 2011 through 2015.

Background and Significance

Through the years, more psychiatric and mental health nurse researchers have been targeting specialty journals for disseminating findings from intervention research. For example, in previous reviews of intervention studies published in the five major psychiatric and mental health specialty journals, there was a higher percentage of quantitative intervention studies conducted from 2006 through 2010 (84%) than in a similar review conducted from 2000-2005 (64%) ( Zauszniewski, Suresky, Bekhet, & Kidd, 2007 ; Zauszniewski, Bekhet, & Haberlein, 2012 ), indicating increased use of more rigorous, statistical analytic methods in published intervention research over time ( Zauszniewski et al., 2007 ; Zauszniewski et al., 2012 ).

Tracking the progress of intervention research disseminated within the specialty journals in psychiatric and mental health nursing is important for two reasons. First, it provides data to show improvements in dissemination efforts of psychiatric and mental health nurse researchers. Second, it calls attention to the importance for continued dissemination of intervention research to practicing psychiatric and mental health nurses who are in the best positions to implement the findings in practice. Therefore, the purpose of this review of the same, five, peer-reviewed psychiatric and mental health nursing journals, covering 2011 through 2015, was to determine the number and types of intervention studies within the specified review period. For consistency, the same criteria for selecting the intervention studies that were described in the previous review ( Zauszniewski et al., 2012 ) were applied: A study was determined to be an intervention study if nursing strategies, procedures, or practices were examined for effectiveness in enhancing or promoting health or preventing disability or dysfunction ( Kane, 2015 ).

Five peer-reviewed nursing journals, regarded as the most frequently read in the mental health nursing profession, were analyzed for the years 2011 through 2015. The journals included in the analysis were Archives of Psychiatric Nursing ; Issues in Mental Health Nursing ; Journal of the American Psychiatric Nurses Associatio n; Journal of Psychosocial and Mental Health Services; and Perspectives in Psychiatric Care .

Journals were reviewed for the type of intervention study (qualitative or quantitative); the study domain (biological, psychological, or social); and the number of intervention studies found within the journals. After review, the agreed upon intervention studies were extracted and individually analyzed by the co-authors.

There were 832 databased articles published from January 2011 through December 2015. However, only 115 (14%) evaluated or tested psychiatric nursing interventions. Of these 115 intervention studies, 14 tested interventions with nursing students, nine involved nurses and mental health professionals, while 92 focused on interventions to promote mental health in clients of care.

This section describes the findings from the 115 intervention studies included in the review. The 23 studies that included nursing students, nurses, and mental health professional, and the 92 that involved recipients of mental health services or care are presented in this section. First, the research settings in which the 115 studies were conducted, and descriptions of the targeted populations are described. Next, the 23 studies’ designs, purposes, and findings are discussed in detail. Third, the 92 studies that involved recipients of mental health services or care are presented using the categories of the bio-psycho-social framework. Finally, the type of data (quantitative, qualitative, or mixed) are discussed and presented in the table.

Research Settings Sixty-six of the 115 intervention studies were completed in the United States. Five studies each were done in Australia and United Kingdom. Four each were completed in Korea, China, and Turkey; three each in Norway, Canada, and Iran; and two each in Taiwan, Mexico, Sweden, France, and Netherlands. One study each was conducted in Jordan, Europe, Iceland, Pacific Islands, Thailand, Spain, Greece, and Singapore

Targeted Populations Fourteen of the 115 intervention studies involved interventions with nursing students, while nine studies focused on nurses and mental health professionals. Ninety-two of the studies examined the effect of the intervention on the client. Examples of the studies describing each of these groups are described below.

Fourteen of the 23 nursing intervention studies involved undergraduate nursing students. Nursing students . Fourteen of the 23 nursing intervention studies involved undergraduate nursing students. One study was conducted in Australia regarding consumer participation ( Happell, Moxham, & Plantain-Phung, 2011 ). In this study, researchers investigated whether education programs introducing nursing students to mental health nursing lead to more favorable attitudes towards consumer participation in the mental health setting after completing the mental health component of the nursing program. Study participants were in the first semester of the final year of the Bachelor of Nursing program. The study used a within-subject design using two points (pre-and post-educational program implementation). Results indicated that students demonstrated positive attitudes toward consumer participation even before completing the mental health component. Only marginal and non-significant changes were noted at the post-test stage. The authors concluded that the findings were not surprising given the positive scores recorded at baseline (ceiling effect) ( Happell et al., 2011 ). Another study investigated the effect of pedagogy of curriculum infusion on nursing students’ well-being and the improvement of quality of patients’ care ( Riley & Yearwood, 2012 ).

Pedagogy of curriculum infusion involves instilling the university values and mission with a focus on educating the whole person, and encouraging faculty to translate the core mission of the university into practice in the classroom. this can be accomplished through a variety of courses that provide students with opportunities for contemplation, reflective engagement, and also action through volunteerism, service, and study abroad. The ultimate goal of the study was to encourage critical thinking through reflective exercises and group discussion. Results indicated that students who have experienced the curriculum infusion showed an ability to be self-advocates when discussing their work challenges. Also, they were able to identify specific nursing actions for patient safety; to recognize the patient as a partner in care; and to demonstrate respect for patients' uniqueness, values, and desires as evidenced by case analysis and personal reflections ( Riley & Yearwood, 2012 ).

Three intervention studies explored simulation to see its impact on improving the learning experiences of the nursing students. Three intervention studies explored simulation to see its impact on improving the learning experiences of the nursing students ( Kameg, Englert, Howard, & Perozzi, 2013 ; Kidd, Knisley & Morgan, 2012 ; Masters, Kane, & Pike, 2014 ). Different simulations were used in the three studies; all of them were deemed effective. For example, the results of the study conducted by Kidd and colleagues indicated that undergraduate, mental health nurs­ing students perceived that Second Life® virtual simulation was moderately effective as an educational strategy and slightly difficult as a technical program ( Kidd et al., 2012 ). Also, second degree and traditional BSN students found that a tabletop simulation, which was developed as a patient safety activity and involved checking-in a patient admitted to a psychiatric care unit, was a good learning experience and helpful to prepare students for situations they may experience in the workplace ( Masters et al., 2014 ). The third study used a high-fidelity, patient simulation (HFPS) to assess senior level nursing student knowledge and retention of knowledge utilizing three parallel, 30-item Elsevier Health Education Systems, Inc. (HESITM) Custom Exams. Although students’ knowledge did not improve following the HFPS experiences, the findings provided evidence that HFPS may improve knowledge in students who are at risk (defined as those earning less than 850 on HESI exam). Students reported that they viewed this simulation as a positive learning experience ( Kameg et al., 2013 ).

An additional intervention study used a quasi-experimental design to explore perceptions of student nurses toward nurses who are chemically dependent, using a two-group, pretest–posttest design (prior to formal education and after receiving substance abuse education). Results indicated that the student nurses in this study had positive perceptions about nurses who are chemically dependent before the intervention; and the education program appeared to reinforce their existing attitudes. ( Boulton & Nosek, 2014 ).

Mitchell et al. ( 2013 ) investigated the impact of an addiction training program for nurses consisting of Screening, Brief Intervention, and Referral to Treatment (SBIRT), and embedded within an undergraduate nursing curriculum, on students’ abilities to apply an evidence-based screening and brief intervention ap­proach for risky alcohol and drug use in their nursing practice. Results indicated that the SBIRT program was effective in changing the undergraduate nursing students’ self-perceptions of their knowledge, skills, and effectiveness in screening and intervening for hazardous alco­hol and drug use. Furthermore, this positive perception was maintained at 30-day follow-up ( Mitchell et al., 2013 ).

Luebbert and Popkess ( 2015 ) investigated the impact of an innovative, active-learning strategy using simulated, standardized patients on suicide assessment skills in a sample of 34 junior and senior baccalaureate nursing students. Additionally, Schwindt, McNelis, and Sharp ( 2014 ) evaluated a theory-based educational program to motivate nursing students to intervene with persons having serious mental illness. Other intervention studies among nursing students focused on improving students' interpersonal relationships; communication competence; empathetic skills; and confidence in performing mental health nursing skills among nursing students ( Choi, Song, & Oh, 2015 ; Choi & Won, 2013 ; Fiedler, Breitenstein, & Delaney 2012 ; Ozcan, Bilgin, & Eracar, 2011 ; Stiberg, Holand, Ostad, & Lorem, 2012 ).

Nursing staff and mental health professionals . Interventions among the nursing staff and mental health professionals accounted for nine of the nursing intervention studies. The majority of these studies were nursing interventions to educate the nursing staff. Educational interventions included: training videos ( Irvine et al., 2012 ); a continuing education course on suicide awareness ( Tsai, Lin, Chang, Yu,& Chou, 2011 ); an education program using simulation ( Usher et al., 2014 ; Wynn, 2011 ); an educational workshop ( White, Hemingway, & Stephenson, 2014 ); training on family-centered care ( Wong, 2014 ); and the impact of the completion of a 26-week trial on nursing staff’s experience for working as a cardio-metabolic health nurse ( Happell et al., 2014 ).

Terry and Cutter ( 2013 ) used a mixed methods pilot study to evaluate the effect of education on confidence in assessing and addressing physical health needs following attendance at a module titled “Physical Health Issues in Adult Mental Health Practice.” The majority of the participants had studied at the university during the previous five years, at either the diploma or the degree level. Results showed improvement in confidence scores for all study participants following the module; participants were able to identify new knowledge and perspectives for practice change.

Results indicated that care zoning increased the nursing team’s capacity to share information and to communicate patients’ clinical needs... Finally, the study conducted by Taylor and colleagues ( 2011 ) used a pragmatic approach to increase understanding of the clinical-risks needs in acute in-patient unit settings. Each patient was classified according to three zoning levels using a traffic light system: red (high level of risk), amber (medium/moderate level of risk), and green (low level of risk). The level of risk was based on multiple factors including clinical judgment and team discussion ( Taylor et al., 2011 ). Results indicated that care zoning increased the nursing team’s capacity to share information and to communicate patients’ clinical needs, as well as to enhance their abilities to address complex clinical presentation and to seek support when needed.

Intervention Domains

Ninety-two of the studies examined the effect of an intervention for the client. In the following section, we will describe the intervention domains of these 92 articles and provided examples. Additional detail is included in the Table .

Interventions in the Biological Domain Eight interventions were in the biological domain. Study interventions included yoga, dancing, diet, medication, electroconvulsive therapy (ECT), exercise, walking, and educational intervention on metabolic syndrome. Four interventions used various kinds of exercises, including walking ( Beebe, Smith, Davis, Roman, & Burke, 2012 ); dancing ( Emory, Silva, Christopher, Edwards, & Wahl, 2011 ); yoga ( Kinser, Bourguigion, Whaley, Hauenstein, & Taylor, 2013 ); and group exercise program ( Stanton, Donohue, Garnon, & Happell, 2015 ). Diet was also used as an intervention. For example, Lindseth, Helland, and Caspers ( 2015 ) used dietary intake of a high or low tryptophan diet as an intervention. Results indicated improvement in patients’ mood, depression, and anxiety for those consuming a high tryptophan diet as compared to those who consumed a low tryptophan diet ( Lindseth et al. 2015 ). A third category within the biological domain was the use of medications as an intervention. One study tested the use of different psychotropic medications for patients diagnosed with schizophrenia ( Zhou et al., 2014 ). A second used ECT as a treatment modality and measured scores on the Montgomery Asberg (MA) Depression Rating Scale before and after the course of treatment ( Pulia, Vaidya, Jayaram, Hayat, & Reti, 2013 ). A final category was an educational program on metabolic syndrome provided to mental health counselors who performed intake assessments on patients newly admitted to two outpatient mental health facilities. ( Arms, Bostic, & Cunningham, 2014 ). Prior to the intervention, neither facility screened for metabolic syndrome at intake or referred patients with a body mass index (BMI) >25 for medical evaluation. Following the intervention, 53 of 132 patients had a documented BMI >25, and 47 of 53 patients were referred to a primary care provider for evaluation. These findings suggested that screening for metabolic syndrome and associated illnesses will increase the rate of detection of chronic conditions ( Arms et al., 2014 ).

Interventions in the Psychological Domain ...the psychological domain had the largest number of intervention studies. Compared to the other domains, the psychological domain had the largest number of intervention studies. Twenty-four of the 92 total intervention studies extracted were in the psychological domain. The intervention studies in the psychological domain included emotion, behavior, and cognition (e.g., counseling) in addition to studies that focused on behavior therapy and psychoeducational programs. Examples of psychological domains studies included: counseling regarding tobacco cessation treatment ( Battaglia, Benson, Cook, & Prochazka, 2013 ); counseling regarding sexual assault ( Lawson, Munoz-Rojas, Gutman, & Siman, 2012 ); resourcefulness training intervention for relocated older adults ( Bekhet, Zauszniewski, & Matel-Anderson, 2012 ); and resilience training and cognitive therapy in women with symptoms of depression aged 18-22 years of age ( Zamirinejad, Hojjat, Golzari, Borjali, & Akaberi, 2014 ) Please see the Table for further details.

One study utilizing an intervention from the psychological domain examined a brief, six- session, cognitive-behavioral intervention among patients with alcohol dependence and depression. The researchers used a quasi-experimental design with a control group and pretest, posttest, and follow-up assessments. Results indicated that the mean depression scores decreased significantly in both the experimental (n = 33) and control groups (n = 27) at the one-month follow-up (Week 7). However, only the experimental group showed significant differences in their mean depression scores between pre- and posttest. At Week 7, the experimental group showed significantly lower mean depression scores than the control group ( Thapinta, Skulphan, & Kittrattanapaiboon, 2014 ).

Interventions in the Social Domain The social domain considers the patients’ environment and its impact on patients’ adjustment and responses to stress. Nine studies involved use of the social domain in their interventions. The social domain considers the patients’ environment and its impact on patients’ adjustment and responses to stress. Interventions in this domain included family, friends, and social support, as well as community interactions ( Zauszniewski et al., 2012 ). One example of an intervention in the social domain involved studying the long-term impact of safe shelter and justice services on abused women’s ability to function after receiving services ( Koci, 2014 ). Another example of an intervention study in the social domain was a pilot, randomized, controlled trial study by Simpson, Quigley, Henry, and Hall ( 2014 ). In this study, the researchers evaluated the selection, training, and support of a group of peer workers recruited to provide support to service users discharged from acute psychiatric unites in London, comparing peer support with usual care ( Simpson et al., 2014 ) (see Table ). A third example in the social domain was designed to help participants successfully transfer from hospitals to the community by enhancing staff participation, creating/maintaining supportive ward milieus, and supporting managers throughout the implementation process ( Forchuk et al., 2012 ).

The study conducted by Horgan, McCarthy, and Sweeny ( 2013 ) was another example of research in the social domain. This study included designing a website for people ages 18-24 who were experiencing depressive symptoms. The website provided a forum to allow participants to offer peer support to each other; it also provided information on depression and links to other supports ( Horgan et al., 2013 ).

Combinations of the Domains Many studies used more than one domain as interventions. Many studies used more than one domain as interventions (see Figure ). Almost half (49%) of the 92 reviewed studies (n = 45) tested an intervention that included two domains. Thirty studies were psychosocial, twelve were biopsychological, and three were biosocial. In addition, six studies (7%) tested intervention with all three domains (biopsychosocial). In the following section, one study from each combination will be described. Again, additional information is provided in the Table .

Figure. Psychiatric Nursing Interventions: Examples of Domains and Their Total Numbers

Iskhandar Shah and colleagues ( 2015 ) studied and tested an intervention from the biopsychological domain using a single-group, pretest–posttest, quasi-experimental research design. Their intervention program included three daily, one-hour sessions incorporating psychoeducation and virtual-reality-based relaxation practice in a convenience sample of twenty-two people with mental disorders. Results indicated that those who completed the program had significantly lowered subjective stress, depression, and anxiety, along with increased skin temperature, perceived relaxation, and knowledge ( Iskhandar Shah et al., 2015 ).

Pedersen, Nordaunet, Martinsen, Berget, and Braastad ( 2011 ) studied an intervention from the biosocial domain. Their intervention program tested the impact of a 12-week, farm-animal-assisted intervention consisting of work and contact with dairy cattle, on levels of anxiety and depression in a sample of fourteen adults diagnosed with clinical depression. The twice-a-week program involved video recording each participant twice during the intervention. Participants were given the choice of either choosing their work tasks with animals (e.g., milking, feeding, hand feeding, moving animals) or the choice of spending their time in contact with farm animals (e.g., patting, stroking, and other non-work-related physical contact). Results indicated that levels of anxiety and depression decreased, and self-efficacy increased during the intervention. Interaction with farm animals (social) via work tasks showed a greater potential for improved mental health than merely animal contact, but only when progress in working skills (biological aspect) was achieved, indicating the role of coping experiences for a successful intervention. ( Pedersen et al., 2011 ).

The NP often accompanied the participant to medical and mental health appointments... Chandler, Roberts, and Chiodo ( 2015 ) conducted a study in the psychosocial domain that examined the feasibility and potential efficacy of implementing a four-week, empower-resilience intervention (ERI) to build resilience capacity with young adults who have identified adverse childhood experiences. The intervention included using mindfulness-based stress reduction (psychological domain) and social support with guided peer and facilitator interaction (social domain). The study randomly assigned a purposive sample of female undergraduate students between the ages of 18 and 24 years of age into two groups: intervention (n = 17) and control (n = 11), and used a pretest–posttest design to compare symptoms, health behaviors, and resilience before and after the intervention program. Results indicated that subjects in the intervention group reported greater building of strengths, reframing resilience, and creating support connections as compared with the control group ( Chandler et al., 2015 ).

Interventions in the biopsychosocial domain include all three components (biological, psychological, and social). There were six studies that included all three domains in their interventions. Hanrahan, Solomon, and Hurford ( 2014 ) used a randomized controlled design to deliver a transitional care model (TCM) intervention to patients with serious mental illness who were transferring from hospital care to home. The intervention group (n = 20) received the TCM intervention delivered by a psychiatric nurse practitioner (NP) for 90 days post hospitalization and the control group (n = 20) received the usual care. The intervention by the nurse practitioner included helping the patients adapt to the home by focusing on managing problem behaviors and physical problems, managing risk factors to prevent further cognitive or emotional decline, promoting adherence to therapies, and integrating physical and mental care approaches. The NP often accompanied the participant to medical and mental health appointments to facilitate communication, translate information to specialty providers, and advocate for the participant ( Hanrahan et al., 2014 ).

Table. Research Classifications by Domains, Design, and Type of Data Used

  Discussion

Although substantial progress is being made to develop and test interventions for persons with psychiatric and mental health challenges and their families, there remains much work to be done. Nurse scientists and practitioners share a professional obligation to persons entrusted to their care, which includes providing the highest quality care grounded in solid empirical evidence ( Willis, Beeber, Mahoney, & Sharp, 2010 ). This review yields evidence for the continued dissemination of findings from intervention studies from 2011 through 2015. To perform the analysis reported here, we employed methods that were similar to those used for amassing information from the intervention studies in two previous reviews ( Zauszniewski et al., 2007 ; Zauszniewski et al., 2012 ) in order to facilitate comparisons over time.

... the continued publication of evidence from countries outside the United States remains important... During the review period (2011-2015), 57% of the published intervention studies took place in the United States (U.S.) while 43% were conducted outside the U.S. (i.e., internationally). These percentages compare with 72% and 54% of published U.S. intervention studies and 28% and 46% published international intervention studies in the 2000-2005 and 2006-2010 reviews, respectively. The somewhat lower percentages (28% and 46%) of international intervention studies within the current time frame (2011-2015) may indicate a need for more descriptive research to identify distinguishing characteristics of international populations and important phenomena that may be amenable to intervention prior to the systematic testing of interventions. However, the continued publication of evidence from countries outside the United States remains important for developing globally relevant interventions for psychiatric nursing practice.

...there have been dramatic increases through the years in the overall number of studies that have tested interventions that tap more than one domain. Of the 115 intervention studies from 2011 through 2015 found in the five journals, nurses, student nurses, nursing staff, or other mental health professionals were the intervention recipients in 23, representing 20% of the intervention studies. This percent is higher than the 14% reported in the previous review conducted from 2006 through 2010, indicating a slightly greater focus on testing interventions in mental health care professionals in recent years. Although the interventions tested in these populations are not focused directly on outcomes for clients with mental health issues, promoting or preserving the mental health of professional caregivers most certainly affects those for whom they provide care.

Analysis of published intervention studies in the 5-year interval from 2011 through 2015 revealed an increase in the number of studies of psychiatric patients or clients in the five selected journals. For this time frame, we found 92 intervention studies in comparison with 71 from 2006 through 2010 and 77 from 2000 through 2005, which reflect 5 and 6-year intervals respectively.

We also noted fewer intervention studies where all three domains were integrated within the intervention... Moreover, there have been dramatic increases through the years in the overall number of studies that have tested interventions that tap more than one domain. For example, 33% of intervention studies from 2011 through 2015 tested psychosocial interventions, compared to 17% in the previous review (2006-2010) and 12% in the one prior to that (2000-2005). In addition, 13% of the studies from 2011 through 2015 tested biopsychological interventions compared with 4% and 5% in the previous two reviews. However, there was a slightly lower percent of biosocial intervention studies, specifically 3% in comparison with 4% from 2000-2005 and 6% from 2006-2010. We also noted fewer intervention studies where all three domains were integrated within the intervention, specifically only 6% in comparison with 17% in the previous time frame (2006-2010). Yet, our review revealed a larger percent of biopsychosocial intervention studies than from the review conducted from 2000-2005 (1%). Despite the lower number of studies that integrated all three intervention domains, there was an overall trend toward testing interventions that were not restricted only to one domain, indicating increased attention toward more holistic interventions.

... the overall trend shows a lesser focus on testing interventions within a single domain over time... There were 41 intervention studies between 2011 and 2015 that focused solely on one domain. With the exception of the biological domain (9%), interventions within the psychological (26%) and social (10%) domains were fewer than in previous reviews. For example, there has been a clear downward trend in the percent of psychological intervention studies over time with 57% from 2000-2005 to 38% from 2006-2010 and 26% in this current review. Intervention studies within the social domain decreased from 17% in 2006-2010 to 10% in this review. Studies of interventions in the biological domain have fluctuated over time from 11% in 2000-2005 down to 1% from 2005-2010 and up to 9% in the review reported here. However, the overall trend shows a lesser focus on testing interventions within a single domain over time, pointing perhaps to a growing interest in determining effective interventions that are multifaceted and target multiple factors that affect a person’s health.

Implications: Research Needed

The mind and body do not function independently of each other; therefore, when considering the focus of nursing research, we need to target both systems. Nursing has as its foundation a holistic approach to patient care. At this point in our history as we build a knowledge base, a multifaceted approach is needed when planning nursing research. This study of nursing interventions in our research has explored the biological, psychological, and social domains. Studies in the biopsychosocial domain would benefit our knowledge base and improve the criteria for more accurate, evidence-based nursing interventions.

Medicine has increasingly focused on the mental health component of medical illnesses. Nursing research would be strengthened by focusing on the possibility of medical illness and its relationship to mental illness. This nursing research approach'‹ would support our holistic philosophy of care and increase our knowledge of the whole person. It would provide the best evidence-based approach to planning treatment. In addition, it would serve to increase the sphere of psychiatric nursing beyond the psychiatric unit in health care settings.

...an increase in multicultural studies is needed to further strengthen our evidenced based practice. Finally, an increase in multicultural studies is needed to further strengthen our evidenced based practice. The individual person is complex. Identified culture provides important information as to how patients view health and illness. This information is an important component when planning our evidenced based care and should not be isolated from the patient presentation.

Tracking the progress in intervention research relevant for psychiatric and mental health nursing practice is essential to identify evidence gaps. This current, systematic review of intervention studies published in the most accessible psychiatric and mental health nursing journals for practicing nurses, educators, and researchers in the United States has revealed a somewhat lower number of studies from outside the United States; a slightly greater focus on studies of nurses, nursing students, or other mental health professionals as compared with clients who receive their care or services; and a continued trend for testing interventions that captured more than one dimension. Tracking the progress in intervention research relevant for psychiatric and mental health nursing practice is essential to identify evidence gaps. Though substantial progress has been made through the years, there is still room to grow.

Abir K. Bekhet, PhD, RN, HSMI Email: [email protected]

Jaclene A. Zauszniewski, PhD, RN-BC, FAAN Email: [email protected]

Denise M. Matel-Anderson, APNP, RN Email: [email protected]

Jane Suresky, DNP, MSN Email: [email protected]

Mallory Stonehouse, MSN, RN Email: [email protected]

Arms, T., Bostic, T., & Cunningham, P. (2014). Educational intervention to increase detection of metabolic syndrome in patients at community mental health centers. Journal of Psychosocial Nursing & Mental Health Services, 52 (9), 32-36. doi:10.3928/02793695-20140703-01

Battaglia, C., Benson, S.L., Cook, P.F., & Prochazka, A. (2013). Building a tobacco cessation telehealth care management for veterans with posttraumatic stress disorder. Journal of the American Psychiatric Nurses Association , 19 (2), 78-91. doi:10.1177/1078390313483314

Beebe, L.H., Smith, K., Davis, J., Roman, M., & Burke, R. (2012). Meet me at the crossroads: Clinical research engages practitioners, educators, students, and patients. Perspectives in Psychiatric Care, 48 (2), 76-82. doi: 10.1111%2Fj.1744-6163.2011.00306.x

Bekhet, A.K., Zauszniewski, J.A., & Matel-Anderson, D.M. (2012). Resourcefulness training intervention: Assessing critical parameters from relocated older adults’ perspectives. Issues in Mental Health Nursing, 33 (7), 430-435. doi:10.3109/01612840.2012.664802

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May 31, 2018

DOI : 10.3912/OJIN.Vol23No02Man04

https://doi.org/10.3912/OJIN.Vol23No02Man04

Citation: Bekhet, A.K., Zauszniewski, J.A., Matel-Anderson, D.M., Suresky, M.J., Stonehouse, M., (May 31, 2018) "Evidence for Psychiatric and Mental Health Nursing Interventions: An Update (2011 through 2015)" OJIN: The Online Journal of Issues in Nursing Vol. 23, No. 2, Manuscript 4.

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Mental health in nursing

A student's perspective.

Halsted, Candis DNP-PMHNP, RN; Hart, Virginia T. DNP, RN, PMHNP-BC

At Radford University School of Nursing in Radford, Va., Candis Halsted recently earned her DNP and Virginia T. Hart is an assistant professor and interim psychiatric mental health NP program coordinator.

The authors have disclosed no financial relationships related to this article.

A stigma around mental health issues within healthcare and nursing itself has created a culture of perfectionism in the workplace, and nurses struggle to live up to the expectations while pushing aside their feelings, thoughts, and needs. Inspired by one author's personal experiences, this article explores mental health issues many nurses confront today.

Inspired by one author's personal experiences, this article explores mental health issues many nurses confront today.

I DECIDED TO RETURN to school in 2015 after practicing as a nurse in various settings for 7 years. I subscribe to the adage that knowledge is power. My drive for additional education and experience was based on my desire to achieve a higher status, assume more control over my practice, and to garner more respect from other healthcare professionals. As I immersed myself in my graduate studies, however, I found my desires, self-image, and professional viewpoint had changed.

I have always endeavored to be the best student, greatest employee, and most dependable teammate. Those efforts took on a feverish intensity during periods of transition—student to nurse, nurse to working mother, mother and nurse to professional student. Good was not good enough, and my drive to be the best and greatest was an integral part of my self-worth. Unfortunately, it led to anxiety, depression, hopelessness, and isolation that negatively impacted my education, practice, and personal life.

It was not until my clinical rotations as a psychiatric-mental health NP student that I came to realize the magnitude of the situation. There I was, taking courses on trauma-informed care and giving my patients tools for building self-efficacy, self-compassion, and coping skills while simultaneously ignoring my own needs.

Having left the workplace to focus on my online studies, I was isolated, lacking confidence, feeling overwhelmed, and overcompensating for some perceived shortcoming that I could not even define. I felt hopeless and defeated. I experienced bouts of anxiety and depression so intense I lost my sense of purpose. I considered dropping out of school many times, but I gave in to the expectations of others. I forced myself to continue pushing aside my own needs, persisting despite my growing depression and anxiety.

Looking back, I had so many chances to speak up and reach out for help. I could have spoken with nurse managers, coworkers, fellow students, and faculty a hundred different ways on so many occasions. Instead, I allowed the culture of silence and my own perfectionism to rule.

At my lowest point, I made the life-altering decision to reach out for help—first to my husband, then a therapist, a fellow student, and finally my school faculty. With their assistance, some serious self-reflection, and a lot of self-help reading, I am working to address my mental illness and establish a sense of well-being.

That is not to say that I have it all figured out. I still struggle many days to keep faith in my strengths and abilities. The things I have learned and witnessed, the obstacles I have encountered and overcome, whether academic, professional, or personal, have humbled me and restored my desire to return to the love, service, and justice at the core of my professional drive and practice. I am once again prioritizing my values and making sure my actions reflect them. Among those values is the desire to work toward the unification of our profession and to advocate for policy changes that support the mental health of all nurses. Inspired by my personal experiences, this article explores mental health issues many nurses confront today.

A pervasive problem

Although mental health and suicide among nurses have emerged as areas of professional concern in recent years, little research or literature exists regarding profession-specific risk factors, prevalence of mental illness, and suicide rates. With little to no concrete statistics to draw from, the true incidence of mental illness within the nursing profession is unknown. Furthermore, little has been done to bring these problems to the attention of the general public or to acquire the recognition and support of the professional community. 1-3

What can be found are decades of research stating that nursing is psychologically demanding and can contribute to poor mental health in a variety of ways, such as depression, anxiety, secondary trauma, compassion fatigue, and burnout. 1-7 The occupational hazards of nursing can also compromise work-life balance. Add to this various individual risk factors such as genetic predisposition or history of personal trauma, as well as the fact that academic standards for the profession favor those who are exacting and high-performing. It stands to reason that nurses are in jeopardy of significantly elevated levels of stress and maladaptive coping. 5,8 When ongoing, this can lead to impaired functioning. In the professional setting, impairment has been correlated with increased risk for errors, patient harm, and clinical ineffectiveness. 9

Mental illness can be defined as clinically significant impairment in social, conceptual, and practical functioning. 9,10 Although very common, mental illness is often untreated. 11 One in five adults will have some experience with mental illness each year, but less than half will receive treatment. 11

Nursing has a hidden culture of stigma and silence regarding mental illness, which serves to minimize and overshadow those experiencing clinically significant distress. 6,12 Competition, intimidation, and bullying among nurses are pervasive across practice and in academic settings. 13,14 These behaviors can breed psychologically hazardous and hostile environments. Fear of becoming a target may result in blame, shame, self-stigmatization, isolation, and suffering in any individual with potentially undesirable characteristics in such settings, regardless of his or her mental health status. Such abuses and fear can promote conformity and negatively impact disclosure and help-seeking behaviors in stressed, distressed, and impaired individuals. 1,2,5,13

The issue is exacerbated by a lack of respect and recognition for nursing that is still present within the healthcare culture at large. The traditional hierarchy holds physicians as experts, not nurses. Even advanced practice nurses are diminished, often referred to as “mid-level providers” and “physician extenders.” 15 These attitudes undermine the autonomy and dignity of nurses, especially when they collaborate with other healthcare disciplines. 14

In addition, while healthcare entities and societies champion the rights of the patient, the need to protect the basic human dignity and professional image of nurses is often overlooked. 14 Fundamental protections and rights for nurses are being compromised every day when we are expected to tolerate long hours, interrupted (or nonexistent) breaks, heavy patient caseloads, incivility, and even violence in the workplace. Nurse unions across the country are threatening walkouts and going on strike because of the failure of hospitals to address these issues. 16,17 The situation is not helped by the fact that guiding and governing bodies for nursing practice are numerous yet, in my opinion, self-segregated.

Systemic change

Although some organizations have created emotional wellness programs, a cohesive or public effort to address systemic problems is lacking. 1-3 Until employers, boards of nursing, and nursing organizations place the same importance on the well-being of nurses and risk mitigation, nurses may continue to suffer in silence. Within the currently disjointed system, we cannot hope to make substantive changes without offering our passion and expertise as well as identifying and supporting means for promoting self-care and wellness among the thousands of practicing nurses and preprofessionals experiencing distress or symptoms of mental illness.

Pressures and barriers to mental health and help-seeking extend to the academic setting. 4-5 For professional nurses returning to school, the pressure associated with practice and professional expectations may be exacerbated by their increased need to balance a variety of personal and/or family responsibilities, deadlines, financial obligations, leisure time, and peer competitiveness. Despite these contributory risk factors, I have seen few—if any—educational programs for health and helping disciplines, such as nursing, medicine, and social work, place value on assessing students' stress and distress. In commiserative discussions with others doing graduate work in nursing, social work, occupational therapy, and physical therapy, I have yet to meet anyone who felt the faculty took action to address the genuine difficulties many of them faced in balancing their lives. In short, students (myself included) feel devalued by the lack of respect, holistic consideration, and mentorship they encounter. Academic learning environments have a great need to support improvement of the emotional well-being and psychological resiliency of students and for improving the accessibility of support, counseling, and mental health resources. 4,5

I encourage you to take a long, hard look at yourself and those around you. If you are struggling, please reach out to someone you trust and let them know you are not okay. If you are not sure that what you are experiencing is normal or cause for concern, there are many websites that provide education and information on how to identify mental health problems, as well as hotline crisis intervention services and referrals to local counseling. These websites often have articles and tips on how to improve your mental health through physical, spiritual, and psychological self-care. (See Mental health resources .)

No mental health concern is too big or too small. If you are not well, talk to a friend, family member, professional, or help hotline. If you suspect a coworker, colleague, or student needs help, please reach out. Something as simple as asking if they are okay and giving them the space and time to express their feelings can make all the difference. As Edward Everett Hale once said, “I am only one, but still I am one. I cannot do everything, but still I can do something. And because I cannot do everything, I will not refuse to do the something that I can do.” 18 We owe it to ourselves, our profession, our patients, and their families to seek help and to offer help to our fellow nurses in need.

For anyone requiring immediate crisis intervention or assistance finding a local mental health provider, the following resources are available:

• Mental Health America: 1-866-400-6428 for referrals, 1-800-273-8255 for crisis
• National Alliance on Mental Illness HelpLine 1-800-950-6264
• National Suicide Prevention Helpline 1-800-273-8255

Crisis Text Line available 24 hours a day, text “HOME” to 741741

Mental health resources

• American Psychological Association
• www.apa.org
• American Psychiatric Nurses Association (APNA)
• www.apna.org
• MentalHealth.gov
• www.mentalhealth.gov
• National Alliance on Mental Illness
• www.nami.org
• National Suicide Prevention Lifeline
• https://suicidepreventionlifeline.org
• Crisis Text Line
• www.crisistextline.org
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anxiety; compassion fatigue; depression; emotional wellness; mental health; nursing; suicide prevention

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The Future of Psychiatric-Mental Health Nursing: Observe, Reflect, and Take Action to Empower Knowledge for the Greater Good

• Cite this article
• https://doi.org/10.1080/01612840.2023.2270066

Introduction

Where do we start how about now, the future of nursing: a guide for advancement in the us, priority #1: support nurses to advance health equity, priority #2: capitalize on nurses’ potential, priority #3: strengthening nursing education, summary of recommendations to promote the next decade of pmhn, disclosure statement, additional information.

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The purpose of this article is a call for action to identify areas of concern and promise for the specialty of psychiatric-mental health nursing to flourish in the twenty first century and beyond in the United States. Bits and pieces of this call for action may be relevant to other countries where psychiatric-mental health nursing has had similar trends. However, this paper focuses on the issues, barriers, and politics of education, practice, and research for nurses in the United States who gravitate to psychiatric-mental health and endeavor to rise above the value-laden past that perpetuates the marginalization of not only the specialty, but also the work that PMHN do and for the individuals that they are meant to care for in the new millennial. Much of the history of PMHN knowledge and care is value-laden, biased and riddled in patriarchy, fundamental religious views from centuries ago, and a basic fear of the unknown. It is well over due to sort through the closets and filing cabinets of the specialty’s knowledge to clear out the stigma, the myths, the unknown and the “doctor knows best” world view. If PMHN is to survive and truly heal or comfort the suffering that is observed and witnessed first-hand in the twenty first century, a deliberate and purposeful approach is needed.

Psychiatric-mental health nursing (PMHN) has sometimes had an isolated and marginalized past in the discipline of nursing. Often compartmentalized, psychiatric wards were located away from the rest of the hospital and down a long corridor to a locked unit. For some nursing students, it was the “dreaded” clinical rotation. Considering this mired history, it is important to understand the reasons why there continues to be a lack of interest in the specialty and whether it will impact the future workforce. A recent special issue of the history of mental health nursing ( Issues in Mental Health Nursing , 2023, Vol 44) highlighted thoughtful articles about ‘who mental health nurses are’ and ‘from whence mental health nurses have come’ as a specialty. The articles explored issues related to the philosophical and epistemological roots of what is called, psychiatric-mental health nursing and provided opportunities for rich discussion among health care professionals and those who are curious about the past practices, the ongoing stigma about mental health and the myths of psychiatric illnesses that continue into the twenty first century. The January 2023 special issue set the stage to be able to purposefully plan and take an active role in the future, endeavoring to answer the question, where does PMHN want to be in 10 years?

To answer this question and several more, it is essential that PMHNs employ the process of observation and reflection now to plan for the actions that will sustain the specialty’s future. Holding space to participate in this process includes defining (or revising) the role of a psychiatric-mental health nurse (PMHN) whether it is as a generalist (RN) or specialist (NP) as well as where PMHNs will practice in the future. The Scope and Standards of Psychiatric-Mental Health Nursing (ANA, Citation 2022 ) have been carefully revised over the years by experts within the specialty, however, it is also important to identify any barriers to progress made as well as build upon the strengths that have guided the evidenced based research and practice of the last seven decades. At every level of nursing, having dialogue and efficient conversation about the future is a critical part of this process. Much like the quality improvement model, PMHNs need to ask, what works, what doesn’t and what do we need to change at a local and national level. Rather than to accept the status quo and/or assuming that things will be difficult to alter or redefine, the “here and now” is one way that encourages a participation in the future for the next generation of nurses.

Engaging in this type of ‘here and now’ reflection, PMHN can continue to establish a collective memory (e.g. past history), while forging the professional bonds and identities that define the role and practice of PMHN (Raeburn et al., Citation 2023 ). Amassing stories, honoring experiences and the preserving the past hopefully acknowledges to any discipline to learn from that history, while creating the next stage of epistemological development. Yet, the very nature of this reflective process and the subsequent proposed actions can elucidate more questions in the present stance. These questions can promote discussions such as ‘how in this twenty first century do PMHNs know what to do in their role and practice’ and/or ‘what constitutes that knowledge?’ ‘How do PMHN understand how to care for individuals and families?’ Where does that knowledge come from and is it useful in the present time? Some of the knowledge that PMHNs use today, in the twenty first century, still has links, albeit, dangerous connections to the past practices of shaming, blaming and marginalizing individuals for their suffering (Soltis-Jarrett, Citation 2003 ). These questions and discoveries can be a place to start when employing the critical conversations about the future of our discipline.

The ways and/or patterns of how nurses ‘know’, and what establishes nursing knowledge was uncovered in the twentieth century with various approaches to knowledge development and the birth of middle range theories of nursing to guide nursing practice. Middle range nursing theories were developed at the intersection of practice and research to help with everyday activities and tasks (Smith et al., Citation 2023 ). This, rather than to simply follow medical doctor’s orders and/or repeat the mistakes of past generations that shamed or blamed illness and disease on the individual. And yet, psychiatric-mental health nursing has, at times, remained on the margins of the discipline and continues to be oppressed by stigma, a lack of understanding about psychiatric illnesses and blatant misconceptions, even among expert nursing colleagues. Do PMHNs turn a blind eye or confront the stigma, myths, and misconceptions? As little as 40 years ago, when embarking on a nursing career and working in medical nursing, I started to gravitate toward psychiatric-mental health and was told that only the bad or weak nurses go to work in psychiatric settings. It was the first mirror placed in front of me to question; am I a bad or weak nurse? What was wrong with psychiatric nursing? Is that still an issue in the present healthcare system? Are we asking the right questions about ourselves? What is it that other nurses do not see or understand about the specialty? What areas of psychiatric-mental health nursing knowledge need to be addressed and clarified if the specialty is going to move forward?

Until the last century, much of the knowledge about nursing care was passed down from one generation of nurses to another, with nurse’s training viewed as an apprentice role. The notion of being ‘educated’ as a nurse was not truly introduced until nurses received academic degrees. Prior to that, the focus was on nurse’s ‘training’. The role of nurses gaining any recognition for their knowledge was fraught for many decades within the medical community by (often) male physicians standing over them, telling them what to do and how to do it. Nurses followed the medical model and followed physician’s orders. This still occurs in the twenty first century, even though nurses are with patients and their families for much of the time on inpatient wards and even in community settings. Through the perseverance of many nursing scholars, an ongoing collection of theoretical frameworks and middle range theories have lit the way to develop meaning and an understanding to what Nightingale ( Citation 1859 ) first wrote in Notes on Nursing: What It Is and What It Is Not. Nurses have recognized the value of education and training as a process of emancipation from the medical model and currently celebrate their ability to define their advanced practice roles (e.g. nurse practitioner or clinical nurse specialist.). More importantly, nurses have learned to apply concepts that guide nursing practice and uphold the principles that shifted from being an apprentice to developing nursing knowledge and evidence-based practice in the twenty first century. Psychiatric-Mental Health Nursing needs to continue this pursuit of knowledge development and to have a philosophical and systematic approach for how that knowledge is gathered, learned, and communicated, especially if the specialty is going to advance in the future. PMHNs also need to be able to question the standards of practice that are not appropriate, ethical quandaries that arise due to new treatments, and/or evidenced based practices that do not align with the present-day healthcare systems policies and regulations. And, in the ‘here and now’, it is critically important for PMHNs to consider, to whom does this knowledge and practice benefit? Is it the patient and/or their families or does it benefit the bottom-line profit margins of large healthcare systems and corporations such as the pharmaceutical industry? Patient-centered care needs to be an action-oriented, not just a rhetorical promise.

Much of the history of PMHN knowledge and care is value-laden, biased and riddled in patriarchy, fundamental religious views from centuries ago, and a basic fear of the unknown (Soltis-Jarrett, Citation 2003 ). It is well over due to sort through the closets and filing cabinets of the specialty’s knowledge to clear out the stigma, the myths, the unknown and the “doctor knows best” world view. If PMHN is to survive and truly heal or comfort the suffering that is observed and witnessed first-hand in the twenty first century, a deliberate and purposeful approach is needed.

The purpose of this article is a call for action to identify areas of concern and promise for the specialty of psychiatric-mental health nursing to flourish in the twenty first century and beyond in the United States. Bits and pieces of this call for action may be relevant to other countries where psychiatric-mental health nursing has had similar trends. However, this paper focuses on the issues, barriers, and politics of education, practice, and research for nurses in the United States who gravitate to psychiatric-mental health and endeavor to rise above the value-laden past that perpetuates the marginalization of not only the specialty, but also the work that PMHN do and for the individuals that they are meant to care for in the new millennial.

To consider the future of nursing and more importantly, the future of psychiatric-mental health nursing, it is imperative that we (whether as students, generalists, or specialty practitioners) begin or continue to have conversations about what we observe, witness, or hear in the hallways of academe, in the practice offices or the hospital wards. Setting up a time to have the conversations seems daunting, but it is not impossible. The aim is to keep a check on the specialty and to uncover observations and threats when the nursing profession staggers and/or perpetuates the principles that have been purposefully deconstructed and illuminated as biased, value-laden, oppressive, and self-depreciating. Language is one example whereby PMHN can acknowledge the need for this process. For instance, uncovering value-laden or demeaning terminology in nursing continues to be slow to change. The naming of an individual as “that cardiac patient” or another as “an addict”, while also describing the result of a urine drug screen as “dirty”, is slowly being replaced by language that seeks to separate the dichotomy that individuals and their illnesses are one and the same. Nurses know that language can oppress and shame. Therefore, to reframe an individual as being diagnosed with a cardiac illness, or the adolescent diagnosed with a substance use disorder seeks to separate the shame, blame, and bias inherent in medical and nursing terminology. This simple correction begins a process of change that can be a first step toward the future.

The critical paradigm is one option for the future that encourages nurses to move beyond the cause and effect of illnesses (positivism) and even beyond the lived experience of illness (phenomenology) toward a more participatory, shared knowledge that empowers the participants. The aim of this philosophical approach and subsequent methodologies seek to assist participants to make decisions about what constitutes knowledge for and about them, as well as the choices that they make (shared decision-making) about their health and illnesses, rather than to function as a passive research subject, being told what to do and how to do it (Soltis-Jarrett, Citation 2003 , Citation 2004 ). This shared knowledge is a form of participatory research which seeks to reframe a situation in which an individual or group of individuals are experiencing deep and remedial suffering because of the way their lives are arranged (Fay, Citation 1987 ). These ‘arrangements’ are now often described as the social determinants of health (SDOH), the non-medical factors that influence health outcomes, such as poverty, access to healthcare, safe neighborhoods, food inadequacy and domestic violence (Hacker et al., Citation 2022 ). Rather than to blame or shame individuals and/or communities for their ill health or social situations, participatory research seeks to assist people to understand (e.g. health literacy) and to be able to act in fuller, more satisfying lives (Fay, Citation 1987 , Freire, Citation 1972 ). The future of PMHN can embrace this approach (and others) to empower those diagnosed with behavioral health and/or substance use disorders and participate in their own health care, wellness, and recovery. Knowledge is power and although words and meanings change over time, it is vital to understand how history shapes the present and can influence decisions for the future. Several national reports have recommended that consumers of healthcare become more active participants in their health maintenance as well as have access to options for when they are ill. To embark on this ambitious process and plan, the discipline of nursing and, PMHN, as a specialty, will need to be mindful about not only the lived experience of those individuals but the population health needs of communities across the US. Taking steps to understand the ‘remedial sufferings’ of a community is more than identifying the social determinants of health based on community assessments (Fay, Citation 1987 ). It is essential to ask communities what they experience and how they understand what the issues are, leading to the barriers to health maintenance. Using this framework as a base, considerations for the future of PMHN can be identified and systematically planned. Starting in the here and now, there are reports that can assist our specialty to plan and implement a future that is not only a collective memory, but a collective future while actively participating in the creation of their professional bonds and identities with themselves as well as those that they care for in PMHN (Raeburn et al., Citation 2023 ). The next section will present and discuss a recent report that has made recommendations for the future of nursing in the next decade. Ironically, these recommendations align well with the notion of participatory research and community engagement. And, more importantly, they put the individual, family and/or community at the center of care with a focus on health equity.

Two publications, The Future of Nursing: Leading Change, Advancing Health (IOM, Citation 2011 ) and The Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity (NASEM, Citation 2021 ) have focused on how the discipline of nursing can engage with individuals, families, and communities in the US. Each publication presented recommendations to enact and strengthen the nursing workforce and ultimately, collaborate with communities of people across the nation to realize and attain their full health potential. Although the reports are quite ambitious and visionary, and without a nationalized health policy that acknowledges that health care is a fundamental human right, the US will continue to struggle with health equity, structural racism, and health disparities. Nurses most certainly need to persevere to address the inequities but also acknowledge and rise to identify the barriers (oppressors) that impede progress and to embark on developing policies that promote health, wellness, and patient-centered care. As previously stated, this is endeavored by action rather than just rhetoric.

Using three sets of recommendations that were made in the most recent report, the Future of Nursing 2020–2030 (NASEM, Citation 2021 ), the following section will consider how psychiatric-mental health nursing can plan and implement its own future, with an emphasis on acknowledging the barriers and how to navigate ‘uncharted seas’, those places where change may be turbulent and choppy. It will endeavor to weave the past to the present and where psychiatric-mental health nurses need to focus to ensure that the future of this specialty continues to flourish and grow. Each priority will address how the specialty of psychiatric-mental health nursing can observe, reflect, and act to empower a future for the greater good that integrates the social determinants of health, the community’s population and environmental health needs, trauma-informed care, and health equity as core concepts and competencies throughout any type of clinical and experiential learning (NASEM, Citation 2021 ). Although there are 10 sections in the current document, the Future of Nursing 2020–2030 (NASEM, Citation 2021 ), the following three priorities will be used initiate discussion about the future of psychiatric-mental health nursing in the remainder of this paper: (a) SUPPORT NURSES TO ADVANCE HEALTH EQUITY; (b) CAPITALIZE ON NURSES’ POTENTIAL; and (c) STRENGTHEN NURSING EDUCATION. Each priority was chosen specifically to initiate the call to action to purposefully plan with ideas to ponder and discuss. With a focus on finding strength in numbers and the collective power that nurses have, the future can be productive and active, if nurses keep their eyes open and their ears to the ground.

Promoting health and well-being for all should be a national priority, and a collective and sustained commitment is needed to achieve this priority. To chart this path, nurses should be fully supported with robust education, resources, and autonomy” (NASEM, Citation 2021 , p. 359).

Nurses, both the registered nurse (RN) and the Advanced Practice Registered Nurse (APRN) working in psychiatric mental health, can promote health and wellness as well as assess and manage acute and chronic illnesses within their respective scopes of practice. A Psychiatric Mental Health Nurse Practitioner (PMHNP) can advance health equality by being integrated into all facets of healthcare including both specialty settings and expanding to nontraditional settings such as primary and secondary schools, college campuses, national organizations (e.g. AARP), and social clubs such as the Boy and Girl Scouts, to name a few. The concept of Behavioral Health Integration (BHI) needs to have a planned and purposeful place in nursing education, practice, and research, promoting psychiatric-mental health nurses (generalists/RN and specialists/NP) as active members of any team (Soltis-Jarrett et al., Citation 2017 ). To silo mental health (and psychiatric-mental health nursing) is to oppress the needs of those individuals in our communities who deserve whole health care, rather than to focus only on physical health and wellness. How can this be actualized? Two examples follow.

Example 1. Reclaiming holistic care with all APRNs leading the way

Over the past decade, schools of nursing have embraced the notion of whole health care, and some have placed greater emphasis on behavioral health and substance use disorders for Nurse Practitioners who will work in primary care settings. Providing additional content that brings together PMH-NP students and their primary care peers (e.g. FNP and AGNP students) to learn to work together while in graduate school, promotes a form of interprofessional education between the different population nursing foci and the clinical sites in the communities (Soltis-Jarrett, Citation 2017 ; Citation 2019 ; Citation 2023 ). This is another example of how even graduate nursing schools have previously siloed NP students by population foci to move them quickly through the program so that they can fill the gaps of healthcare shortages. However, bringing the specialties together in teams that can support and help each other, particularly in rural America, promotes a collegiality and can lessen burnout when specialty care referrals are limited or not available (Soltis-Jarrett, Citation 2018 ).

For the past 8 years, one graduate NP program has found that by offering Behavioral Health Integration traineeships for Primary Care NP and PMH-NP students, the graduates of the traineeship have yielded remarkable outcomes. The BHI Scholars (as they are called) have endorsed that the traineeship and the tuition assistance have been ‘life-changing’ giving them a window into the notion of working with their peers to solve complex, real-life issues. Some of the primary care nurse practitioner students have been able to report their awareness and experiences of stigma and marginalization that often occurs in primary care and/or other non-psychiatric healthcare settings (Soltis-Jarrett, Citation 2016 , Citation 2019 , Citation 2023 ). Having the additional knowledge to address these barriers and acquire the advanced skills has empowered the Primary Care NP students to not fear the unknown, but rather to engage with their patients to assist them to make decisions about their health and well-being in a more holistic or Whole Health manner. The additional advantage of learning to collaborate with their PMH-NP colleagues in graduate school and post-graduation has also been a positive outcome for the BHI Scholars. There are now ‘curbside’ consults and ‘warm handoffs’ that bring two NP specialties together (Primary Care and PMH) to problem solve and lessen the isolation that NPs often report feeling in rural and remote practices as community agencies and health centers witness the increased preponderance of mental health and substance use problems in 2023.

The notion that ‘knowledge is power’ goes without being said, as the NP students who seek to learn these skills and embrace the BHI Scholar traineeship are prepared to screen for behavioral health and substance use disorders, implement brief interventions (such as Motivational Interviewing) and initiate treatment for common psychiatric and substance use disorders as part of their total care. This type of education and training also promotes the idea of health care for the whole person (mind/body). By having accessibility to a PMH-NP, (either embedded in primary care or available for consultation), supports the primary care NP and encourages their patients to stay for treatment in one setting (primary care) rather than to be referred out to specialty care. There is also a model of how NPs can work together collaboratively to provide guidance as well as when to refer outside of primary care settings (Soltis-Jarrett, Citation 2018 ; Citation 2019 ). This model is most useful when there is a lack of access to behavioral health and substance use services in rural and/or underserved areas. Using this knowledge in action, Primary Care NPs can be empowered to become competent to assess and manage common behavioral health and substance use problems and learn how to work collaboratively with PMH-NPs. Having this option has been shown to be valuable to both the patient and the providers, decreasing stigma and increasing satisfaction of nursing care (Soltis-Jarrett, Citation 2018 ). And as a bonus, it brings the NP colleagues together, into the fold, helping them to lean into the notion that there is no health without mental health. And this collaboration focuses on the patient-centered, population health needs of their communities where the NPs practice. Their partnership promotes an interactive and supportive environment which decreases shame and the myths related to mental health and substance use disorders. RNs (generalists) can work alongside NPs and can also be active members of the team (Soltis-Jarrett, Citation 2018 ). Example two will highlight the importance of educating pre-licensure nurses to work in the community rather than only to focus on the inpatient psychiatric wards in hospitals for clinical experiences. Educating and training pre-licensure nursing students to experience whole health care is another means for promoting health equity and decreasing stigma.

Example 2. Reclaiming the role of community mental health nursing (CMHN)

Many in the specialty of psychiatric-mental health nursing may remember the concept of community mental health nursing (CMHN), a subspeciality area of community health nursing that focuses on the health and wellness of individuals while psychiatric nursing was a concept that focuses more on acute and chronic illnesses, often requiring a higher level of care including hospitalization and intensive outpatient programs (Grob, Citation 2014 ). Community mental health nursing has slowly disappeared from the landscape as other disciplines have claimed the role and the programs that are more aligned with rehabilitation/occupational health, social work, and recreational therapy. Stepping back and reflecting on why this occurred, requires a visit to the past to understand how nurses were once empowered to take the lead in this subspecialty, however, slowly gave their power to other disciplines.

Soon after the Community Mental Health Care Act (CMHA) of 1963 was passed nurse generalists (RN) could opt to work in a community setting to focus on activities that fostered mental health (e.g. life and coping skills; reintegration into communities after institutional care) (Koldjeski, Citation 1984 ). The CMHA appropriated funding to build community mental health centers and provide mental health care in the community, instead of institutional hospital settings (Toth, Citation 1963 ). Community mental health centers grew across the US and were designed to manage the large numbers of individuals released from long-term psychiatric institutions (e.g. asylums) which was called de-institutionalization. Lowering the walls of the asylum meant permitting individuals to reintegrate into their communities which was the aim of this movement worldwide, even in other countries such as Australia. Glenside Hospital, a state institution for the seriously mentally ill in Adelaide, South Australia is one example of the ‘lowering of the walls’ (Glenside Hospital Historical Society, Citation 1975 ) and like the articles published in the special issue on the History of Mental Health Nursing (IMHN, 2023), there was the promise of modernized treatments. Where are these nurses and community mental health centers now? Do we need to rebuild them or integrate them into a whole health setting? Again, Behavioral Health Integration (BHI) has laid the path to embedding behavioral health in primary care (e.g. co-location) and embedding primary care services into behavioral health settings (e.g. reverse co-location), especially for those individuals who have a severe and persistent psychiatric illness. This bidirectional type of care can increase access to whole health care for all individuals and families and has been demonstrated as a model for vulnerable populations with complex and overlapping health and social needs (DeFosset et al., Citation 2023 ; Soltis-Jarrett, Citation 2018 ). Does this system of care, once successful and promising need to be reclaimed? There are places to start this process of change and to seriously consider ensuring that we educate pre-licensure nursing students in community mental health agencies rather than only on hospital wards.

The birth of the ACT model (Assertive Community Teams) was developed and implemented more than 50 years ago and continues even today. While the community mental health centers were successful, the strategy to maintain them started to decompensate as government administrations changed and especially when funding was slashed around 1969. At the same time, the Nixon administration sought to “phase out federal programs for training mental health personnel and new community mental health centers, leaving the states to decide if they wanted to continue such programs at their own expense” (see NIH: https://profiles.nlm.nih.gov/spotlight/tg/feature/mental ).

The ACT model was one innovative solution for picking up the pieces of a broken mental health system in 1975. It is a form of community-based mental health care for individuals experiencing serious psychiatric illness that interferes with their ability to live in the community, seek treatment when needed and/or manage their symptoms (SAMHSA, Citation 2008 ). The ACT model is a service-delivery model, not a case management program and its primary goal is recovery through community treatment and habilitation (SAMHSA, Citation 2008 ). Registered Nurses (RN) have been recruited to the ACT programs and have embraced the principles of the model, working alongside, and with interprofessional teams. However, there appears to be a lack of education and training in academic programs to prepare RNs for this specialized role and/or limited opportunities to offer exposure through clinical experiences. As behavioral health and substance use disorders are integrated into healthcare systems, the call for additional training and education for RNs is warranted whether as a generalist or a specialist. Over the next decade, the discipline must reclaim this role to bring RNs back into the outpatient settings and utilize their skills of generalist nursing. The next section will focus on the second priority chosen for discussion, capitalizing on nurses rather than oppressing nurses’ ability to be a part of the solution. This priority focuses on Nurse Practitioners and the restrictions placed upon them in some areas of the US.

To engage fully in advancing health equity, all nurses need the autonomy to practice to the full extent of their education and training, even as they work collaboratively with other health professionals. They are, however, frequently hindered in this regard by restrictive laws and institutional policies. Policy makers and health care systems need to lift permanently all barriers that stand in the way of nurses in their efforts to address the root causes of poor health, expand access to care, and create more equitable communities (NASEM, Citation 2021 , p. 363).

As of January 2023, over 50% of the US (32 states and the District of Columbia) have acknowledged the importance of full practice authority, thus removing laws that regulate reduced or restrictive NP practice (AANP, Citation 2022 ). The remaining states have differing levels of restriction and many with the highest restrictions also have the poorest health outcomes per various demographic reports. Not having full practice authority unfairly places oppressive barriers to NPs who can competently address “the root causes of poor health, expand access to care, and create more equitable communities where individuals and families are in most need” (NASEM, Citation 2021 , p. 363). This is best exemplified by the Health Professional Shortage Areas (HPSA) and Medically Underserved Areas (MUA) regions across the US where even though NPs chose to live and work, they are unable to practice to their full extent because of the difficulty in finding a collaborating or supervising physician. Some NPs are also being limited in their ability to prescribe certain medications or treatments. Despite 50 years of research asserting that NPs provide safe, high-quality, cost-effective, patient-centered care, state policy makers and health care systems continue to defer to those in power who oppose full practice authority (Buerhaus et al., Citation 2018 ; DesRoches et al., Citation 2017 ; Kippenbrock et al., Citation 2019 ; Liu et al., Citation 2020 ; Muench et al., Citation 2019 ; Naylor & Kurtzman, Citation 2010 ).

When COVID-19 was first identified in 2020, psychiatric-mental health nurses were already experiencing a workforce shortage. With the lack of psychiatrists and poor access to behavioral health and substance use services nationwide, the wait times in emergency departments reached a critical level. As COVID-19 spread and deaths increased, psychiatric-mental health nurses were keenly aware of the next ‘tsunami’ or health crisis that was going to crash down upon health care systems: symptoms of depression, anxiety, and substance use disorders flooding the emergency departments and community health centers because of the once in a lifetime global pandemic combined with isolation from loved ones, and misinformation about the seriousness and lethality of the virus. Over the past 3 years, the preponderance of deaths by suicide and/or opioid poisoning has not just impacted adults across the US, it has also tragically impacted children, adolescents, and young adults (Centers for Disease Control and Prevention [CDC] 2023.). Suicide is now the 2nd leading cause of death for children, youth, adolescents, and young adults (aged 10–44), and the numbers of suicides reported continue to rise (CDC, Citation 2022 ). The actual numbers of deaths by suicide are suspected to be even greater than reported because the category of unintentional and accidental deaths have not been clarified or linked to mental health or substance use disorders as a possible cause (e.g. automobile accidents, falls from high places).

This is a clear and present call for action to confront the barriers that impede the voice of nurses and those barriers which prevent the progress of nursing’s accomplishments from being heard. One action item would be for nurses to join their professional organizations and consider volunteering to have a seat at the table of those who create policies that influence healthcare. Attending professional conferences and listening to podcasts about the barriers to healthcare can be another way to inspire the future PMHNs to learn more about the importance of health equity and advancing healthcare for the greater good. It also promotes the next NP generation to be able to address the root causes of poor health, expand access to care, and create more equitable communities (NASEM, Citation 2021 , p. 363) without just adding the social determinants of health to course content as a factor of care. Unfortunately, those who regulate and/or restrict NP practice cannot ‘see’ that they are blinded by their own unrestrained eagerness to possess and control knowing and knowledge (Freire, Citation 1972 ), and subsequently control others through their lack of willingness to focus on the community’s health needs, the suffering of those who are voiceless and/or the notion that healthcare is a basic human right, not a privilege of some who can afford or access it. To overcome these obstacles, education can be one solution to emancipating students in the health professions to learn the who and what the oppressors are in their states and communities. Learning about how laws are made, and policy is developed is another critical piece of nursing that needs to be addressed as part of general nursing education or lifelong continuing education.

Nursing schools need to prepare nurses to understand and identify the social, economic, and environmental factors that influence health by embedding content on SDOH throughout their curricula. Schools need to ensure that nurses have substantive, enduring, relevant community-based experiences and that they value diverse perspectives and cultures to help all people and families thrive. Nurses should have this content updated and reinforced throughout their careers through continuing education (NASEM, Citation 2021 , p. 368).

This recommendation is ambitious and to some extent, rhetorical. The discipline of nursing has, for decades, focused on the social, economic, and environmental factors that influence health. Many of our past nursing leaders (e.g. Lillian Wald, Clara Barton, Hazel Johnson-Brown, Mary Breckenridge) have been instrumental in advocating for the poor, the marginalized and those who do not have a voice in their health and wellbeing. As the most trusted profession, nurses have gained the respect and confidence of their communities, especially when coupled by a knowledge of the cultural and ethnic heritage of where they were raised and those that they serve. The whole notion of increasing diversity in health care has supported those within a community to either seek additional education and training (as a nurse or NP) or to be actively recruited to advance their education (with funding and support) so that they can return to their own communities to provide clinical competent and culturally sensitive care to those who are most vulnerable. Having that cultural understanding is an incredible asset and providing financial support for those recruited is critical but funding for tuition can be a major concern. Money is indeed a core issue that impacts nursing education.

The US is in a state of flux in the 21st century, with some university schools of nursing ‘flush’ with cash and others, struggling to make ends meet. Many public universities are dependent upon their state’s budgets, the politics of moment and yet again, those who are in power. For the past two decades, schools of nursing have been struggling with securing clinical training sites and procuring relevant community-based experiences to teach the value of diversity and cultural practices amongst the people who live in their respective states. The recent opposition to discussions whether our communities suffer from structural racism, misogyny and/or limiting who can be called a ‘doctor’ are unsettling because they once again distract and deter from the critical issues at hand: the individuals and families that are in desperate need of mental health and substance use services. There is no doubt that there are dominant, biased and value laden approaches to health and illness, both in rural and urban areas, however, exposing nursing students to a diverse classroom setting and a variety of clinical experiences can promote the future of healthcare for the greater good while also exposing the inequities inherent in health care settings. This is another example of how powerful reflection in action can be as nursing students are asked to observe and identify inequities while caring for individuals and families.

As one would expect, there are multiple barriers that obstruct nurses from advancing healthcare, especially in community settings and for individuals and families who are often the most vulnerable and oppressed by lack of access to health care. Stigma within some communities only worsens the ability for individuals to seek help for symptoms of psychiatric illnesses or substance use disorders. For the future of PMHN to progress and act, academic institutions need to prioritize creating educational and clinical experiences for pre-licensure nursing students in the community and with a focus on mental health and substance use disorders. This, rather than to exclusively place nursing students in long term psychiatric settings or inpatient hospital wards where there are now limits to their availability because of competing needs of many schools requiring a mental health or substance related rotation. Those nursing students interested in psychiatric-mental health nursing could opt to have inpatient acute care experiences as well, but offering community options broadens the notion that ‘there is no health without mental health’. An example to consider would be to challenge pre-licensure students to identify a community or a group that is vulnerable and/or at risk for psychiatric illnesses and substance use disorders and develop a proposal for how nurses could intervene, engage, and assist the community or vulnerable groups. Examples include identifying depression, delirium, and dementia in the elderly by setting up activities and spending time with those who live in nursing homes, teaching coping skills to school age children and/or adolescents (e.g. mindfulness, belly breathing, exercise, and dance). Participating in depression screening events at health fairs, visiting assisted living settings to interview and spend time with individuals in late life can also be part of the psychiatric-mental health clinical hours. There is a plethora of options that can be offered to balance the traditional notion of severe and persistent psychiatric illnesses and acute care. There is an ongoing, growing literature that describes how community mental health nurses have participated in various interventions to assist individuals, families and communities in the identification and recovery of psychosis and/or a diagnosis of schizophrenia in young adults and adolescents (Cunningham & Peters, Citation 2014 ; Macleod et al., Citation 2011 ) thus, exposing nursing students to preventative interventions in their clinical training as well as secondary and tertiary care. Thinking outside of the box and moving outside of the acute care hospitals as the primary training of pre-licensure nursing students is a way to avoid the barriers and difficulties inherent in finding clinical sites while it also prepares a future for community mental health nurses or nurses who may be interested in behavioral health integration in medical settings. Each opportunity can capitalize on the potential of nurses and the practice of nursing in nontraditional settings.

Throughout this article, the future of PMHN was considered with recommendations for how to plan for the next decade and to reclaim some of the practices of the past (such as community mental health nursing) while ensuring that the specialty reflect on its own quality improvement. This includes the importance of making the space and time as nurses, to consider the ongoing environmental and political changes impacting communities as well as to assess the population health needs of individuals in a region or state. This, rather than to generalize healthcare needs across the nation. This process is essential to creating (or reclaiming) roles that can be filled with community mental health nurses or PMHNP to plan.

To prepare for the future of PMHN, the following recommendations are a place to start for advancing the solutions for the greater good and for empowering the next generation.

Promoting health and well-being for all should be a national priority, and a collective and sustained commitment is needed to achieve this priority. To chart this path, nurses should be fully supported with robust education, resources, and autonomy (NASEM, Citation 2021 , p. 359).

Make time and space for all practicing nurses to focus on quality improvement. What works, what does not and what can be implemented to create change? Administrators need to ensure that this time is made for nurses while they are being paid, on duty or at work.

Encourage all nurses to join professional organizations with the focus on learning not only the evidenced based best practices but also how policies impact the health and well-being of our communities. Make the professional membership fees reasonable (and accessible) for nurses based on their income and where they live and work. Professional organizations need to create scholarships for those who cannot afford the fees to still be included. Members should be encouraged to sponsor other nurses.

Literacy is the foundation of knowledge. Providing opportunities for advancing education, whether as a degree or lifelong continuing education is critical. Leveraging schools of nursing to prioritize Health Resources and Services Administration (HRSA) grant funding to recruit and support the future of nurses and nursing. Schools of Nursing need to acknowledge the importance of training grants (e.g., HRSA) as equally important as research grants and provide time for the grant proposals to be written and for faculty to mentor other faculty.

Through education, training and inclusiveness, nurses need to be a part of the solution thereby lifting the restrictions to practice independently without the constraints of physician oversight. The surge in mental health and substance use disorders, particularly among those aged 10–44, should be a wakeup call to legislators and community leaders. Nurses are ideally positioned to lobby their leaders to recognize that there are solutions and removing barriers is one of them.

Promoting mentoring, advocating for nurse internships, traineeships and the transition to practice is critical for all nurses. Setting nurses up for failure is what was once called ‘eating our young’ or horizontal violence. This must be monitored and identified by nursing administrators, leaders, and senior members of the discipline. ‘Protecting our young’ needs to replace the motto of the past. Promoting the health and wellbeing of nurses needs to be a priority and sustained over all positions in healthcare.

Reclaiming some of the previous roles that belonged to nurses (e.g., community mental health nursing, school nursing) and ensure that funding is made available for these positions. This necessitates that all nurses can be exposed to a variety of clinical experiences and the possibility of changing positions across their careers. Ensuring that ongoing lifelong continuing education is accessible and part of the workday.

Faculty and leaders in nursing education need to come together and think outside of the box about providing a variety of clinical experiences that broaden the notion of psychiatric-mental health nursing whether it is in the community, behavioral health integration or acute settings. Faculty need to embrace the notion that there is no health without mental health and create scenarios whereby mental health is included in the care of all individuals, families, and groups.

Universities and colleges of nursing need to encourage faculty to write HRSA Grants that increase the diversity of the classrooms and recruit, retain, and prepare nurses and NPs to provide clinically competent and culturally sensitive care that focuses on the whole health of individuals. For too long, the notion of training grants (e.g., HRSA grants) has not been valued nor promoted as equal to the development of nursing knowledge (e.g., scientific grant proposals) in academia. The ground in the pursuit of knowledge or development and implementation of training grants needs to be leveled and faculty need to be given mentorship and time to develop and be successful in grants and funding that will recruit, support and graduate nurses and NPs to be the next generation and future of psychiatric-mental health.

No potential conflict of interest was reported by the author.

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35+ Nursing Research Topics on Mental Health Care

Understanding and addressing mental health challenges is crucial to nursing education, equipping future nurses to provide comprehensive patient care. This article delves into nursing research topics on mental health care, offering nursing students insights into its significance, focused research questions, project ideas, and essay prompts.

What You'll Learn

Introduction to Mental Health Care

Mental health care is a cornerstone of holistic patient care, an essential concept for nursing students to grasp as they embark on their journey toward becoming competent healthcare professionals. In a world marked by increasing stressors, comprehending mental health challenges, their ramifications, and effective care strategies is paramount. This article explores the realm of mental health care, furnishing nursing students with a deeper understanding of its importance and implications for their future roles.

10 Targeted PICOT Questions on Mental Health Care

• Population: Adults in psychiatric care; Intervention: Daily RS questionnaire implementation; Comparison: Units without daily survey; Outcome: Reduced RS utilization; Timeframe: 6 months. Can the integration of a daily RS questionnaire for adults in psychiatric care lead to a significant decrease in restraint and seclusion utilization within 6 months, compared to units without this survey?
• Population: Adolescents with anxiety disorders ; Intervention: Mindfulness meditation; Comparison: Standard relaxation techniques; Outcome: Reduction in anxiety symptoms; Timeframe: 8 weeks. Does engaging in mindfulness meditation for 8 weeks result in a more substantial reduction in anxiety symptoms among adolescents with anxiety disorders, compared to utilizing standard relaxation techniques?
• Population: Elderly patients with depression; Intervention: Group music therapy ; Comparison: Individual counseling; Outcome: Improvement in depressive symptoms; Timeframe: 12 weeks. Is there a more pronounced improvement in depressive symptoms among elderly patients with depression exposed to group music therapy for 12 weeks, compared to those receiving individual counseling?
• Population: Inpatients with schizophrenia; Intervention: Family psychoeducation; Comparison: Standard treatment; Outcome: Decreased hospital readmissions; Timeframe: 1 year. Can family psychoeducation for inpatients with schizophrenia lead to a noteworthy reduction in hospital readmission rates within a year, compared to standard treatment alone?
• Population: Children with attention deficit hyperactivity disorder (ADHD); Intervention: Regular physical activity; Comparison: No structured exercise; Outcome: Improvement in ADHD symptoms; Timeframe: 3 months. Will regular physical activity over 3 months substantially improve ADHD symptoms among children compared to those lacking structured exercise?
• Population: Pregnant women with prenatal depression ; Intervention: Yoga therapy; Comparison: Support groups; Outcome: Reduction in depressive symptoms; Timeframe: Throughout pregnancy. Does integrating yoga therapy throughout pregnancy lead to a noteworthy reduction in prenatal depressive symptoms among pregnant women, compared to participation in support groups?
• Population: Veterans with post-traumatic stress disorder (PTSD); Intervention: Service dogs; Comparison: Medication and therapy; Outcome: Decreased PTSD severity; Timeframe: 6 months. Over a 6-month period, does the inclusion of service dogs in treatment result in a significant decrease in the severity of PTSD symptoms among veterans, compared to medication and therapy alone?
• Population: Individuals with bipolar disorder ; Intervention: Smartphone app for mood tracking; Comparison: Traditional mood charting; Outcome: Enhanced mood management; Timeframe: 3 months. Can the use of a smartphone app for mood tracking over 3 months lead to more effective mood management among individuals with bipolar disorder, when compared to traditional mood charting?
• Population: Patients in substance abuse rehabilitation; Intervention: Art therapy; Comparison: Cognitive-behavioral therapy (CBT); Outcome: Improved emotional expression; Timeframe: 10 sessions. Does the incorporation of art therapy into substance abuse rehabilitation over 10 sessions facilitate improved emotional expression compared to traditional cognitive-behavioral therapy (CBT)?
• Population: Children with autism spectrum disorder (ASD); Intervention: Animal-assisted therapy; Comparison: Standard interventions; Outcome: Increase in social interaction skills; Timeframe: 8 weeks. Within an 8-week period, does animal-assisted therapy result in a more significant increase in social interaction skills among children with ASD, compared to standard interventions?

EBP Project Ideas on Mental Health Care

• Assessing the efficacy of virtual reality exposure therapy for treating phobias.
• Establishing a peer support initiative for nurses managing workplace stress.
• Formulating guidelines for identifying and addressing self-harm behaviors in adolescents.
• Analyzing the impact of a relaxation space in reducing stress among healthcare staff.
• Developing a training module for nurses on de-escalation techniques during psychiatric crises.

Nursing Capstone Project Ideas on Mental Health Care

• Investigating the perception of seeking mental health care among healthcare professionals.
• Designing a mental health first aid program for schools to detect early signs of mental distress in students.
• Examining the connection between childhood trauma and emerging mental health disorders in adulthood.
• Crafting a comprehensive care plan for elderly patients with coexisting physical and mental health conditions.
• Evaluating the role of family involvement in the recovery of individuals with schizophrenia.

5 Nursing Research Paper Topics on Mental Health Care

• The influence of social media on body image and its implications for adolescent mental health.
• Probing the correlation between sleep quality and mood disorders.
• Exploring cultural factors shaping the manifestation and management of depression.
• The effectiveness of mindfulness-based interventions in mitigating burnout among healthcare professionals.
• Investigating the psychological impact of extended isolation on astronauts during space missions.

Nursing Research Questions on Mental Health Care

• How does childhood trauma impact the development of borderline personality disorder in adulthood?
• What communication strategies are most effective for nurses interacting with patients diagnosed with schizophrenia?
• How do socioeconomic factors contribute to disparities in accessing mental health care services?
• What psychological effects arise from prolonged hospitalization among pediatric patients ?
• Which interventions yield the best results in preventing suicide among LGBTQ+ youth?

Essay Topics & Examples on Mental Health Care

• The Role of Nurses in Raising Mental Health Awareness in Educational Settings.
• Scrutinizing the Ethics of Involuntary Psychiatric Treatment: Balancing Patient Rights and Public Safety.
• Unpacking the Psychological Toll of the COVID-19 Pandemic on Healthcare Personnel.
• Tackling the Stigma of Mental Illness : A Nursing Perspective.
• Integrating Complementary Therapies in Psychiatric Nursing: Challenges and Benefits.

In their journey toward nursing professionalism, embracing the intricate realm of mental health care is vital. The PICOT questions, project concepts, research themes, and essay ideas shared here form a solid foundation for meaningful exploration and impactful contributions to the field. By immersing themselves in these avenues, nursing students can cultivate a profound understanding of mental health care, preparing them to offer holistic, patient-centered care that tends to both physical and psychological needs. Contact our writing services for those seeking additional guidance in crafting impactful academic work.

FAQs: Exploring Mental Health Care in Nursing

Q1: Why is mental health important in nursing?

A1: Mental health plays a pivotal role in nursing as it contributes to patients’ overall well-being. Addressing mental health challenges enables nurses to provide holistic care, acknowledging the interconnectedness of physical and psychological health.

Q2: What are the 4 principles of mental health nursing?

A2: The four principles of mental health nursing encompass building therapeutic relationships, promoting autonomy and self-determination, providing evidence-based care, and fostering a safe and supportive patient environment.

Q3: What are the different types of mental health nurses?

A3: There are various types of mental health nurses, including psychiatric-mental health nurses, geriatric psychiatric nurses, child and adolescent psychiatric nurses, and forensic psychiatric nurses, each specializing in different patient populations and settings.

Q4: What are the 6 C’s of nursing?

A4: The 6 C’s of nursing are Compassion, Competence, Communication, Courage, Commitment, and Care. These principles guide nurses in providing patient-centered care that encompasses both physical and psychological well-being.

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Nursing Students’ Perceptions of Effective Factors on Mental Health: A Qualitative Content Analysis

Roghieh sodeify, phd.

1 Department of Medical-Surgical Nursing, School of Nursing, Khoy University of Medical Sciences, Khoy, Iran

Fatemah Moghaddam Tabrizi, PhD

2 Reproductive Health Research Center, School of Nursing and Midwifery, Urmia University of Medical Sciences, Urmia, Iran

Background:

Mental health is a fundamental and widespread concept with individual meanings. The purpose of this study is to perceive and clarify the factors influencing mental health from the perspectives of nursing students

The present qualitative study was conducted in Khoy, Iran from July-December 2018. Twenty nursing students were selected as the research participants through purposeful sampling method and interviewed using semi-structured in-depth interviews. All interviews were recorded, transcribed, and then analyzed with Graneheim and Lundman’s approach of conventional content analysis. The Trail version of the MAXQDA 10 software was applied to conduct the coding process

Data analysis revealed four themes and 12 sub-themes. The themes included feeling of self-worth, religious beliefs, socio-economic factors, and behavioral factors.

Conclusion:

The results showed that mental health in nursing students is a multidimensional phenomenon and is influenced by various factors. The current results could help the nurse educators to intervene and provide suitable, effective, practicable, and culture based mental health services and also help the nursing students achieve mental stability. Therefore, it is suggested that further qualitative and interventional studies should be conducted in this area

I NTRODUCTION

Mental health is one of the most important requirements of man and an important aspect of health. As defined by the World Health Organization (WHO), health means full physical, mental and social well-being, and it doesn’t refer to the lack of illness or infirmity. 1 The central part of health is mental health because all health-related interactions are carried out mentally. 2 Health is a perceptual concept based on learning, values and beliefs of each individual who is influenced by the environment, family, and community. If the concept of health is understood abstractly, its effects in life will not be clear. 3

Several definitions of mental health have been made: lack of mental illness, emotional balance, social harmony, feeling of comfort, integrity of personality, self and environmental awareness, ability to play a social, physical and emotional role, ability to co-ordinate with others, modification and improvement of the individual and social environment, resolution of conflicts and personal preferences logically, fairly and appropriately, the ability to adapt to the normal stresses of life, and finally self management. The concept of mental health, according to the WHO, refers to a status beyond the absence of mental disorders and it includes mental well-being, self-efficacy, autonomy, competence, social relations, social communication, prosperity, and intellectual and emotional potentialities. 4 , 5

Many factors affect mental health. Researchers consider reasons such as personality structures and cognitive and attitudinal components such as hope, optimism, empathy, affiliation, forgiveness, religion and spirituality in the stability of a sense of well-being and health. 6 , 7 Studies have shown that those with a high psychological well-being also have a better physical health. These people are generally happy, optimistic, and positive, and have emotional stability, self-esteem, and high self-efficacy. High mental health is positively associated with the logical perception of others and negatively associated with suicidal ideation, unprofessional behavior and burnout. 8

The results of many studies in and out the country (IRAN) show that nursing students have lower general and mental health than other health related disciplines and non-medical students. 9 , 10 In fact, nursing education does not create a suitable environment for nursing students. According to the nursing education curriculum, nursing students, in addition to learning theoretical courses, are placed in various clinical settings to acquire knowledge, skills and clinical judgment to achieve professional competence. 9 During this period, they experience stressful events that affect their personal and professionals life. 11 Some previous researches in this area also revealed that stressors which affected the students’ mental health were related to academic training. The most common stressors included ‘stress experience in the educational environment’, ‘relationships at work’, ‘issues of death and suffering, ‘inadequate knowledge and training’, ‘insufficient hospital resources’, and ‘communication and procedural aspects of client care’. 12

The consequences of a meta-analysis study in Iran during a 23-year period between 1991 and 2015 showed that the prevalence of mental disorders among students in Iran using random models was 33%. Unfortunately, the prevalence rate showed an increasing rate over time while in other countries this rate was below 20%. 13 Previous studies conducted in United States, Iran, Singapour, India, and Malaysia showed that mental health issues are a growing concern among college student 14 , 15 and depression, alcohol use, stress, low sleep quality, excessive daytime sleepiness, and anxiety are major mental health problems among nursing students. 8 , 16 The results of another study which assessed the general health of nursing and other health related disciplines students indicated that mental disorders were observed 19.5%. 17 Findings of some studies showed that a very small percentage of nursing students had a good status of happiness as an indicator of the mental health. Happiness was claimed to be essential in developing nursing students as future nurses since happy nurses are more energetic, creative, successful, sociable, and more interested in caring. 18 , 19 In general, the results of most empirical research indicate that nursing students are at a relatively poor level of mental health which could have undesirable personal and professional consequences. 4 , 8 , 9 In fact, major changes in the social, family, and personal life of the nursing students and experience of traumatic events in various clinical setting can lead to some psychological problems. Considering the fact that young people and university students include more than one third of the whole population of Iran, it is important to be aware of their perceptions of the factors affecting mental health. Nursing educators are always concerned about the knowledge and skills of nursing students. One of the obstacles in this regard is mental health problems. Therefore, the researchers tried to get deeper understanding about the factors affecting nursing students’ mental health. Regarding the fact that mental health is formed in the socio-cultural context and due to low knowledge about the mental health of nursing students, the researchers decided to use nursing students’ own experiences to discover and deeply understand this phenomenon. Thus, they chose the qualitative content analysis method to perceive and clarify the factors influencing mental health from the perspectives of nursing students.

M ATERIAL AND M ETHODS

The present qualitative study using content analysis approach was conducted in Khoy, Iran during July-December 2018. In accordance with qualitative research, sampling was started with purposeful method and done with theoretical sampling with maximum variation. In the purposeful sampling, the researcher is looking for those who have a rich experience of the phenomena under the study and have the ability and desire to express it. 20

The participants in this study were 20 nursing students who were studying at Khoy Medical Science University, Iran. The inclusion criteria for the study were having at least one semester of university experience and willingness to express their own experiences. Exclusion criteria for the study were having a mental or physical illness during the previous year based on the participants’ own self report.

Data collection was done through in-depth semi-structured interviews. The time and place of the interviews were agreed upon by the parties and they were conducted in a private class at the university by the first author. In the first instance, the researcher initially referred to the participants and presented the purpose of the research and if they were willing to participate in the research, an interview was scheduled. The open questions were designed as an interview guide to provide an open and interpretative response and follow-up questions were asked after the interviewees’ responses. The general question in all interviews was: When do you feel you have mental health and when not? Which factors increase or decrease your mental health? As the interview went on, more detailed questions were asked about the influential factors (inhibitors or facilitators) expressed by the participants. The duration of interviews varied from 30-50 minutes. The guiding principle in the sampling of qualitative research is the saturation of the data to the extent that no new data is obtained. 20 In general, 20 interviews were conducted with 20 students to achieve theoretical saturation. No new data or concept was obtained after analyzing the last (18th) interviews. However, two more interviews were conducted to ensure data saturation. Data analysis process was carried out continuously and concurrently with data collection.

Interviews were analyzed using Graneheim and Lundman’s (2004) conventional content analysis guidelines. 21 (i) The recorded interviews were transcribed (ii) The researchers listened to the recordings and reviewed the transcripts several times to find the meaning units. (iii) The meaning units from the statements of the participants were extracted in the form of initial codes. (iv) Codes were categorized according to the conceptual similarities to be minimized. (v) This trend continued across all the analysis units until themes and subthemes emerged. Each interview was recorded and typed in MAXQDA software, version 10.

Guba and Lincoln’s criteria were used to assure the trustworthiness and rigor of the data. Credibility was achieved by reviewing the transcripts by participants themselves and using their complementary ideas as well as the prolonged engagement of the researchers with the data. For conformability, peer examination was done on the process of the work and research findings. For transferability, an extensive description of details regarding the methodology and context was included and sampling was done purposively. And finally for dependability, all accomplished activities were recorded precisely from the first step of the study. 22

This study was approved by the research ethic committee of Khoy Medical University (IR.KHOY.REC.1398.005). Written informed consent was signed by all participants. They were made aware of ethical, confidentiality (anonymity in publishing) and voluntary participation principles and recording of their interviews.

The participants in the study were in the age range of 20-24 years. They were 12 female and 8 male undergraduate nursing students from different semesters ( Table 1 ). The analysis of the findings from the interview resulted in the extraction of four themes. They were classified as: feeling of self-worth, religious beliefs, socio-economic factors, and behavioral factors. ( Table 2 ).

Demographic characteristics of the participants

Themes and sub-themes extracted from the interviews

Theme 1: Feeling of Self-Worth

Throughout the interviews, nursing students with various statements tried to express this important theme that their mental health is influenced by factors affecting their feeling of self- worth, and as long as students have a positive perception of themselves, their mental well-being will increase. The components of the feeling of self-worth in this study include: ‘confirmation’, ‘success’, ‘autonomy’, ‘self-acceptance’, and ‘hope’ that are discussed in detail below. In fact, students described in a variety of ways how to gain feeling of self-worth for mental health.

1.a. Confirmation

Participants believed that when they received positive feedback from others and were confirmed, they were both satisfied and mentally health.

“People around you have a lot of influence. For example, when your parents accept, care about, and listen to you well, you feel quite well off, but when they say come on, forget it, and she’s really young, you feel worthless and upset” .(p.4)

1.b. Success

Most participants say that they feel relaxed when they feel successful or have a successful experience of overcoming problems.

“I think mental health is a sense of success. When your work is done successfully, it has a good effect on your minds. Imagine you are in charge of a task and you are just cutting the mustard” .(p.18)

“When you fulfill your colleagues’ expectations and reach the required standard, you feel relaxed” .(p.10)

1.c. Autonomy

Participants said that they had psychologically good feelings when parents or relatives did not create a constraint for them, or when they felt independent and were able to manage their own affairs a and make decisions or once others respected their decisions, they were emotionally well-off. But when faced with resistance, they did not experience a good psychological feeling.

“I feel psychologically healthy when I am independent in my own work and decide for myself. We youth need to be free, we need to think independently” .(p.10)

“When my friends and acquaintance give me power and freedom and respect my decision, I feel psychologically healthy” .(p.5)

1.d. Self-acceptance

Participants thought someone as a healthy person if s/he values himself and accepts him/herself with all the weaknesses and abilities.

“To have mental health, first of all, one needs to accept herself/himself, I value my own self. I accept myself as I am” . (p.15)

Participants believed that having hope for the future was also the key to health. They expressed hope as a driving force behind the development of mental health.

“When you have the hope of life, you are healthy; that is, there is something that pushes you forward” .(p.8)

Theme 2: Religious Beliefs

Another extracted theme of the study was religious beliefs. This theme consisted of ‘participating in religious ceremonies’ and ‘reciting the holy Quran and other religious books’.

2. A. Participating in religious ceremonies

Students asserted that participating in religious ceremonies, praying and asking God to provide help to meet their needs, help them overcome the problems and make them feel calm and relaxed.

“When I attend religious ceremonies, I feel well at the time” . (p. 3)

2.b. Reciting the holy Quran and other religious books

Students stated that they were turning to religious books when they felt lonely, depressed and troubled, and thus became mentally relaxed.

“Whenever I feel depressed or bored, either physically or mentally, I prefer to recite the holy Quran or pray. It helps me feel calm” .(p.5)

“I don’t feel lonely by reciting the holy Quran and thinking about God” .(p.7)

Theme 3: Socio-Economic Factors

Socio-economic factors were one of the most important and influential experiences in the mental health. This theme consisted of ‘social support’ and ‘economical support’.

3. a. Social Support

Students expressed that when they had a sense of family support and had suitable social relationships, such as the ability to communicate with parents, family, friends or university teachers, they felt mentally relaxed, and vice versa. This information empowered them.

“When your family understands you, you feel happy, but sometimes they cause you feel disappointed and depressed. Sometimes, they don’t live up to your expectations” .(p.6)

“My parents always remind me to inform them if any problem occurs, and I always do it. When I keep them posted on how my works go on, I feel mentally relaxed” .(p.17)

“When I’m getting along with my friends well, I feel mentally relaxed but when it is hard to get along with them or dispute a problem with them, I feel bored and tired” .(p.5)

“When I don’t behave like my friends, they often reject me or taunt me. They are the reasons to drive me up the wall” .(p.15)

“When you are in an environment where you feel you have a supporter, for example, a professor who can help you solve your problems, you can tolerate everything and you feel mentally sound” .(p.10)

3. b. Economical support

Students expressed that having at least the financial resources and having fun with their friends made them feel happy and ultimately mentally healthy. But they did not feel happy when they themselves had to work to meet their own education costs and when there was no possibility of having fun because of financial problems.

“Nowadays, being well off can calm you down mentally. When you have some money to have fun with, then you’re happy” .(p.13)

“It makes you upset when the prospects for the job are unclear or when you’re not sure what the future holds” .(p.18)

“When you have to work hard to help fund your studies, when you cannot go out and have fun with your friends, when you cannot dip into your own pocket, it is then that you feel small and humiliated” .(p.20)

Theme 4: Behavioral Factors

This theme includes the following sub-themes of disengagement, exercise, and balanced use of social networks. During the interviews, students often pointed to the role of these factors in mental health. According to the expressed experiences, nursing students described some behavioral factors in maintaining mental health and reducing their stress. They struggled to gain psychological stability by refraining from encounter with problems, physical and sports activities, which were often irregular, and also having self-control over the use of cyberspace.

4.a. Disengagement

Most participants stated that they were not involved in problems to maintain mental peace. They used ineffective mechanisms to solve problems such as avoidance and escape from problems.

“There are so many problems to which I do not want to think about. I try to avoid problems myself” .(p.15)

4.b. Physical exercise

Participants expressed that by exercising; they reduced their mental conflicts and experienced a sense of mental relaxation.

“The days I exercise myself or go to the gym, I feel happier. It makes me get rid of some intrusive thoughts. It helps you forget your daily problems for a few hours” .(p.13)

4. c. Balanced use of social networks

Another factor that participants felt to be effective in the sense of mental health was the balanced use of social networks and believed that excessive use of it caused anger and nervousness.

“I have a roommate who is always head over heels for social media. When you talk to her, she starts shouting and fighting. It has made her very nervous” .(p.7)

D ISCUSSION

The results of this study showed that there are many factors influencing the students’ perceptions of mental health. Data analysis revealed four themes and twelve sub-themes. The four themes were classified as: Feeling of self-worth, religious beliefs, socio-economic factors, and behavioral factors.

The feeling of self-worth theme included the five sub-themes of ‘confirmation’, ‘success’, ‘autonomy’, ‘self-acceptance’, and ‘hope’. Participants believed that when they received positive feedback from others and were confirmed, or when they were trying to succeed, or when they felt more autonomous, highly self-confident, ‘self-acceptance’, and hopeful, they found a positive perception of themselves, and this contributed to their mental well-being. Findings of some studies showed that there was a significant reverse correlation between self-reported stress and self-acceptance. This finding emphasized the importance of creating a sense of positive self-perception and self-confidence among nursing students to improve their mental health. Indeed, self-confidence in nursing students was considered as a buffer and protective shield in the face of stress and prevented mental disorder. Thus, the nursing students who have a sense of self-esteem have a high ability to communicate and can play an effective role in the development of the profession, handle fatigue and pressure, and positively impact the interpersonal relationships, quality of care, and job satisfaction. 23 , 24

The participants in the present study considered autonomy as an effective factor in creating positive sense of self-worth and in achieving mental well-being. The findings of this study are in line with those of a research done in Iranian context in which the researchers studied the concept of health in adolescents’ point of views. They expressed that autonomy and sense of independence is another key factor affecting health. They also continued that preventing adolescents and young people’s access to independence and posing unfair and undeserved restrictions for them can lead to some unsatisfactory consequences such as depression, hiding, urging, recklessness and immorality (night party, runaway, cigarette smoking, and addiction) and double dealing. 25

Another key sub-theme of the study was ‘hope’. The findings of the present study showed that those nursing students who had hope for the future had a better psychological feeling. Findings of a study conducted in Turkey reveled that university students have some negative mental states such as hopelessness and suicidal behavior. Their findings suggest that there are significant correlations among life satisfaction, hope, and mental health. 26 In fact, having self acceptance and positive self-image can act as a social protection factor against stress and anxiety. Those who feel good about themselves and are more confident also have a good sense of life and can successfully face problems and are able to handle them easily. Hope also makes life meaningful. It prevents us from mental breakdown and protects us from harmful situations. 6 In sum, it is argued that self-acceptance has been inversely associated with depressive symptoms, anxious symptomatology, and disruptive behaviors.

Another important theme of the research was religious beliefs. Participants stated that they felt mentally healthy when they participated in religious ceremonies. We know different religions have different beliefs. Several studies have shown a reciprocal relationship between different religious beliefs and mental health. The findings of research in Hindu system of beliefs showed that there was a significant negative correlation between the components of religious commitment, beliefs, and emotions, and components of general health (physical complaints, anxiety, depression and social dysfunction). They also proved that religion had a protective and supportive role for teenagers. 27 Another study conducted in Iranian context revealed that religiosity attitude was considered as a main factor affecting self-esteem and psychological hardiness and could promote psychological well-being. 28 Hence, institutionalizing of this religious teaching, trust in God, by health service developers and planners seems to be necessary in confronting the disruptive factors in mental health.

Another theme was socio-economic factors Participants in the present study described their mental health with various statements. Receiving emotional and spiritual support from family, friends, and university professors and their proper relationships, their empathy and verbal attention helped the students’ mental health. Indeed social support gives students a perception of being loved, cared, respected, and belonging to communication network. The results of the present study are in line with those reported in other studies. 29 , 30 In the present study, poor economic conditions had negative effects on the students’ perception of mental health. Economic deprivation, lack of a bright futures, and unemployment were regarded as mental and annoying concern which was affecting the mental health of the majority of participants. Generally, poor mental health is related to poor economic conditions. WHO states that mental health is determined by socio-economic and environmental factors, and economic crisis is likely to negatively affect the mental health. 31 Another study also mentioned that economic crisis can be associated with a higher use of prescription medications and an increase in hospitalization for mental disorders. 32

The last theme extracted from the study was behavioral factors. Participants stated that they do some behaviors such as disengagement, physical exercise, and use of social networks to relive stress.

Disengagement from problems is an avoiding and ineffective strategy to deal with stress. Therefore, it is necessary to provide students with the necessary training on effective coping strategies. Some studies have reported adverse coping strategies such as drinking alcohol, smoking, and waterpipe. 33 , 34 Participants in this study did not state the use of these materials perhaps because of the embarrassment and unfavorable views toward those who consume these materials in Iranian Islamic culture. In a qualitative study conducted in Malaysia, students showed that they used effective adaptive strategies and did not use undesirable behaviors. 35

In this study, nursing students expressed exercise and physical activities as another type of solution or strategy to achieve mental health. Although these activities were carried out irregularly and restrictively, they were described as useful in reducing daily stress. The results of a study in this area showed that increased physical activity which has been associated with life satisfaction, happiness, and positive attitude toward life can lead to the promotion of physical and mental health. 36

The balanced use of social networks was another subtheme of the study. Students argued that the high use of cyberspace or social networks has harmful effects on the nerves .Internet addiction and its association with mental distress can impact their academic achievement and long term career goals among medical students. Internet addiction would also indirectly impact the community of health care professionals and the society. There was a significant relationship between the student internet addiction and anxiety symptoms. 37 The results of another study showed that severe prevalence of internet addiction among nursing students was associated with poor mental health and depression without any impact on academic performance. 38

The strength of this study is that it increases our knowledge of the factors affecting the mental health of nursing students as a qualitative study conducted for the first time in Iran. However, as it is common for all qualitative studies, the results of the study cannot be generalized to other contexts and disciplines. Future qualitative and interventional studies are also suggested to be carried out in other contexts and on the students of other disciplines.

C ONCLUSION

The results showed that mental health in nursing students is a multidimensional phenomenon and is influenced by various factors. The current results could help the nurse educators to intervene and provide suitable, effective, practical, and culture based mental health services and help the nursing students achieve mental stability. Promoting physical activities among nursing students, training problem-solving skills and activating the student counseling centers at universities are suggested. Nurse educators and clinical psychologist can provide opportunities for nursing students to express their own concerns and learn the strategies to cope with crises. Finally, deep religious and moral beliefs can be effective in providing mental health to students.

A CKNOWLEDGEMENT

First, the researchers express thanks to the University of Medical Sciences, Khoy, Iran, for its support in carrying out this study. (Grant no. 1018). Our special thanks go to the nursing students who were voluntarily interviewed. Without them, this study would not have been possible. Their honesty and commitment were essential in carrying out this study.

Conflict of Interest: None declared.

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Risk factors and consequences of mental health problems in nurses: A scoping review of cohort studies

Affiliations.

• 1 Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China.
• 2 National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China.
• 3 Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China.
• 4 School of Computer Science and Engineering, Central South University, Changsha, Hunan, China.
• 5 Central South University, Xiangya Nursing School, Changsha, Hunan, China.
• 6 Department of Thoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China.
• 7 Department of Neurosurgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China.
• 8 School of Nursing at Ningxia Medical University, Yinchuan, Ning Xia, China.
• PMID: 38622945
• DOI: 10.1111/inm.13337

Mental health problems in nurses are prevalent and impairing. To date, no literature has comprehensively synthesised cohort evidence on mental health among nurses. This scoping review aimed to synthesise the existing literature on the risk factors and consequences of mental health problems in nurses. A systematic search was conducted on PubMed, EMBASE, Epistemonikos database, Web of Science, CINAHL, and PsycINFO from inception to March 2023. We identified 171 cohort studies from 16 countries, mostly (95.3%) from high-income economies. This review indicated that nurses worldwide encountered significant mental health challenges, including depression, cognitive impairment, anxiety, trauma/post-traumatic stress disorder, burnout, sleep disorder, and other negative mental health problems. These problems were closely related to various modifiable risk factors such as nurses' behaviours and lifestyles, social support, workplace bullying and violence, shift work, job demands, and job resources. Moreover, nurses' mental health problems have negative effects on their physical health, behaviour and lifestyle, occupation and organisation, and intrapersonal factors. These findings provided an enhanced understanding of mental health complexities among nurses, and shed light on policy enactment to alleviate the negative impact of mental health problems on nurses. Addressing mental health among nurses should be a top priority.

Keywords: cohort study; mental health; nurse; risk factor; scoping review.

© 2024 The Authors. International Journal of Mental Health Nursing published by John Wiley & Sons Australia, Ltd.

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