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Improving mental health education in nursing school

Bennett, Courtney DNP, PMHNP-BC, FNP-BC

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doi: 10.1097/01.NURSE.0000769868.09336.15
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FOR YEARS, NURSING has been ranked the number one trusted profession in the annual Gallup Poll of trusted professionals.1 As one of the largest groups of healthcare professionals, nurses provide care across the life span in a variety of settings. During the COVID-19 pandemic, nurses have been embraced nationwide as modern-day heroes. That perception is grounded in a tradition of excellence in nursing education and the efforts of institutions to build a strong, competent, and diverse nursing workforce.

However, within an ever-changing healthcare system is a need for increased mental health education among nurses. Mental health is an integral component of the well-being of all individuals and should be integrated into primary healthcare.2 The World Health Organization (WHO) acknowledges that health is more than merely the absence of disease or infirmity. Rather, it is “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.”2

Because mental and physical health are interconnected, both should be closely connected in the undergraduate education of nurses. This article discusses the nurse's role in providing care to individuals with mental illness and the importance of integrating more mental health education into undergraduate nursing curricula.

Examining the evidence

Nurses have historically been educated to care for patients with complex psychiatric disorders in both primary and behavioral health settings. Yet, despite this education, the WHO has found that many nurses are inadequately prepared to provide mental health care.3 Despite the availability of literature concerning the importance of mental health, mental illness risk factors, and mental health-related disparities, mental health promotion and disease prevention continue to be minimized in mental health education.4

An exploratory descriptive study was conducted in a metropolitan ICU located in Melbourne, Australia, to survey the attitudes, skills, and knowledge of ICU nurses caring for patients with mental illness.5 The study found that the ICU nurses felt they needed more training and education to care for patients with mental illness in the ICU.5 While many of these nurses believed that mental health care is important, stigma and stereotyping was also apparent.5

Similarly, in a study conducted by Wolf and colleagues, ED nurses felt underprepared to care for patients who presented to the ED with behavioral health concerns. Lack of education was one of the contributing factors.6

Other studies suggest that nurses in acute medical care settings find it challenging to care for patients with comorbid physical and mental illnesses and that undergraduate training is often not considered adequate for mental health literacy.7 Stereotyped views and stigma toward individuals with mental illness can also negatively affect the nurse-patient relationship.7 The quality of educational preparation and clinical time in mental health is critical to preparing undergraduate nursing students in the care of patients with mental illness.

Prevalence and disease burden

Approximately one in five adults worldwide is affected by a mental disorder.8 Mental illness is the largest contributor to disability worldwide and causes extensive personal suffering and economic costs.9 According to the WHO, mental disorders account for 13% of the global burden of disease, with major depressive disorder carrying the heaviest burden.10,11

The Substance Abuse and Mental Health Services Administration (samhsa) estimates that in 2018, 47.6 million adults in the US had a mental illness, 20.3 million had a substance use disorder, while 9.2 million had both a mental and substance use disorder (co-occurring disorders). Yet of disease, with major depressive disorder carrying the heaviest burden.10,11

The Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that in 2018, 47.6 million adults in the US had a mental illness, 20.3 million had a substance use disorder while 9.2 million had both a mental and substance use disorder (co-occurring disorders). Yet less than half (43.3%) utilized mental health services.12

The gap in treatment is partially due to lack of access to care and shortages of mental health professions, which is expected to continue to rise nationwide.13-15 Other factors that contribute to the gap in treatment include patients' inability to afford treatment expenses and/or lack of insurance coverage, stigma, patient perception of treatment, lack of anonymity, limited access to transportation, lack of knowledge of locations of treatment facilities, residence in a rural or underserved community, lack of culturally competent care, and low insurance reimbursement rates.16

In addition, individuals with mental illness have an increased risk of developing complications such as type 2 diabetes, heart disease, and stroke.17 Individuals with mental illness are twice as likely to die prematurely from preventable health disorders.13,18 These findings may result from the barriers cited above as well as poor health literacy and greater exposure to risk factors for illness such as smoking, heavy alcohol use, and obesity.19 The education and training of nurses is essential for bridging mental health literacy gaps, improving access to mental health services, improving patient-care outcomes, and reducing stigma surrounding mental illness.20,21

Role of nurses

Nurses are at the forefront of providing care to individuals with mental illness in various healthcare settings. They help promote early identification of mental illness and assist in preventing further health decline. Working alongside other healthcare professionals with the goal of improving patient-care outcomes, nurses provide a safe and supportive environment.

Nurses educate and provide support to not only the patient with mental illness but to the family as well. Also, as mental health treatment transitions from the institution to the community, nurses often fulfill the role of case manager, care coordinator, and patient advocate.22

The education of nurses in mental health is essential to improving the recognition of mental disorders in primary health care and the referral of patients to specialized mental health providers to prevent treatment delays.3 According to the American Association of Colleges of Nursing, “Quality patient care hinges on having a well-educated nursing workforce. Research has shown that lower mortality rates, fewer medication errors, and positive outcomes are all linked to nurses prepared at the baccalaureate and graduate level.”23

Strategy Rationale
Attain the competency-based American Nurses Credentialing Center Psychiatric-Mental Health Nursing Certification
  • validates and strengthens nurses' knowledge about caring for patients with psychiatric disorders

Seek membership in professional psychiatric nursing organizations on local, state, and national levels
  • encourages nurses to remain up-to-date on current practices

  • gives nurses role-related competencies, continuing-education opportunities, certifications, educational conferences, and networking opportunities

  • allows nurses' voices to be heard and be at the forefront of practice changes

Seek professional development opportunities
  • enhances professional nursing practice and helps nurses remain up-to-date on current practices

Subscribe to professional nursing journals
  • provides current and evidence-based information

Seek internship and fellowship opportunities at mental health centers
  • provides additional mental health training and learning opportunities

Enroll in the American Nurses Association Mentoring Program
  • provides flexible learning opportunities

  • pairs nurses with more experienced nurses for career advice

Seek educational pathways to advance education (for example, by earning a BSN, MSN, DNP, or PhD)
  • helps nurses meet the complex demands of healthcare and learn advanced techniques to improve patient care

Educational challenges

Quality of mental health nursing care depends on a well-educated nursing workforce.3,24 According to the landmark report The Future of Nursing: Leading Change, Advancing Health issued in 2011 by the Institute of Medicine (now the National Academy of Medicine), nurses should achieve higher levels of education and training.23 Nursing education should also “serve as a platform for continued lifelong learning and include opportunities for seamless transition to higher degree programs.”3,24

Healthcare systems change regularly, even in the area of mental health, as do technology and treatment modalities. Mental health education is critical to preparing nursing students to care for patients with mental illness and working collaboratively with other healthcare professionals. However, preparing nurses to meet this responsibility is not without challenges.

Mental health education is initially introduced in classroom settings by nurse educators who play a pivotal role in preparing nurses with the necessary skills and education for the workforce. Nurse educators design, implement, and teach the required mental health curriculum, which includes the responsibility to provide education that fosters empathy, respect, and inclusivity for patient with psychiatric illnesses.25,26 However, the shortage of nurse educators often causes mental health content to be taught by faculty with little to no mental health clinical experience, which can undermine the learning experience.27

Another challenge is aging and retiring faculty—the average age of doctoral-prepared professors is 51.28 Budget restraints, competitive practice sites compensation, increased workload, and fewer nurses with masters and doctoral degrees available to teach have also contributed to this quandary.28

Along with faculty shortages, less instructional time dedicated to the teaching of mental health content compared with medical-surgical content is an issue. Adequate teaching time is crucial for students because mental health competencies are based on the skills and information taught.29

Mental health preparation should be relevant to practice and reflect changes in the healthcare system. For example, mental health care has shifted from acute care units and hospitals to more community-based care, and mental health nursing education should incorporate this change.30

Content vs. concept

In most traditional nursing programs, educational content is taught using a content-based curriculum rather than a concept-based curriculum.31 In a content-based curriculum, extensive information is presented in a short period of time. Although this educational approach provides students with an extensive knowledge base for the National Council Licensure Examination (NCLEX), it allows minimal time for students to apply the information taught. This results in students memorizing information for temporary recall and limits development of problem-solving skills.31

In contrast, a concept-based curriculum provides students with selective information to apply and store in their long-term memories for retrieval. Concept-based curricula is learner-centered and focuses on understanding concepts using examples to facilitate active learning in which students are required to demonstrate application of the concepts in clinical contexts.31

Utilizing a concept or set of concepts helps students to understand the content more thoroughly, thereby increasing their level of learning.31 Adopting a concept-based curriculum requires nursing educators to learn new ways to present concepts and examples in classroom activities. Revising or implementing a concept-based curriculum, while not without challenges, is one method that can help lessen the gap between practice and education.31

Clinical challenges

Clinical learning plays an important role in the development of practical nursing skills, yet nursing students spend less clinical hours in mental health sites than in medical-surgical settings.32 For example, nursing students may spend 12 clinical hours each week for 10 weeks in a medical-surgical rotation but only 8 hours each week for 3 to 4 weeks in a mental health rotation. This limits students' exposure to critical knowledge that could be gained in the clinical setting. Although only an estimated 4% of RNs enter the workforce in mental health and substance abuse settings, all nurses at some point in their career will encounter a patient with a mental illness and they must be prepared to provide care.33

Mental health clinical rotations also focus primarily on patient communication and group therapy, often at the expense of nursing skills such as physical assessment and medication administration. This limitation has the potential to reduce students' perception of integrated care, for most individuals with mental health disorders also present with comorbidities such as diabetes, hypertension, obesity, and hypothyroidism. Some health disorders such as delirium can also mimic mental illness and nursing students must learn to recognize the difference. Mental health clinicals should provide students with learning opportunities that address the full spectrum of mental health care from admission to discharge.

Limited mental health clinical sites also present challenges and have led many nursing programs to utilize simulation.34 Although simulation is beneficial for giving students the opportunity to increase their understanding of mental illness and develop empathetic care practices, it does not replace interactive contact with patients who have mental health issues.34 Interactive contact is vital to help nursing students develop and enhance positive and trusting therapeutic relationships with patients and improve health-related outcomes.35

Most nursing programs also require undergraduate students to complete a practicum or internship before graduation in a medical setting to gain supervised practical experience and observe the role of a nurse. However, the option of a mental health practicum or internship is rarely if ever offered. This greatly impacts developing students' attitudes toward mental health and decreases the likelihood that they will choose a career in psychiatric nursing.36

Nursing students are often apprehensive about caring for patients with psychiatric disorders because they assume these patients are dangerous, incompetent, and impulsive.37 Education about clinical safety and de-escalation of aggressive or potentially violent behaviors should not be limited to mental health clinical rotations as this content is applicable in any setting.

The stigma associated with mental illness can also cause nurses to view a career in mental health as less favorable, which is another challenge for educators to overcome.38 Nurse educators are the key to breaking the cycle of stigma associated with mental illness and substance use disorders.

In a descriptive online survey examining students' perceptions of mental health nursing among colleges in the midwestern US, students receiving preparation in clinical practice demonstrated a greater sense of preparedness for practice in mental health nursing, held fewer stereotypes associated with mental illness, and reported lower levels of anxiety while working with individuals with mental illness.15 The more exposure students have to mental health nursing through clinical experience and theory, the better prepared they are to care for individuals with mental health issues.15,36 Students are also more likely to consider careers in mental health nursing.36

Adopting effective educational strategies

Educating Nurses: A Call for Radical Transformation identifies four changes nurse educators can utilize to meet the demands of health care:24

  • focus on concrete concepts in content and thinking that can be applied to practice (for example, a patient with anxiety may also exhibit tachycardia and tachypnea)
  • extend practice to the classroom (for example, case studies, role play, simulation)
  • expand critical thinking to include multiple ways to think (for example, scientific reasoning, clinical reasoning, clinical imagination)
  • include intentional methods to internalize ways to develop professionally in nursing (for example, continuing education, advanced learning opportunities).

Nursing education is traditionally taught in large amounts of information, often leaving students with little to no time to develop problem-solving skills. Eventually, faculty will need to adopt new ways to present concepts and activities that promote learning and problem-solving skills.31 Utilizing those essentials can also help nurse educators in closing practice-education gaps and better prepare nurses to meet the complex healthcare needs of patients.24,31

Nurse educators can utilize teaching based on the Quality and Safety Education for Nurses (QSEN) competencies, which may help change some of the stigma and negative attitudes about those with mental health disorders.39 The QSEN competencies include patient-centered care, teamwork and collaboration, quality improvement, evidence-based practice, safety, and informatics.39 QSEN's overall goal is to promote quality and safe patient care.39 For additional strategies nurse educators and nurses can utilize to improve mental health nursing education, see Nursing strategies to improve mental health education.29,31

In an ever-changing healthcare system, nurses must be educationally prepared to care for the complex needs of patients with mental health disorders and concurrent physical health disorders. Nurse educators must be willing to tackle these challenges to ensure educational content is delivered in a manner that promotes learning and develops a nursing workforce prepared to meet the demands of healthcare services and provide safe and high-quality care.


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    behavioral health; mental health education; mental health nursing; mental illness; nursing education

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