Positioning Psychiatric and Mental Health Nursing as a Transformative Force in Health Care

Abstract

From the perspective of psychiatric and mental health nurses in Sweden, this discussion paper aims to position psychiatric and mental health nursing as a transformative force contributing to enforcing person-centered values and practices in health care. We argue the potential impact of psychiatric and mental health nursing on service user health and recovery, nursing student education and values, and the organization and management of health care. Psychiatric and mental health nursing is discussed as a caring, reflective, and therapeutic practice that promotes recovery and health. Implications for nursing education, research, management, and practice are outlined.

Introduction

More than twenty years ago Barker et al. (1999) asked: “What are psychiatric nurses needed for?”. They concluded that psychiatric nurses are in a position where they can coordinate lines of communication and actions to deliver appropriate psychiatric and mental health care. More important, they also described how nurses due to the nature of their professional work have an unique opportunity not only to know about the patient but getting to know the person. Even though the paper by Barker et al. rather focused on how nurses need to balance such intimacy in order to care not only for patients’ needs but also for themselves, it positioned psychiatric nursing as a profession with specific responsibilities and opportunities.

However, since 1999 society as well as health care systems have changed. In Sweden, as in other countries, the benefit of psychiatric and mental health nursing and nurses is questioned, most recently since an official report of the Swedish government suggested that psychiatric care should no longer be a nationally regulated nursing specialication (SOU, 2018, p. 77). Instead of specialicing in psychiatric care, nurses should develop general competencies on advanced level. The same report also suggests an advanced specialist nurse education that, in high degree, focus on medical skills as a means to address the shortage of physicians. From the perspective of Swedish psychiatric and mental health nurses this is an alarming development, especially as Sweden is experiencing a critical shortage of nurses specialiced in psychiatric and mental health care (National Board of Health & Welfare, 2014), while also experiencing an increase in mental ill-health (Public Health Agency of Sweden, 2018; Swedish Social Insurance Office, 2016). We consider re-directing resources from psychiatric caring, i.e. from close interaction with patients, to other areas as problematic. We realize, however, that the ability and responsibility to articulate the unique and irreplaceable contribution of psychiatric and mental health nursing as having a unique value by its own lies within the profession. Thus, we take it upon ourselves to argue the further relevance of psychiatric and mental health nursing, and thus also psychiatric and mental health nurses. Even though we primarily address the Swedish context we believe that our main points have relevance also for other countries. We argue that the future of psychiatric and mental health nursing in Sweden lies in psychiatric and mental health nurses clarifying and expanding their scope of practice, and for psychiatric and mental health nursing to further develop as a caring, reflective, and therapeutic practice that promotes recovery and health. Our point of departure is our own experiences as nurses, researchers, and teachers, of psychiatric and mental health nursing as a transformative force in health care. Lexical definitions suggest a transformative force to be a strength, energy, or active power able to cause important and lasting change in someone or something. In this paper we will seek to clarify our understanding of psychiatric and mental health nursing as a transformative force for good that integrates: (1) a practice disposing of powerful approaches, actions, and interventions that can create important and lasting changes in the lives of persons experiencing mental health problems; (2) a body of knowledge entertaining powerful values, ideas, and perspectives that can create important and lasting changes in how health care for people experiencing mental health problems is perceived, organized, and delivered.

Psychiatric and mental health nursing practice is having a significant impact on the health and recovery of service users. Psychiatric and mental health nursing research and theory is making substantial contributions when it comes to developing and managing the organization and delivery of health care. The study of psychiatric and mental health nursing on any level have a profound impact on how nursing students perceive themselves, their role and responsibilities, their practice, and the persons experiencing mental health problems they encounter.

Contributing to person-centered care

The modern health care system is most often fragmented in somatic versus psychiatric care (Happell et al., 2012). Individuals with an impaired ability to express their needs are at risk of being outside everyone’s responsibility and being offered isolated treatments for different types of symptoms even though most health issues derive from a complexity of the person’s entire life situation (Jormfeldt et al., 2018). Even though vague differences regarding the definition of mental health exists between European countries, most countries implicitly adopt a traditional view of health as a lack of symptoms rather than having and maintaining the ability to live a good life regardless of symptoms (Keogh et al., 2017). The holistic and indivisible nature of health are often disregarded (Jormfeldt, 2011). For people with severe mental illness (SMI) there are significant inequalities in physical health (Moore et al., 2015), increasing mortality (Nordentoft et al., 2013), and several years shorter life expectancy compared to the general population (Walker et al., 2015), partly due to stigmatization, insufficient support (Jormfeldt & Hallén, 2016), and side effects of medical treatment. While a more holistic health perspective has developed globally in nursing science during recent decades, nursing practice and nursing research still tend to adopt a view of health that often overlooks the positive dimensions of health, such as physical, social, and mental strengths (Hwu et al., 2001; Keogh et al., 2017).

The shift from institutional to community-based mental health services has been uneven and has stalled in some countries, and people with mental health problems continue to face human right issues of great concern (Turnpenny et al., 2017). Psychiatric and mental health nurses continue to engage in harmful practices in the interest of safety and risk management (Slemon et al., 2017). In the Swedish context Topor et al. (2016) suggests that a network of micro-institutions offering help but also control has replaced the total institutions.

Given this background, it is encouraging to witness an opposing trend emphasizing person-centered and recovery-oriented values in psychiatry and mental health (Gabrielsson et al., 2016). This development is most welcome considering that psychiatric and mental health nurses are struggling to give care according to professional beliefs and values, although practice is sometimes experienced as driven more by the short term needs of the organization than by the needs of patients (Gabrielsson et al., 2016; Graneheim et al., 2014). Also, mental health service users have expressed their needs of being encountered as whole human beings, as opposed to being viewed solely as psychiatric patients, which further strengthens the importance of embracing the multidimensional nature of health without exceptions among mental health service users (Blomqvist et al., 2018). Person-centered care focuses on a meaningful life for the patient and must not be confused with patient-centered care, which focuses on a functional life (Håkansson Eklund et al., 2019). It has been suggested that health care is undergoing a transition toward person-centered care that represents a paradigm shift (Ekman et al., 2011). In Sweden a focused research initiative has contributed to an increased awareness at governmental and policy levels of the importance of person-centered care (Ekman et al., 2015).

A focus on illness and deficits tends to emphasize the patient’s experience of being ill and disabled and, for that reason, psychiatric and mental health nursing need to focus on achieving and maintaining health from an individualized and holistic perspective (Jormfeldt, 2011). The specific competencies required from the mental health nurse embrace the ability to acknowledge and bridge nursing theories of positive aspects of holistic health into concrete health promotion activities through mental health nursing activities across boundaries between different health care organizations and authorities in society (Jormfeldt et al., 2018). Nursing is continuously influenced by changes in socio-political forces, pragmatism, and finances (Clarke, 2006), and so the role of psychiatric and mental health nurses also changes. In Sweden, as in several other countries, an advanced special degree in psychiatric and mental health nursing has evolved; however, confusion exists regarding what the exact role of the psychiatric and mental health nurse actually implies. The advanced degree of specialist nurse in psychiatric care was introduced in 2001 and, arguably, does not reflect the last 20 years of knowledge development in psychiatric and mental health nursing. The Swedish Association of Psychiatric and Mental Health Nurses (2014), however, emphasizes person-centredness in their specification of competencies required of nurses specialiced in psychiatric care. Also, in the European context, Jormfeldt et al. (2018) suggest that master’s level mental health nurses should demonstrate engagement in person-centered nursing practice. We urge psychiatric and mental health nurses to step up and take the lead in enforcing person-centered values and practices. For this to happen we need to clarify psychiatric and mental health nursing as a transformative force in health care.

Psychiatric and mental health nursing

To clearly identify psychiatric and mental health nursing as a transformative force in its own right, we suggest the consistent use of the term psychiatric and mental health nursing when referring to the theory, research, and practice of nursing relating to mental health and/or psychiatric care (Swedish: omvårdnad inom psykisk hälsa och psykiatrisk vård). During the last decades, the concept of mental health nursing and its possible association or difference from psychiatric nursing has been greatly discussed (Hurley & Lakeman, 2011). Mental health nursing is practiced worldwide, but confusion often exists regarding its name (Santangelo et al., 2018a). Santangelo et al. (2018b) suggest that the term should be mental health nursing rather than psychiatric nursing, as psychiatry is often related to the medical profession (Santangelo et al., 2018b). Mental health nursing has been described to be more concerned with the future development of an individual, rather than with the causes of an individual’s mental health problems (Barker et al., 1997). Mental health nursing has also been suggested to comprise ethos, practice, and knowledge and has been conceptualized as a “self-determined discipline incorporating a broad range of knowledge that translates to a holistic practice” (Santangelo et al., 2018a, p. 271). In the psychiatric context nurses embracing recovery and person-centered values might need to partake in care involving the use of a dominant medical terminology, coercion, and psychiatric drugs, suggesting a need for mental health nursing to separate itself form traditional medically oriented psychiatry (Barker & Buchanan-Barker, 2011). While the concept of psychiatric nursing does relate to the psychiatric context, we believe that as long as psychiatry and psychiatric care exists, nursing and nurses have an important role to play in safeguarding and supporting people subject to psychiatric care and treatment. The medical paradigms of care have often dominated mental health care, but the essence of mental health nursing should not be considered inferior to these paradigms (Santangelo et al., 2018b). We propose that psychiatric and mental health nursing should be the concern of both generalist and specialist nurses. While we recognize a primary focus on mental health as a defining feature of psychiatric and mental health nursing, we also recognize the context of psychiatric care as an important domain for psychiatric and mental health nursing. Thus, we propose the use of the term psychiatric and mental health nursing. It is, however, important to emphasize that psychiatric and mental health nursing is not defined by its context, nor limited to psychiatric care. Given a holistic view on health and recovery, psychiatric and mental health nursing as a transformative force have the potential to benefit people with various health care needs in various settings.

Supporting recovery and promoting health

Psychiatric and mental health nursing constitutes a transformative force for good in health care by applying a holistic view to health and recovery, challenging the false and problematic division of human needs of body and mind and the notion that the only outcomes of care that matter are only those readily defined and measurable. A holistic view on health and recovery is supported by The World Health Organization’s (1991) statement that the concepts of health and health potential include both physical and mental health in the context of personal development through life. Furthermore, health has shown to be positively related to subjectively experienced self-esteem, empowerment, and quality of life, and only to a minor extent adversely related to psychiatric symptoms (Jormfeldt et al., 2008). From a health perspective, individual goals and desires are vital and the process of reaching individual goals is a superior pathway toward heath including physical and mental aspects of individual wellbeing (Jormfeldt, 2011). A multidimensional holistic concept of health, regarding individual preferences as a theoretical foundation for mental health nursing, provides opportunities to meet and include the service users’ physical health care needs. Such a perspective constitutes a transition away from the traditional medical perspective with emphasis on illness in terms of deficits in specific organs, to a holistic perspective in which ‘wellness’ is also highlighted. Successful mental health nursing consists of a positive, non-medicalized, strengths-based, and empowering approach toward mental health and mental health users with a focus on building resilience (Lahtinen et al., 2005).

This understanding of health aligns with recovery principles and a recovery-orientation that is person-centered, strengths-based, collaborative, and reflective. Recovery means beginning and completing a highly individualistic journey of healing and improvement to overcome the consequences of mental illness (Topor et al., 2011). By focusing on personal recovery rather than the reduction of symptoms, psychiatric and mental health nursing questions power structures by acknowledging experts by experience as partners in the development and delivery of care. It is important to recognize that recovery approaches have been used as a pretext to limit support to persons with mental health problem (Moth, 2020). However, although a recovery orientation suggests that people with serious mental illness can utilize their experiences and overcome difficulties associated with mental illness and treatment (Deegan, 1988) it also emphasize the contribution of others in enabling such processes through relationships, adequate material conditions, and responsive services and supports (Topor et al., 2011). A recovery-orientation acknowledges that people experiencing mental health problems face discrimination and social exclusion, and that social and structural barriers shape, facilitate, and impede recovery (Morrow & Weisser, 2012). Thus, a recovery-orientation helps define the perspective of psychiatric and mental health nursing by emphasizing not only the needs but also the rights of people experiencing mental health problems. Guiding principles of a recovery-orientation in mental health include self-direction, peer-support, empowerment, respect, responsibility, hope, and an understanding of recovery as holistic, nonlinear, strengths-based, individualized, and person-centered (Centre for Substance Abuse Treatment, 2007). Barker and Buchanan-Barker (2010) argue that the necessary work toward recovery should start as soon as possible, i.e., at the first contact with care. Psychiatric and mental health nursing constitutes a transformative force by focusing on how psychiatric and mental health nurses can work together with service users in supporting recovery processes.

Therapeutic in its own right

We claim that psychiatric and mental health nursing is therapeutic. We base this claim on a post-modern view of therapy as more oriented toward caring than curing (Montgomery & Webster, 1994). Rather than having a limited focus on peoples’ symptoms and problems, such an approach accounts for multiple needs as well as for what might give a person a sense of safety, dignity, and hope. This understanding of therapy is also in line with the etymological origins in the Greek word therapeia, and the understanding of the person delivering therapy as an attendant serving for the sick, rather than curing a disease which is a meaning ascribed to therapy as late as in 1846 (Etymonline, 2020). This give primacy to the healing potential of the therapeutic relationship, rather than to specific psychotherapeutic methods. This is in line with the description of the therapeutic relationship as the most powerful ‘common factor’ in psychotherapy, i.e. a factor with a therapeutic potential which is not dependent on a specific therapeutic method (Richardson, 2001; Wampold, 2001). In other words, even if we do not define psychiatric and mental health nursing as “psycho-therapy” we assume that there are factors that could be considered “therapeutic” also in nursing, and that the relationship is amongst them. In psychiatric and mental health nursing the therapeutic relationship, or alliance, accounts for a view of the other as capable. Hence, the alliances are characterized by mutual partnerships and associated not only with patient experiences of trust and quality of care, but also outcomes of care (Edvardsson et al., 2017; Zugai et al., 2015). This view of nursing as interpersonal and therapeutic dates back to Peplau (1952/1992) and several researchers have put forth the therapeutic value of nurse-patient relations in practice (Altschul, 1971, 1972; Cahill et al., 2013; Delaney et al., 2017). The theoretical and ontological underpinnings has been further elaborated on by nursing theorists such as Eriksson (1992a, 1992b), Travelbee (1971), and Watson (1996), thus contributing to the knowledge base of psychiatric and mental health nursing. In line with Barker et al. (1999) Cameron et al. (2005) also describe “getting to know “the person as a specific nursing intervention where transference and counter-transference processes are involved and where reflective nursing practice requires nurses to also have a therapeutic and containing function. As psychiatric and mental health nurses are in direct and close contact with these patients, they are also in a position where they can communicate with the person about his/her problems and support them in addressing and managing those problems.

However, it is not only the nurse-patient relationship that has a therapeutic value. As patients who are admitted to psychiatric care might suffer from complex mental health problems and be diagnosed with severe mental illness they also have complex caring needs that could be addressed by specific nursing interventions. These too have therapeutic value, contributing to patient health and recovery. For example, implementation of the Tidal Model (Barker & Buchanan-Barker, 2005) has made a difference for both patients and nurses in different psychiatric settings (Cook et al., 2005; Gordon et al., 2005; Henderson, 2013; Savaşan & Çam, 2017). During the last few years other nursing interventions with therapeutic potential have been developed and presented, for example “The Systematic Activation Method” (Clignet et al., 2017), the “Family Strength Oriented Therapeutic Conversation Intervention” (FAM-SOTS) (Sveinbjarnardottir & Svavarsdottir, 2019), “Time Together” (Molin, 2019), a “Personal-Recovery-Oriented Caring Approach to Suicidality” (PROCATS) (Sellin, 2017), and “Equine-assisted nurse-led interventions” (Jormfeldt & Carlsson, 2018). Even though the latter needs more testing, the emergence of interventions that have a clear focus on supporting patients’ resources and facilitate recovery rather than curing indicate that knowledge developed and applied within psychiatric and mental health nursing have a therapeutic potential.

In addition, based on psychiatric and mental health nurses’ existing knowledge and awareness of the potential of nurse-patient interactions as a key element in a therapeutic approach, nurses can easily integrate methods developed within different psychotherapeutic traditions in their nursing care (Cleary et al., 2017; Parrish et al., 2013; Ross, 2015). This is also visible in the Nursing Interventions Classification (Butcher et al., 2018), which gives numerous examples of nursing interventions with roots in psychotherapy, such as counseling, cognitive restructuring, and self-esteem enhancing. Even though this mean an application of knowledge originally developed from another perspective, it is done as a part of the nursing profession and need to be congruent with the philosophical underpinnings of contemporary nursing.

Acknowledging the therapeutic potential of psychiatric and mental health nursing is essential for expanding psychiatric and mental health nurses’ scope of practice. This is not to be confused with task shifting—psychiatric and mental health nurses incorporating psychotherapeutic and medical perspectives and interventions in their nursing practice should not do it as a replacement for another profession, but as an expert on applying the knowledge within their area of professional responsibility—nursing. For example, when psychiatric and mental health nurses are able to prescribe and monitor medication, patient safety is improved and patients experience high quality and holistic care, as nurses are able to integrate different types of interventions and are more likely to know the patient and follow him/her over time (Cleary et al., 2017; Parrish et al., 2013; Ross, 2015). However, in order to avoid an uncritical adaption of technique and build on the possibilities to apply knowledge and skills on the premises of the nursing profession, psychiatric and mental health nursing also need to be reflective.

Caring and reflective

Psychiatric and mental health nursing constitutes a transformative force by being a caring and reflective practice. The caring and reflective dimensions of psychiatric and mental health nursing challenge what we perceive as a persistent and dominant narrow focus on standardized medical and nursing care in Sweden, and contribute in the shift toward person-centered care by focusing on the human experience of unique individuals in unique situations. With a medical paradigm dominating mental health care, nursing and especially caring often become invisible. In a historical perspective, psychiatric and mental health nurses have been complicit in grave atrocities (e.g. McFarland-Icke, 1999). For psychiatric and mental health nursing to remain not only a transformative force, but also a force for good in health care, we maintain it necessary to stay focused on the caring aspects of nursing. Barker (2000) argues that the appreciation of caring has become clearer and that caring for differs from caring about someone and caring with someone. Caring is described as the inner core and essence (Eriksson, 1992b), the art (Smith, 1999), and the central emphasis of nursing (Leininger, 1984). Caring is more than an attitude or philosophy, it is concrete work (Eriksson, 1992b)—or, as Barker describes it, a dance and an ethic in and of itself (Barker, 2000).

Staying focused on the caring aspects is not easy as psychiatric and mental health nursing is under constant external and internal pressures to shift focus from caring to curing. Curing is not basic to nursing and is commonly associated with actions performed on instead of shared with the patient (Davies & Janosik, 1991). Nonetheless, caring has become associated with curing and the shift of emphasis from caring to curing has accelerated (Schout & De Jong, 2018). To understand why this is so, one might consider that the nursing and caring science knowledge base has often been criticized for being “unscientific” (Dahlberg et al., 2016). Arguably, in its striving for professional and academic status, the discipline of nursing contributes to the devaluation of the emotional understanding of nursing, “to care for” (Herdman, 2004). Such a rationalization of nursing is evident in conceptualisations such as “evidence-based nursing” and “the nursing process” and the subordination of the emotional, caring aspect of nursing to cognitive and instrumental aspects. A single minded emphasis on technical rationality fails to appreciate that professional practice contains an element of artistry (Schön, 1983). We are confident that a caring relationship and the narrative story of each unique person are essential features of caring in psychiatric and mental health care. Engaging in caring, with its focus on health and well-being, suffering, lived body, and caring relationships (Dahlberg et al., 2003), is not optional but rather a moral commitment and responsibility for psychiatric and mental health nurses. It is undeniably challenging to strive for genuine caring in our contemporary care environments, and psychiatric and mental health nurses could risk being discouraged by barriers to moral caring acts and person centered care. It is no surprise that patients and their relatives report a lack of respect, participation, and meaningful relationships and activities in psychiatric and mental health care (e.g., Jormfeldt & Hallén, 2016; Looi et al., 2015; Molin et al., 2016), or that nurses experience general and moral stress when unable to follow their professional and ethical values (e.g., Gabrielsson et al., 2016; Molin et al., 2016). Therefore, encompassing solid ground psychiatric and mental health nursing research and theory and rejecting a dualistic view requires advanced competencies and moral courage in psychiatric and mental health care nurses.

For psychiatric and mental health nursing to make a difference as a caring practice it needs to be informed by nursing research and theory that focuses on the lived experience of mental health and ill-health, care and treatment. Caring based on caring science means having a life-world perspective with the centrality of understanding “how it is to live” for a person within his/her life world. The prerequisite for caring is patient perspective: understanding the patient and his/her situation (Dahlberg et al., 2003). One central insight in this is that this prerequisite strives for reaching that understanding, rather than just gaining complete and accurate knowledge. In today’s shift toward person-centered care, this approach seems highly central. However, such life-world led health care requires reflective practices (Todres et al., 2007).

For psychiatric and mental health nursing to be a transformative force in health care psychiatric and mental health nursing knowledge needs to be trustworthy and relevant for practice. Can nursing knowledge be described, challenged, and developed in a trustworthy manner if professional practice is, to some extent, situational and created in the moment? The answer is “yes”, and a holistic, person-centered, caring approach to nursing necessitates regarding psychiatric and mental health nursing as a reflective practice. Reflective practice is the integration of theory and practice, a requisite for personal and professional development, and a strategy for fostering person-centered approaches to care (Goulet et al., 2016). Being professional is not so much about being able to apply theory to practice in a linear process, but rather about appreciating the unique quality of situations, and being able to adapt practice to the situation at hand (Schön, 1987). This is done by challenging the initial understanding of the situation, constructing a new understanding, and testing it (Schön, 1987). This also means that professional practical knowledge is not always readily translated into theoretical knowledge, which brings forth the dilemma of rigor or relevance (Schön, 1983). The concept of reflective practice is useful as it suggests that the knowledge base for professional practice might meet expectations of rigor and relevance at the same time. For psychiatric and mental health nursing to make a difference, psychiatric and mental health nurses need to value their own and their colleagues’ practical knowledge, as well as be able and willing to challenge that knowledge from a theoretical base. This might be facilitated by various reflective practices (Ghaye & Lillyman, 2010). Service users’ experiential knowledge also needs to be valued and incorporated into practice as well as research. Psychiatric and mental health nurses play an important role in initiating and facilitating reflective practices, and thus the recovery-focused transformation of mental health services (Gabrielsson & Looi, 2019).

Implications

The therapeutic potentials in psychiatric and mental health nursing can make a difference in an era in which mental ill health is increasing and resources are lacking. We claim that psychiatric and mental health nursing can make a difference based on the therapeutic nature of the nurse-patient relationship, as well as the knowledge and skills associated with advanced psychiatric and mental health nursing. In other words, psychiatric and mental health nursing needs to be recognized as having a therapeutic value by itself, not as a “second best” alternative when other resources such as physicians or psychotherapists are lacking.

Although nursing curricula varies amongst Swedish higher education institutions, we sense an overall need to expand the role of psychiatric and mental health nursing in basic and advanced level nursing education. Given the transformative potential of psychiatric and mental health nursing, and the many challenges facing Swedish health care regarding psychiatry and mental health, we also recognize a continued need for nurses who specialice in psychiatric and mental health nursing.

We need to acknowledge the need for psychiatric and mental health nurses to expand the scope of practice. In this we must recognize the need to develop the role and function of Advanced Nurse Practitioner (ANP) specialicing in psychiatric and mental health nursing in the Swedish context, and understand that psychiatric and mental health nurses qualifying as ANP can incorporate medical and psychotherapeutic perspectives and interventions in a caring and reflective nursing framework.

To ensure the impact of psychiatric and mental health nursing as a transformative force, specialist nurses advocating psychiatric and mental health nursing as a caring, reflective, and therapeutic practice that promotes recovery and health, are needed in both individual interactions and at all organizational administration, community, and policy levels regarding mental health services.

Conclusion

The future of psychiatric and mental health nursing in Sweden lies in its further development as a caring, reflective, recovery-oriented, health-promoting, and therapeutic practice that makes a difference. Psychiatric and mental health nurses, whether clinicians, researchers, educators, or managers, can and must contribute in achieving good health and well-being and reducing inequalities for all people. For this to happen, psychiatric and mental health nurses need to overcome challenges posed by a dominant medical paradigm, the devaluation of caring, and the questioning of their professional expertise. This requires a renewed belief in the therapeutic potential of psychiatric and mental health nursing and the courage and perseverance of mental health nurses to shape their own future.

Authors' contributions

HJ wrote a first draft of the paper to which HT, SG, and LWG provided additions. SG was responsible for revising the paper with the input of all authors. All authors approved of the final version to be published.

Acknowledgments

We acknowledge the valuable contributions of the members of the board of the Swedish Association of Psychiatric and Mental Health Nurses in the initiation and development of this manuscript: Jenny Karlsson, Joffen Kleiven, Britt-Marie Lindgren, Eva Lindgren, Jenny Molin, Simon Steinmo, and Paul Stråby.

Disclosure statement

This paper was initiated by the Swedish Association of Psychiatric and Mental Health Nurses. All authors are members of the association. HJ is the chairman and HT is a member of the board. SG is the editor-in-chief of the associations journal.