https://orcid.org/0000-0002-1453-4850
Abstract
The mental health nursing profession has experienced various challenges since its inception. This discursive review considers these challenges, including how mental health nurses have and can continue to overcome adversity as individuals and as a profession. The discussion examines the influence of the profession’s historical involvement in institutionalization and coercive care; the continuing impact of stigma; and the increasing demand for mental health services, amidst chronic staff shortages. Collectively, mental health nurses must harness strong therapeutic relationships, intra- and multi-disciplinary collaboration, personal and professional resilience, education that prepares them for the future, and sector-wide planning and innovation, to respond positively to these challenges. These approaches will support mental health nurses to overcome adversity and achieve positive outcomes for the profession and people with the lived experience of mental illness.
Introduction
Since its inception, the mental health nursing profession has faced various challenges. These challenges include the move from providing institutional and custodial care (Montenegro et al., Citation2023), to delivering community and recovery-oriented care, with ongoing tensions between consumer-centred approaches and the medical treatment model (Cleary, Citation2003; Hurley et al., Citation2022). Other challenges worldwide, are the underprioritizing of mental health and the ongoing underinvestment in mental health services (Mahomed, Citation2020); the chronic shortages experienced by the mental health nursing workforce (Brimblecombe, Citation2023; White & Brooker, Citation2020); ensuring rigorous education and training for mental health nurses (Doyle et al., Citation2018; Evans, Citation2022); and the continued, negative representations of mental health nurses, including limited representations of the holistic and supportive nature of their scope of practice (Gabrielsson et al., Citation2020; Citation2021; Liljeqvist et al., Citation2020). An additional and unexpected challenge was the COVID-19 pandemic, with mental health nurses also supporting people who were affected by the stress of physical isolation and/or physical illness, grieving the loss of loved ones, and experiencing uncertainty and change (Foye et al., Citation2021).
The outcomes of persevering through long-term adversity for mental health nurses as individuals and as a profession are uncertain. A recent international report published by the International Council of Nurses (ICN) reports low job satisfaction among the mental health nursing workforce, with reasons including the challenges faced in the daily work of mental health nurses (Stewart et al., Citation2022). Outcomes of the profession persevering through long-term adversity are less clear. Research undertaken by Dorfman et al. (Citation2022) suggests chronic adversity can adversely affect a person’s mental health and give rise to maladaptive thought patterns. The researchers go on to point out that, while working through different types of adversities does not necessarily offer a direct path to gain wisdom, reflecting on an adverse experience with a self-distanced perspective “can help preserve wisdom in the face of adversity” (Dorfman et al., Citation2022, p. 570).
This discursive review considers some of the current challenges faced by the mental health nursing profession, including the long-term effects of adversity. Questions addressed include: What attributes or characteristics have supported the profession to withstand diverse challenges over many decades? What are the effects of adversity on mental health nurses and the profession as a whole? How can the profession build on its strengths to continue growing, developing and innovating, and move forward proactively into an uncertain future? Answers to these questions are distilled into practical suggestions for overcoming adversity and consolidating, to enable a better future for the mental health nursing profession.
Past challenges
The evolution of the mental health nursing profession began in the 1800s in the United Kingdom (UK) when nurses replaced asylum attendants to care for the residents of institutions (Royal College of Nursing, Citation2021). Over time, the profession addressed the practice issues encountered in these settings with targeted training and education for nurses (Raeburn et al., Citation2023). For example, the first training school for nurses in psychiatric settings in the United States (US) was established in 1882 (American Psychiatric Nurses Association, Citation2023), with the educational preparation of mental health nurses continuing to evolve with the incorporation of studies in communication, psychology, and sociology, alongside various psychological and pharmacological therapies (Nolan, Citation2020). As institutional abuses were reported or uncovered, mental health nurses went on to seek registration with governing authorities, to ensure a minimum standard of practice with, the UK the first country to institute national psychiatric nurse registration in the 1920s (Chatterton, Citation2004; White & Brooker, Citation2020).
The progress made by the mental health nursing profession since its inception shows its resilience and capacity to overcome challenges to achieve improvements in standards of care and outcomes for people with mental illness. In so doing, the profession has developed unique skills and capabilities, such as supporting consumers holistically to enable their physical, behavioral, psychological, social, and emotional health and wellbeing (American Psychiatric Nurses Association, Citation2023; Graham et al., Citation2020). Yet perceptions of mental health nurses have (and continue to be) shaped by the profession’s socio-historical roots, including its association with psychiatric institutions and coercion (Jones, Citation2023; Raeburn et al., Citation2023). Such perceptions include mental health nurses as controlling custodians, rather than compassionate carers (Paradis-Gagné et al., Citation2021).
The notion of compassionate care in psychiatric settings underwent considerable development in the postwar period. This development paralleled the development of the first-generation of psychotropic medications and the process of deinstitutionalization (Gronfein, Citation1985); together with the rise of nursing theorists, such as Joyce Travelbee, Helena Render and Hildegard Peplau’s interpersonal relations (Clark, Citation2023). Specifically, the seminal work of Peplau (Citation1952) on the Theory of Interpersonal Relations in Nursing highlighted the centrality of the therapeutic relationship between the nurse and the person experiencing symptoms of mental illness; and unpacked the qualities of this type of relationship, including improved outcomes when there is a strong engagement between the nurse and person experiencing health issues (Hagerty et al. Citation2017).
Continuing to adapt to the ever-changing needs and preferences of people, communities, and populations, mental health nurses also honed their knowledge, skills and capabilities in observation, holistic assessment, using diverse approaches and interventions to support consumers and carers across multiple domains (Australian College of Mental Health Nurses, Citation2013). Despite the challenges faced, this scope of practice suggests adversity had also been an opportunity to adapt, grow and develop.
This very process of adaptation has presented additional challenges to those seeking to define the distinctive role of mental health nurses. For example, there is no definitive list of the capabilities of mental health nurses, which has led to confusion about the roles, identities and capabilities of the mental health nursing workforce (Hurley et al., Citation2022). While the multi-faceted scope of practice of the profession enables mental health nurses to meet the diverse needs and preferences of people who experience mental illness, it has also resulted in the under-utilization of the skills and capabilities of mental health nurses in some areas of practice (Abt et al., Citation2022; Hurley et al., Citation2022).
The specific challenge of COVID-19
The under-utilization of mental health nurses was not a problem during the COVID-19 pandemic. Rather, issues already experienced in relation to mental health service provision, such as chronic staffing shortages, increased levels of mental illness in the community, and limited access to stretched services (Triliva et al., Citation2020) were exacerbated by the challenges associated with the pandemic itself (Stewart et al., Citation2022). These challenges included restrictive public health measures, such as physical distancing and isolation, which negatively affected many mental health consumers, who reported, for example, higher levels of distress or frustration (Foye et al., Citation2021).
In a rapid review on the impact of COVID-19 on the mental health workforce, adversity experienced during the pandemic included higher workloads and workplace violence, changed roles, burnout, reduced job satisfaction, challenges with telehealth, problematic work-life balance, vicarious trauma, increased psychological distress and psychosocial challenges (Crocker et al., Citation2023). During the COVID-19 pandemic, mental health nurses struggled to maintain the delivery of high-quality health care in the context of rapid changes to practice, heightened work pressures, increases in sick leave, staff turnover, and increased intentions to resign (West et al., Citation2020). In one study, over 60 percent of those surveyed felt the changes to work practices occurred too quickly, and 40 per cent believed consumers were no longer receiving an acceptable standard of care because of these changes (Foye et al., Citation2021). About a third of respondents believed their workloads had increased, and this was higher in bed-based environments. This situation necessitated further adaptation of the practice of mental health nurses (Foye et al., Citation2021) in a context fraught with overburdened hospitals and constantly changing procedures or protocols (Ward-Miller et al., Citation2021). The pandemic provided opportunities for mental health nurses to demonstrate resilience and adaptability—although, in some instances, experiences of trauma from the pandemic have led to nurses leaving the profession (Boyden & Brisbois, Citation2023; Dahan et al., Citation2022).
Current challenges
The many changes and improvements implemented by the mental health nursing profession to their practice over the decades have done little to alter the negative perceptions of or attitudes toward the profession. For example, perceptions that nurses who work in mental health or behavioral-based specialties are the ‘poor cousins’ of nurses who focus primarily on providing physical healthcare remain largely unchanged (King, Citation2017). Today, community understanding of the mental health nursing workforce continues to be shaped by the range of workplace settings in which they work. Brimblecombe (Citation2023) reports that in the UK, the proportion of nurses working in community settings now constitutes more than half of all nurses, in contrast to hospital settings. Irrespective of the setting, many services delivered by mental health nurses support consumers who are required to receive treatment in line with relevant mental health legislation (Hardy et al. Citation2022; Light et al., Citation2017). Such workplace settings have strong links to coercive care, thereby confirming the stereotypes of mental health nurses.
Another global challenge currently faced by the profession is the association between high-stress clinical settings, low job satisfaction, and poor retention (Mukaihata et al., Citation2022; Stewart et al., Citation2022; Zheng et al., Citation2017). This suggestion could explain the worldwide shortage of mental health nurses and many in the profession working in acute (high-stress) services. Importantly, the World Health Organization suggests the global shortage is preventing the delivery of adequate mental health care for people and populations, particularly in developing nations (Stewart et al., Citation2022).
Mental health nursing workforce
Recent figures place mental health nursing numbers globally, at roughly 300,000 (Stewart et al., Citation2022); however, ratios vary significantly between countries. Africa has less than one nurse per 100,000 people, Europe has 25.2 per 100,000, low-income countries have 0.4 per 100,000 and high-income countries 29 per 100,000 (Stewart et al., Citation2022). Reasons for this include issues encountered with the recruitment of mental health nursing. For example, in the UK, about 12% of all nursing vacancies are in mental health (British Medical Association, Citation2019). Additionally, despite mental health being an acknowledged priority area in the UK, the shortfall between the current number of mental health nurses and the stated national target is not being met, and achieving this target is arguably impossible, with the proportion of mental health nurses in the National Health Service (NHS) decreasing (Brimblecombe, Citation2023). Similarly concerning, in the US, over half of registered mental health nurses and advanced practitioners are 50 years old or more, with over 25 percent of the current mental health nursing workforce set to retire within the next six years (Della Volpe, Citation2022).
Government and organizational responses to the worldwide shortage of mental health nurses are varied. In some countries, responses include calls for additional resources and/or funds; and international recruitment by richer countries from the poorer countries (Phiri et al., Citation2022). However, in a post-COVID era, additional resources and funds are scarce. Moreover, international recruitment raises ethical questions about richer countries compromising the health systems of poorer nations by luring nurses away from supporting their own often struggling health systems, with the promise of better wages and conditions (Runnels et al., Citation2011; Walton-Roberts, Citation2020).
Other countries have tried different approaches to address the workforce shortages. For example, one reason for the introduction of the comprehensive educational preparation and the generic licensing of registered nurses in Australia was to enable nurses to work in diverse settings, including mental health, and thereby reduce workforce shortages in specific areas (Health Workforce Australia, Citation2014). Recruitment and retention of mental health nurses remains a pressing concern, with more mental health nurses needed across the world to address the COVID-19 pandemic consequences (Baines, Citation2022).
The challenge of workforce shortages is even more concerning in light of the limited access provided to mental health nursing leaders, to engage in strategic discussions on health and workforce planning and policy decision-making (Hurley et al., Citation2022). One reason for this exclusion could be the inadequate understanding of the scope of practice of mental health nurses (Lakeman & Hurley, Citation2021) and negative stereotypes, such as mental health nurses being “lazy”, unskilled or “strange” (Alexander et al., Citation2015, p. 451). Another reason could be the continuing dominance of the medical model in influencing and shaping policy and strategic planning, worldwide (Lam & Chung, Citation2022; Sugiura et al., Citation2020). Irrespective of the reasons, changing negative perceptions and addressing the causes of endemic shortages will best occur when mental health nurses are invited to sit at the decision-making table to support strategic policy development that affects the profession and its vital role in supporting people with the lived experience of mental illness (Pearson, Citation2019).
Overcoming adversity
Despite the considerable challenges faced over the years by mental health nurses, the profession continues to move forward as a dedicated workforce. This dedication raises the question of how the profession has prevailed. From a pragmatic viewpoint, we could argue that mental health nurses will continue to make themselves available when there are people in need of help or support. From a socio-cultural viewpoint, the narrative of overcoming adversity leading to personal growth may resonate with those who seek to draw meaning from the experience of hardship (Jayawickreme & Infurna, Citation2019), with individual mental health nurses possibly viewing adversity as an opportunity for learning and development. Certainly, lifelong learning (in mental health) is identified as an opportunity to expand the influence of psychiatric nurses and to general nurses (Merwin, Citation2020).
From a professional viewpoint, the key characteristics of the profession, developed over the years in response to various challenges, have enabled mental health nurses to adapt and overcome. Derived from the issues discussed in previous sections of this paper, these key characteristics include, first, the mental health nurses’ capacity to develop strong relationships; second, the collaboration between mental health nurses and key stakeholders; third, the resilience of individual mental health nurses and the profession; fourth, the education provided by and for mental health nurses; and finally, the commitment to plan and engage in future-focussed innovation. Each of these factors is now considered.
Relationships
The therapeutic relationship between mental health nurses and people experiencing symptoms of mental illness is critical to recovery (Romeu-Labayen et al., Citation2022). Building on the seminal work of Peplau (Citation1952), which suggests that interpersonal relations are core to nursing, mental health nurses use therapeutic relationships to engage with consumers, form a working alliance, and increase the effectiveness of interventions (D’Antonio et al., Citation2014; Tolosa-Merlos et al., Citation2023).
The skills and attitudes of mental health nursing practice are integral to building therapeutic relationships, and include creating a positive and safe environment, demonstrating empathy and authenticity, building trust, utilizing effective communication skills, and providing the consumer with choice (Moreno-Poyato & Rodríguez-Nogueira, Citation2021; Tolosa-Merlos et al., Citation2023; Wright, Citation2021). Importantly, while mental health professionals generally understand the importance and steps needed to develop therapeutic relationships, the nature of the nurses’ work significantly adds to the concept. For example, in hospital settings, nurses spend more time with consumers than other health professionals, giving nurses additional opportunities to listen, engage, collaborate with, and care for the person’s physical, mental, and social needs, in practical and personal ways.
The expertise of mental health nurses in developing and maintaining therapeutic relationships gives rise to various opportunities for the profession. Certainly, not all relationships are therapeutic; nevertheless, relationship-building skills are transferrable and useful for building professional relationships across all settings. For mental health nurses, such relationships include providing positive and mutual support for colleagues, and for building strategic and constructive networks (Delgado et al., Citation2021). In addition to aiding with the development of personal growth and purpose, strategic and constructive networks are integral to the development of the profession. For example, cohesive groups with a unified worldview and common goals are more likely to exercise influence and/or be invited to join the policy decision-making processes.
Collaboration
During the COVID-19 pandemic, the collaboration of nurses across all areas of health care enabled the swift changes required to meet consumers’ needs (Ward-Miller et al., Citation2021). At the same time, collaboration is both a process and an outcome (Reid et al., Citation2018). Indeed, more than a means to an end, it is also an end in itself, with people often prevailing through adversity because of collaboration with others.
Webster et al. (Citation2021) identify collaboration as one of the core skills of mental health nurses as it plays a key role in consumer-centred mental health services. In contemporary services, mental health nurses collaborate with consumers to plan their care, encouraging and supporting them in their recovery journey (Hartley et al., Citation2020). Collaboration also provides a means by which mental health nurses, as individuals and a profession, can influence consumers, carers, other health professionals, and community members, to shape perceptions and understandings of the profession.
Resilience
Resilience is an individual ability and/or interactive person-environment process (Foster et al., Citation2019). For example, mental health nurses can develop personal resilience by taking the time to self-care (Ward-Miller et al., Citation2021). By extension, resilient individuals will influence the people and environment around them when interacting at work. At the same time, strategies to achieve professional resilience must include the employers’ commitment to support and sustain the workforce.
Cleary et al. (Citation2014) go further when considering resilience, positing a mutually interactive relationship between professional identity, the specific practice of that profession, and professional resilience. For example, mental health nurses with a strong sense of professional identity, and expertise in relationship building and collaboration, will serve to build and strengthen the mental health profession. Consequently, the profession will likewise be nurtured if individual resilience is nurtured. Personal and collective resilience, then, enables the profession to withstand adversity and use the experience to grow and innovate (Cleary et al., Citation2014; Thapa et al., Citation2021).
Education
Education is key to building a sustainable mental health nursing profession for the future. It must begin with mental health nurses sitting at government and organizational decision-making table(s) to develop strategies, policies, and standards for the preparation of nurses working in mental health settings. Seeking alignment between education, strategies, policies, and standards will also ensure the preparation of mental health nurses is targeted to meet the requirements of future mental health initiatives of nations globally (Stewart et al., Citation2022).
Significantly, there is currently no evidence to support that one educational pathway, whether undergraduate or post-graduate, is superior to the other in relation to the quality of mental health nurses who graduate. For example, in Australia, recommendations have been made for a direct-entry, three-year mental health nursing degree to address the workforce issues faced by the profession (Australian Government Productivity Commission, Citation2020). The ICN, however, identifies various pathways for the preparation of mental health nurses, including direct entry programs, minimum hours working in a mental health service, and post-graduate study (Stewart et al., Citation2022). In the UK, for example, mental health nurses are educated at the undergraduate level, while mental health nurses in the US and Australia undertake post-graduate preparation (Edward et al., Citation2015; Kaas, Citation2020). Perhaps what is most important is that nurses are adequately prepared to enter the profession and then supported with ongoing education throughout their careers. It is also necessary to provide nurses with the knowledge, skills and attribute to overcome future challenges and adversity. Such knowledge, skills and attitude could include the capacity to innovate (Kaas, Citation2020) when faced with change and uncertainty.
Supporting the mental health nursing profession to achieve such future-focused innovation and change would include enabling the development of, first, the attributes required to adapt and, second, knowledge and skills that are transferrable to evolving and challenging service settings (Cleary et al., Citation2019). This education and training would include facilitation by mental health consumers and carers (Cleary et al., Citation2011), and innovations such as hi-tech simulation (Pfeiffer & Wands, Citation2021). There is also a need to integrate mental health education and build research capacity into the ongoing professional development of all health workers, to promote the delivery of safe and high-quality mental health care worldwide (Wainberg et al., Citation2017); and to educate people and communities on the role and contribution of mental health nurses, to minimize the stigma still attached to the role (Gouthro, Citation2009; Stewart et al., Citation2022) which is associated with recruitment and retention challenges (Harrison et al., Citation2017).
Planning and innovation
Planning provides a sense of coherence and enables the development of strategies and goals to overcome adversity and make a difference moving forward (Betke et al., Citation2021). For the mental health nursing workforce, such planning would ideally encompass local, national, and international planning, with diverse groups of mental health nurses learning from one another. The planning could also include mental health nurses being supported by the mental health professional bodies in each jurisdiction or country and coming together for networking opportunities, including conferences, and supporting one another to improve the quality of care and services delivery, worldwide.
Of particular note is the need to draw on the knowledge and wisdom of mental health nurses who carry decades of invaluable experience and consider the challenges of succession planning (Merwin, Citation2020). For example, mental health nurses who have adapted to the change of de-institutionalization and learned to manage the tensions of working within recovery-oriented services dominated by medical and legal imperatives can provide insights on how to face and overcome adversity. Also important is the need to discuss how to replenish the mental health nursing workforce through the life cycle of recruitment, retention, and retirement (Brimblecombe, Citation2023; Merwin, Citation2020). While such discussions would ideally influence the development of national and international policies and strategies, they are also integral to the mental health nursing profession, innovating to support positive outcomes for people with mental illness, regardless of the challenges.
Conclusion
The mental health nursing profession has experienced diverse challenges over many decades, including changes to service settings and models of care to meet the needs and preferences of consumers, carers and the community. Other issues include the ongoing stigma experienced by the profession and the lack of inclusion of mental health nurses in developing mental health policies and plans. Attributes that have supported the profession during difficult times include skills in building relationships, the capacity of mental health nurses to collaborate, and professional resilience. Developing and consolidating educational pathways that challenge the profession, strategic planning, and innovation will enable the mental health nursing profession to prevail, grow, and thereby better support people with the lived experience of mental illness to achieve positive outcomes.
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