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3 Peer-Reviewed Articles That Explain What That Explain What The Literature Reveals About the Issue

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3 Peer-Reviewed Articles That Explain What That Explain What The Literature Reveals About the Issue

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The purpose of this study is to identify and compare important stakeholder viewpoints on the fundamental skills required of mental health nurses. Most of the direct care and treatment for individuals with mental disorders is provided by mental health nurses. It is helpful to learn about the essential abilities of a mental health nurse from the viewpoints of patients who utilize mental health services, mental health nurses, clinical leaders in the field, psychiatrists, and mental health nurse academics (Moyo et al., 2020).

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Abstract

This study aims to identify and contrast key stakeholder perspectives about the core competencies of mental health nurses. Mental health nurses provide much of the direct care and treatment to patients with mental disorders. The perspectives of users of mental health services, mental health nurses, mental health nurse clinical leaders, psychiatrists, and mental health nurse academics regarding the core competencies of a mental health nurse are informative to improve the quality of care given to patients. We will use concept mapping to compare and contrast the views of different stakeholder groups ( n = 50, 10 per group) about the core competencies (knowledge, skills, and attitudes) of mental health nurses. There are six stages in concept mapping: preparation, generation of statements, structuring of statements, representation of statements, interpretation of maps, and utilisation of maps. The Good Reporting of A Mixed Methods Study (GRAMMS) checklist will guide this study. The final output is a "concept map" that can be used and interpreted to understand core mental health nursing competencies. This study will provide insight into the perceived core competencies of mental health nurses from a variety of perspectives.

Keywords: mental health nurse, competencies, concept mapping, users, psychiatrist

1. Introduction

Clinical competencies can be defined as a combination of knowledge, clinical skills, and attitudes [ 1]. Mental health nurses are registered nurses that have had specific psychiatric training either at an undergraduate or postgraduate level. There is a lack of clarity about what the core competencies of a mental health nurse are. For example, some Australian authors have argued that mental health nurses need to be expert in trauma-informed care [ 2], despite a paucity of evidence that this is an effective way of working [ 3]. In England, there has been a strong emphasis on enhancing the physical health of people with severe mental illness as a core focus of the work of mental health nurses [ 4, 5].

Mental health nurses provide care and treatment to patients in a variety of inpatient and community settings [ 6, 7]. The majority of the mental health nurse's working day should be spent providing direct patient care [ 8]. The competencies which nurses can apply during their time with patients may impact clinical outcomes [ 1, 9].

1.1. Patient Perceptions of Mental Health Nurses' Core Competencies

Bee et al. [ 10] conducted a systematic review that examined service user views and expectations of registered mental health nurses. The authors included 92 qualitative and 40 observational studies that reported service user views about mental health nurse competencies. Included studies generally had a high risk of bias. Bee et al. [ 10] reported that the patients expect mental health nurses to fulfil a multi-faceted role in which practical and social support are provided alongside the delivery of more formal psychological interventions. Patients perceived nurses to be professional experts with the necessary skills and training to diagnose, prioritise mental health problems, and respond effectively to deteriorations in their mental health state. The majority of inpatients felt that mental health nurses were inaccessible and spent insufficient time providing direct care. Patients also perceived that nurses lacked collaborative skills; for example, patients were not involved in the planning of their treatment. The positive personal qualities of nurses reported by patients included empathy, respect, and compassion. Being dismissive or judgmental and adopting a coercive approach were identified as undesirable nursing attributes by patients.

1.2. Perceptions of Mental Health Nurses about Their Core Competencies

Delaney and Johnson [ 11] reported a meta-synthesis of the qualitative literature about mental health nurses' perceptions of the core aspects of their role. Sixteen studies were included in the synthesis. Three themes were reported: 1. the nurses' efforts to forge engagement with patients, 2. activities which maintained the safety of the unit, and 3. interventions which nurses viewed as educating/empowering patients. The reported observations are limited by the qualitative nature of the study design, which means that observations cannot be generalised beyond the included participants.

1.3. Gap in Knowledge

Previous research has focused on patient and nurse perceptions of the core competencies of mental health nurses. There are other stakeholder groups whose work is interdependent with that of clinical mental health nurses, who will have important views on their core competencies. Psychiatrists, for example, work closely with mental health nurses around the prescribing and administration of psychotropic medication. Nurse managers tend to be focused on patient safety issues; as a consequence, they may have different views on nurse competencies. Mental health nurse academics are another group that will have a further perspective that should be informed by a more contemporary understanding of the evidence base. Understanding mental health nursing competencies from these multiple stakeholders, we argue, may inform debate about curriculum development for this group of workers.

2. Materials and Methods

2.1. Concept Mapping

We will use a genuine mixed-method design. Concept mapping will be used to identify and contrast the perceptions of five stakeholder groups-users of mental health services, mental health nurses, mental health nurse clinical managers, psychiatrists, and mental health nurse academics-about their perceptions of the core competencies of mental health nurses. Concept mapping is a type of structured conceptualisation method used to organise and represent ideas from identified populations [ 12]. We will combine qualitative interviews with multivariate statistical analyses to describe views of the stakeholders on the core competencies of mental health nurses and visually represent these ideas as "concept maps" [ 13, 14].

The reporting of this study will adhere to the guidelines for Good Reporting of A Mixed Methods Study (GRAMMS) [ 15] (refer to Supplementary File S1).

2.2. Why Concept Mapping?

Concept mapping has been extensively used in a variety of settings, including community mental health and public health [ 16, 17]. It is a useful methodological approach to understanding complex phenomena. In health research, it is emerging as a novel methodological approach. It has been used to develop a deeper understanding of medication adherence [ 18] and why people do not access psychological services [ 19]. One method cannot adequately identify and compare the views of multiple stakeholders about the competencies of mental health nurses. Understanding the core competencies of mental health nurses is a complex topic that lends itself well to concept mapping as a methodology.

3. Study Setting and Population

This study will be conducted in the state of Victoria, Australia. We will recruit and collect data from five participant groups: users of mental health services, mental health nurses, nurse managers, psychiatrists, and nurse academics.

All participants will be aged 18 years or over, able to communicate comfortably in English, and have access to and can use a personal computer. Additionally, we will apply the following inclusion criteria for each stakeholder group:

Users of mental health services;

Have personal experience of mental health problems;

Licensed to practice as a registered nurse in Australia and currently working in a mental health setting;

Licensed to practice as a registered nurse in Australia and working in a mental health setting in a leadership role (manager, team leader or director of nursing);

Licensed to practice as a psychiatrist in Australia and currently working in a mental health setting;

Mental health nurse academics;

Working in a School of Nursing (or equivalent) in an Australian University and self-defines as a specialist in mental health.

4. Sample Size

We intend to recruit approximately 50 participants (ten in each participant group). There is no agreed limit on the number of participants required for concept mapping. Rosas and Kane [ 12] recommend that a minimum of 20 participants should complete the clustering task. Ariadne [ 20] reported that the minimum number of participants for concept mapping is 8-10, but there is no limit to the maximum number of participants.

5. Recruitment

5.1. Users of Mental Health Services

Convenience and snowballing techniques will be used to recruit users of mental health services through consumer advocacy groups. Potential participants will initially be contacted by telephone and/or email by a member of the researcher team. Research objectives, how the participant will be involved in the study, and the potential benefits and risks of participating in the study will be explained. Written information and a consent form will be sent (by email) to potential participants. If they agree to take part, participants will be asked to email a scanned or photographed copy of the signed consent form to the research team. Participants will be encouraged to contact the research team by phone or email if they have any additional questions about the study.

5.2. Professional Groups

Mental health nurses, mental health nurse clinical leaders, psychiatrists, and mental health nurse academics will be recruited via social media (Twitter, Facebook, LinkedIn). Additionally, we will use snowballing techniques, asking participants for contacts that might be interested in participating in building our sample. Potential participants can contact the research team by email or telephone to express interest in the study. They will be contacted by a study researcher, who will explain the study and send written information about the research. As with users, professional participants will be asked to send a photographed copy of the consent form via email or text message.

6. Scheduling Times for Concept Mapping Task

A study researcher will schedule convenient dates and time with participants for each of the concept mapping activities: brainstorming and prioritising and clustering. All research activities will be completed online using video conferencing technology.

7. Demographic Data

The following demographic information will be collected for all participants: 1. age in years, 2. gender (male/female/other), 3. highest academic qualification (high school/undergraduate/graduate/postgraduate).

From users of mental health services, we will additionally record 1. type of mental disorder (common (e.g., depression, anxiety) or severe (e.g., schizophrenia, bipolar)), 2. approximate duration of mental health problem (in years), 3. ever hospitalised (yes/no), 4. employment status (employed/unemployed).

We will ask the professional groups to provide the following information: 1. The country where the primary clinical qualification was awarded, 2. Years of experience working in clinical practice.

8. Ethics Considerations

Ethical approval will be sought from the participating university's human research ethics committee before starting the study (Approval No. [HEC20257]). There are ethical issues with this study that require consideration. First, consent will be obtained electronically. Second, interviews will be conducted using video conferencing technology. Links to video interview will be password protected (to prevent so-called "video bombing"). We will audio record interviews that will be retained for data analysis. The recorded interviews will be deleted after data analysis.

It is possible, albeit unlikely, that participants may be known to the researcher because they have worked with the researcher in previous roles. Consequently, they may perceive that there is an expectation that they will participate in the research. We will acknowledge this issue with potential participants and emphasise the voluntary nature of taking part.

8.1. Risks Associated with Taking Part in the Study

Participation in any research study is associated with risk, however minimal [ 21]. We anticipate that some participants may have had previous negative experiences associated with psychiatric hospital admission, and being asked to talk about the attitudes, skills, and knowledge of mental health nurses may cause distress. If this occurs, we will stop the interview and check if the participant would like to take "time out," postpone the interview, or consider withdrawing from the research. A member of the research team will be available to provide psychological support to the participant if necessary. Additionally, we will advise participants about online psychosocial support and counselling services that are available (for example, au.reachout.com, beyond blue- https://www.beyondblue.org.au).

8.2. Risk Mitigation during the COVID-19 Pandemic

The fieldwork for this study will be conducted during the COVID-19 pandemic. COVID-19 is a highly infectious disease caused by SARS-COV2 [ 22]. In Australia, during the pandemic, people are required to physically distance and engage in other infection control measures to reduce transmission [ 23]. Consequently, interviews will be conducted using video conferencing.

8.3. Potential Benefits of This Research

We do not anticipate any direct benefits to participants from being involved in the study. We anticipate that the findings from this research will inform the curriculum of mental health nurse training internationally, with the ultimate aim of ensuring that psychiatric nurses have the required skills to work with people experiencing mental illness.

9. Data Collection Procedure

Concept mapping requires participants to take part in a "brainstorming" interview and complete a series of online computer-based tasks (prioritising and clustering). There are six discreet phases in the concept mapping process [ 13]:

9.1. Phase 1: Preparation

In the preparation phase, the task is to decide on the focus question and identify participant groups. The focus of this study is, "what are the core competencies (knowledge, clinical skills, and attitudes) of a mental health nurse?" We will seek to elicit the views of users of mental health services, psychiatric nurses, clinical leaders, psychiatrists, and nurse academics.

9.2. Phase 2: Generation of Statements (Brainstorming) (via Video Conferencing)

Interviews will be conducted using video conferencing technology. We will audio record interviews, which will be retained for data analysis. Participants will be interviewed individually and asked to generate statements in response to the following question: "What are the most important competencies (knowledge, skills, and attitudes) of a mental health nurse?" Participants will be asked to give simple statements and avoid jargon. Participants will be asked to try and avoid long sentences, use conditional formulations (if, then), make comparisons (e.g., "is better than"), use double negatives, make value judgements ("I think it would be good if") [ 20]. Listening back to the interview, a researcher will extract individual statements that are singular, specific, and abstract (interviews are not transcribed in concept mapping). If we generate more than 98 statements, we will need to combine repetitive or overlapping concepts into single statements, as this is the maximum number that can be entered into the ARIADNE software package [ 20].

9.3. Phase 3: Structuring of Statements (Completed Online)

Structuring of statements will consist of two tasks: prioritising and clustering. Both tasks will be completed online using the ARIADNE software package. Participants will be emailed a link to ARIADNE software to enable them to participate.

9.3.1. Phase 3a: Prioritisation

Participants will be asked to rank statements in order of importance (i.e., what are the most essential competencies of the mental health nurse), from 1 (least important) to 5 (most important). Each point on the scale must have an equal number of statements. Participants will be advised not to consider the lowest category "unimportant" but "least important" to avoid a situation where participants refuse to place statements in the lowest category because they still consider them important [ 20].

9.3.2. Phase 3b: Clustering

Participants will be asked to group statements that seem to belong together into clusters. Clusters are not required to have equal numbers of statements. Participants can give clusters names if they chose to do so (this is not a required part of the process). Participants will follow the following rules: each statement must be included in a cluster; each statement can only be used once [ 14, 20].

9.4. Phase 4: Representation

The individual clusters and priorities will be entered into the ARIADNE software package and combined to form a group product. The principal component analysis will be used to generate concept maps.

9.4.1. Principal Component Analysis

Principal component analysis (PCA) will be performed to identify hidden patterns in a dataset, reduce the dimensionality of the data by removing the noise and redundancy in the data, and identify correlated variables [ 24]. PCA will enable us to summarise and to visualise the information in a dataset containing opinions described by multiple inter-correlated quantitative variables [ 24].

9.4.2. Generation of a Concept Map

Concept maps will be generated, with each statement presented as a singular dot point. The map represents the "distances" between statements: the more often participants put statements in the same category (clustering), the smaller the distance between them on the map. Statements that are rarely or never linked by participants are shown far apart on the map [ 20]. On the concept map, these "distances" are translated into spatial relationships. We will use "latent preferences" to represent the differences between individual participants and between categories of participants [ 20].

9.5. Phase 5: Interpretation of Concept Maps (via Video Conferencing)

ARIADNE generates up to eight concept maps that need to be qualitatively interpreted and explained [ 20]. Concept maps produced by ARIADNE will be reviewed by three members of the research team and three participants (via a group video meeting). Participants will be invited to participate in this phase and will be included on a first-come, first-served basis. Researchers and participants will be tasked with coming to a consensus about the concept map that best represents the core competencies of mental health nurses.

The location of the statements on the map will be interpreted to determine which statements or clusters seem to go together logically and which do not [ 20]. The four cardinal directions of the compass (North, South, East, and West) will guide the interpretation and labelling of the clusters. The statements on the northern part of the map will be interpreted as contrasting with those on the southern aspect. The same applies to the western and eastern parts of the map [ 20].

The width of the line around each cluster will be used to establish the relative importance which participants attached to each cluster. The thicker the outline, the higher the average priority given to the statements in that cluster [ 20]. The relative importance of each cluster will be calculated using prioritising data (mean, SD, and 95% CI) [ 18]. We will generate a table of clusters by rank of importance that will inform an interpretation of the ranking of the relative importance of different clusters of competencies of mental health nurses.

9.6. Phase 6: Utilisation of Concept Maps

We will report how we will use the concept maps to inform the curriculum of mental health nurse training internationally.

10. The Time Commitment Involved

Typically, participant involvement in the study will take between one and a half and two hours. The brainstorming task takes around 30 min and prioritising and clustering an additional hour. If participants take part in interpreting concept maps, this will take an additional hour.

11. Limitations

Our study will be limited by the sampling methods we will use. Sampling and selection biases are inherent inconveniences and snowball sampling [ 25]. Participants in the population of interest do not have the same probability of being included in the final sample [ 26]. Sample diversity cannot be achieved through snowball techniques, which is a necessary condition for valid research findings. For example, the participants least keen to cooperate or with a different view are less likely to be referred for an interview [ 27, 28].

There is a possibility that if participants have worked with researchers previously, this may introduce the potential for social desirability bias; this is an acknowledged limitation of this study.

12. Conclusions

The views and opinions of the users of mental health services, psychiatric nurses, and psychiatrists on the core competencies of mental health nurses are essential in informing the focus and content of mental health nurse education internationally. Based on our review of the literature, there is a clear gap in knowledge about mental health nurse contemporary core competencies. Our study uses a true mixed-methods approach to develop a sophisticated conceptualisation of mental health nursing competencies from multi-dimensional perspectives. We intend to identify the core competencies of mental health nurses from five separate stakeholder groups and develop a meaningful list of core competencies for mental health nurses.

Author Contributions

N.M.: conceptualised the research project, design of the project, and wrote the initial draft. R.C. reviewed and edited the manuscript. R.G. and M.J.: supervised the project and edited the manuscript. All authors have read and agreed to the published version of the manuscript.

Funding

This study is part of a doctoral studentship from La Trobe University.

Conflicts of Interest

The authors declare no conflict of interest.

Footnotes

Publisher's Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

2. Bateman J., Henderson C., Kezelman C. Trauma-Informed Care and Practice: Towards a Cultural Shift in Policy Reform across Mental Health and Human Services in Australia. Mental Health Coordinating Council; Sydney, NSW, Australia: 2013. [ Google Scholar]

13. Kane M., Trochim W. Concept Mapping for Planning and Evaluation. Volume 50 SAGE Publications; Thousand Oaks, CA, USA: 2007. [ Google Scholar]

Articles from Nursing Reports are provided here courtesy of Multidisciplinary Digital Publishing Institute (MDPI)

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What Are the Core Competencies of a Mental Health Nurse? Protocol for a Concept Mapping Study

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This study aims to identify and contrast key stakeholder perspectives about the core competencies of mental health nurses. Mental health nurses provide much of the direct care and treatment to patients with mental disorders.

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The most important group to provide and safeguard people's health is the nursing staff. Their mental health and the caliber of the nursing care are tightly associated. An important task for hospital leaders is to coordinate the mental symptoms of the nursing staff and mobilize the nursing staff in order to solve nursing staff problems, fully explore their potential, enhance their overall quality, and offer patients a variety of multi-level, individualized health services. In nursing management, a positive psychological attitude and a culture of innovation within the nursing staff are beneficial for encouraging nurses to think outside the box, enhancing their sense of belonging at work, and raising the standard of nursing care. The purpose of this hospital-based study is to investigate how nursing personnel at various levels rate their mental health (Du et al., 2020).

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Man-Li Du, RN, a Wan-Xin Deng, RN, a Wen Sun, RN, a Ching-Wen Chien, PhD, b Tao-Hsin Tung, PhD, c,∗ and Xin-Chun Zou, MS d,∗

Monitoring Editor: Bishnu Prasad Coulagai.

Abstract

To assess the mental health of nurses and to find the post responsibility and psychological status of clinical nurses.

A total of 447 nursing staff at different levels in a teaching hospital was assessed by nursing post responsibility scale and mental symptom checklist (SCL-90) then compared with each other. The study period was from April 1, 2018 to April 30, 2018.

There was a positive correlation between the responsibility of post and interpersonal relationship (r = 0.11, P < .05), depression (r = 0.10, P < .05) and hostility (r = 0.10, P < .05). Post risk was negatively correlated with somatization (r = −0.10, P < .05), job involvement scope and communication ability were negatively correlated (r = −0.11, P < .05). Based on the multiple linear regression, knowledge and skills (β = −0.20, P = .02) and risks of the post (β=0.20, P  < .01) both significantly related to SCL-90 total score.

In conclusion, knowledge and skills and risks of the post associated with mental health of clinical nurses. The sustainable development of nursing post responsibility requires healthy physiological and mental health.

Keywords: depression, hostility, mental symptoms, nursing staff

1. Introduction

The mental health of nursing staff is one of the valued topics of nursing research. In recent years, great changes in society have been made. Higher demands on the skills and quality of nursing staff.[1] Nursing staff are strictly required to conduct level nursing post duty training to improve their professional skills. Post responsibility is based on the results of post analysis, according to the necessary criteria, the nature of the work, intensity, responsibility, complexity and the required qualifications and other status differences in a comprehensive assessment.[2]

Nursing staff is the key group to provide and protect health for people. Their mental health is closely related to quality nursing service. How to coordinate the mental symptoms of nursing staff and mobilize nursing staff is an important task for hospital leaders to solve the problems of nursing staff, to fully explore their potential, to improve their comprehensive quality and to provide patients with diversified, multi-level and individualized health services.[3] In nursing management, the positive psychological attitude and good atmosphere of innovation of nursing staff are helpful to promote nurses' divergent thinking, to improve their sense of work belonging, and to improve the quality of nursing service.[4] Therefore, this hospital-based study is conducted to explore the assessment of mental health among nursing staff at different levels.

2. Methods

2.1. Setting and participants

The purposive sampling for this hospital-based study was conducted in Guangdong, China from April 1, 2018 to April 30, 2018. A total of 447 nursing staff were selected at a fully certified regional and teaching hospital. Based on the nursing career development and the actual situation in the study hospital, the nursing functional promotion post consisted of four levels, that is, N1 (primary nurse): 1-3 years; N2 (senior nurse): 3-5 years; N3 (nursing leader): 5-8 years; N4 (specialist nurse): 8 years or more. In China, from the medium and long term Plan for the Construction of Professional and Technical personnel (2010-2020),[5,6] the proportion of professional and technical personnel in accordance with the high, middle and primary level is 10:40:50.

In this study, all participants completed a questionnaire pack at one time point. In addition, for the calculation of the sufficient statistical power, a sample size of 447 achieves 95% power using effect size 0.05 and 7 predictor with a significance level (alpha) of 0.05.[7]

2.2. Procedures and ethical considerations

This study was approved by hospital's institutional review board (gzhdfy2018hl01). All procedures were performed in accordance with the guidelines of our institutional ethics committee and adhered to the tenets of the Declaration of Helsinki. All subjects information was anonymous.

First, researchers contacted and explained the research procedures and emphasized that participants' responses were anonymous and confidential. Then the selected subjects were informed by the researcher that the survey was voluntary, the results would remain anonymous, and there were no right or wrong answers. It was also emphasized that the investigation was being done only for the purpose of studying participants' subjective perceptions. Finally, study subjects were asked to sign a letter of authorization before completing the self-report questionnaire.

2.3. Measurement instruments

2.3.1. Nursing post responsibility scale

Job responsibilities, including knowledge and skills, post responsibilities, post risks, job complexity, scope of work and communication skills and innovation skills are 6 dimensions. The scale has 36 evaluation factors; each item has the corresponding post representative.[8]

2.3.2. Mental health assessment tool

The Symptom Check List-90 (SCL-90) is a self-report clinical rating scale. From the clinical and academic viewpoint, the SCL-90 not only has been designed as a general measure of psychiatric outpatient symptomatology, but also was developed with primary emphasis on validity as a criterion measure in clinical trials where focus is on the relative efficacy of psychotherapeutic agents.[9] There are 9 factors in the SCL-90, including somatization, obsessive symptoms, interpersonal relation, depressed, anxious, hostility, terrifying, bigoted, and mental degeneration.[9] Each item on this scale was measured on a 5-point Likert scale, with 1-5 indicating the severity of the symptoms as follows: "1: no", "2: light", "3:moderate", "4:quite heavy", and "5:severe". A higher answered score reflected a higher frequency and intensity of symptoms.[10] In this study, the total score greater than 160 was considered to be positive for psychological symptoms.[11,12]

2.4. Data analysis

Statistical analyses were performed using SPSS 20.0. Subjects' characteristics were reported as means and standard deviation (SD) for continuous variables and proportions for categorical variables. In the univariate analysis, the independent t-test method or χ ²-test was adopted and the Pearson's correlation coefficient was used to assess the association of the mean value. The multiple linear regression model was used to assess the independent effects of relevant factors on SCL -90 values after controlling for the covariates. A two-sided P value < .05 was considered statistically significant.

3. Results

A total of 447 clinical nurses (100% response rate) were assessed with self-rating scale for nursing posts and psychological symptoms. Table ​Table1 1 shows that number of N1, N2, N3, and N4 were 213 (47.7%), 144 (32.2%), 51 (11.4%), and 39 (8.7%), respectively. The mean ± SD total points of nursing duty score and SCL-90 score were 458.72 ± 95.16 and 124.45 ± 34.43.

Table ​Table2 2 shows that the nursing post responsibility is correlated with the interpersonal relationship, depression and hostility in SCL-90 ( P < .05), and there is a positive correlation between the responsibility of the post and the interpersonal relationship, depression and hostility in SCL-90 ( P < .05). There was a negative correlation between post risk and somatization symptom ( P < .05), more significant correlation with total score of SCL-90 ( P < .05), and negative correlation between job involvement scope and communication ability and anxiety and hostility ( P  < .05).

From Table ​Table3, 3 , the proportion of N4 in the positive signs of SCL-90 is the highest, and the proportion of N4 in the positive signs of SCL-90 is increasing with the higher level. In addition, as mention in the method, the SCL-90 total score greater than 160 was considered to be positive for psychological symptoms. Table ​Table3 3 also indicates that the subjects with SCL-90 total score ≥160 had higher scores of risks to the post than those <160 (108.49 ± 35.38 vs 92.69 ± 31.81, P  = .001).

The effects of independent factors of SCL-90 total score were examined by the multiple linear regression model. Table ​Table4 4 shows that knowledge and skills (β = −0.20, P = .02) and risks of the post (β = 0.20, P  < .01) both significantly related to SCL-90 total score after adjustment for confounders.

4. Discussion

4.1. Clinical implications

In China, the SCL-90 is one of the important assessment tools for mental health and used widely in clinical mental health practice.[10] This tool uses have ranged from evaluation of the mental health in various groups, as well as comparisons of different symptom groupings.[13] This study showed that 11.9% of the nurses' score of SCL-90 is estimated more than 160, indicating that they possibly had unhealthy mental tendencies, and medical staff had problems in interpersonal relationships, depression, hostility and anxiety. It also implied that if the clinical nurses with symptoms of depression and hostility, in addition to understand and fully affirm their work achievements, they may conduct individual mental health counseling. If the mental symptoms do not relieve and gradually affect daily life, clinical nurse staff may further reach to professional psychological counseling and treatment suggestions.

The physical, cognitive, and emotional demands inherent in nursing practice have been indicated to have a negative effect on the physical and psychological well-being.[14] Nursing staff's mental health is worse than the general population, especially in ages less than 40-year nurse group have higher incidences of mental health problems.[15,16] Previous academic studies used SCL-90 accessing nursing mental health in various populations also found that the Chinese nurse group faces greater occupational pressure and is different from the psychological status of ordinary adults.[17-20] There is consistent in our study when compared with other researches. In addition, the symptoms of depression and hostility were obvious among nurses at different levels. The higher the nursing posts, the more medical comprehensive quality education they accepted, the higher their professional skills, the higher their social status, the higher their professional competitiveness, the higher their professional development career, the higher their professional skills, and the higher their scientific research and teaching work. High workload, high repeatability, the risk of disease infection and the improvement of medical level require higher professional competence of medical staff, so that nurses feel greater occupational stress.[21,22] Physical and mental injury, increased turnover rate, affect the stability of the medical team, increase medical risk. High intensity of work can cause bad mental state, increase depression and hostile mood, meanwhile induce mental illness in long turn, so it is very meaningful to enhance the mental health of nurses.

From the viewpoint of clinical practice, mental health is an issue that needs preventive interventions due to the stressors that subjects are exposed to in the workplace could inflict mental pain and increase the risk of incident physical health problems.[23] Mental health refers to the best state of mind and body of each individual under subjective and objective conditions. Mental health does not mean absolute perfection.[24] The nature and characteristics of nursing work determine that nurses' mental symptoms are becoming more and more prominent and complex, and that nurses face stress or threat in clinical practice in their duties. This is a phenomenon that all nursing staff believed is widespread.

4.2. Methodological considerations

Several methodological limitations should be considered when interpreting the results of this study. First, the study population is based on a voluntary selection, that is, the participants done not only would potentially introduce self-selection bias, but also Hawthorne effect is inevitable due to the subjects were made a conscious decision to be in the selected study hospital. Voluntary bias could be viewed as that comes from the situation that a special sample could contain only those subjects who are totally willing to participate in the investigation and who participate and know the topic especially interesting are more likely to volunteer for that study, same to those who would like to be evaluated on a positive level.[25,26] Second, we conducted measurements only at a single time point, which might not reflect long-term exposure to the factors related to nurse' mental health. Third, due to the use of the SCL-90 remains controversial in the study of mental health assessments, further study is needed to determine its reliability and validity in evaluations of Chinese clinical nurses' psychological health.

Finally, this study only obtained subjects from one teaching hospital in Southern China as the target population. Therefore, the results of this study should not be extrapolated to hospitals in other regions of China. Future studies using random sampling approach of hospitals over wider regions would make the findings more discursive.

5. Conclusion

In conclusion, knowledge and skills and risks of the post associated with mental health of clinical nurses. The sustainable development of nursing post responsibility requires healthy physiological and mental health. It is also propitious to establish reasonable planning of human resources and establish self-expectation and self-encouragement standard of nursing staff.

Acknowledgments

The authors thank the Sunflower Statistical Consulting Company, Kaohsiung, Taiwan for statistical advice.

Author contributions

Conceptualization: Man-Li Du, Ching-Wen Chien.

Data curation: Wan-Xin Deng, Wen Sun, Tao-Hsin Tung.

Formal analysis: Wen Sun.

Methodology: Man-Li Du.

Resources: Wan-Xin Deng.

Writing - original draft: Man-Li Du.

Writing - review & editing: Ching-Wen Chien, Tao-Hsin Tung, Xin-Chun Zou.

Footnotes

Abbreviations: SCL90 = Symptom Check List-90, N4 (specialist nurse) = 8 years or more, SD = standard deviation, N1 (primary nurse) = 1-3 years, N2 (senior nurse) = 3-5 years, N3 (nursing leader) = 5-8 years.

How to cite this article: Du ML, Deng WX, Sun W, Chien CW, Tung TH, Zou XC. Assessment of mental health among nursing staff at different levels. Medicine. 2020;99:6(e19049).

As the National Health Research Institute had addressed the confidentiality assurance issue, a full review of this study was proved by the Institutional Review Board of Huadu District Maternal and Child Health Hospital of Guangzhou, Guangdong, China (gzhdfy2018hl01).

The authors have no funding and conflicts of interest to disclose.

References

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Articles from Medicine are provided here courtesy of Wolters Kluwer Health

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Assessment of mental health among nursing staff at different levels

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To assess the mental health of nurses and to find the post responsibility and psychological status of clinical nurses.A total of 447 nursing staff at different levels in a teaching hospital was assessed by nursing post responsibility scale and mental ...

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The nursing workforce in mental health is underutilized despite growing need for mental health professionals on a global scale. This is partly because people don't fully comprehend their functions, identities, and capacities. The purpose of this work was to thoroughly clarify the professional identity and potential of mental health nurses by compiling and synthesizing published data on their clinical duties. In five electronic databases, we looked for relevant studies published between 2001 and 2021 (Hurley et al., 2022).

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International Journal of Mental Health Nursing

John Hurley, PhD, CMHN, MSc Nursing, Professor, 1 Richard Lakeman, MMH (Psychotherapy), DNSCi, Fellow ACMHN, Associate Professor, 2 Paul Linsley, RMN DSci, MMedSci, Associate Professor, 3 Mike Ramsay, RMN, DEd, MSc, Professional Lead, 4 and Stephen Mckenna‐Lawson, RN (Mental Health), MA, PgDip, Lecturer 5

Abstract

Despite rising international needs for mental health practitioners, the mental health nursing workforce is underutilized. This is in part due to limited understandings of their roles, identities, and capabilities. This paper aimed to collate and synthesize published research on the clinical roles of mental health nurses in order to systematically clarify their professional identity and potential. We searched for eligible studies, published between 2001 and 2021, in five electronic databases. Abstracts of retrieved studies were independently screened against exclusion and inclusion criteria (primarily that studies reported on the outcomes associated with mental health nursing roles). Decisions of whether to include studies were through researcher consensus guided by the criteria. The search yielded 324 records, of which 47 were included. Retained papers primarily focused on three themes related to mental health nursing clinical roles and capabilities. Technical roles included those associated with psychotherapy, consumer safety, and diagnosis. Non‐technical roles and capabilities were also described. These included emotional intelligence, advanced communication, and reduction of power differentials. Thirdly, the retained papers reported the generative contexts that influenced clinical roles. These included prolonged proximity with consumers with tensions between therapeutic and custodial roles. The results of this scoping review suggest the mental health nurses (MHNs) have a wide scope of technical skills which they employ in clinical practice. These roles are informed by a distinctive cluster of non‐technical capabilities to promote the well‐being of service users. They are an adaptable and underutilized component of the mental health workforce in a context of escalating unmet needs for expert mental health care.

Keywords: mental health nursing roles, mental health nurse identity, scoping review

INTRODUCTION

Mental health services in Western countries were struggling to meet the needs of their populations prior to the COVID‐19 pandemic (Triliva et al. 2020). Deteriorating mental health outcomes have been occurring despite increasing expenditure in many of these countries (McCartan et al. 2021). Suicide rates, particularly for youth, have continued to increase despite focused attention on this issue (Glenn et al. 2020), and rates of depressive disorders, anxiety disorders, and adjustment disorders are also rising in developed countries (World Health Organisation 2017). Given the poor physical health status and pre‐mature mortality of those with mental health problems (Happell et al. 2019), the negative impacts on well‐being are significant. One key driver for this deterioration in the mental health of the population has been shortages of, and poor access to, specialist mental health clinicians (Delaney 2017).

BACKGROUND: Scope of the challenges

There is a high prevalence of mental health conditions across the general population, with youth particularly impacted (McGorry 2021). Further deterioration and heightened complexity of these problems can be expected if mental health service delivery is not improved in a timely manner. It has been widely recognized that the current mental health workforce is insufficient both in numbers and capability preparedness to address the needs of populations, particularly those with moderate to severe conditions (Delaney 2017; Productivity Commission 2020). Attracting health and social care professionals into mental health practice over other more profitable and less stigmatizing work options has been a long‐standing challenge (Brenner et al. 2017). Historically, mental health nurses (MHNs) and other professionals have been practising within specific and arguably restrictive scopes of practice structured around health service need, rather than the holistic needs of service users. This already finite workforce consequently has a constrained scope of therapeutic practice, necessitating multiple and often ineffectual contacts with service users over extended periods of time (Productivity Commission 2020).

The global pandemic has exacerbated these structural weaknesses of mental health services whilst simultaneously increasing the acuity, complexity, and volume of service user need (Pierce et al. 2020). In the search for strategies remedies to address these challenges numerous programmes and funding initiatives have been launched. Interestingly very few, if any, have recognized the psychotherapeutic potential of MHNs or collaboratively involved them as part of the solution. In Australia, the Federal Government increased access to psychologist services (Australian Medical Association 2020), despite recent reviews suggesting that the impact of this service has been minimal with benefits largely confined to urban centres for those who can pay top up fees (Productivity Commission 2020). In the United Kingdom, the National Health Service Mental Health Implementation Plan 2019/2020-2023/2024 excludes MHNs from clinical areas involving psychological therapies and psychotherapy (NHS England 2019). In Europe, the European Commission Horizon 2020 Project also excludes any role MHNs may have in contributing to mental health responses to COVID‐19 ( European Commission, ND). The rationale for excluding MHNs from treatment programmes, despite their scope of practice being well matched to meet the needs of the population, are unstated. However, in the context of multiple previous exclusions, it is probable that this reflects a shallow construction of the professional identity of the MHN and what clinical roles they might contribute (Molloy et al. 2016). Identity refers to key defining characteristics of an individual or group and is constructed internally by the individual or group, as well as being socially constructed (Eisenberg 2001; Giddens 1997). Where such external identity descriptions, explanations, and/or representations are finite and unrepresentative so too is the attributed worth and value of the performance roles of that identity (Gergen 1999). This is a barrier to MHNs to being fully utilized to ameliorate, prevent, and otherwise respond to the unmet mental health needs of the community.

Clarification of the role and identity of the MHN

Historically the clinical roles and identity of MHNs have been poorly understood and articulated (Peplau 1997). There is no undisputed definition of mental health nursing (Barker & Buchanan‐Barker 2011) outside of the pragmatic position of holding a named specialist qualification in it (Australian College of Mental Health Nursing 2010). Having roots in the asylum model of care, MHN roles are often seen as primarily custodial, basic, and under their practice under the direction of medicine (Wand et al. 2021). Despite the move to community models of mental health service provision some 40 years ago, the bulk of MHN workforce remains confined to in‐patient settings (Australian Institute of Health & Welfare 2021). This perpetuates asylum‐based perceptions of MHN roles and narrow constructions of the identity of the MHN. Constructing a counter narrative about MHN roles and hence identities is challenging. Much of the work of MHNs is undertaken out of public view, and the limited media attention it attracts is often negative (ABC News 2014; Tonso et al. 2016). The roles and identity of the MHN are difficult to reduce to a comprehensible essence due to the sheer diversity of roles being undertaken that encompasses settings from primary through to tertiary care. Internationally, the undergraduate preparation of MHNs has been found to be largely inadequate to commence specialty practice (Hunter et al. 2015) and mental health content in comprehensive nursing programmes is particularly weak (Happell & Gaskin, 2013), eroding the specialist identity of mental health nursing. This is then exacerbated with underprepared comprehensive graduates utilizing the title of MHN when working in mental health settings.

To date there has not been a comprehensive scoping of the evidence literature on the clinical practice roles of MHNs, as reported from the perspectives of MHNs. Such a scoping offers opportunity for enhanced understandings of the full scope of clinical practice of MHNs and hence, their identity. This can highlight the unutilized clinical worth of MHNs and better position them as an important strategic solution systemic challenges facing services and hence service users.

METHODS

As evident from our preceding critical discussions, there is a need for conceptual clarification and enhanced defining of mental health nursing clinical roles and hence identity. Scoping reviews are typically deployed to achieve these ends (Tricco et al. 2018a). Typically, a scoping review will seek a wide breadth of literature making a systemic critical appraisal of findings very difficult to undertake (Peters et al. 2015). In many cases a scoping review will also thematically analyse this breadth of literature in response to a wider objective for the review and a more specific research question (Pollock et al. 2021). Additionally, scoping reviews are used to collate the contexts of phenomena, in this case the contexts influencing mental health nursing in clinical practice settings (Pollock et al. 2021; Tricco et al. 2018b).

Aim

The aim of this review is to collate and synthesize peer‐reviewed published data on what clinical roles and identities have MHNs been undertaking for the past two decades, from the perspectives of MHNs. This time period was chosen to ensure cotemporary relevance of those clinical roles to inform current and future utilization of MHN's therapeutic potential. The perspectives of MHNs were sought as they are the most central stakeholder to their roles and the holders of their professional identity. Additionally, a collation of peer‐reviewed published data on their roles has not yet been undertaken. The purpose of systematically clarifying these clinical roles and hence professional identities is to contribute to the evidence base that would support this greater utilization of MHNs for service user's benefit. The review was guided by the following research question: what clinical roles and identities have MHNs been undertaking, from the perspectives of MHNs?

Design

Following the updated scoping review guidance of Pollock et al. ( 2021), this review used the JBI ScR framework and the PRISMA‐ScR extension. Additionally, the design utilized the recommended 'PCC' format: Population, Concept, and Context (Peters et al. 2020).

Population - Registered MHNs

Concept - The clinical practice roles of MHNs construct the professional identity of the discipline

Context - All MHN clinical practice settings.

The full protocol is outlined in Table  1 :

Table 1

Inclusion criteria

Exclusion criteria

Databases

CINAHL, MEDLINE, PsycINFO, PubMed and Cochrane

Peer‐reviewed papers from 2001-2021.

Other databases.

Process

An initial email discussion was held with a university librarian and informatic expert in February 2021 to outline the research topic, aim, and research question, as well as suggested key terms. The university librarian ran multiple searches prior to a direct meeting with one of the researchers to further refine search terms and to select databases. Multiple searches were then undertaken using combinations of selected keywords over a range of databases in order to establish the most efficient collection of papers eligible within the protocol outlined in Table  1 . All researchers then met to review this process and to confirm agreement with the use of database and search terms. The main second search was then undertaken on March 8 th, 2021. Following this search and subsequent screening two researchers independently reviewed those papers excluded and those papers included from the reference list search of all retained papers and reached 75% agreement on those retained. The search strategy and yield are presented in Figure  1 .

Study characteristics

There were 47 papers that reported the roles of the MHN within clinical settings. Most studies were undertaken in the Australia ( n = 17) then EU countries ( n = 11) and the United Kingdom ( n = 10) followed by New Zealand ( n = 3) and the United States of America ( n = 3), as well as multinational settings ( n = 3). The remaining papers were from a single country. The majority of the papers adopted qualitative methods. Of these, poorly defined qualitative methods were used in ( n = 13), focus groups ( n = 7), phenomenology ( n = 6), survey ( n = 5), ethnography ( n = 4), grounded theory ( n = 4), mixed survey and interview ( n = 2), observational studies ( n = 2), Delphi ( n = 2), and other ( n  = 2).

Results

See Table  2 .

Table 2

Author, year, country

Aim

Study design

Sample

Main findings on MHN roles and identities

Debyser et al. ( 2018). Belgium

To clarify and understand the self‐perceptions of MHNs and peer workers in order to identify the specificity and potential complementarity of both roles.

A qualitative descriptive design exploring critical incidents. Data collection was personalized case reports on the MHN's daily role. Analysis was by coding and thematic analysis.

Nurses ( n = 12) and peer‐workers ( n  = 8) (data‐sets for each group separated out for analysis).

MHN roles included de‐escalations, protecting vulnerable patients, behavioural modification, ameliorating emotional distress, and problem‐solving counselling. Competencies supporting these roles included emotional regulation, empathy, critical reflection, teamwork, unconditional positive regard, relationship engagement, and advanced communication.

Santangelo et al. ( 2018a). Australia

The study aimed to explore models of mental health nursing practice to provide a theoretical framework for contemporary and productive client focused practice. The study used constructivist grounded theory.

Grounded theory techniques.

36 Australian Mental Health Nurses who identified their practice as autonomous. Mental health nurse participants were overwhelmingly female ( n not given), over 40 years of age and with at least 10 years' experience in mental health nursing. Eighty‐six per cent of participants were working in a community setting of which 58% were currently engaged in primary care settings. The remaining 14% were working in hospital‐based settings.

Ten attributes which distinguish mental health nurses from others were formulated and expressed as the 'Ten P's. Mental health nurses are 'present', 'personal', 'participant partnering', 'professional', 'phenomenological', 'pragmatic', 'power‐sharing', 'psycho‐therapeutic', 'proud', and 'profound'.

Santangelo et al. ( 2018b). Australia

This qualitative study explored the nature, scope, and consequences of mental health nursing practice using a grounded theory approach and seven focus groups.

Grounded theory.

Australian based study with 36 MHNs, 5 service users, and 1 colleague in 2012 (see Santangelo et al., ( 2018a).

The study offers a distinct nature and identity of mental health nursing. The mental health nursing perspectives are based upon relational interplay between the nurse and the client that in turn supports recovery focused practices: Mental Health Nursing is '‡ client‐focused and flexible in its practice boundaries in order to better satisfy client needs, achieving this through an intimate caring relationship with clients. It is executed in a "special" way that co‐constructs interaction, understanding and meaning between the mental health nurse and their client in order to develop therapeutic interventions that aid the recovery process. The consequences of the nature and scope of this practice result in positive outcomes that are led by the client and facilitated to the optimum level of functioning with life, that is acceptable to the client they serve' (p.270).

Terry ( 2020). U.K.

The primary focus of this study was to examine how talk about mental health nursing was handled by participants from multiple perspectives.

Descriptive

30 interviews were conducted in the UK with service users ( n = 13) and nurses ( n = 17), and three focus groups were held with first‐ and third‐year nursing students ( n = 18), amounting to 2022 min of audio‐recorded data. The six steps of Braun and Clarke ( 2006) were followed in order to analyse the data.

Participants highlighted that mental health nurses often have an 'in the middle' label because the complexity of their work can be hard to describe. The following were reported to be major themes: Nurses are co‐ordinators of everybody else, Nursing work is limited by co‐ordination, Bridging the gap, Jack of all trades and master of none, Being in the middle.

Zeeman et al. ( 2002). Australia

To obtain information regarding the current role of the community mental health nurse (CMHN).

Questionnaire

All community mental health nurses working in one Adult Program in Fremantle, Australia ( N  = 12).

Core roles of the MHN were found to be working with consumes experiencing psychosis within the home environment, responding to community crisis needs and home visiting consumers, as well as ongoing case management. Other core roles included liaising with the wider mental health team, undertaking a range of complex assessments and meeting the consumer needs for health, finances, mental health and social factors. MHNs were key in maintaining consumers with complex needs in least restrictive environments.

Discussion

Data from scoping reviews can be structured into themes (Pollock et al. 2021). The following represents a narrative account of this body of research with respect to the broad content themes evident from a reading of the 47 included studies. The use of the terms 'technical and non‐technical' offers contestability where such roles, identity, and capability merge. Other descriptors such as curative and supportive were considered along with soft skills such as inter‐personal or social competencies and hard skills such as Intelligence Quotient. However, the terms technical and non‐technical are reflective of the Organisation for Economic Co‐operation and Development's (OECD) (2021) structuring of capabilities to enable work roles and were hence used. Non‐technical capabilities are clustered around those of social and emotional capabilities such as communication, team‐work, and situation‐awareness skills.

Technical MHN roles

The acute unit-based observational study by Fourie et al. ( 2005) identified that maintaining consumer safety was a central role of MHNs within acute in‐patient settings. These assertions were also made in other studies (Debyser et al. 2018; Hamilton & Manias 2007; Hurley & Lakeman 2021; Seed et al. 2010). The reported role capabilities of the MHN to reduce aggression and promote safety included preventative assessment through observations, consumer engagement, and medication management, as well as promoting the use of emotional regulation skills with service users.

Providing psychoeducation especially regarding symptoms, symptom management, and medication use with service users and others in their social and support network consumers was a technical role capability used by MHNs across multiple studies, which also made reference to communication micro skills (MacNeela et al. 2010; McKenna, et al. 2014; Rasmussen et al. 2017; Seed et al. 2010). Psychological interventions including (but were not limited to) cognitive behavioural therapy (CBT) and solution‐focused brief therapy (SFBT) were provided by MHNs to service users with serious mental health within the papers reviewed (Browne & Hurley 2018; Carlye et al. 2011; Deacon et al. 2006; Hurley 2009; Hurley 2012; Hurley & Lakeman 2021; Neela et al. 2007; Smith & Macduff 2017). These psychotherapy roles were prized by MHNs as evident in Hurley and Lakeman ( 2011 p.747) 'You then want to focus more on the counselling aspect of the mental health nursing role, that's because that is where you see yourself most effective'. These findings were echoed in a recent Australian national survey of MHNs by Hurley et al. ( 2020). Findings here indicated MHNs are highly capable of adapting or providing psychotherapy to people with moderate to severe mental health problems, whilst also fulfilling other roles, including physical health care interventions.

However, these distinct technical capabilities within in‐patient settings were reported as being obscured by more generic roles: 'Sharing life experiences and engaging in activities which "normalize" the situation were valued highly by a number of respondents' (Hercelinskyj et al. 2014, p.29). This covertness of the MHN role repertoire and identity, especially within in‐patient settings, was also found in studies by Hamilton and Manias ( 2007), Delaney and Johnson ( 2014), and Moe et al. ( 2013).

Elsom et al. ( 2007) in their qualitative study of community‐based MHNs identified expanded practice roles where MHNs were leading holistic assessments, mandated assessments under State Mental Health Acts, as well as formulating, diagnosing, and recommending medications to prescribers or adjustments to medication regimes. Expanded roles were also described by Kudless and White ( 2007) in their survey of MHNs in the United States of America. These included medication prescribing, monitoring, and responding to side effects, as well as bio‐psycho‐social assessment and offering psychological therapies. However, Crawford et al. ( 2008) linked MHN expanded roles, to nurses leaving the discipline due to their practice being restricted by a lack of recognition.

Non‐technical MHN roles

MHNs build therapeutic connections to promote well‐being or ameliorate emotional distress with service users utilizing their personal lived experience. This was reported in a United Kingdom-based mixed methods study (Oates et al. 2017) with the use of the personal self also evident in the qualitative United Kingdom-based study by Hurley ( 2009). In their small phenomenological study of Norwegian MHNs, Akerjordet and Severinsson ( 2004) identified emotional intelligence (EI) capabilities as being pivotal for MHNs to be able to construct trusting and positive relationships with consumers and carers: 'High quality nursing care may emerge when the MHN is able to create a relationship, characterized by mutual confidence and trust' (p.166). EI capabilities such as resilience were connected to MHN identity by Cleary, Jackson, and Hungerford (2014), whilst those of self‐awareness, emotional regulation, and developing and acknowledging others were also identified by Hurley ( 2012) as enabling MHN technical capabilities in psychological therapies.

Similarly, self‐understanding and authentic self‐reflection were identified as essential capabilities for MHNs within intervention roles with people experiencing emotional distress. In their phenomenological study, Humble and Cross ( 2010) found that MHNs reported a respectful curiosity towards the lived experience of Australian military veterans receiving care. Rydon ( 2005) undertook a focus group study of MHN capabilities valued and needed by service users and their family members in New Zealand. Participants placed high value on the MHNs capability to enact inter‐personal communication that builds hope and mutual respect through MHN self‐awareness and minimization of power differentials between MHNs and those they worked with. Delaney and Johnson ( 2014) identified generating consumer engagement as a core MHN role within in‐patient settings. These findings were closely mirrored by consumer participants in an Australian‐based qualitative study by Gunasekara et al. ( 2014), and MHN participants in Santangelo, Procter, and Fassett's ( 2018a, 2018b) grounded theory study. Additionally, recovery‐based values of respect, validation, and trust building were evident in a focus group study of McKenna et al. ( 2014), a qualitative study on coercion reduction by Landeweer et al. ( 2010) and a study focused on reducing stigma in Belgium by Sercu et al. ( 2015). This is in contrast to Magnusson et al. ( 2004) study where MHNs were reported to assume paternalistic roles to fulfil perceived duties to services and service users.

MacNeela et al. ( 2010) in their Delphi study on essential elements of MHN care found the coordination, organization, and communication of care was a core role of the MHN, as did Schoppmann and Lüthi ( 2009) in their observational study on the roles of the in‐patient MHN. Similar capabilities were found by Cleary ( 2003) where simultaneous demands of decision‐making and prioritizing multiple tasks were core MHN roles. These roles differ from organizational administrative tasks through being aligned to meet consumer needs. Therapeutic dexterity was a prominent capability identified by Deacon et al. ( 2006), a term used to describe the MHN navigating between organizational administration, care coordination, and direct therapy roles. The philosophical and explanatory positioning of MHNs also showed inherent tensions, often between psychodynamic and interpersonal models of care contrasting with medical model roles (Carlye et al. 2011; Rydon 2005).

Generative contexts of roles and identity

The roles and identities within the reviewed papers were reported as being undertaken within contexts that influenced those roles and identities. In an acute unit case study design, Deacon et al. ( 2006) found that the 24 hour a day proximal contact between MHN and service user within chaotic and unpredictable contexts were formative and unique experiences for MHNs. These experiences engendered a connection to service users and a foundation for an empathic relationship which other disciplines were challenged to replicate. Cleary ( 2003) reported similar in‐patient contexts of unpredictability and intense workload demands. Rydon ( 2005) in their consumer‐based study identified that the roles and even attitudes of MHNs varied depending on community and in‐patient context, a finding also evident in the MHN study of Carlye et al. ( 2011). Hinsby and Baker ( 2004) in their small secure unit‐based study. Here, tensions between care and risk control roles in order to optimize safety were reported as influential, a finding also evident in Felton, Repper, and Avis's case design study of both in‐patient and community settings.

Fourie et al. ( 2005) and Seed et al. ( 2010) uncovered the role tensions for MHNs who are responding to perceived unaligned organizational administrative needs and the therapeutic needs of service users. This combination of administrative, coordinating, and therapeutic roles was also found to lead to heavy MHN workloads in in‐patient settings (Cleary 2003), consultant liaison roles (Sharrock & Happell 2001), and in community settings (Zeeman et al. 2002). This mirrored Terry's ( 2020) findings in a qualitative study of MHNs and service users. Here the role tensions between administration and care provision were found to give rise to a blurring of roles and ambiguity of professional identity. This role blurring was also evident in Browne and Hurley's ( 2018) and Lakeman and Hurley's ( 2021) studies where the psychotherapeutic MHN roles clashed with those associated with psychiatric roles as required by Mental Health Acts and other legislation.

Low perceived worth towards MHN clinical roles was another influencing context. This was reported in Elsom et al.'s ( 2007) community setting. Here limiting attitudes of medical doctors towards MHN expanded practice capabilities were a prominent barrier, whilst the limiting attitudes of non‐nursing community clinicians were reported by White and Kudless ( 2008, p.1079) 'It doesn't matter how educated we are or what we can do. Advanced degrees do not mean anything. We are not recognized for the complex care we can provide.' The limiting of MHN roles and identity was also reported in Sercu et al. ( 2015) ethnographic case study and observation paper where MHN identification with the medical model and its associated stigma directly influenced MHN identity. Medical model hegemonic influences upon MHN identity were also found by Lakeman ( 2012) in an Irish survey regarding what counted as good mental health nursing. Government policy on MHNs delivering clinical services was evident in the Hurley et al. ( 2014) study of the mental health nurse incentive programme and in a subsequent national survey Hurley et al. ( 2020) reporting MHN's as being at the service of medical disciplines and of less importance than other mental health professionals. This finding echoed that of Crawford et al. ( 2008), where interviewed MHNs reported an identity of public servant, were subservient and subordinate to medicine, and lacked recognition. Some 12 years later, Waddell et al. ( 2020) in their survey and focus group study also found the value MHN work was not recognized. Similarly, Crowther and Theresa Ragusa's ( 2011) study of MHNs in rural Australia found low regard towards MHNs compared to other disciplines with a consequent challenge in recruiting new people.

Limitations

This review sought to clarify potential therapeutic roles of MHNS, and hence needed to be broad in its approach. Consequently, differences in educational structures, tiers of MHN practice, or mandated scopes of practice were not considered. Incorporating international papers allowed for the full breadth of MHN role potential to be captured. However, a limitation of this decision is that there are distinct differences in the MHN role across these settings that require further research. Additionally, in line with scoping review methods a critical analysis on the quality of the research design within each was not undertaken (Tricco, et al. 2018b). However, there is worth highlighting that variances were apparent in the stance of how the roles of the MHN were described across the 47 papers. These variances were widely typified by a lack of critical examination of the efficacy of the MHN roles being reported. Papers such as Rydon ( 2005) were part aspirational and part observational. Such aspirational positioning of the MHN role was also evident in Hercelinskyj et al. ( 2014) through espousing the worth of MHN counselling roles in the absence of describing them. Further, more focused reviews are indicated.

Conclusion

This scoping review sought to clarify the clinical roles and hence identities of the MHNs. The results of this review suggest that MHN clinical practice can be highly technical. Such roles include those promoting safety, aggression reduction, and suicide prevention, as well as psychotherapy roles for people with complex and challenging needs. Complex assessment, diagnostic, formulation, prescribing, and physical health promotion and maintenance roles were all reported as being undertaken and often led by MHNs. These technical capabilities were enacted alongside and often embedded within a cluster of values, interpersonal capabilities, and communication‐based roles that reflect what the OECD refer to as non‐technical based roles and capabilities (OECD 2021).

Data from the scoping review suggest that both these technical and non‐technical practice roles of the MHN are influenced by multiple mechanisms. Often, these were characterized by tension. These included tensions between psychodynamic, biomedical, and interpersonal models of care, tensions between administrative, coordinating, and therapeutic roles and also those between psychotherapeutic and roles required by legislation (Lakeman 2012).

The breadth of MHN clinical capabilities and roles found within this review suggest the identity and therapeutic potentials of MHNs can be whatever they, health services, or service users want them to be. The MHN could as easily be a psychotherapist in the community as they could be managing aggression in an in‐patient setting. Arguably, the MHN non‐technical capabilities, as well as their capacities to navigate role tensions and challenging work environments, are poorly understood in terms of how they enable the more visible technical roles and capabilities. Findings from this review can be argued as positioning the MHN as an underutilized, versatile and valuable addition to future workforce reforms to meet consumers' needs.

Relevance to clinical practice

Across the papers reviewed there are varying and often conflicting opinions about the role of the MHN. Much of this situation would seem to stem from the profession itself. An examination of the role of the MHN immediately offers opportunity for differing beliefs about how nurses contribute to the therapeutic interventions. The breadth of clinical focus areas within the scoped papers was reflective of the diversity in which MHNs seek to situate their clinical activities. Findings here indicate the MHN has capabilities to ameliorate distress and improve both mental and physical well‐being for service users. However, MHNs have been poor in articulating what it is they do, and this subverts the contribution they make to the care of people with mental illness.

Funding

External funding was Council of Australian University Librarians for this study.

Acknowledgment

Ms Jill Dombrow (BA, BBus) Librarian, Southern Cross University. Open access publishing facilitated by University of New South Wales, as part of the Wiley - University of New South Wales agreement via the Council of Australian University Librarians.

Notes

Declaration of conflict of interest: There are no conflicts of interest to declare.

Authorship statement: All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors, and all authors are in agreement with the manuscript.

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Utilizing the mental health nursing workforce: A scoping review of mental health nursing clinical roles and identities

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International Journal of Mental Health Nursing John Hurley, PhD, CMHN, MSc Nursing, Professor, 1 Richard Lakeman, MMH (Psychotherapy), DNSCi, Fellow ACMHN, Associate Professor, 2 Paul Linsley, RMN DSci, MMedSci, Associate Professor, 3 Mike Ramsay, RMN, DEd, MSc, Professional Lead, 4 and Stephen Mckenna‐Lawson, RN (Mental Health), MA, PgDip, Lecturer 5 Despite rising international needs for mental health practitioners, the mental health nursing workforce is underutilized.

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Mental Health Playbook For Healthcare Workers

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The Code Blue team meets right after following the incident to evaluate the case's specifics and pinpoint areas in need of improvement. This is known as a hot debrief (Anne, 2022).

At less regular, predetermined periods, cold debriefs are conducted, and they often include aggregate case-specific data. A hot debrief takes place right away following an event and concentrates solely on the code that just happened while the specifics are still recent (Anne, 2022).

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Direct Adverse Outcomes Related to Post Traumatic Stress Disorder

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Direct Adverse Outcomes Related to Post Traumatic Stress Disorder

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Exposure to sexual violence in one or more forms, whether it is actual or threatened (Post-Traumatic Stress Disorder in Nursing, 2021).

One or more of the following symptoms that were present before the trauma and started appearing after it (Post-Traumatic Stress Disorder in Nursing, 2021).

One or more experiences that show a persistent avoidance of the stimuli connected to the traumatic event (Post-Traumatic Stress Disorder in Nursing, 2021).

Adverse changes in mood and cognition that started after the traumatic event or got worse, as shown by two or more episodes (Post-Traumatic Stress Disorder in Nursing, 2021).

Trauma-related changes in arousal and reactivity that started or deteriorated after the traumatic incident, as shown by two or more events (Post-Traumatic Stress Disorder in Nursing, 2021).

Significant functional impairment or anguish is brought on by the disturbance in a variety of spheres of life, including social and professional ones (Post-Traumatic Stress Disorder in Nursing, 2021).

There is no medical condition, medicine, or substance usage that could explain the disturbance (Post-Traumatic Stress Disorder in Nursing, 2021).

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People who have been subjected to a traumatic experience, such as learning about a loved one's unexpected death, either directly or indirectly may develop PTSD. Nurses and other professionals who are regularly exposed to distressing incidents at work may also experience it cumulatively. Nursing professionals are exposed to PTSD triggers when working in healthcare settings, such as resuscitating patients, managing bleeding, and taking part in other life-saving and end-of-life treatments (Post-Traumatic Stress Disorder in Nursing, 2021).

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The mental health condition known as post-traumatic stress disorder is brought on by experiencing or witnessing a horrific event. Flashbacks, nightmares, excruciating anxiety, and uncontrollable thoughts about the incident are just a few possible symptoms. The majority of people who experience traumatic circumstances might initially struggle to adjust and cope, but with time and adequate self-care, they typically get better. You may have PTSD if the symptoms worsen, last for weeks, months, or even years, and affect your daily functioning. It can be crucial to seek appropriate treatment after developing PTSD symptoms in order to lessen symptoms and enhance function (Mayo Clinic, 2022b).

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Our emotional, psychological, and social well-being are all parts of our mental health. It influences our thoughts, emotions, and behaviors. Additionally, it influences how we respond to stress, interact with others, and make good decisions (How Do I Know if I Need Therapy?, 2017).

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Veterans of war who have flashbacks, nightmares, and severe anguish when reminded of prior triggering experiences frequently suffer from post-traumatic stress disorder PTSD. The prevalence of PTSD among healthcare professionals, particularly those who have observed their patient code and were not debriefed or given time to deal during their shift, is less well recognized (PTSD in Frontline Healthcare Workers - Institutes of Health, 2021).

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Nurses involvement is important because they all have to recognize when crisis is about to hit their mind space. Self awareness is the number one key prevention and cure in terms of Post Traumatic Stress Disorder.

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The Impact of Post Traumatic Stress Disorder on Nurses

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The Impact of Post Traumatic Stress Disorder on Nurses

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Nurses who are suffering from PTSD may face a wide range of symptoms, including nightmares, flashbacks, or intrusive thoughts. Low self-esteem, discontentment, a lack of enjoyment, or a sense of numbness are frequently experienced.  To avoid talking about the incidents or even just thinking about them, some nurses start to isolate themselves from people and environments. Lastly, nurses who are not in there 100% are more likely to commit mistakes. There is always a chance that fatigue and burnout will set in among nurses, just as there is with any work environment or life situation that has grown demanding and stressful.  The risk of this phenomena can result in subpar work performance, a diminished motivation to accomplish work-related goals, and a diminished capacity for both mental and physical care of patients in stressful circumstances that contribute to traumatic and stressful occurrences (Supporting Mental Health for Nurses: Why It Matters, 2022c).

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Because nurses are likely to witness numerous traumatic events while working, such as patients dying, patients in life-threatening situations, verbal and physical abuse by patients, and visiting family members are all PTSD triggers for nurses, work-related stress is one of the main causes of PTSD in nurses. Last, but not the least nurses are expected to get over their emotions after a code blue event which unable nurses to cope properly (Mann, 2023).

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Nurses working in specific healthcare environments are more likely to get PTSD as a result of their jobs. According to a study that was published in the Journal of Heart and Lung Transplantation, up to 48% of nurses who work in critical care units ICUs are diagnosed with PTSD. A study that was published in Frontiers in Psychiatry found that among emergency responders, emergency and psychiatric nurses experienced the highest rates of PTSD symptoms (Mann, 2023). According to a survey done in 2021 by the Centers for Disease Control and Prevention CDC, 10% to 20% more public health employees than front-line healthcare providers and the general public reported having PTSD symptoms (CDC, 2021).

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Not everyone who goes through a horrific event will get PTSD, but the more closely a person is connected to the event, the greater the likelihood that they will develop PTSD. The length and abruptness of the incident are two other crucial elements.Additionally, the illness is more likely to develop if the person already suffers from depression and if the event results in major changes in their lives (Mann, 2023).

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Being a victim of, or witnessing, a major accident or natural disaster, suffering from an assault, being the victim of physical or sexual abuse, child maltreatment, or domestic abuse are all examples of traumas that can lead to PTSD symptoms. PTSD can also manifest itself after going through or seeing a stressful occurrence at work. Ultimately, for nurses who experienced code blues they are not equipped with enough time of debriefing and coping with the traumatic event (Mann, 2023).

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By being aware and taking our own Mental Health in our hands we can equip ourselves with ways we can prevent Post Traumatic Stress Disorder.

"Promoting Evidence-based interventions like mindfulness and relaxation techniques" (Supporting Mental Health for Nurses: Why It Matters, 2022c).

"Developing policies that prioritize staff well being, which could involve mandatory breaks, providing adequate parental sick leave, and limits on shift length" (Supporting Mental Health for Nurses: Why It Matters, 2022c).

"Appointing a chief wellness officer to spearhead efforts to build wellness culture and provide a voice for the mental health concerns of clinical staff" (Supporting Mental Health for Nurses: Why It Matters, 2022c).

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When nurses refuses involvement and shrug off the crisis, it creates a false sense of "okayness". This can pile up and exacerbate the issue, because emotional trauma does not heal on it's own, it requires Psychological intervention, sometimes pharmacological.

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Analysis: Why Should Us Nurses Involve Ourselves?

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Analysis: Why Should Us Nurses Involve Ourselves?

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"Besides the benefits to patient care, providing nurses with mental health support provides numerous other potential benefits, including: More engaged and efficient nursing staff. Decreased turnover rates. Cost savings from reducing the amount of time nurses take off for mental health issues" (Supporting Mental Health for Nurses: Why It Matters, 2022).

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"Prior studies indicated that the major barriers to mental healthcare access comprise limited availability and affordability of mental healthcare services, insufficient mental healthcare strategies, lack of education about mental disorders, negative attitudes toward mentally disordered patients, and stigma" (Saxena et al., 2007; Ayele et al., 2011; Moses et al., 2011).

Ethical: It is not ethical for a nurse going through a crisis to continue on working.

Legal: A nurse capability can be questioned, and considered unsafe when they are on crisis.

Financial: Wether a nurse quits, commit suicide, or for whatever factor the hospital loses them temporarily or permanently they would have to spend an enormous amount of money to re-train a replacement nurse.

Social Implications: The stigma surrounding PTSD and crisis can be it's own consequence and reason why nurses try to burry their feelings.

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-Self-Awareness
The stigma around mental health difficulties and requesting mental health support still exists, which might keep nurses from receiving the care they require, as shown by the findings of the ANF survey. By normalizing talks about mental health and ensuring that staff are aware of the services accessible to them, health care organizations can contribute to the reduction of stigma (Muhorakeye & Biracyaza, 2021).

-Evidence Base
The COVID-19 pandemic has been particularly difficult for nurses since they have been fighting it head-on. The significance of attending to nurses' mental health problems has been highlighted by their experiences throughout the pandemic (Muhorakeye & Biracyaza, 2021).

Preparation for Leadership Role

These two curricular concept have stuck with me the most because the key concept for nursing are mostly having self-awareness and evidence base historical correlation. Sentara College of Health Sciences have taught me that self-awareness could lead to greater success as a nurse. Self-awareness is a fundamental wherein as nurse we recognize our bias and separate them outside of our emotional output. Being aware of once personal emotion an biases will effectively deliver care for they are able to not take things on a personal level. On the other hand evidence base theories that correlates with the history is very handy when researching about specific care goal. Evidence base historical theorem would allow us to grasp a foundation as long as the same premise is recognize. In this case Covid19 truly affect the population, but hit the nurses the most. With the current evidence practice we have, we are able to intervene and determine the right course to take action and be a leader of change.

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Nurses CRYING & Feeling Overwhelmed and Depressed!?

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How will nurse the nurse's involvement help resolve or improve the issue?

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How will nurse the nurse's involvement help resolve or improve the issue?

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When the nurse fail to recognize their own trouble mind setting it is easy for them to be on crisis.

A nurse who is in crisis can be a danger to themselves, or the patients.

Nevertheless, A self aware nurse who seeks help is gonna be able to function while having an ongoing therapy treatment.